Reading through the entire 906-page health care reform bill — formally known as The Patient Protection and Affordable Care Act — is possible, as it’s posted on the Internet (http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf).
But to save time, we focus on the provisions most important for those who are working or seeking work, as well as for those in cancer treatment or recovery. They’re grouped, for simplicity, into three categories:
- Benefits and services
- New rules for insurance companies
- New routes for workers to obtain coverage
Benefits and Services
All new health plans sold on or after September 23, 2010, must cover certain preventive health services--such as mammograms, flu shots, colonoscopies and cholesterol checks — without charging a co-pay or deductible or other cost-sharing. For a complete list of the covered services, visit www.healthcare.gov/what-are-my-preventive-care-benefits/
As of September 23, 2010, you now have a way to appeal insurance company coverage determinations — as well as claims. An external review process is now set up. Those enrolled in a health plan must get a notice about available internal and external appeals processes and be told of the availability of assistance to help complete the process. For more information on appeals, visit www.healthcare.gov/how-do-i-appeal-a-health-insurance-companys-decision/
New Rules for Insurance Companies
Rescinding Coverage Prohibited:
In the past, if you made an error or a technical goof on your application for insurance, the insurance company could use this against you to deny payment once you had a claim. This practice is illegal, effective September 23, 2010. The practice came to light after reports in the media described women with breast cancer losing coverage due to these application errors.
Restrictions and Bans on Coverage Limits:
As of January 1, 2014, health insurance companies can’t impose lifetime or annual dollar limits on benefits deemed essential, such as hospital stays.
Tougher Rules on Rate Hikes:
States are being encouraged to set up programs requiring their insurance companies to justify their premium increase requests. States that do this will be eligible for $250 million in new grants. Those companies that have excessive or unjustified rate hikes may be excluded from participating in state Health Insurance Marketplaces.
New Rules on Insurance Company Spending:
At least 85% of the premiums collected by insurance companies for large employer plans have to be spent on health care services and quality improvement, under the new law. For small employers and individual plans, companies have to spend at least 80% of the premiums on quality improvement and benefits. The penalty? If companies don’t do this, they have to give rebates to consumers, beginning January 1, 2011.
New Routes, Rules for Workers to Obtain Coverage
Help for Those with Pre-Existing Conditions:
As of January 1, 2014, health insurance companies cannot deny selling someone a policy based on a pre-existing condition. Furthermore, health insurance companies can only look at four factors when determining premiums:
- Are you purchasing an individual or family policy
- Geographic area
- Tobacco use (in most states)
Buying Insurance from the Marketplaces:
Beginning in 2014, you can buy insurance from a Health Insurance Marketplace if your employer doesn’t offer it. The marketplaces are designed to offer a choice of competitive health plans that must meet certain benefits and cost standards and be affordable. Each state has a Health Insurance Marketplace. Some are being run by the state, some by the federal government, and some in a partnership between the state and federal government. For more information about the Marketplace in your state, visit healthcare.gov.
There may also be financial assistance available to you to purchase health insurance in the Marketplace. Individuals with incomes between 133% and 400% of the Federal Poverty Level (in 2013, approximately $15,858–$46,680) may be eligible for a new kind of tax credit to help buy private health insurance coverage. Once you enroll in a qualified health plan, you can control how much of your tax credit you want to use to help pay your monthly health plan premiums. The tax credit is sent directly to your insurance company and applied to your premium, so you pay less out of your own pocket. The amount of tax credit you are eligible for depends on how much income you or your family earns. For an estimate of the amount of financial assistance you may be eligible for, use The Kaiser Family Foundation’s Subsidy Calculator.
As of January 1, 2014, everyone who can afford basic health insurance must obtain it; the alternative is to pay a fee to help offset the cost of care for Americans without insurance. Exception: If affordable coverage is not available, you will be eligible for an exemption.
To keep up with healthcare reform as it unfolds, check out www.healthcare.gov. And for a year by year look at the new provisions, go here www.hhs.gov/healthcare/facts-and-features/key-features-of-aca-by-year/index.html.