Private Insurance: Adequacy
Adequacy of Coverage features materials about benefits and cost-sharing, which make or break the quality of an insurance policy.
From Families USA
Consumer-Friendly Standards for Qualified Health Plans in Exchanges: Examples from the States outlines the minimum standards for qualified health plans as set out in the Affordable Care Act. It then provides examples from eight state-based exchanges and one partnership exchange state on how to implement those standards in consumer-friendly ways. (January 2013)
How Can We Establish an Essential Health Benefits Package that Meets Consumers’ Needs? provides background information and talking points on the critical issues that need to be addressed to ensure that consumers in the exchanges, individual and small group markets, and Medicaid benchmark plans have access to comprehensive coverage. (November 2011)
Making the Most of Accountable Care Organizations (ACOs): What Advocates Need to Know provides an overview of ACOs; the promise they hold; and how they could change Medicare, Medicaid, and the health care landscape. It also identifies key challenges in their development and suggests how advocates can get involved in ways that benefit patients. (September 2011)
The Perils of Health Insurance Sold Across State Lines explains the hidden dangers in legislation—being pushed at the state and the federal level—that lets out-of-state insurers evade state regulation. (July 2011)
The Affordable Care Act: Patients' Bill of Rights and Other Protections is a compilation of all of our fact sheets to date on consumer rights and protections. (April 2011)
Implementing Health Insurance Exchanges: A Guide to State Activities and Choices describes the requirements in the Affordable Care Act that exchanges must meet and outlines key questions that states and consumer advocates will need to consider as the exchanges are designed. (October 2010)
Families USA had prepared a series of fact sheets on the Patients' Bill of Rights and other consumer protections in the Affordable Care Act that took effect on September 23. (September 2010)
Families USA's Comments on the Mental Health Parity and Addiction Equity Act (MHPAEA) Interim Final Rules: Our comments to the Departments of Health and Human Services, Labor, and Treasury on MHPAEA support the rules, which make mental health and substance use disorder services more accessible and affordable for consumers in large employer plans. (May 3, 2010)
Comparative Effectiveness Research: A Potential Tool for Reducing Health Care Disparities counters misinformation about comparative effectiveness research and outlines steps to take to make it more useful in the fight against health care disparities. (August 2009)
Understanding the Role of the "Exchange" or "Gateway" discusses the new health insurance marketplace, or exchange, that is being developed in national health reform proposals. This short piece looks at how an exchange would work and how it could help middle-class and low-income families find and keep the affordable, quality health care they deserve. (July 2009)
CoverTN, Tennessee's Barebones Health Plan: A Case Study uses Tennessee's barebones health plan as an example to examine how limited-benefit plans fail to meet the health coverage needs of consumers. 16 pp. Print copies free. (May 2009)
Limited-Benefit Plans: Expanding Coverage or Holding Your State Back? examines the negative effects of limited-benefit insurance plans (also known as "barebones" or "mandate-lite" plans) based on how these plans have fared in some states. This brief also discusses how advocates can respond to limited-benefit proposals in their states. (October 2008)
An Unequal Burden: The True Cost of High-Deductible Health Plans for Communities of Color discusses the full costs associated with high-deductible health plans and why these expenses are disproportionately unaffordable for racial and ethnic minorities. It also examines several myths about health savings accounts (HSAs), which are often coupled with such health plans. (September 2008)
Empty Promise: Searching for Health Insurance in an Unfair Market discusses how the individual health insurance market differs from the employer market and examines what happens to consumers who seek coverage in the individual market. Problems in the individual market include policies that don't provide quality coverage; policies that are very expensive or that cost more than advertised; and the fact that many applicants cannot obtain a policy at any price. (August 2008)
Failing Grades: State Consumer Protections in the Individual Health Insurance Market. Laws protecting consumers purchasing health coverage in the individual market vary across the country. In many states, insurance companies can deny coverage, raise premiums significantly, refuse to cover treatment for certain conditions, and even revoke the coverage of policyholders who have been paying premiums for years. (June 2008)
