Show notes
For this episode, I read the entire Patient Protection and Affordable Care Act. The following is a resource for finding information within the Patient Protection and Affordable Care Act. My goal was to highlight the portions of the bill that will most directly affect our lives and put them into plain, understandable English. I'd also like for you to be able to find the text that makes these rules within the bill. The easiest way to search within a bill is by section number. You'll have to read a bit to find exactly what you're looking for, but this outline will tell you which section you can find the different provisions in. Anything "in quotes" is exact text from the bill. There are two versions of the Patient Protection and Affordable Care Act (Public Law 111-148) you can read. This version is 906 pages. This version is 2,409 pages (the margins and the font are bigger). If you are going to attempt to read the Patient Protection and Affordable Care Act, you must know that Title X amends the first nine titles and The Reconciliation Act amended the whole bill. This means that the law is often not what the text says. Here is a section by section summary of the changes made by Title 10 and the Reconciliation Act. This document was provided to the United States Senate for clarification. TITLE I: "QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS Subtitle A: "Immediate Improvements in Health Care Coverage for All Americans" Section 1001: Rules on health insurance minimums that became effective immediately Insurance company can't drop you when you get sick, unless you committed fraud Health insurance plans have to provide - at no extra charge: All of the preventatives services on this list Immunizations Preventative care screenings for kids Kids can stay on their parent's insurance plans until their 26th birthday Insurance companies must cover at least 60% of medical payments The health insurance companies need to provide customers with a summary of benefits, which can only be 4 pages long with a minimum of 12-pt font and must include limitations, co-payments, deductibles, and percentage of medical costs covered by the insurance company. If they fail to provide the summary, the health insurer has to pay $1,000 for each customer who didn't receive it Employers are not allowed to only offer coverage to their high-paid employees Section 1001 as changed by amendment (See Section 10101): No lifetime limits or "unreasonable annual limits" on the value of benefits for any customer They can place limits on things that are not essential health benefits Gun ownership health dangers must be ignored: Prevention programs can not collect information related to the presence of guns or ammunition in someone's home Premium rates can not be affected by the presence of a gun in someone's home Medical Loss Ratio Health insurance companies covering large groups must spend 85% of your premiums on you, or they have to issue a rebate check. Health insurance companies covering people in the individual market or small groups through exchanges have to spend 80% of your premiums on you or issue a rebate check. Hospitals must publish a list of standard charges for their services. Health insurance companies have to let you go to any primary care doctor that you choose and who can accept you The insurance company must have an appeals process for customers and must continue coverage while claims are in appeals If you get treatment in an out-of-network emergency room, your health insurance has to pay for those services. Health insurance companies can't require prior approval for emergency services. Health insurance companies can not require advance approval to go to get gynecological services. Section 1003: Premium Increase Reviews The Federal government and the States will review annual premium increases. States can recommend that a health insurance company be excluded from the exchange for unjustified premium increases. Subtitle B: "Immediate Actions to Preserve and Expand Coverage" Section 1101: Creates the "high risk health insurance pool program" to cover people with pre-existing conditions until January 1, 2014 Could only be run by non-profit private insurers or States Insurer had to cover at least 65% of customer's medical costs Could vary premiums based on age no more than a 4:1 ratio Only open to United States citizens or lawful residents who had no health insurance for the 6 months prior to enrollment Provided $5 billion (this money ran out & the government stopped accepting new applicants on February 15, 2013 - the House Republicans would have added money only if the Public Health fund were defunded, as explained in episode CD026) High risk pool ends on January 1, 2014 and customers will then buy their insurance on the exchanges, when health insurers will not be allowed to deny them coverage anymore Section 1102: Reimbursement for employers who give health coverage to "early retirees" Employers who provide health insurance to people over 55 years old but under 65 (when Medicare kicks in) will be reimbursed for a portion of that expense. Payments will be 80% of the amount over $15,000 up to $90,000. Payments must be used for health care expenses & can not be used as general