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Patient Protection and
Affordable Care Act
and you

There was a lot of discussion about the size and complexity of the Patient Protection and Affordable Care Act when President Obama signed it in 2010. The Act puts in place strong consumer protections, provides new coverage options and gives you the tools you need to make informed choices about your health

The Supreme Court has now upheld much of the actís constitutionality. Hence it is a good time to review the key provisions and their implementation timing.

Below are the key elements of the Act:

If you seek legal advice contact: Michael Kelly Attorney

1) Lifetime coverage limits. Insurance companies can no longer impose such limits.

2) Annual insurance cap is sharply limited and eliminated entirely in 2014.

3) Pre-existing conditions exclusion

4) End of "rescissions." You cannot be dropped when you get sick.

5) Young Adult Coverage Can remain on parents' insurance until they are 26.

6) Seniors’ Coverage

7) Rebates from Insurers. If their administrative cost ratio is too high.

Below are the implementation plans and summary of the plans features:

Implemen- tation Date
Program Feature
1-Jan-10 Providing Small Business Health Insurance Tax Credits Up to 4 million small businesses are eligible for tax credits to help them provide insurance benefits to their workers. The first phase of this provision provides a credit worth up to 35% of the employer's contribution to the employees' health insurance. Small non-profit organizations may receive up to a 25% credit.
1-Apr-10 Allowing States to Cover More People on Medicaid States will be able to receive federal matching funds for covering some additional low-income individuals and families under Medicaid for whom federal funds were not previously available. This will make it easier for states that choose to do so to cover more of their residents.
2010 Relief for Four Million Seniors Who Hit the Medicare Prescription Drug "Donut Hole" An estimated 4 million seniors reached the gap in Medicare prescription drug coverage known as the "donut hole" in 2010. Each eligible senior received a one-time, tax free $250 rebate check.
1-Jun-10 Expanding Coverage for Early Retirees Too often, Americans who retire without employer-sponsored insurance and before they are eligible for Medicare see their life savings disappear because of high rates in the individual market. To preserve employer coverage for early retirees until more affordable coverage is available through the new Exchanges by 2014, the new law creates a $5 billion program to provide needed financial help for employment-based plans to continue to provide valuable coverage to people who retire between the ages of 55 and 65, as well as their spouses and dependents.
1-Jul-10 Providing Access to Insurance for Uninsured Americans with Pre-Existing Conditions A Pre-Existing Condition Insurance Plan (PCIP) provides new coverage options to individuals who have been uninsured for at least six months because of a pre-existing condition. States have the option of running this new program in their state. If a state has chosen not to do so, a plan has been established by the Department of Health and Human Services in that state. This program serves as a bridge to 2014, when all discrimination against pre-existing conditions will be prohibited.
23-Sep-10 Extending Coverage for Young Adults Under the new law, young adults are allowed to stay on their parent's plan until they turn 26 years old. (In the case of existing group health plans, this right does not apply if the young adult is offered insurance at work.) Check with your insurance company or employer to see if you qualify.
23-Sep-10 Providing Free Preventive Care All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance.
23-Sep-10 Prohibiting Insurance Companies from Rescinding Coverage In the past, insurance companies could search for an error, or other technical mistake, on a customer's application and use this error to deny payment for services when he or she got sick. The new law makes this illegal. After media reports cited incidents of breast cancer patients losing coverage, insurance companies agreed to end this practice immediately.
23-Sep-10 Appealing Insurance Company Decisions The law provides consumers with a way to appeal coverage determinations or claims to their insurance company, and establishes an external review process.
23-Sep-10 Eliminating Lifetime Limits on Insurance Coverage Under the new law, insurance companies are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays.
23-Sep-10 Regulating Annual Limits on Insurance Coverage Under the new law, insurance companies' use of annual dollar limits on the amount of insurance coverage a patient may receive is restricted for new plans in the individual market and all group plans. In 2014, the use of annual dollar limits on essential benefits like hospital stays will be banned for new plans in the individual market and all group plans.
23-Sep-10 Prohibiting Denying Coverage of Children Based on Pre-Existing Conditions The new law includes new rules to prevent insurance companies from denying coverage to children under the age of 19 due to a pre-existing condition.
