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Healthcare Reform: Coverage, Services, Care


The Patient Protection and Affordable Care Act is a 906-page document on healthcare reform which outlines the type of coverage, preventive services and care that all Americans are entitled to receive going forward.  Several reforms have already taken place, while most others will be put into effect by 2014 or later.  The first reforms that took effect were the elimination of pre-existing conditions for children and youths under 19 years of age,  small business tax credits, expanded  health coverage for young adults, and help for Medicare beneficiaries when they reach the "donut hole."

Of particular interest to my family are expanded healthcare coverage for young adults and the elimination of pre-existing condition exclusions in new health insurance plans.  We were able to include our 23-year old son, whom we had to remove from our existing coverage when he turned 21, in our policy until he turns 26.  His employer did not offer health insurance, so consequently, he was left without coverage because he could not afford to purchase individual health insurance.  Likewise, we were relieved to know that my husband, who is very seriously ill, would not be denied health coverage should we need to change our insurance company after 2014.

The links below provide a few highlights and more information about healthcare reform enacted by President Obama in March 2010.

Patient Protection and Affordable Care Act, as passed by Congress, and signed by President Obama, March 23, 2010.
The Obameter: Require Insurance Companies to Cover Pre-Existing Conditions - Obama Promise #51



Health Insurance Marketplace - Information & Application


From HEALTHCARE.GOV - a Federal Government website managed by the US Dept. of Health and Human Services:




The Affordable Care Act Becomes Law
March 23, 2010

On March 23, 2010, President Obama signed the Affordable Care Act. The law puts in place comprehensive health insurance reforms that will roll out over four years and beyond, with most changes taking place by 2014. Others have already begun. Use this timeline to learn about what’s changing and when.

Changes to note:
    •    50% discount for name-brand drugs in the Medicare "donut hole"
    •    Expanded coverage for young adults
    •    Small business tax credits
    •    Pre-Existing Condition Insurance Plans

Insurance Protections for Children in the Affordable Care Act

Under the Affordable Care Act, health plans cannot limit or deny benefits or deny coverage for a child younger than age 19 simply because the child has a “pre-existing condition”—that is, a health problem that developed before the child applied to join the plan.

Some Important Details
This rule applies whether or not your child’s health problem or disability was discovered or treated before you applied for coverage.

The new rule doesn’t apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family (and is not a job-related health plan) on or before March 23, 2010 (the date that the new law was passed).
These protections will be extended to Americans of all ages starting in 2014.




Preventive Care and Services

If your plan is subject to these new requirements, you may not have to pay a copayment, co-insurance or deductible to receive recommended preventive health services, such as screenings, vaccinations and counseling.

For example, depending on your age, you may have access at no cost to preventive services such as:
    •    Blood pressure, diabetes, and cholesterol tests
    •    Many cancer screenings, including mammograms and colonoscopies
    •    Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression and reducing alcohol use
    •    Routine vaccinations against diseases such as measles, polio or meningitis
    •    Flu and pneumonia shots
    •    Counseling, screening, and vaccines to ensure healthy pregnancies
    •    Regular well-baby and well-child visits, from birth to age 21
Some Important Details
    •    This preventive services provision applies to people enrolled in job-related health plans or individual health insurance policies created after March 23, 2010. If you are in such a health plan, this provision will affect you as soon as your plan begins its first new “plan year” or “policy year” on or after September 23, 2010.
    •    If your plan is “grandfathered,” these benefits may not be available to you.
    •    If your health plan uses a network of providers, be aware that health plans are only required to provide these preventive services through an in-network provider. Your health plan may allow you to receive these services from an out-of-network provider, but may charge you a fee.
    •    Your doctor may provide a preventive service, such as a cholesterol screening test, as part of an office visit. Be aware that your plan can require you to pay some costs of the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit.
    •    If you have questions about whether these new provisions apply to your plan, contact your insurer or plan administrator.  If you still have questions, contact your State insurance department.
    •    To know which covered preventive services are right for you—based on your age, gender, and health status—ask your health care provider.



Prescription Drug Discounts
Effective January 1, 2011

Seniors who reach the coverage gap will receive a 50 percent discount when buying Medicare Part D covered brand-name prescription drugs. Over the next ten years, seniors will receive additional savings on brand-name and generic drugs until the coverage gap is closed in 2020.




Preventive Services Under Medicare

Starting January 1, 2011, you will pay nothing for many preventive services if you get the services from a doctor or other health care provider who accepts assignment. The services that qualify are listed below.

  • Yearly wellness exam. If you are new to Medicare, your “Welcome to Medicare” physical exam is now covered without cost sharing during your first 12 months of Part B coverage. This exam is a one-time review of your health as well as education and counseling about preventive services and other care.  If you’ve had Part B for longer than 12 months, you can get a yearly wellness visit to develop or update a personalized prevention plan based on your current health and risk factors.
  • Tobacco use cessation counseling. This benefit is now considered a covered preventive service, whether or not you have been diagnosed with an illness caused or complicated by tobacco use.  While still a covered service, the coinsurance and deductible will apply if you have already been diagnosed with a tobacco related illness.
  • No more Medicare Part B deductible or copayment for these screenings if certain coverage criteria apply:
  • Bone mass measurement
  • Cervical cancer screening, including Pap smear tests and pelvic exams.
  • Cholesterol and other cardiovascular screenings
  • Colorectal cancer screening (except for barium enemas.)
  • Diabetes screening
  • Flu shot, pneumonia shot, and the hepatitis B shot
  • HIV screening for people at increased risk or who ask for the test
  • Mammograms
  • Medical nutrition therapy to help people manage diabetes or kidney disease.
  • Prostate cancer screening (except digital rectal examinations.)