Reward/Penalty Plans for Wellness: Coming Soon to an Office Near You? Encouraging healthy lifestyles is important, but might some wellness plans place your access to health care at risk? This piece explores some of the hidden effects that reward/penalty plans for wellness may have on consumers, as well as the problems that these plans might present in both employer-sponsored coverage and Medicaid. (January 2008)
- The National Committee for Quality Assurance (NCQA) has released a draft of standards that will be used to accredit or certify reward/penalty plans and other types of wellness programs. Click here to read Families USA's comments on these standards. (June 2008)
Too Great a Burden: America's Families at Risk finds that more and more American families are spending a substantial share of their incomes on health care costs, and most of these families have insurance. Faced with high health care costs and tight budgets, families are turning to credit cards to finance their care, and many are falling into medical debt. (December 2007) l state reports
Retail Medical Clinics: Okay in a Pinch, but No Substitute for Real Health Coverage provides an overview of the growing trend of clinics popping up in stores such as Wal-Mart, Target, and CVS. While their convenience is appealing, the tradeoff may be piecemeal services that lack appropriate oversight. Consumers should use such clinics only to supplement care from their regular primary care physician. 6 pp. Free (August 2007)
A Pound of Flesh: Hospital Billing, Debt Collection, and Patients' Rights provides an overview of some of the progressive reform measures that state policymakers have implemented to help families struggling with medical debt. (March 2007)
What Consumers Need to Know about Purchasing Health Insurance as an Individual (July 2005)
The Bush Administration's Health Proposals in the Economic Stimulus Package A Health Policy Memo (October 8, 2001)
The Best from the States II: The Text of Key State HMO Consumer Protection Provisions This 49-page publication offers the relevant text of state laws and regulations addressing important managed care consumer protections, including emergency room services, access to providers, liability, and more. (October 1998)
Hit and Miss: State Managed Care Laws This 45-page report surveys state legislation addressing common problems with managed care. It analyzes state-by-state activity on 13 illustrative consumer protections and finds that many Americans are left unprotected. The spottiness of state consumer protections is compounded by ERISA, which preempts state laws for those in "self-insured" plans¬--one out of three people with employer-provided coverage. (July 1998)
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From Other Organizations
Top Ways Health Reform Helps provides the top five ways the Affordable Care Act helps the following groups: Medicaid beneficiaries, older adults and people with disabilities, women, and children and young adults. It also explains how the health care law addresses disparities and helps people get coverage. The lists are divided into provisions that are already in effect and those that are coming soon. (National Health Law Program, March 2012)
Under the Affordable Care Act, 105 Million Americans No Longer Face Lifetime Limits on Health Benefits breaks down the number of Americans who are enjoying improved coverage without lifetime limits by age group, state, and race or ethnicity. (Department of Health and Human Services (HHS), March 2012)
Fifty-Four Million Additional Americans Are Receiving Preventive Services Coverage without Cost-Sharing under the Affordable Care Act breaks down the number of Americans who are receiving preventive services with no cost-sharing by age group, state, and race or ethnicity. (Department of Health and Human Services (HHS), February 2012)
Frequently Asked Questions on Essential Health Benefits Bulletin answers questions for advocates and policy makers who are working to define the Essential Health Benefits package in their state. Topics include funding of state-mandated benefits, selection of benchmark plans, and coverage of preventive health services. (Centers for Medicare and Medicaid Services (CMS), February 2012)
Essential Health Benefits: Balancing Affordability and Adequacy answers the following questions: How do states select and design “benchmark” plans that are both comprehensive and affordable? How will states and HHS ensure that benefits are sufficiently standardized so that consumers and employers can choose plans based on differences in premiums and cost-sharing? And are there opportunities for using the essential health benefits to lower health spending? (Alliance for Health Reform, February 2012)
Healthy People 2010 Final Review assesses progress in achieving the objectives that were set by the Department of Health and Human Services 10 years ago, including improving access to high-quality care, eliminating health disparities, and increasing the quality and years of healthy life. (The Centers for Disease Control and Prevention, October 2011)
