Understanding the Patient Protection and Affordable Care Act

Filling the Medicare Part D Donut Hole
  • If you have Medicare prescription drug coverage and have to pay for your drugs in the “Donut Hole” in coverage, in 2010 you’ll get a one-time, tax-free $250 rebate from Medicare to help pay for your prescriptions.
  • Starting in 2011, if you have high prescription drug costs that put you in the donut hole, you’ll get a 50% discount on covered brand-name drugs while you’re in the donut hole. Between 2010 and 2020, you’ll get continuous Medicare coverage for your prescription drugs and by 2020 the donut hole will be completely closed.
Insurance Exchanges
  • Affordable Insurance Exchanges are designed to make buying health coverage easier and more affordable.
  • Start in 2014
  • Look for and compare private health plans
  • Get answers to questions about your health coverage options
  • Find out if you’re eligible for health programs or tax credits that make coverage more affordable
  • Enroll in a health plan that meets your needs
  • For individuals and families, the Exchange is a single place where you can enroll in private or public health insurance coverage.
  • For small employers, the Exchange is a way to level the playing field, where you have better choice of plans and insurers at a lower cost, the way larger employers do now.
Appealing Health Care Decisions
  • When an insurance plan denies payment for a treatment or service, you can request an appeal.
  • For plan years or policy years beginning on or after July 1, 2011, when your plan denies a claim, it is required to notify you of:
    • The reason your claim was denied.
    • Your right to file an internal appeal.
    • Your right to request an external review if your internal appeal was unsuccessful.
    • The availability of a Consumer Assistance Program
  • If you don’t speak English, you may be entitled to receive appeals information in your native language upon request. This right applies to plan years or policy years beginning on or after January 1, 2012.
Children's Pre-Existing Conditions
  • Under the Affordable Care Act, health plans cannot limit or deny benefits or deny coverage for a child younger than age 19 simply because the child has a “pre-existing condition”—that is, a health problem that developed before the child applied to join the plan. 
  • This rule applies whether or not your child’s health problem or disability was discovered or treated before you applied for coverage.    
  • The new rule doesn’t apply to “grandfathered” individual health insurance policies.
  • These protections will be extended to Americans of all ages starting in 2014
Consumer Assistance Programs
  • Many states offer help to consumers with health insurance problems. The Affordable Care Act improves these services with grants that help states start or strengthen Consumer Assistance Programs
  • If your state does not have a Consumer Assistance Program grant, some state and federal government offices may still be able to help you
  • Before the Affordable Care Act, you often had to fend for yourself when trying to find affordable health insurance or resolve problems with a health plan
  • Before the Affordable Care Act, you often had to fend for yourself when trying to find affordable health insurance or resolve problems with a health plan
  • In addition to helping consumers with immediate problems, Consumer Assistance Programs will help consumers understand other Affordable Care Act reforms designed to make the health insurance marketplace more competitive and patient-centered in 2014 and beyond
Curbing Insurance Cancellations
  • The Affordable Care Act stops health plans from retroactively canceling your insurance coverage solely because you or your employer made an honest mistake on your insurance application
  • Before the Affordable Care Act, if your insurance company found that you’d made a mistake on your insurance application, the insurance company might “rescind” your benefits
  • Under the new law, an insurer cannot rescind your coverage simply because you made an honest mistake or left out information that has little bearing on your health
  • This provision applies to all health plans, whether you get coverage through your employer or purchase it yourself
Preserving Doctor Choice and Ensuring Emergency Care
  • The Affordable Care Act helps preserve your choice of doctors by guaranteeing that you can choose the primary care doctor or pediatrician you want from your health plan’s provider network and that you can see an OB-GYN doctor without needing a referral from another doctor
  • You select the doctor: The new rules permit you to choose any available participating primary care provider as your doctor and to choose any available participating pediatrician as your child’s primary care doctor
  • No health plan barriers to OB-GYN services: The new rules also prohibit health plans from requiring a referral from a primary care provider before you can seek coverage for obstetrical or gynecological (OB-GYN) care from a participating OB-GYN specialist
