Health Care Reform Matrix
Health Care Reform Matrix
With your learning team, complete the Health Care Reform matrix below. Listed in this matrix are some of the topics addressed by the Patient Protection and Affordable Care Act policy. You are required to describe the issue, in your own words, and list 2-3 points about each topic under each heading in the matrix.
Describe the issue:
Key concerns regarding the issue:
How is this issue addressed in the current health care environment? How will this issue be addressed by the Patient Protection and Affordable Care Act?
Patient Bill of Rights
A newly implemented set of protections that apply to health coverage starting on or after September 23, 2010. The patient bill of rights was implemented to end common insurance abuses such as discrimination against children with preexisting conditions, ban on insurance companies dropping or limiting coverage for individuals in their utmost time of need, and coverage for preventive care. In the past insurance companies were known to deny coverage for people with preexisting conditions including children. Also in the past insurance companies were allowed to deny coverage for preventive treatments.
Currently in the health care environment insurance companies are no longer allowed to discriminate against children with preexisting conditions and are not allowed to deny or limit coverage. Individuals are now entitled to coverage regardless of their health status. The affordable care act has implemented the patient bill of rights which makes it mandatory for insurance companies to accept individuals and provide coverage regardless of their health status and regulates coverage for certain preventive testing mandatory such as cancer screening, immunizations and hearing and vision test for children and newborns
Medical Loss Ratio
Medical loss ratios are defined as when an insurance company spend a substantial portion of consumer premium dollars on administrative costs and profits including executive salaries and marketing. Lawmakers have raised some concerns about the MLR provisions, including the issue that insurers are not allowed to deduct insurance agent, broker and salary bonuses and commissions from their medical loss ratio expenses The ACA requires certain health insurers to provide consumer rebates if they do not meet a set financial target known as a medical loss ratio (MLR)
Beginning in 2011 all health insurers are required to publicly submit data reports detailing aggregated state level financial data as well as income from premiums and expenditures on health care claims quality improvement taxes licenses and regulatory fees under the ACA.
State-based Health Insurance Exchange
Online State Health Insurance comparison websites
A state can offer it’s own insurance or work with other states to establish regional insurance coverage exchanges People who are not able to obtain affordable insurance through their workplace, Medicaid or CHIP had the opportunity to purchase health insurance during open enrollment October 2013. 25 states out of the 50 united states have decided not to run an exchange for their specific state residents People who are not offered affordable insurance through their workplace must purchase coverage individually which can be quite expensive. Residents of states that do not offer specific insurance can explore coverage’s offered by regional exchanges The Act promises to give individuals health coverage by reforming the insurance markets and insurance. Individuals can compare and contrast coverage. Coverage will be of one of two packages, Family/Individual coverage and Small Business coverage.
Federally-facilitated Insurance Exchange
Federal government will have to be aware of insurance laws that are state specific Federally Facilitated exchanges do not have the option to regulate which health plans are purchased through the exchanges like states do States are allowed to decide which health plans they want to have participating in their exchange If plans out side of the federally facilitated exchanges offer coverage that is less-comprehensive and more affordable residents may choose to purchase that rather than the federal The National Committee for Quality Assurance use accrediting companies to determine which health plans are qualified Residents are able to chose which insurance provider they would like to purchase from if they chose to do so All health plans within the state will be allowed to participate in the Affordable Care Act It is projected that as sicker people begin to make more claims on coverage purchased through exchanges the price for coverage will increase
Consumer Assistance Programs
Consumer assistance programs under the Affordable Health Care Act were implemented to help and assist consumers with filing complaints, Appeals, as well as to assist consumers in enrollment in health care coverage, and educate consumers on the rights and responsibilities. Also by law data is collected on consumer inquiries and complain as well as problems to help identify concerns with in the marketplace and strengthen enforcement in a quality improvement
A ley concern with consumer assistance programs is the lack of adequate funding. Aside from the lack of adequate funding consumer assistance programs were put in place to address consumer complaints and concerns and assist consumer when enrolling in health care coverage, as this will be a fundamental necessity to expanding coverage to millions of Americans. new resources will help develop and expand programs to help consumers with health insurance questions and concerns consumer assistant programs vary from state to state but typically states are utilizing consumer assistance programs to help improve coverage expansion Future federal funding and the improvement of available resources can help states improve consumer assistance programs which deal with consumer complaints, enrollment concerns, and enrollment and coverage assistance
Pre-existing Condition Insurance Plan
A pre-existing condition is a health or medical condition that a patient has prior to having an active insurance policy. These conditions include but are not limited to: Heart problems, Cancer, Asthma, or Kidney disease. This plan also known as PCIP provides coverage for those patients with pre-existing conditions under a special plan. In the past patients have been denied medical insurance due to pre-existing conditions or received medical benefits but exclude pre-existing conditions. Therefore, patients have larger out of pocket costs for the medical care they really need.
