Patient Protection and Affordable Care Act
Obamacare Health Care Reform

Main Features of PP-ACA – Health Reform

• Peter Lee of Covered CA on what’s next for ACA 4.2022  Listen  *  Read
• Guaranteed Issue and NO Pre Existing Condition Clause!  ^{PHSA 2704 (a), 42 USC 300 gg IRC 9815 ERISA 715national underwriter.com Health Reform Facts Q & A 252}
• 2014 – Requirement to have Health Insurance – CA Mandate 
  Require U.S. citizens and legal residents – Federal Mandate no longer in effect, but CA has one – to have qualifying health coverage (phase-in tax penalty for those without coverage).
  An insurance-less person would have to pony up whichever is greater: $695 for each uninsured family member, up to a maximum of $2,085; or 2.5 percent of household income. ^{(Christian Science Monitor,  Section 1501, 5000A,  HR 3590 Page 124,   Section 1002 HR 4872 Page 4)}
  Constitutionality?
• Government Subsidy & CA Premium calculator
  
• SMALL BUSINESS TAX CREDITS
  Offers tax credits to small businesses to make employee coverage more affordable.  Tax credits of up to 35 percent of premiums will be available to firms that choose to offer coverage.  Effective beginning calendar year 2010.  (Beginning in 2014, the small business tax credits will cover 50 percent of premiums.)  This is in addition to IRS Section 106
  • individual.tax.credit.36BFactSheet
• NO DISCRIMINATION AGAINST CHILDREN under 19 WITH PRE-EXISTING CONDITIONS—Prohibits new health plans in all markets plus grandfathered group health plans from denying coverage to children with pre-existing conditions.  Effective 6 months after enactment.  (Beginning in 2014, this prohibition would apply to all persons.) ^{CA Assembly Bill 2244}
• HELP FOR UNINSURED AMERICANS WITH PRE-EXISTING CONDITIONS UNTIL EXCHANGE IS AVAILABLE (INTERIM HIGH-RISK POOL)—
  • Provides access to affordable insurance for Americans who are uninsured because of a pre-existing condition through a temporary subsidized high-risk pool.  Effective in 2010.
    National Conference of State Legislatures
    Choice Administrators on Exchanges
    Christian Science Monitor
    Our Website for information quotes
    Individuals & Families
    Employer Groups 2 – 50
• ENDS RESCISSIONS—Bans insurance companies from dropping people from coverage when they get sick.  Effective 6 months after enactment.
  • Blue Cross FAQ’s
    Blue Cross FAQ’s for Small Employer Groups
    AB 2470 De La Torre 2010
• BEGINS TO CLOSE THE MEDICARE PART D DONUT HOLE—Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010.  Effective for calendar year 2010.  (Beginning in 2011, institutes a 50% discount on prescription drugs in the donut hole; also completely closes the donut hole by 2020.)
• FREE PREVENTIVE CARE UNDER MEDICARE
  • —Eliminates co-payments for preventive services and exempts preventive services from deductibles under the Medicare program.  Effective beginning January 1, 2011.
• EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS’ INSURANCE
  • —Requires new health plans and certain grandfathered plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice.  Effective 6 months after enactment.
• HELP FOR EARLY RETIREES—Creates a temporary re-insurance program (until the Exchanges are available) to help offset the costs of expensive premiums for employers and retirees for health benefits for retirees age 55-64.  Effective in 2010.
• BANS LIFETIME LIMITS ON COVERAGE—
  • Prohibits health insurance companies from placing lifetime caps on coverage.  Effective 6 months after enactment. ^{health care.gov Blue Cross Flyer HHS Memo 12/9/2010}
  • Los Angeles Times $21m claim to Medi-Cal poses huge challenge 7.17.2017
• BANS RESTRICTIVE ANNUAL LIMITS ON COVERAGE
  • —Tightly restricts the use of annual limits to ensure access to needed care in all new plans and grandfathered group health plans.  (Beginning in 2014, the use of any annual limits would be prohibited for all new plans and grandfathered group health plans.) ^{health care.gov  * Blue Shield – info – NOTE definition of Essential Benefits Blue Cross Flyer}
• Mandated 10 Essential Benefits  California has even more
• FREE PREVENTIVE CARE UNDER NEW PRIVATE PLANS—Requires new private plans to cover preventive services with no co-payments and with preventive services being exempt from deductibles.
  
• NEW, INDEPENDENT APPEALS PROCESS—Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan.  Effective 6 months after enactment.
• ENSURES VALUE FOR PREMIUM PAYMENTS—Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent.
  
• COMMUNITY HEALTH CENTERS—Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years.  Effective beginning in fiscal year 2011.
• INCREASES THE NUMBER OF PRIMARY CARE PRACTITIONERS—Provides new investments to increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, and physician assistants.  Effective beginning in fiscal year 2011.
• PROHIBITS DISCRIMINATION BASED ON SALARY
• —Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees.  Effective 6 months after enactment.
  • FAQ’s BC/BS
    Management Carve Out
    Page 17 Section 2716 HR 3590
• HEALTH INSURANCE CONSUMER INFORMATION (Web Portal)—Provides aid to states in establishing offices of health insurance consumer assistance in order to help individuals with the filing of complaints and appeals. Effective beginning in fiscal year 2010.
  • Section 2793 Page 20 HR 3590
    More info on Web Portals Health Care.gov
• HOLDS INSURANCE COMPANIES ACCOUNTABLE FOR UNREASONABLE RATE HIKES
  • —Creates a grant program to support States in requiring health insurance companies to submit justification for all requested premium increases, and insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new Health Insurance Exchanges.  Starting in plan year 2011.
    Rate Review SB 1163
  • 80% Medical Loss Ratio (MLR) – Actuarial Value
  • CA Insurance Rate Regulation
  • Premium increases? Why are they always going up?
  • Financial Impact of Health Care Reform on Premiums
• Grandfathering Exemption

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Health Reform Guide

FAQ’s 11/20101.2011

• Employer Group Changes  – ACA/Obama Care

  • Kaiser Health Care Reform 34 pages  Rev 4.2013
  • UNUM Guide to Health Care Reform Rev 4.2013
  • Blue Shield Info on EmployER Responsibilities
  • Blue Shield FAQ’s 6.2013
  • More info on Small Group Definitions vs. Large Group
  • Aetna Website
  • 3/2012 Generic Summary
  •  
  • Health Reform in a Nutshell
  • 
  • UHC 2013 Guide 
• HELP FOR EARLY RETIREES—The new Early Retiree Reinsurance Program is a temporary program that will provide reimbursement to participating employers with 51 or more covered employees for a portion of the cost of health coverage to early retirees. To participate, the plan must provide coverage for retired employees who are 55-64 years of age who are not eligible for Medicare.
  •  Early Retiree Reinsurance Program *  FAQ’s
  •  Fact Sheet HCTC Health Coverage Tax Credit Regulations
  • Blue Shield FAQ’s Program Regulations Fact Sheet checklist
  •  Application instructions regulations
  • Aetna’s Website

Resources on the New Health Reform Law

• Private Health Insurance Provisions in the Patient Protection and Affordable Care Act (PPACA) ^{Congressional Research Service}
• ^{PPACA/Health Care Reform_What’s Next_050213.webinare}
• Obama Care Facts.com