revenue or count as income. Provided $5 billion for this program Program ends on January 1, 2014, when everyone can buy insurance on the exchanges Section 1104: Orders the Secretary of Health & Human Services to develop "uniform standards" for health information electronic data entry The rules will be for communication between hospitals/doctors and the health insurance companies. Allows for the creation of "machine readable identification cards" Penalty fee will be assessed beginning on April 1, 2014 for health insurance companies that don't comply Fee is $1 per customer covered until they've completed the electronic information requirements. The fee is imposed for each day the plan is not in compliance. The fee is increased annually and capped at $20 per customer or $40 per customer if the insurance company purposely provides false or incomplete information. Penalty fees are paid to the Treasury Department and are due November 1 of each year starting in 2014. Subtitle C: "Quality Health Insurance Coverage for All Americans" Section 1201: Health Insurance Market Reforms Health insurance companies can not exclude someone for having a pre-existing condition This law became effective for children starting six months after the Affordable Care Act was signed Premium rates are allowed to vary based on the following factors only: The number of people covered by the plan (individual or family) Location Age, but the rate can not vary more than a 3:1 ratio for adults Tobacco use, but the rate can not vary more than a 1.5:1 ratio Health insurance companies must accept every employer or individual customer who applies for coverage during their open enrollment periods. Health insurance companies can not deny a customer coverage due to health status, mental or physical illnesses, history of claims, medical history, genetic information, domestic violence history, disability, or any other health-related factor. Health insurance companies also have to renew your insurance policy Health insurance companies can offer rebates or premium discounts as a reward to customers' participation in wellness programs including: Reimbursement for fitness center memberships A disease testing program that does not base the reward on outcomes Waiving co-payments or deductibles for preventative care visits (prenatal care & well-baby visits) Reimbursement for programs that help people quit smoking, regardless of whether or not they can actually quit A reward for attending health education seminars Waiting periods can not be longer than 90 days This does not apply to the individual market (added by Section 10103) Section 1201 as changed by amendment (See Section 10103) Health insurance companies can't deny coverage for approved clinical trials for treatment of cancer or another life-threatening disease. Section 1251: Grandfathered health care plans Nothing in the Affordable Care Act forces an individual to cancel the coverage they currently have. Grandfathered plans are exempt from the provisions of Subtitle A and Subtitle C, except for the provisions specifically listed below. New employees and their families can be enrolled in health plans that existed before the Affordable Care Act was enacted. Section 1251 as changed by amendment (See Section 10103) Grandfathered plans must provide the easily understood summary of benefits from Section 1001 to their customers. Grandfathered plans must issue rebate checks under the Medical Loss Ratio just like new plans Health insurance companies covering large groups must spend 85% of your premiums on you, or they have to issue a rebate check. Health insurance companies covering people in the individual market or small groups through exchanges have to spend 80% of your premiums on you or issue a rebate check. Section 1251 as changed by the Reconciliation Act (See Public Law 111-152) Grandfathered plans are prohibited from enforcing waiting periods over 30 days. Grandfathered plans are prohibited from enforcing lifetime or annual limits to coverage (group plans only). Grandfathered plans can not drop you when you get sick. Grandfathered plans will also have to cover children until their 26th birthday. Grandfathered plans can not refuse an employee with pre-existing conditions. Subtitle D: "Available Coverage Choices for All Americans" Section 1302: Essential Health Benefits Requirements Essential health benefits to be included in all "qualified health plans": Ambulances Emergency room services Hospitalizations Maternity and newborn care Mental health Substance abuse treatment Behavioral health treatment Prescription drugs Rehabilitation services and devices Laboratory services Preventative care Chronic disease management Pediatric care, including dental and vision Health insurance companies are allowed to cover more than these minimums Coverage for emergency services can not require prior authorization Health insurance companies can't limit coverage because the ambulance took you to an out-of-network emergency room Out of pocket expense caps In 2014, an individual can not be charged more than $5,000/year for out-of-pocket expenses (not including premiums); after that, it can be increased by the same percentage as premium increases. Deductibles for employer-paid