2010 Holding Insurance Companies Accountable for Unreasonable Rate Hikes The law allows states that have, or plan to implement, measures that require insurance companies to justify their premium increases to be eligible for $250 million in new grants. Insurance companies with excessive or unjustified premium increases may not be able to participate in the new Affordable Insurance Exchanges in 2014.
2010 Rebuilding the Primary Care Workforce To strengthen the availability of primary care, there are new incentives in the law to expand the number of primary care doctors, nurses and physician assistants, including funding for scholarships and loan repayments for primary care doctors and nurses working in underserved areas. Doctors and nurses receiving payments made under any state loan repayment or loan forgiveness program intended to increase the availability of health care services in underserved or health professional shortage areas will not have to pay taxes on those payments.
Oct-10 Establishing Consumer Assistance Programs in the States Under the new law, states that apply receive federal grants to help set up or expand independent offices to help consumers navigate the private health insurance system. These programs help consumers file complaints and appeals; enroll in health coverage; and get educated about their rights and responsibilities in group health plans or individual health insurance policies. The programs also collect data on the types of problems consumers have, and file reports with the U.S. Department of Health and Human Services to identify trouble spots that need further oversight.
2010 Strengthening Community Health Centers The law includes new funding to support the construction of and expansion of services at community health centers, allowing these centers to serve some 20 million new patients across the country.
2010 Payments for Rural Health Care Providers Today, 68% of medically underserved communities across the nation are in rural areas, and these communities often have trouble attracting and retaining medical professionals. The law provides increased payment to rural health care providers to help them continue to serve their communities.
1-Jan-11 Prescription Drug Discounts In 2011, seniors who reach the coverage gap will receive a 50 percent discount when buying Medicare Part D covered brand-name prescription drugs. Over the next ten years, seniors will receive additional savings on brand-name and generic drugs until the coverage gap is closed in 2020.
1-Jan-11 Free Preventive Care for Seniors The law provides certain free preventive services, such as annual wellness visits and personalized prevention plans, for seniors on Medicare.
1-Jan-11 Bringing Down Health Care Premiums To ensure premium dollars are spent primarily on health care, the new law generally requires that at least 85% of all premium dollars collected by insurance companies for large employer plans are spent on health care services and health care quality improvement. For plans sold to individuals and small employers, at least 80% of the premium must be spent on benefits and quality improvement. If insurance companies do not meet these goals because their administrative costs or profits are too high, they must provide rebates to consumers.
1-Jan-11 Addressing Overpayments to Big Insurance Companies and Strengthening Medicare Advantage Today, Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than is spent per person in Original Medicare. This results in increased premiums for all Medicare beneficiaries, including the 77% of beneficiaries who are not currently enrolled in a Medicare Advantage plan. The new law levels the playing field by gradually eliminating this discrepancy. People enrolled in a Medicare Advantage plan will still receive all guaranteed Medicare benefits, and the law provides bonus payments to Medicare Advantage plans that provide high quality care.
1-Jan-11 Improving Care for Seniors after They Leave the Hospital The Community Care Transitions Program helps high-risk Medicare beneficiaries who are hospitalized avoid unnecessary readmissions by coordinating care and connecting patients to services in their communities.
1-Oct-11 New Innovations to Bring Down Costs The Independent Payment Advisory Board will begin operations to develop and submit proposals to Congress and the President aimed at extending the life of the Medicare Trust Fund. The Board is expected to focus on ways to target waste in the system, and recommend ways to reduce costs, improve health outcomes for patients, and expand access to high-quality care.
1-Oct-11 Increasing Access to Services at Home and in the Community The new Community First Choice Option allows states to offer home and community based services to disabled people through Medicaid rather than institutional care in nursing homes.
1-Jan-12 Encouraging Integrated Health Systems The new law provides incentives for physicians to join together to form Accountable Care Organizations. In these groups, doctors can better coordinate patient care and improve the quality, help prevent disease and illness, and reduce unnecessary hospital admissions. If Accountable Care Organizations provide high quality care and reduce costs to the health care system, they can keep some of the money that they have helped save.
