Wednesday, September 7, 2011

Important provisions of the Affordable Care Act

FV Indiana recognizes that the implementation of the Affordable Care Act requires learning about the new rules and systems families will need to navigate. As part of our ongoing efforts to explain the ACA, we will be posting regular articles. This one, written by Family Voices Health Information Specialist Emily McKinley, highlights several of the new provisions:

In March 2010, President Obama signed into law the Affordable Care Act (ACA), healthcare legislation meant to regulate healthcare and insurance while minimizing the number of Americans without or denied coverage. Additionally, the ACA, includes measures intended to improve the overall quality of healthcare while minimizing fraud, waste, and other sources of exorbitant costs. The legislation is quite extensive and is being implemented in a stepwise approach. Provisions of the law were enacted beginning in summer 2010, and new provisions will continue to take effect throughout 2015.


In 2010, twenty provisions of the law commenced. Those provisions included new consumer protections, such as prohibiting denial of coverage for children based upon pre-existing conditions and prohibiting insurance companies from rescinding coverage due to errors on the insured’s application paperwork. Additionally, the law served to eliminate lifetime limits on insurance coverage for essential benefits as well as place restrictions on annual insurance coverage limits.


2010 also ushered in quality improvement measures such as establishing an external appeals process through which the insured may contest coverage denials, and establishing that all new insurance plans cover specific preventative care services without charging a deductible, co-pay or coinsurance.

Measures intended to lower the costs of healthcare and insurance coverage included provisions that allow young adults up to 26 years of age to stay on their parents’ insurance plans as well as providing new pre-existing condition insurance plans, most of which are administered by individual states. Furthermore, provisions have been made to increase Medicaid coverage to serve more people, increase payments for rural healthcare providers and strengthen community health centers. These measures are all supported by additional funding, to include federal funds that match percentages of state contributions.


This year, provisions have been and continue to be introduced that target improving care and lowering costs, especially for senior adults. Perhaps the most relevant 2011 provision for families of children and youth with special health needs is increasing access to community and home based services for individuals who are disabled. This Community First Choice option will be funded through Medicaid, and it is effective October 1. The Community First Choice option will allow attendant services, to include assistance with activities of daily living, instrumental activities of daily living, and health-related tasks. Federal funds will provide a 6% match of state funds for the Community First Choice option.

2012 initiatives include cost-cutting measures, such as linking payment to quality outcomes and reducing paperwork and associated administrative costs. Additionally, there will be measures to more accurately understand and reduce health disparities based on race, ethics, and language. Consumers will have greater access to affordable care through a provision providing a voluntary long-term care insurance program, CLASS, which will provide cash benefits to adults who become disabled.

Important milestones for 2013 include quality improvement measures such as increasing access to preventative care. Funds will be made available to state Medicaid programs that cover certain preventative care services at no cost. Moreover, the law stipulates that as primary care physicians prepare to welcome more Medicaid patients in 2014, reimbursements for primary care services provided will be at a rate equal to the Medicaid rates for 2013 and 2014.


Also in 2013, the Children’s Health Insurance Program will be funded for an additional two years. CHIP provides an affordable insurance option for children who do not qualify for Medicaid.

Additionally, healthcare providers are being encouraged to implement billing bundling strategies. That is to say, healthcare systems are encouraged to negotiate and provide patients with a flat-rate bill for each episode of care vice multiple bills for each element of care, such as physician services, facility fees, surgical fees, and so on.

In 2014, some of the most significant ACA provisions will become effective. New consumer protections will prohibit insurance companies from discriminating on the basis of gender or pre-existing conditions when determining eligibility for new or renewal policies. Furthermore, insurance will be unable to charge higher premiums for individuals with pre-existing health conditions and concerns. The law goes further to stipulate that annual limits for insurance coverage will be eliminated on new and existing group plans. Also, a significant measure for families and individuals with special health needs is one that prevents insurers from dropping coverage when the insured opts to participate in clinical trials, including those for life-threatening diseases.

Several consumer cost-savings measures will also be introduced in 2014. One such provision is the introduction of tax credits for individuals who do not receive employer-sponsored insurance and with incomes between 100% and 400% of the federal poverty level (FPL) (approximately $88,000 for a family of four) to offset of the cost of insurance. These credits may be advanced in order to reduce monthly premium payments or may be received with a tax refund.


Also significant in 2014, will be the expansion of Medicaid such that those earning less than 133% FPL, will be eligible for Medicaid. Those not eligible for Medicaid will be required to purchase basic insurance coverage or pay a fee to offset coverage for the uninsured. Exemptions will be made for individuals who establish that affordable coverage is not available.

Finally, 2015 will usher in the last measure of the legislation. This measure aims to compensate a physician for quality of care rather than time taken to deliver those services.

As is evident, the Affordable Care Act is quite extensive and was designed to provide consumer protections, increase access to care, and improve the quality of care while reducing overall system and healthcare costs. Because the legislation is so extensive and includes many measures not outlined here, consumers are encouraged to learn more about the ACA and their rights regarding the legislation. For more information about the ACA, please visit: http://www.healthcare.gov/index.html. There consumers will find an interactive timeline, the full-text legislation, as well as information specific to families, children, seniors, and individuals with special healthcare needs.


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