  • Access to out-of-network emergency room services: In the past, some health plans would limit payment for emergency room services provided outside of a plan’s preselected network of emergency health care providers, or they would require that you get your plan’s prior approval for emergency care at hospitals outside of its networks
  • The new rules prevent health plans from requiring higher copayments or co-insurance for out-of-network emergency room services
Early Retiree Insurance
  • Rising costs have made it difficult for employers to provide quality, affordable health insurance for workers and retirees while also remaining competitive in the global marketplace
  • Many Americans who retire without employer-sponsored insurance and before they are eligible for Medicare see their life savings disappear because of exorbitant rates in the individual market
  • The Early Retiree Reinsurance Program helps employers pay some costs of early retirees’ health insurance claims
FSA/HRA Changes
  • Beginning January 1, 2011, the costs of over-the-counter medications will be reimbursed under a Flexible Spending Account (FSA) or Health Reimbursement Account (HRA) only if the medications are purchased with a doctor’s prescription
Getting Value for your Premium Dollar
  • The Affordable Care Act requires insurance companies to spend your premium dollars primarily on health care
  • The law requires insurers selling policies to individuals or small groups to spend at least 80% of premiums on direct medical care and efforts to improve the quality of care. Insurers selling to large groups (usually 50 or more employees) must spend 85% of premiums on care and quality improvement
Grandfathered Health Plans
  • The Affordable Care Act exempts most plans that existed on March 23, 2010--the day the law was enacted--from some of the law’s consumer protections. This will preserve consumers’ rights to keep the coverage they already had before health reform
Limiting Lifetime and Annual Limits
  • The Affordable Care Act prohibits health plans from putting a lifetime dollar limit on most benefits you receive
  • The Act also restricts and phases out the annual dollar limits a health plan can place on most of your benefits—and does away with these limits entirely in 2014
  • Before the Affordable Care Act, many health plans set an annual limit—a dollar limit on their yearly spending for your covered benefits. Many plans also set a lifetime limit—a dollar limit on what they would spend for your covered benefits during the entire time you were enrolled in that plan. You were required to pay the cost of all care exceeding those limits
  • Under the new law, lifetime limits on most benefits are prohibited in any health plan or insurance policy issued or renewed on or after September 23, 2010
  • The law says that none of these plans can set an annual dollar limit lower than
    • $750,000—for a plan year or policy year starting on or after September 23, 2010 but before September 23, 2011
    • $1.25 million—for a plan year or policy year starting on or after September 23, 2011 but before September 23, 2012
    • $2 million—for a plan year or policy year starting on or after September 23, 2012 but before January 1, 2014
    • No annual dollar limits are allowed on most covered benefits beginning on January 1, 2014
Medicare Drug Discount
  • The Affordable Care Act includes benefits to make your Medicare prescription drug coverage (Part D) more affordable
  • Starting January 1, 2011, if you reach the coverage gap in your Medicare Part D coverage, you will automatically get a 50% discount on covered brand-name drugs
  • You will also get a 7% discount on generic drugs while in the Donut Hole
  • You can expect additional savings on your covered brand-name and generic drugs while in the coverage gap until the gap is closed in 2020
Medicare Preventative Services
  • Under the Affordable Care Act, if you have Original Medicare you may qualify for a yearly wellness exam and many preventive services for free
  • Yearly wellness exam. If you are new to Medicare, your “Welcome to Medicare” physical exam is now covered without cost sharing during your first 12 months of Part B coverage. This exam is a one-time review of your health as well as education and counseling about preventive services and other care. If you’ve had Part B for longer than 12 months, you can get a yearly wellness visit to develop or update a personalized prevention plan based on your current health and risk factors
  • Tobacco use cessation counseling. This benefit is now considered a covered preventive service, whether or not you have been diagnosed with an illness caused or complicated by tobacco use
  • No more Medicare Part B deductible or copayment for these screenings if certain coverage criteria apply
    • Bone mass measurement
    • Cervical cancer screening, including Pap smear tests and pelvic exams.