Some Important Details

  • For some preventive services, you will pay nothing. You may have to pay co-insurance (a part of the cost) for the office visit when you get these services.
  • Your first yearly wellness exam can’t take place within 12 months of your “Welcome to Medicare” physical exam.
  • If you’re in a Medicare Advantage Plan, check with your plan to see if these benefits will also be free for you.



Allowing States to Cover More People on Medicaid

Effective April 1, 2010

States will be able to receive federal matching funds for covering some additional low-income individuals and families under Medicaid for whom federal funds were not previously available. This will make it easier for states that choose to do so to cover more of their residents.
Learn more about Medicaid




Expanding Coverage for Early Retirees 

Applications for employers to participate in the program available June 1, 2010. Learn more about the Early Retiree Reinsurance Program.

Too often, Americans who retire without employer-sponsored insurance and before they are eligible for Medicare see their life savings disappear because of high rates in the individual market. To preserve employer coverage for early retirees until more affordable coverage is available through the new Exchanges by 2014, the new law creates a $5 billion program to provide needed financial help for employment-based plans to continue to provide valuable coverage to people who retire between the ages of 55 and 65, as well as their spouses and dependents.

For more information on the Early Retiree Reinsurance Program, visit



Provisions of the Affordable Care Act, By Year
2010   2011   2012   2013   2014   2015 

Consumer Protections: Patient’s Bill of Rights

Because of health care reform, insurance companies:
    •    Can no longer deny coverage to children younger than 19 because of a pre-existing condition (Protection for adults will go into effect in 2014).
    •    Can’t take away your coverage based on an unintentional mistake you or your employer made on an application (also known as rescission of health coverage.).
    •    Must allow most children up to age 26 to stay on or be added to their parents’ family health plan.
    •    Must stop putting lifetime dollar limits on coverage (annual dollar limits are being phased out between now and 2014.)
    •    Must provide consumers their choice of any available primary care doctor or pediatrician in a plan’s network.
    •    Must ensure access to out-of-network emergency care without prior authorization or higher cost sharing that would otherwise be charged.
    •    Must meet certain basic standards when they review a consumer’s appeal of a denied claim. (The law also strengthens consumers’ rights to an independent “external” review when an insurer’s “internal review” upholds a claims denial.)
For most consumers, these protections kicked in sometime over the past few months at the start of a new plan or policy year. (Some plans in place when the Affordable Care Act was passed in March 2010 were “grandfathered” or exempt from some – but not all provisions. Always check with your plan or employer to find out if your plan is grandfathered.)


An Act
Entitled The Patient Protection and Affordable Care Act.
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
(a) SHORT TITLE.—This Act may be cited as the ‘‘Patient Protec-
tion and Affordable Care Act’’.
(b) TABLE OF CONTENTS.—The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents.
Subtitle A—Immediate Improvements in Health Care Coverage for All Americans
Sec. 1001. Amendments to the Public Health Service Act.
‘‘Sec. 2711. No lifetime or annual limits.
‘‘Sec. 2712. Prohibition on rescissions.
‘‘Sec. 2713. Coverage of preventive health services.
‘‘Sec. 2714. Extension of dependent coverage.
‘‘Sec. 2715. Development and utilization of uniform explanation of coverage
documents and standardized definitions.
‘‘Sec. 2716. Prohibition of discrimination based on salary.
‘‘Sec. 2717. Ensuring the quality of care.
‘‘Sec. 2718. Bringing down the cost of health care coverage.
‘‘Sec. 2719. Appeals process.
Sec. 1002. Health insurance consumer information.
Sec. 1003. Ensuring that consumers get value for their dollars.
Sec. 1004. Effective dates.
Subtitle B—Immediate Actions to Preserve and Expand Coverage
Sec. 1101. Immediate access to insurance for uninsured individuals with a pre-
existing condition.
Sec. 1102. Reinsurance for early retirees.
Sec. 1103. Immediate information that allows consumers to identify affordable cov-
erage options.
Sec. 1104. Administrative simplification.
Sec. 1105. Effective date.
Subtitle C—Quality Health Insurance Coverage for All Americans
Sec. 1201. Amendment to the Public Health Service Act.
‘‘Sec. 2704. Prohibition of preexisting condition exclusions or other discrimina-
tion based on health status.
‘‘Sec. 2701. Fair health insurance premiums.
‘‘Sec. 2702. Guaranteed availability of coverage.

H.R. 3590—2
‘‘Sec. 2703. Guaranteed renewability of coverage.
‘‘Sec. 2705. Prohibiting discrimination against individual participants and
beneficiaries based on health status.
‘‘Sec. 2706. Non-discrimination in health care.
‘‘Sec. 2707. Comprehensive health insurance coverage.
‘‘Sec. 2708. Prohibition on excessive waiting periods.
Sec. 1251. Preservation of right to maintain existing coverage.
Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers and
group health plans.
Sec. 1253. Effective dates.



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