2011 Health Confidence Survey: Most Americans Unfamiliar with Key Aspect of Health Reform summarizes attitudes toward the health care system. It found that 62 percent of Americans are not at all familiar with the insurance exchanges that are a part of the Affordable Care Act, and it found that overall confidence regarding the health care system has not changed since the law was passed last year. (The Employee Benefit Research Insitute, September 2011)
The Role of Exchanges in Quality Improvement: An Analysis of the Options explains that, because an exchange can aggregate the purchasing power of individuals and small groups, it could improve health care quality as well as payment and delivery. The piece describes options that states could pursue to use their exchanges to drive these improvements. (The Robert Wood Johnson Foundation and the Georgetown University Health Policy Institute, September 2011)
Spillover Effects of Community Uninsurance on Working-Age Adults and Seniors finds that people with private insurance or Medicare who are living in an area with a high rate of uninsurance are less likely to be satisfied with the health care they receive, and they report more difficulty getting the care they need. (The Robert Wood Johnson Foundation and Medical Care, September 2011)
Affordable Care Act Reforms Could Reduce the Number of Underinsured U.S. Adults by 70 Percent explains that, by providing premium assistance and lowering out-of-pocket costs, the new law will help those who have insurance but still struggle to pay for health care. (The Commonwealth Fund, September 2011)
Realizing Health Reform’s Potential: Women and the Affordable Care Act of 2010 looks at how women will benefit from provisions that improve coverage and reduce premiums, eliminate pre-existing condition exclusions, eliminate gender rating, and others. Given that women, on average, use more health services over their lifetimes, the new law is likely to greatly improve women’s experience with the health care system. (The Commonwealth Fund, July 2010)
Patients' Bill of Rights: President Obama has released new rules to implement key consumer protections that were part of the new Patient Protection and Affordable Care Act. (The White House, June 2010) | Families USA Press Release
Survey of People Who Purchase Their Own Insurance looks at the types of people who purchase individual insurance, how much they are spending on premiums and out-of-pocket costs, and their experiences with and responses to premium increases. (Kaiser Family Foundation, June 2010)
What Women Need to Know about Health Reform: Improving Access to Affordable Preventive Care looks at how women will benefit from provisions in health reform that expand coverage for preventive care in private plans, Medicare, and Medicaid, and that eliminate cost-sharing for those services. (National Women's Law Center, June 2010)
What Women Need to Know about Health Reform: Insurance Reforms explains how women will benefit from these reforms given that plans have routinely discriminated against women by using gender rating, treating domestic violence as a pre-existing condition, and denying coverage because they’ve had a c-section or breast cancer. New insurance reforms and the “exchanges” will make it easier for women to get coverage in a private market that treats everyone fairly. (National Women's Law Center, June 2010)
Near-Term Changes in Health Insurance: Newly Enacted Health Reform Legislation Mandates Dozens of Health Insurance Changes details the provisions that go into effect during the first two years. Some of the early changes include requiring new health plans to eliminate cost-sharing for preventive services, create internal and external appeals processes, and ban pre-authorization requirements for emergency services. (Health Affairs, April 2010)
Setting a National Minimum Standard for Health Benefits: How Do State Benefit Mandates Compare with Benefits in Large-Group Plans? compares state-mandated benefits with the services and providers covered under the Federal Employees Health Benefits Program (FEHBP) Blue Cross and Blue Shield standard benefit package. With few exceptions, the FEHBP plan either meets or exceeds the benefits that state mandates require. Under a national standard, states would still have the option of providing other benefits above the national standard. (The Commonwealth Fund, June 2009)
Designing Benefit Standards for a Health Insurance Exchange explains that, in any exchange that is created as part of health reform, it is crucial to establish benefit standards so that all plans cover a comprehensive range of services, thereby ensuring that individuals and small businesses have a choice of affordable, comprehensive plans. These benefit standards would protect people with particular medical conditions from facing excessive costs, and they would better enable consumers to compare plans based on price and quality. (The Center on Budget and Policy Priorities, May 2009)
