Say Ahhh!

  " Beam me up Scotty!"

  - Captain Kirk

Okay Trekkies, I realize Captain Kirk didn't utter those exact words but it is the phrase that comes to mind whenever I hear the word "web portal" bandied about.  The new health care reform web portal (you'll be able to find it at healthcare.gov), slated for launch on Thursday  (July 1st), is designed to provide information about health coverage options available in each state.  I like to picture it as the entrance point for consumers into the mother-ship of health care coverage options in a post health reform universe.  The web portal will need to beam people up to the right quadrant (i.e., match them up with the appropriate public or private insurance options).

On Thursday, one of the key features CCF staff will be looking for is whether the web portal helps to connect families to coverage through Medicaid and CHIP.  This is one of the very best ways to help families secure affordable coverage for their children right away (and, in some instances, their parents, too). We'll be evaluating the new portal based on whether or not it is easy for families to find information on how to enroll their children in CHIP or Medicaid without having to first navigate through the private insurance plan sections of the portal.

We'll also be looking at whether the new portal reflects some of the additional suggestions made by our Senior Program Director, Dawn Horner, in comments on the proposed regulations such as, does it:

• Create a state-level income calculator so families can figure out whether or not they are likely to be eligible for Medicaid or CHIP.
• Provide users with a way to provide feedback and get questions answered so the web portal is interactive.
•  Include information on state or locally funded coverage options for those whose income is not quite low enough to qualify for CHIP or Medicaid.
•  Collect statistics to determine how effective the portal is at referring eligible families to affordable coverage options.

When it is launched this week, the web portal is expected to be a bare-bones "first generation" site intended to start the process of linking consumers with accurate information on public and private health coverage options.  We are hopeful that, even if this first iteration does not incorporate all of these recommendations, the final web portal regulations (that will be released later this year) will do so. Once those regulations are final, HHS will eventually turn the operation over to a private entity to create a more comprehensive portal - all the more reason to make it clear in the regulations how the system should operate for low- and moderate-income families.  We don't want to send them off to boldly go where no man has gone before without a good guide.

By Vincent DeMarco, President, Maryland Citizens' Health Initiative Education Fund,Inc.

Unlike other states where the fight over federal health care reform continues, leaders in Maryland are figuring out how to make comprehensive health care a reality here at home.  We want to make sure that Maryland gets every federal dollar it can under the new legislation - both for the sake of public health and for the well-being of our economy.

We've got a lot going for us: Most importantly, we have leaders who have a solid record of making health care coverage a priority. We passed one of the nation's largest Medicaid expansions since 2007 by extending adult eligibility from 40% of the federal poverty level to 116% of the federal poverty level (i.e. a family of four earning about $25,000 can qualify for free coverage for everyone in the family.) This moved Maryland from 44th to 16th in the nation for providing free coverage to low income adults and insured more than 63,000 Marylanders.  Partly as a result of this expansion to parents and partly as a result of renewed efforts to reach children, over 85,000 previously eligible but un-enrolled children also got health care coverage in our state since January of 2007. This was not an easy investment for our state amid the economic recession. But fortunately, our legislature understood that to have a resilient state, we need to have a healthy state; in Maryland, families who are coping with losing their jobs don't have to worry about losing their health insurance too.

We know that federal funding will be essential to sustain this program and to continue to make sure that every Marylander has quality, affordable health care coverage. Maryland Governor Martin O'Malley created a coordinating council to advise the state and ensure swift, strategic and comprehensive implementation of federal health care reform to fully benefit our state and our citizens.  The Coordinating Council has already met, and is currently collecting comments and questions from the public involved to ensure transparency and facilitate consumer feedback for excellent program design.

On June 10, the council met to develop a preliminary list of critical issues, establish a feasible work plan, and hear from a panel of stakeholders to learn what they perceive as critical decisions for the council to make or priority topics for the council to consider. We are participating in these meetings and encourage others who are interested in this process to participate as well. The next meeting is July 1 from 9AM-1PM in Annapolis

We think Maryland is a great model for other states to follow. Here's a link to our letter to the coordinating council highlighting specific initiatives we support to ensure affordability, strengthen public health insurance programs, promote awareness about new coverage opportunities and bolster our health care workforce.  We thank the Georgetown Center for Children and Families for the opportunity to share this great news with you and welcome your feedback from the field in other states as well!

Editor's Note: The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

(Editor's Note:  We want to welcome a new voice to our blog and hope that she'll be a frequent contributor to Say Ahhh!  Sabrina Corlette has taken over the reins from our former colleague Karen Pollitz and is our new resident expert on regulation of the private health insurance market and consumer protection issues.  While she's technically with the Health Policy Institute, she collaborates closely with CCF.)  

By Sabrina Corlette, Research Professor, Georgetown University Health Policy Institute

On Tuesday, I sat in the East Room of the White House and listened to the President as he announced the release of a set of rules implementing provisions of the Affordable Care Act that will help protect consumers from some of the worst insurance industry abuses.  I couldn't help but think back ten years ago, when I was a staffer in the U.S. Senate, working on "Patients' Bill of Rights" legislation.  At the time, I met with many patients and families from around the country who'd suffered from decisions by their health plan to deny or limit needed care, and to limit their choice of doctors.  Many of these families had children with special health care needs and were facing terrible decisions about what tests, surgeries, and drugs they could afford because their health plan was not providing the coverage they needed.

