Patient Protection and Affordable Care Act (PPACA, P.L. 111-148), as amended by §1003 of the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152).
What is the requirement to offer coverage?, Employers are not required to provide coverage. Instead, large employers face penalties for choosing not to provide health insurance to their employees and dependents of their employees., Plans must include “essential health benefits.”, Some plans that do not meet the requirement because essential health benefits are not included:, Example: coverage only for accident, or disability income insurance, Example: coverage issued as a supplement to liability insurance, Example: coverage issued as a supplement to liability insurance, Example: liability insurance, including general liability insurance and automobile liability insurance, Example: workers’ compensation or similar insurance, There are 10 "essential health benefits" outlined in the law:, (1) Ambulatory patient services., (2) Emergency services., (3) Hospitalization., (4) Maternity and newborn care., (5) Mental health and substance use disorder services, including behavioral health treatment., (6) Prescription drugs., (7) Rehabilitative and habilitative services and devices., (8) Laboratory services., (9) Preventive and wellness services and chronic disease management., (10) Pediatric services, including oral and vision care.
Employers must provide notice to employees about certain aspects of the health insurance plan., Employers must give notice of:, an Exchange, the availability of a tax credit for premium assistance, the loss of an employer's contribution to an employer-provided health benefit plan if the employee purchases a plan through an Exchange.
Employers who do not comply with the law will be subject to a fine. The fine is based on whether the employer offers health insurance to the workforce, whether it is accessible, and whether the insurance is affordable., Does the employer offer health insurance to full time employees?, The employer does not offer health insurance., The employer will pay a fine for not offering coverage if:, The employer fails to offer their full-time employees and their dependents the opportunity to enroll in minimum essential coverage, AND, At least one full time employee receives a tax credit or a cost sharing subsidy for paying their health care costs on an Exchange., The employer does offer health insurance., The employer will pay a penalty for not offering affordable coverage if:, Employees have to pay more then 9.5% of their family income for the employer coverage, The employer pays less then 60% of covered health care expenses, The employer has a waiting period for enrollment of more than 60 days.
Employers must report certain information regarding the health insurance coverage provided to their full-time employees., (1) whether such employers provide their full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employer-sponsored plan., (2) the length of any waiting period for such coverage., (3) the months during which such coverage was available., (4) the monthly premium for the lowest cost option in each of the enrollment categories under the plan., (5) the employer's share of the total allowed costs of benefits provided under the plan., (6) identifying information about the employer and full-time employees.
The size of the employer and the amount of average annual wages paid to its workforce determine whether a business is exempt from any provision of the law and what benefits are available., Fewer than 25 full time equivalent employees and average annual wages of less than $50,000., The Small Business Tax Credit, Allows qualified small employers to elect, beginning in 2010, a tax credit for 50% of their employee health care coverage expenses., A business with fewer then 50 full time equivalent employees will not be subject to the penalty., Businesses with fewer the 100 employees may participate in state-based exchanges that make it easier to find high quality coverage and compare prices.
Patient Protection And Affordable Care Act, Pl 111-148, § 1501, 10106, 124 Stat 119 (2010)
The individual mandate requires individuals to maintain basic health care coverage beginning in 2014., What is the coverage requirement?, There are 10 "essential health benefits" outlined in the law:, (1) Ambulatory patient services., (2) Emergency services., (3) Hospitalization., (4) Maternity and newborn care., (5) Mental health and substance use disorder services, including behavioral health treatment., (6) Prescription drugs., (7) Rehabilitative and habilitative services and devices., (8) Laboratory services., (9) Preventive and wellness services and chronic disease management., (10) Pediatric services, including oral and vision care., Penalty, Individuals who do not purchase health insurance for themselves and/or their dependents will face a tax penalty., In 2014, the penalty is $95, In 2015, the penalty is $350, In 2016, the penalty will be $750, Exceptions, Some individuals have been excepted from the individual mandate. This means they will not be penalized for being without insurance., Individuals who are part of a religious group opposed to acceptance of benefits from a health insurance policy., Undocumented immigrants., Incarcerated persons., Members of an Indian Tribe., Family income below $9,350 for individuals or $18, 700 for a family., Individuals who would pay more than 8% of their family income for health insurance., Individuals who are insured through another source or combination of sources automatically satisfy the individual mandate., Medicare, Tricare, An employer plan, The veteran's health plan, A grandfathered plan, Other insurance that the pays for., PATIENT PROTECTION AND AFFORDABLE CARE ACT, PL 111-148, March 23, 2010, 124 Stat 119, Grandfathered Plans, Healthcare consumers can keep the coverage they had before the law went into effect. These "grandfathered" plans are required to comply with the uniform coverage and medical loss provisions by 2014.
