"Grandfathered" Health Plans

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What does it mean if my health plan is "grandfathered" under the new health care reform law?

During the debate on health care reform, President Obama often promised Americans: "If you like the health care plan you have now, you can keep it." Therefore, the legislation exempts plans that were already in existence on March 23, 2010-the date it was signed into law-from certain requirements that apply to all new plans. Exempt plans are known as "grandfathered" plans.

Readers seem to have two main concerns about these plans. They want to know whether grandfathered plans must stay exactly the same as they were on March 23-same benefits, same premiums, same copayments - in order to continue to be exempt in future years. And they also ask whether these plans will give them fewer consumer protections and benefits than will be required of new plans.

Administration officials say that the rules for grandfathered plans try to strike a balance between these two concerns-requiring certain new protections to be added to these policies but also allowing the plans a certain amount of flexibility so that they will not lose their grandfathered status if they only make routine changes from year to year.

Some new consumer protections apply to all plans, whether they're grandfathered or not:

• A plan cannot exclude coverage for your children if they have preexisting medical conditions.
• A plan can no longer cancel your coverage if you become sick and had made an unintentional mistake on your application for insurance.
• A plan cannot impose lifetime limits on coverage.
• A plan must extend coverage to your adult children up to age 26.

Some new consumer protections and benefits are not required under grandfathered plans:

• They need not offer screenings and other preventive measures for free.
• They need not provide guaranteed access to ob-gyns and pediatricians.
• Individual grandfathered plans are not required to abolish annual coverage limits.

Grandfathered plans can lose their exempt status only if they do one of the following:

• Significantly cut benefits, such as eliminating all or nearly all benefits to treat a specific condition such as diabetes, cystic fibrosis or HIV/AIDS.
• Raise charges that are based on a percentage of costs-for example, increasing your share of a hospital bill from 20 to 25 percent.
• Significantly raise copays-for example, from $30 to $50 for a doctor visit over the next two years.
• Significantly raise deductibles-for example, increasing from $1,000 to $1,500 over the next two years.
• Reduce the employer's share of the premium by more than 5 percent-for example, so that the employee's share rises from 15 to 21 percent.
• Reduce existing annual benefit limits or add limits.
• Reduce existing lifetime limits on coverage.

The National Association of Insurance Commissioners has a detailed chart available online that describes the differences between grandfathered and new plans, and what rules each must follow. Click here to view the chart   

View the full article online 

 Basics of Dental Health Insurance

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Understanding the alphabet soup of dental insurance plans can be a difficult endeavor for most people.

Two common insurance acronyms include PPO and HMO. Managed care plans are often either PPO or HMO, standing for preferred provider organization and health maintenance organization.

With PPO insurance plans, the companies negotiate fee schedules with dentists in exchange for the dentist being put on a list of "preferred" providers. Employers give the list to their employees to match them up with dentists who participate with the dental plan. Dental insurance can help people pay for dental treatment, but it has its limitations. Most insurance plans have a deductible of $50 to $100, pay only a specified percentage for each type of treatment, and have a yearly maximum amount of funds available for dental care.

Most PPO plans cover preventive care, dental cleanings, dental exams, protective dental sealants, X-rays, and fluoride treatment at 80-100 percent. Basic care, including root canals, tooth extractions, and dental fillings are usually covered at 80 percent. Major care such as dental crowns, dental bridges, and full and partial dentures as well as periodontal care are often covered at 50 percent.

Many insurance companies have a yearly maximum of $1000. Dental insurance is not cumulative, so if you don't use it, you lose it. It is interesting, and disappointing, to note that when dental insurance companies became common in the early 1970's, the yearly maximum in many was the same $1000 it is today, even though the cost of delivering dental care has nearly tripled since then.

HMO's have received a barrage of negative publicity in recent years, primarily in the medical community, for dubious "gag" clauses in the contracts, bureaucratic snafus, and the limitation of appropriate care of patients by their physician. While some HMO insurance plans may be adequate for practitioners in the medical community, they are more difficult to justify in the dental community. The main reason is that practice overhead is generally higher in the average dental practice than the average medical practice, and the financial compensation from most HMO's is very low. 65 to 70 cents of every dollar received at the average dental office is consumed by office overhead, including staff salaries, supplies, laboratory fees, rent, etc.

The reduced fees allowed by dental HMO's have participating dentists doing many dental treatments at a financial loss. A recent study by the American Dental Association found that the average dental HMO does not even adequately reimburse inexpensive preventive dental care. Consequently, a dental practice with a majority of patients having HMO insurance is often forced to see patients quickly -- too quickly in my opinion, to develop the necessary rapport essential to the dentist-patient relationship. A dentist I know told me that when an HMO patient comes into his office for a cleaning, he does not give that patient the "free" toothbrush that he routinely gives to his other patients.

Wellness Tip of the Month 

Indulge Your Sweet Tooth and Protect Your Heart!

Yes, it's true, chocolate can be good for you!  Much of the recent research suggests that consumption of chocolate, in moderation, may help prevent high blood pressure, improve heart health, and provide a bounty of antioxidants our bodies need.  But all chocolate is not created equal, and not all types of chocolate offer these health benefits.  So although your choice in chocolate bars can't change the world, and they indefinitely should not replace other healthy food options, chocolate can be a healthy treat if you choose wisely.

Here's a perfect example of how you enjoy chocolate in a healthy way!   H3's Super Soft Chocolate Cake with Oreo Cream Filling.       A light, yet decadent dessert - perfect to share with the ones you love!        For more healthy recipes, visit Hilton Head Health's official blog at www.h3daily.com.

Super Soft Chocolate Cake with Oreo Cream Filling   Click here to view & print the recipe

Beginning February 21^st, tune in to A&E Monday nights at 10pm to see Hilton Head Health on their newest weight loss docudrama Heavy - filmed right here on Hilton Head Island. 

Cheney Maddox is responsible for H3 Direct, a corporate wellness program, facilitated by Hilton Head Health (H3), designed to take the inspiration of H3's Healthy Lifestyle™ program, delivered to your door.  It's not too late to begin a program for your company in 2011 - call 843-785-3919 for information about how you can invest in your employees' health in the New Year for less than a quarter a day!