Currently with the changes that are being done with the healthcare reform, insurance companies are not allowed to deny coverage to patients due to a pre-existing condition. However, there is an exception with grandfathered plans which don’t benefit the patients at all. PCIP was started to help those patients who need the coverage while the reform is fully enforced. PCIP was closed due to funding could not be guaranteed. However as of 2014 the exchange plans were opened to those who need it and provide coverage for pre-existing conditions. This allows patients to obtain coverage for their medical conditions without having to pay extra premiums or meet certain guidelines in order for medical services to be considered for payment.
Annual Limits Alisha
In the past many health coverage plans included a lifetime dollar limit or annual limit that the healthcare plan would cover for a patients treatment and patients were required to pay all funds exceeding that limit patients with expensive healthcare would face paying costs when they exceeded their lifetime limits
Coverage for Young People
Young Adult Coverage is provided for dependants under the age of 26. This allows them to maintain insurance coverage through their parents. This plan is available even if the dependant gets married, has their own insurance, a student or living independently. Before the Affordable Care Act adult children would be removed from policies due to their age, school status or where they lived.
Are dependents required to get parents insurance when they can get their own?
The young adult coverage is not a requirement. Parents can decide if they add their children and if they continue to do so until they are 26 years of age. Some policies offer additional coverage for young adults but they need to check with their insurance carrier. The young adult does not have to be financially dependant or live with their parents in order to receive coverage. This issue was addressed to help lower the amount of uninsured individuals. They ensured that increased premiums will not exist in order to make it affordable and convenient. The Affordable act states an insurance carrier cannot increase payment or deny to add a dependant. They provided a special enrollment period in September 2010 in order for young adults to take full advantage of the changes.
According to “Healthcare.gov” (2014), “Grandfathered plans are those that were in existence on March 23, 2010 and haven’t been changed in ways that substantially cut benefits or increase costs for consumers. Insurers must notify consumers with these policies that they have a grandfathered plan.” (Grandfathered health insurance plans). These types of plans can be obtained from employer or individually (paid directly by the consumer)
A key concern with this type of policy is changes that can be made such as increased premium payments. These plans are not subject to have a fixed rate or fixed increase. Individual policies do not have to cover pre-existing conditions even with the new reform law in place This plan can limit which doctors a patient can visit.
There is a way around this type of insurance plan. If there is a significant change in the policy the insured individuals need to be notified. With significant change the policy may be required to drop the “Grandfathered plan” status and therefore positive changes in the insured’s coverage.
Considerations were taken when making the decisions for this law. The law did not go into effect until March 2010 therefore old policies do not fall under this act. The only insurance policies that were going to be impacted are those that became effective 04/01/2010.
Due to the high rise in cost and health care, Americans throughout the world were unaware and uneducated about health care prevention. Therefore, individuals had minimal knowledge how to decrease the chances of disease.
75% of health care costs on chronic illnesses can be prevented 7 out of 10 deaths a year are due to illnesses that could have been prevented with the use of preventative health care The ACA helps make prevention for Americans, affordable and accessible. The act ensures that most of their health plans cover the recommended preventative services. Americans with private health insurance are able to gain access to preventative services at no cost. In March 2010 congress passed a new health legislation law, “Affordable Care Act”, in which makes health care, and preventative care services an easier and less costly way for Americans to have access to these types of services.
Review of Insurance Plans
The Affordable Care Act is providing health care coverage to millions of Americans. On January 1, 2014 , the health care market was open to those who wanted to sign up under the Affordable Care act. There are 5 different categories or “metal levels” of coverage in the Marketplace.