plans are capped at $2,000/year for individuals or $4,000/year for family plans. After 2014, these numbers can be increased by the same percentage as premium increases. Out-of-pocket caps do not include amounts for non-network providers or non-covered services Levels of Coverage Bronze: Covers 60% of medical costs Silver: Covers 70% of medical costs Gold: Covers 80% of medical costs Platinum: Covers 90% of medical costs Catastrophic Coverage available only on the individual market Plan provides no benefits until the person has spent the $5,000/year out-of-pocket limit (or whatever the limit is for that year, adjusted for inflation) Available only to people under 30 years old Available only if a monthly premium would exceed 8% of that person's income Section 1303 as changed by amendment (See Section 10104): Abortion Rules States can prohibit abortions from being offered by health insurance plans offered through the exchange. States must pass a law to do this. Health insurance plans do not need to include abortions. No Federal funds can be used to pay for abortions. No hospital or doctor's office can be discriminated against by insurance companies for not providing abortions. Section 1311: Health Insurance Exchanges States will be given Federal grants to set up their own health insurance exchanges, which are websites where people will compare and purchase their insurance plans. Grants will stop being awarded on January 1, 2015. Exchanges will include an "enrollee" satisfaction system for plans covering more than 500 people. Secretary must determine yearly open enrollment periods Stand-alone dental plans will be allowed on the exchanges. States are allowed to require more benefits than the Federal government requires, but must make up cost to individuals for extra costs if they're eligible for a tax credit. By 2015, exchanges must be self-sustaining and can charge user fees. Exchanges have to publish all payments required by the Exchange & the administrative costs. Interstate and regional exchanges are allowed. Creates "navigator" positions They will inform the public on the health plans, help people enroll, and help people understand their tax credits. Navigators are not allowed be employees of the health insurance industry Section 1311 as changed by amendments (See Section 10104) Health insurance companies need to publicly disclose - in plain language - information on claims payment policies, enrollment, denials, out-of-network charges, and customer rights. Section 1312: Health Insurance Eligibility & Members of Congress All customers in with a company's individual plan will be considered part of a one risk pool. All customers enrolled as employees of small businesses will be considered part of one risk pool. The individual and small business pools may be merged if the State determines it appropriate. Starting in 2017, States can permit large employers (over 101 employees) to offer insurance through the Exchange. Health insurance companies can offer insurance outside of the Exchanges. Only United States citizens and lawfully present foreigners will be allowed to purchase health insurance on the Exchange. Prisoners will not be eligible to buy insurance on Exchanges while they're still incarcerated The Federal Government can only offer health plans to members of Congress that are offered through an Exchange. Section 1312 as changed by amendment (See Section 10104) Agents and brokers are allowed to enroll employers and individuals in health insurance plans and help them apply for tax credits and out-of-pocket reductions. Section 1321: States Must Create Exchanges or Federal Government Will Do It For Them Department of Health and Human Services will provide an exchange for a State if the State will not have it's own operational by January 1, 2014. Section 1322: Grants for Creation of Non-Profit, Member-Run Health Insurance Companies The goal is to have at least one non-profit, member-run health insurance company in each State offer insurance on the individual and small business exchanges. If a State doesn't have a non-profit, member-run option, they will be loaned money to create one or to have one from elsewhere expand into their State. The loan must be repaid within 15 years (added by Section 10104) The non-profit, member-run health insurance companies are not allowed to use Federal funds for marketing. A health insurance company will not count as a non-profit, member-run insurance company unless "any profits made by the organization are required to be used to lower premiums, to improve benefits, or for other programs intended to improve the quality of health care delivered to its members." Non-profit, member-run health insurance companies will be tax exempt. Section 1323: Optional State Public Option (Killed by amendment: See Section 10104) States are allowed to offer a public option, labeled "community health insurance", but they are not required to. Section 1331: States Can Buy Insurance for Low-Income People Who Don't Qualify for Medicaid or Medicare To qualify for this program, if offered by your State: Must be a resident of the offering State Must be under 65 years old Your income needs to be between 13…
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