Meeting Enrollees’ Needs: How Do Medicare and Employer Coverage Stack Up? finds that elderly Medicare beneficiaries reported greater overall satisfaction with their health coverage, better access to care, and fewer problems paying medical bills than those under age 65 who are covered by job-based plans. This study was designed to examine whether a public plan could potentially improve access to necessary services and reduce the burden of medical bills for individuals under age 65. (The Commonwealth Fund, May 2009)
Snapshots from the Kitchen Table: Family Budgets and Health Care shows the central role of health care costs and coverage in a household’s economic stability. It finds that health care costs were of particular concern, with many families forgoing doctor visits, skipping prescription medications, and postponing needed care. Even those with health insurance reported delaying care in order to avoid copayments, rising deductibles, and out-of-pocket costs. (Kaiser Commission on Medicaid and the Uninsured, February 2009)
Spending to Survive: Cancer Patients Confront Holes in the Health Insurance System highlights the challenges that cancer patients may face in paying for life-saving care even when they have private health insurance. High cost-sharing, caps on benefits, and lifetime maximums contribute to high out-of-pocket costs, while waiting periods and restrictions on eligibility for public programs can leave patients who are too ill to work without an affordable insurance option. (Kaiser Family Foundation, February 2009)
Nowhere to Turn: How the Individual Health Insurance Market Fails Women looks at the experiences of women seeking coverage in the individual insurance market between July and September, 2008. The report finds that many women face obstacles obtaining comprehensive, affordable health coverage. These challenges include being charged higher premiums than men, a practice known as “gender rating,” and being unable to find affordable maternity coverage. (National Women’s Law Center, September 2008)
On Their Own: Far from a Remedy, Individual Health Insurance Is a World of Pain details an investigation of individual health insurance and found that regulation of this market varies from state to state. Expenses normally run higher than insurance available through an employer. The investigation also found that 76 percent of uninsured adults said that they could not afford individual insurance.(Consumer Reports, January 2008)
The Illusion of Coverage: How Health Insurance Fails People when They Get Sick describes how private insurance fails to protect people from financial hardship when they become ill or are injured. The report discusses the aspects of insurance that lead to medical debt and that hamper people's ability to make meaningful choices when purchasing health plans, as well as the consequences of medical debt. It also provides recommendations on how to provide people with access to comprehensive and affordable insurance products. (The Access Project, March 2007)
Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families examines the implications of rising out-of-pocket costs for all privately insured Americans. The report also analyses the experiences of adults with employer-sponsored coverage compared to those insured through the individual market. (The Commonwealth Fund, September 2006)
Distribution of Out-of-Pocket Spending for Health Care Services takes a detailed look at out-of-pocket spending for health care, and, in particular, how out-of-pocket costs vary among different groups for different services. Comparisons focus on, for example, what types of drugs and treatments are most often handled out-of-pocket and what share of total health spending occurs out-of-pocket by income bracket. (Kaiser Family Foundation, May 2006)
Designing Maine's DirigoChoice Benefit Plan DirigoChoice is Maine's innovative private-public partnership that offers health insurance to employees of small businesses, the self-employed, and the uninsured. This report discusses the process that Maine went through in developing a plan for DirigoChoice and outlining the health care benefit package that would be provided. (National Academy of State Health Policy and the Commonwealth Fund, December 2004)
Rising Health Costs, Medical Debt and Chronic Conditions About 57 million working-age Americans (18-64 years old) live with chronic conditions such as diabetes or depression. In 2003, more than one in five—12.3 million people with chronic conditions—lived in families that had problems paying their medical bills. Rising health costs have hit low-income, privately insured people with chronic conditions particularly hard: Between 2001 and 2003, the proportion of such people who spent more than 5 percent of their income on out-of-pocket health care costs grew from 28 percent to 42 percent. (Center for Studying Health System Change, September 2004)
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