That was ten years ago.  While the bill never garnered the votes it needed for passage, the difficulties those families faced never went away.  Thousands of children continue to be denied coverage because of a "pre-existing" medical condition.  Families that dutifully pay their premiums are abruptly dropped from their policies after filing a claim - and told it's because they didn't fill out their application correctly.  And countless children with high cost medical conditions are hitting their plans' annual and lifetime limits on coverage, leaving families to forgo needed treatment or face medical bankruptcy. 

On Tuesday, as I listened to the President describe the insurance reforms that will be effective in September of this year in this latest round of rulemaking, I realized - it took ten long years, but we finally passed that "Patients' Bill of Rights".  It was one of the happiest moments of my life.

So what does this rule do?

First, it says that insurance companies can no longer deny or limit coverage for children who have a pre-existing medical condition.  This provision is estimated to help up to 162,000 children gain access to coverage they don't currently have.  This provision applies to all plans except individual policies that are grandfathered (i.e., those that were in existence prior to the law's enactment and have not made significant changes since.)  For families that are in grandfathered plans, they may need to change their policy in order to get the necessary coverage for their child.

Second, it stops insurance companies from setting lifetime limits on coverage, and restricts the amount of annual limits on essential benefits.  The ban on lifetime limits applies to all plans, while the restrictions on annual limits apply to all plans except those individual policies that are grandfathered.  The restrictions on annual limits are adjusted over time - in the first year the limits can be up to $750,000, in the second year up to $1.25 million, and in the third year up to $2 million.  Starting in 2014, all annual limits on coverage of essential benefits are banned.  HHS is charged with defining what constitutes the essential benefits package, which will determine what items and services would be covered under the annual limits restrictions.  However, HHS has not yet issued those regulations, and families will temporarily need to rely on plans' "good faith" definitions of what constitutes essential benefits.

Third, it stops insurance companies from retroactively cancelling a policy because of an unintentional mistake on an application.  This is a particularly nasty industry practice that leaves people stranded just when they need coverage the most. This rule applies to all plans, including those that are grandfathered.

Fourth, it makes clear that health plan enrollees have the freedom to choose any available participating primary care provider in their plan's network, including any available participating pediatrician for their children.  It also prohibits companies from requiring a referral to see an OB/GYN.  This applies to all plans except those that are grandfathered.

Lastly, it prohibits all plans except those that are grandfathered from charging higher cost-sharing for patients who need to use an out-of-network emergency room.  And it sets some requirements for how plans reimburse out-of-network providers to help protect patients from potential "balance billing." 

These new rules, which will go into effect starting September 23, 2010, will provide critical relief and peace of mind to thousands of families who count on their insurance to be more than an empty promise.  It was a long time in the making, but we finally did it.

Probably the most frequently asked question we get here at CCF is "what are the key decisions states need to make under health reform?"  Today, we begin to answer that question through a new "starter" list of the most immediate questions state policymakers, and the child and family advocates working with them, need to ask when considering health reform implementation. With over 1,000 pages in the health reform bill, this list will certainly grow - but there is a set of critical decisions states should consider now to be prepared for when the bulk of reforms go into effect in 2014.

Today President Obama held a press conference about a number of new regulations being issued by his Administration that he says constitute a new "Patients' Bill of Rights".  Many of these new regulations have important ramifications for children who receive coverage through the private market and in particular, children with special health care needs. 

In another life, I worked with both children and adults with special health care needs and I have seen firsthand how much agony and perseverance parents and family members must have to make sure their child or relative gets the care they need.  These new regulations have the potential to mitigate some of what these families experience on a daily basis. 

A good example of the impact these new regulations could have on real families was articulated by the Restemayer family, who were at the White House today for President Obama's press conference.  The Restemayer's daughter, Allison, was born with a rare genetic disorder that doctors had told her parents would result in her being significantly delayed and that she was likely to die by the age of 10.  The good news is that Allison has defied those predictions and is now 9 years old and attending school and doing mostly age-appropriate work. 

This only has been possible because years ago -- shortly after Allison's diagnosis at the age of two -- a new drug was approved that has helped her tremendously. Since that time, while the Restemayer's have been hopeful, the family also has constantly been on edge with the fear of losing the health coverage they had through Mr. Restemayer job and not being able to find new coverage because of Allison's pre-existing condition. More immediately, the family is facing the prospect that at some point Allison's care would exceed the $2 million lifetime limit on Allison's insurance plan.  To date, Allison has used $1.7 million of the $2 million her insurance plan allows and her parents are hopeful that the new Patients' Bill of Rights will provide the Restemayers the security of knowing that Allison will be able to stay covered and get the care that she needs to continue moving forward on the path she has been on for the last 9 years. 

To see a You Tube video with Allison and her sister Ashley talking about her disorder, please go here.  To learn more about Family Voices, the organization that has supported the Restemayers and many other families as they navigate the ins and outs of the health care system for their children, go here. In the days ahead, we'll be doing a nitty-gritty analysis of the new regulations aimed at eliminating lifetime limits and banning the exclusion of coverage for children's pre-existing conditions.  For now, though, the Restemayers' story is a powerful reminder of why we all need to be rolling up our sleeves and making sure that health care reform works as intended for families and children.