Premium and Cost Sharing Subsidies, Eligibility, Families with incomes at or below 400% poverty level., Families in this bracket are eligible for premium subsidies that will limit their cost for premiums to 2 - 9% of income., Individuals with incomes between 100 - 250% of the poverty level., Individuals in this bracket are eligible for cost-sharing subsidies to limit out-of-pocket costs.
Care For Dependents, Requires health plans to make coverage available for an unmarried, adult child until age 26.
Preventative Care, The law requires preventive services be provided with no cost sharing for consumers., Screening and Counseling, Diabetes, Depression, Obesity, Cancer, HIV, Sexually transmitted infections, Tobacco use, Healthy eating, Cholesterol, Routine Immunizations, Childhood Preventive Services, Preventive Services for Women
Medicaid, Medicaid coverage is extended to individuals under age 65 who have incomes at or below 133% of the federal poverty line.
Insurers may not restrict coverage based on:, any preexisting condition exclusion, Insurance companies are prohibited from denying coverage to children under the age of 19 due to a pre-existing condition. (As of September 23, 2010), insurance companies will be prohibited from refusing to sell coverage or renew policies to adults because of pre-existing medical conditions. (Effective beginning 2014), any health status-related factor., Examples:, genetic information, evidence of insurability, claims experience, Annual limitations on the dollar value of benefits, lifetime limits on the dollar value of benefits
Health plans retain the right to discriminate based on other factors:, Age, Geographic Area, Tobacco Use, Number of Family members., fraud or intentional misrepresentation of material fact
State health plans are required to: (1) accept every employer and individual in the state that applies for coverage; and (2) renew or continue coverage at the option of the plan sponsor or the individual, as applicable.
Minimum essential health services, What are the minimum essential health services?, (1) Ambulatory patient services., (2) Emergency services., (3) Hospitalization., (4) Maternity and newborn care., (5) Mental health and substance use disorder services, including behavioral health treatment., (6) Prescription drugs., (7) Rehabilitative and habilitative services and devices., (8) Laboratory services., (9) Preventive and wellness services and chronic disease management., (10) Pediatric services, including oral and vision care.
Additional services, Coverage for young adults up to age 26., Wellness Programs, Coverage for emergency services
Link to the full text of the Patient Protection and Affordable Care Act: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf#page=173
States will create the American Health Benefit Exchanges, Consumer health exchanges will allow individuals to purchase health insurance., Eligibility, Legal immigrants, U.S. citizens, Assistance, Individuals will have access to premium and cost charing subsidies to make costs more affordable, Small business health benefit exchanges will allow employers to purchase insurance, Eligibility, Businesses with up to 100 employees, What is an Exchange?, A government agency or nonprofit entity., Offers qualified health plans and rates each plan in the exchange based on quality and price, Certifies health plan premiums and increases in premiums, Implements procedures to certify health plans
Federal Employees, There will not be a public plan option. Instead, public employees will purchase insurance through health benefit exchanges developed by the Office of Personnel Management, At least two multi-state plans will be developed to provide coverage for federal employees., The government will fund non-profit, member-run insurance co-ops in each state
Creating standards and guidelines for Health Benefit Exchanges., The Secretary of Health and Human Services will develop reporting requirements for health plans., Health plans will report premium increases, plan details, and outcome measures as described in the law., The Secretary of Health and Human Services will create standards for advertisements directed to consumers.
Consumer websites, The Secretary of Health and Human Services will develop websites where consumers and businesses in each state can find affordable health insurance.
High Risk Insurance Pools, High risk insurance pools provide coverage to individuals with a preexisting condition until 2014.