    • Cholesterol and other cardiovascular screenings
    • Colorectal cancer screening
    • Diabetes screening
    • Flu shot, pneumonia shot, and the hepatitis B shot
    • HIV screening for people at increased risk or who ask for the test
    • Mammograms
    • Medical nutrition therapy to help people manage diabetes or kidney disease
    • Prostate cancer screening
Patient's Bill of Rights
  • Insurance companies often leave patients without coverage when they need it the most, causing them to put off needed care, compromising their health and driving up the cost of care when they get it
  • Stop insurance companies from limiting the care you need
    • For most plans starting on or after September 23, 2010, these rules stop insurance companies from imposing pre-existing condition exclusions on your children; prohibit insurers from rescinding or taking away your coverage based on an unintentional mistake on an application; ban insurers from setting lifetime limits on your coverage; and restrict their use of annual limits on coverage
  • Remove insurance company barriers between you and your doctor
    • For plans starting on or after September 23, 2010, these rules ensure that you can choose the primary care doctor or pediatrician you want from your plan’s provider network, and that you can see an OB-GYN without needing a referral.Insurance companies will not be able to require you to get prior approval before seeking emergency care at a hospital outside your plan’s network
  • Reviewing Insurers’ Premium Increases
  • Keeping Young Adults Covered
    • Starting September 23, 2010, children under 26 will be allowed to stay on their parent’s family policy
  • Providing Affordable Coverage to Americans without Insurance due to Pre-existing Conditions
    • Starting July 1, 2010, Americans locked out of the insurance market because of a pre-existing condition can begin enrolling in the Pre-existing Condition Insurance Plan (PCIP). This program offers insurance without medical underwriting to people who have been unable to get it because of a preexisting condition. It ends in 2014, when the ban on insurers refusing to cover adults with pre-existing conditions goes into effect and individuals will have affordable choices through Exchanges – the same choices as members of Congress
Pre-Existing Insurance Plan
  • Makes health coverage available to you if you have been denied health insurance by private insurance companies because of a pre-existing condition
Preventative Care
Under the Affordable Care Act, you and your family may be eligible for some important preventive services—which can help you avoid illness and improve your health—at no additional cost to you
  • Depending on your age, you may have access at no cost to preventive services such as:
    • Blood pressure, diabetes, and cholesterol tests
    • Many cancer screenings, including mammograms and colonoscopies
    • Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression and reducing alcohol use
    • Routine vaccinations against diseases such as measles, polio or meningitis
    • Flu and pneumonia shots
    • Counseling, screening, and vaccines to ensure healthy pregnancies
    • Regular well-baby and well-child visits, from birth to age 21
Small Employer Tax Credit
  • The Affordable Care Act helps small businesses and small tax-exempt organizations afford the cost of covering their employees
  • If you have fewer than 25 employees and provide health insurance you may qualify for a small business tax credit of up to 35% (up to 25% for non-profits) to offset the cost of your insurance. This will make the cost of providing insurance much lower
Strengthening Medicare
  • The life of the Medicare Trust fund will be extended to at least 2029, a 12-year extension as a result of reducing waste, fraud and abuse, and slowing cost growth in Medicare
  • The Affordable Care Act makes an historic, ten-year, $350 million investment to prevent, detect and fight fraud in Medicare, Medicaid and the Children’s Health Insurance Program—including criminal efforts to exploit the new law
  • The coordination of care between doctors and the overall quality of care will improve so that you will be less likely to experience preventable and harmful re-admissions to the hospital for the same condition
  • Hospitals will have new, strong incentives to improve your quality of care
  • Starting in 2014, the Affordable Care Act offers additional protections for Medicare Advantage Plan members by taking strong steps that limit the amount these plans spend on administrative costs, insurance company profits, and things other than health care
Young Adult Coverage
  • Under the Affordable Care Act, if your plan covers children, you can now add or keep your children on your health insurance policy until they turn 26 years old
  • Until now, health plans could remove enrolled children usually at age 19, sometimes older for full-time students

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