According to “Marketplace Insurance Categories” (2014), Plans in each category pay different amounts of the total costs of an average person’s care.
Bronze: Your health plan pays 60% on average. You pay about 40%.
Silver: Your health plan pays 70% on average. You pay about 30%.
Gold: Your health plan pays 80% on average. You pay about 20%.
Platinum: Your health plan pays 90% on average. You pay about 10%.
Catastrophic: Catastrophic coverage plans pay less than 60% of the total average cost of care on average. They’re available only to people who are under 30 years old or have a hardship exemption. As of January 1st, 2014 most Americans had to obtain a qualifying health plan. If they did not they will face a fine.
All health plans on the Marketplace can be purchased with subsidies if you qualify.
Currently Plans and estimated prices for 2015 coverage will be available in early November.
The Affordable Care Act wanted to provide individuals and families health care coverage. The Marketplace plans that are offered help consumers find the policies that best meet their needs.
Student Health Plans
Students attending college are often limited to health insurance coverage, possibly leaving students and their families with extreme costs in medical bills. Limited benefits
Not all student health plans are the same
High cost in medical bills
Difficult to understand health insurance plans and coverage
Through the ACA students have preventative coverage and consumer protections. Protections provided to students who enroll are; annual limits, medical loss ratio and notice requirement. In February 2011, a proposed regulation was issued from the HHS for students, therefore ensuring students the enroll in ACA coverage, get the health plan they need. Self-funded, Non-federal Governmental Plans Alisha
A non-Federal governmental employer that provides self-funded group health plan coverage to its employees (coverage that is not provided through an insurer) may elect to exempt its plan from certain requirements of Title XXVII of the Public Health Service (PHS) Act. (CMS 2014) In the past sponsors of self-funded, non-Federal governmental plans were permitted to elect to exempt certain provisions of the Public Health Service (PHS) Act
Medicaid Expansion BREE
Providing states with additional federal funding to expand their Medicaid programs to cover adults under 65 with income up to 133% of the federal poverty level. So the states that have expanded Medicaid, will be able to provide free or low-cost health coverage to people whose income is below a certain level. Medicaid expansion is a voluntary action by each state.
Over 15 million men, women and children will be eligible for Medicaid in State’s that participate in Medicaid Expansion. Although in the states that have not expanded on Medicaid, will leave 5.7 million people uninsured in 2016 .
Currently out of the 50 states , 20 are states still have not expanded their Medicaid program. Supporters of the healthcare law believe that the Medicaid expansion will save both state and federal money while extending healthcare coverage to millions of lower-income Americans. Opponents say it is just another example of government overreach and that it is up to the states to determine whether they can afford such an expansion (“Is Medicaid Expansion Good For The States?” 2014). The Affordable Care Act is actually the reason states are being provided extra funding to expand their Medicaid programs
About.com. (2013). Retrieved from http://patients.about.com/od/AffordableCareAct/a/Pre-Existing-Conditions-And-The-Affordable-Care-Act.htm
CFDA, (N.D). Affordable Care Act (ACA) – Consumer Assistance Program Grants. Retrieved from: https://www.cfda.gov/index?s=program&mode=form&tab=core&id=a8b2f9cc8e4dee31438c7bf8cf918532 Healthcare.gov. (2014). Retrieved from https://www.healthcare.gov/health-care-law-protections/pre-existing-conditions/ Healthcare.gov. (2014). Retrieved from https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/ Health Policy Briefs. (2013). Retrieved from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=84
Kaiser Family foundation, (Feb, 29, 2012). Explaining Health Care Reform: Medical Loss Ratio (MLR). Retrieved from: http://kff.org/health-reform/fact-
Marketplace insurance categories. (2014). Retrieved from https://www.healthcare.gov/choose-a-plan/plans-categories/
Medicaid Expansion Good for the States?. (2014). Retrieved from http://www.usnews.com/debate-club/is-medicaid-expansion-good-for-the-states U.S Department of Labor. (2014). Retrieved from http://www.dol.gov/ebsa/faqs/faq-dependentcoverage.html