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Lambda AIDS Project Director's Update

One (Very) Small Step for Health Care Reform

What Does the Kennedy-Kassebaum Health Coverage Act Mean For You?

Spring/Summer 1997

Many lives have changed and been saved thanks to the dramatic developments in HIV-related treatments. But, contrary to the claims filling newspapers earlier this year, the new drug combinations have not meant the end of AIDS or of the epidemic of discrimination which has shadowed the millions affected.

With the availability of treatments which may eventually make HIV disease a manageable, chronic illness, the perennial problems of insurance and health-care access are even more pressing. Consequently, Lambda's AIDS Project keeps these issues in its sights. In addition to the Galanty and Chubb cases, which deal, respectively, with discrimination in disability insurance and in life insurance, we are investigating insurance company practices such as "capping" health insurance coverage of HIV-related treatment, and refusing to pay for T-cell counts or other important tests and treatments.

Courts increasingly are on our side in cases of insurance discrimination. With many people with HIV living well past the expectations of only a few years ago, it is increasingly unclear what a positive HIV test means in drawing conclusions about a person's life expectancy. The day may come when we successfully can challenge as unjustified by actuarial data or experience any outright denial of any form of insurance -- including life insurance -- on the basis of HIV status.

Because insurance is an immediate concern for anyone with HIV, it's also worth considering what the Kennedy-Kassebaum health insurance legislation offers once it has taken effect in July. After the dust settled over the monumental failure of health care reform, Congress and the White House cooperated in carving out a slice of common ground in the form of the Health Coverage Portability and Accountability Act of 1996. The Act hardly represents a major overhaul, but it did produce some worthwhile improvements in health insurance. What will these reforms mean for you?

There is good news and bad news in terms of coverage access. This new law does nothing to make sure you can get the coverage you need to stay alive and healthy at a price within your means. But the good news for people with HIV and AIDS is that the Act places some limits on coverage exclusions that are based on pre-existing conditions, and it expands both the availability and portability (the ability to change jobs without losing coverage) of health insurance. It also prohibits discrimination in health insurance based on health status (e.g., companies cannot refuse to insure, or provide equivalent insurance to, people with HIV).

The new law means that insurers cannot exclude coverage for a pre-existing condition for more than 12 months after a policy goes into effect. Under the Act, a "pre-existing condition" is limited to medical diagnosis, advice or treatment of a condition during the six-month period before enrollment in the health insurance plan. Pregnant women, newborn and adopted children are completely protected from any pre-existing exclusion under the Act. These rules apply both to persons who are covered through an employer-based group health insurance plan and to those who purchase individual health insurance plans. However, those with individual plans are eligible for the pre-existing conditions protections of the Act, only if they have had at least 18 months of continuous private coverage (i.e., not Medicaid or Medicare) and have exhausted their benefits under COBRA (coverage which employers who offer group insurance and have 20 or more employees must offer you for 18 months after you lose your group coverage, or for 29 months if you were disabled when you left your job).

The Act also has provisions which require insurance companies to sell group health coverage to small employers (those with three to 50 employees). If an insurer offers individual policies at all, it must sell to any individual who qualifies as described in the paragraph above and not eligible for other group or public insurance.

However, the types of coverage which private insurers are required to offer to individuals are quite limited. Furthermore, insurers can avoid covering eligible individuals in states which provide alternative forms of coverage, such as high-risk pools or open enrollment periods by one or more other insurers. At a minimum, persons seeking individual insurance coverage must have a choice that includes at least one option that is comparable to a standard group or individual health insurance plan in that state, and which eliminates pre-existing conditions exclusions.

While the Act makes barely a dent in a health care crisis in which so many of those with HIV are uninsured, the new law does ease the pressure on many who have stayed in bad jobs, or put off treatment, because of difficulty in getting or keeping insurance.

Catherine Hanssens is AIDS Project Director, Lambda Legal Defense and Education Fund.

This article was provided by Lambda Legal. Visit Lambda Legal's website to find out more about their activities, publications and services.
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