How health care bill affects retirees' Rx donut hole

The health care bill just passed will deal with the prescription donut hole, which retirees are quite familiar with. Once retirees get past a certain accumulated value of our prescriptions in a year, as determined by Aetna Medicare, we pay all the costs of certain brand-name drugs till we get out of the donut hole, which I never have.

That's one issue listed in CBS' summary of the bill that President Obama will sign into law.

Others include:

Closes the Medicare prescription drug "donut hole" by 2020. Seniors who hit the donut hole by 2010 will receive a $250 rebate.

Beginning in 2011, seniors in the gap will receive a 50 percent discount on brand name drugs.

Six months after enactment, insurance companies could no longer deny children coverage based on a preexisting condition.

Starting in 2014, insurance companies cannot deny coverage to anyone with preexisting conditions.

To read CBS' summary, go to

CBS summary

I have been reading the actual bill -- thousands of pages.

Here's what I found:

The issuer cannot vary the percentage increase in the premium for a risk group of enrollees in specific health insurance coverage without changing the premium for all enrollees in the same risk group at the same rate.

Nothing shall prevent the offering of excepted benefits so long as it is offered and priced separately from health insurance coverage.

A qualified health benefits plan may not impose any pre-existing condition exclusion.

The premium rate charged for an insured qualified health benefits plan may not vary except

By age so long as the ratio of the highest premium to the lowest premium is not more than 2 to 1.

By premium rating area.

By family enrollment as long as the ratio of the premium for family to individual enrollment is uniform.

If a qualified health benefits plan does not meet a specified medical loss ratio, then the insurer provide rebates to enrollees to meet the loss ratio.
EDITOR’S NOTE: Insurers can’t jack up rates to increase profits above the government’s acceptable ratio. Profits can’t be expanded to provide additional money for CEOs.

No annual or lifetime limit on covered health care items and services.

Covered:

Hospitalization.
Outpatient hospital and outpatient clinic
Services, including emergency department services.
Professional services of physicians and other health professionals.
Services, equipment and supplies in institutional settings, physician offices, patients’ homes or place of resdence.
Prescription drugs.
Rehabilitative and habilitative services.
Mental health and substance use disorder services.
Preventive services.
Vaccines recommended by Centers for Disease Control.
Maternity care.
Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies for children under 21.

Any notifications of changes in health care plans shall provide adequate notice and be in plain English so that clients can understand them.

A health insurance issuer may rescind health insurance coverage only upon clear and convincing evidence of fraud and after adequate notice to the person involved.

Only if an insurer offers a basic plan for an area can it offer a premium plan for that area.
EDITOR’S NOTE: No “Cadillac” plan unless insurer also has a basic plan.

And no plan can have more than 10% cost-sharing than the plan above or below it.

Insurers shall accept all enrollments unless it is at capacity for any more enrollments.

September through November of each year, for not less than 30 days, will be open enrollment for those who want to join a plan.

A child born in the United States who is not otherwise covered shall be covered under Medicaid.

Public option insurers will be under the same rules as private insurers.

Public option premiums will vary, based on how the income compares to the federal poverty level, possibly adjusted for regional cost of living differences.

Employees may opt out of their employer’s insurance plan and choose a public option.

If an employer chooses not to provide insurance, then it must pay 8% of its employees’ salary into the public option plan. This will be adjusted downward for employers with a payroll of less than $400,000.
EDITOR’S NOTE: An attempt to answer the fear that costs would endanger small businesses.

No one can be forced into an insurance plan if it violates their religious beliefs.

Employers can be taxed $100 a day for failing to cover employees as required by the law.

Those who earn $350,000 or more a year will be taxed on a sliding scale for payments intothe public option plan.

Click on the headline to read the actual bill yourself. It make take a while.