1-Oct-12 Reducing Paperwork and Administrative Costs Health care remains one of the few industries that relies on paper records. The new law institutes a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information. Using electronic health records will reduce paperwork and administrative burdens, cut costs, reduce medical errors and, most importantly, improve the quality of care.
1-Oct-12 Reducing Paperwork and Administrative Costs Health care remains one of the few industries that relies on paper records. The new law institutes a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information. Using electronic health records will reduce paperwork and administrative burdens, cut costs, reduce medical errors and, most importantly, improve the quality of care.
1-Jan-13 Improving Preventive Health Coverage To expand the number of Americans receiving preventive care, the law provides new funding to state Medicaid programs that choose to cover preventive services for patients at little or no cost.
1-Jan-13 Increasing Medicaid Payments for Primary Care Doctors As Medicaid programs and providers prepare to cover more patients in 2014, the Act requires states to pay primary care physicians no less than 100% of Medicare payment rates in 2013 and 2014 for primary care services. The increase is fully funded by the federal governme
1-Jan-13 Expanded Authority to Bundle Payments The law establishes a national pilot program to encourage hospitals, doctors, and other providers to work together to improve the coordination and quality of patient care. Under payment bundling, hospitals, doctors, and providers are paid a flat rate for an episode of care rather than the current fragmented system where each service or test or bundles of items or services are billed separately to Medicare. For example, instead of a surgical procedure generating multiple claims from multiple providers, the entire team is compensated with a bundled payment that provides incentives to deliver health care services more efficiently while maintaining or improving quality of care. It aligns the incentives of those delivering care, and savings are shared between providers and the Medicare program.
1-Oct-13 Additional Funding for the Children's Health Insurance Program (CHIP) Under the new law, states will receive two more years of funding to continue coverage for children not eligible for Medicaid
1-Jan-14 Establishing Affordable Insurance Exchanges Starting in 2014 if your employer doesn't offer insurance, you will be able to buy it directly in an Affordable Insurance Exchange. An Exchange is a new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Exchanges will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, Members of Congress will be getting their health care insurance through Exchanges, and you will be able buy your insurance through Exchanges too.
1-Jan-14 Promoting Individual Responsibility Under the new law, most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. If affordable coverage is not available to an individual, he or she will be eligible for an exemption.
1-Jan-14 Ensuring Free Choice Workers meeting certain requirements who cannot afford the coverage provided by their employer may take whatever funds their employer might have contributed to their insurance and use these resources to help purchase a more affordable plan in the new Affordable Insurance Exchanges. These new competitive marketplaces will allow individuals and small businesses to buy qualified health benefit plans.
1-Jan-14 Increasing Access to Medicaid Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in subsequent years.
1-Jan-14 Makes Care More Affordable Tax credits to help the middle class afford insurance will become available for those with income between 100% and 400% of the poverty line who are not eligible for other affordable coverage. (In 2010, 400% of the poverty line comes out to about $43,000 for an individual or $88,000 for a family of four.) The tax credit is advanceable, so it can lower your premium payments each month, rather than making you wait for tax time. It's also refundable, so even moderate income families can receive the full benefit of the credit. These individuals may also qualify for reduced cost-sharing (copayments, co-insurance, and deductibles).
1-Jan-14 Eliminating Annual Limits on Insurance Coverage The law prohibits new plans and existing group plans from imposing annual dollar limits on the amount of coverage an individual may receive.
1-Jan-14 No Discrimination Due to Pre-Existing Conditions or Gender The law implements strong reforms that prohibit insurance companies from refusing to sell coverage or renew policies because of an individual's pre-existing conditions. Also, in the individual and small group market, it eliminates the ability of insurance companies to charge higher rates due to gender or health status.
1-Jan-15 Paying Physicians Based on Value Not Volume A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide higher value care will receive higher payments than those who provide lower quality care.


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