Coverage Now for Sick Children? Check Fine Print

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Coverage Now for Sick Children? Check Fine Print By ROBERT PEAR

WASHINGTON — Just days after President Obama signed the new health care law,

insurance companies are already arguing that, at least for now, they do not have

to provide one of the benefits that the president calls a centerpiece of the

law: coverage for certain children with pre-existing conditions.

Mr. Obama, speaking at a health care rally in northern Virginia on March 19,

said, " Starting this year, insurance companies will be banned forever from

denying coverage to children with pre-existing conditions. "

The authors of the law say they meant to ban all forms of discrimination against

children with pre-existing conditions like asthma, diabetes, birth defects,

orthopedic problems, leukemia, cystic fibrosis and sickle cell disease. The

goal, they say, was to provide those youngsters with access to insurance and to

a full range of benefits once they are in a health plan.

To insurance companies, the language of the law is not so clear.

Insurers agree that if they provide insurance for a child, they must cover

pre-existing conditions. But, they say, the law does not require them to write

insurance for the child and it does not guarantee the " availability of coverage "

for all until 2014.

G. Schiffbauer, a lawyer whose clients include employers and insurance

companies, said: " The fine print differs from the larger political message. If a

company sells insurance, it will have to cover pre-existing conditions for

children covered by the policy. But it does not have to sell to somebody with a

pre-existing condition. And the insurer could increase premiums to cover the

additional cost. "

Congressional Democrats were furious when they learned that some insurers

disagreed with their interpretation of the law.

" The concept that insurance companies would even seek to deny children coverage

exemplifies why we fought for this reform, " said Representative Henry A. Waxman,

Democrat of California and chairman of the Energy and Commerce Committee.

Senator D. Rockefeller IV, Democrat of West Virginia and chairman of the

Senate commerce committee, said: " The ink has not yet dried on the health care

reform bill, and already some deplorable health insurance companies are trying

to duck away from covering children with pre-existing conditions. This is

outrageous. "

The issue is one of many that federal officials are tackling as they prepare to

carry out the law, with a huge stream of new rules, official guidance and

brochures to educate the public. Their decisions will have major practical

implications.

Insurers say they often limit coverage of pre-existing conditions under policies

sold in the individual insurance market. Thus, for example, an insurer might

cover a family of four, including a child with a heart defect, but exclude

treatment of that condition from the policy.

The new law says that health plans and insurers offering individual or group

coverage " may not impose any pre-existing condition exclusion with respect to

such plan or coverage " for children under 19, starting in " plan years " that

begin on or after Sept. 23, 2010.

But, insurers say, until 2014, the law does not require them to write insurance

at all for the child or the family. In the language of insurance, the law does

not include a " guaranteed issue " requirement before then.

Consumer advocates worry that instead of refusing to cover treatment for a

specific pre-existing condition, an insurer might simply deny coverage for the

child or the family.

" If you have a sick kid, the individual insurance market will continue to be a

scary place, " said L. Pollitz, a research professor at the Health Policy

Institute at town University.

Experts at the National Association of Insurance Commissioners share that

concern.

" I would like to see the kids covered, " said Sandy Praeger, the insurance

commissioner of Kansas. " But without guaranteed issue of insurance, I am not

sure companies will be required to take children under 19. "

A White House spokesman said the administration planned to issue regulations

setting forth its view that " the term `pre-existing' applies to both a child's

access to a plan and his or her benefits once he or she is in a plan. " But

lawyers said the rules could be challenged in court if they went beyond the law

or were inconsistent with it.

Starting in January 2014, health plans will be required to accept everyone who

applies for coverage.

Until then, people with pre-existing conditions could seek coverage in high-risk

insurance pools run by states or by the secretary of health and human services.

The new law provides $5 billion to help pay claims filed by people in those

pools.

Federal officials will need to write rules or guidance to address a number of

concerns. The issues to be resolved include defining the " essential health

benefits " that must be offered by all insurers; deciding which dependents are

entitled to stay on their parents' insurance; determining who qualifies for a

" hardship exemption " from the requirement to have insurance; and deciding who is

eligible for a new long-term care insurance program.

As originally conceived, most of the new federal requirements would have taken

effect at the same time, in three or four years. The requirements for people to

carry insurance, for employers to offer it and for insurers to accept all

applicants were tied together.

But as criticism of their proposal grew, Democrats wanted to show that the

legislation would produce immediate, tangible benefits. So they accelerated the

ban on " pre-existing condition exclusions " for children.

Consumers will soon gain several other protections. By July 1, the health

secretary must establish a Web site where people can identify " affordable health

insurance coverage options. " The site is supposed to provide information about

premiums, co-payments and the share of premium revenue that goes to

administrative costs and profits, rather than medical care.

In addition, within six months, health plans must have " an effective appeals

process, " so consumers can challenge decisions on coverage and claims.

http://www.nytimes.com/2010/03/29/health/policy/29health.html