ABC's of Health Care Reform and You

Benefits

Overall, the Affordable Care Act requires that insurance plans sold to individuals and small businesses must cover items and services in a minimum of 10 categories. These categories are: ambulatory services, hospitalization, maternity and newborn care, mental health and substance abuse, prescription drugs, preventive and wellness services, chronic disease management, rehabilitative services, laboratory services, and pediatric services. However, federal regulators shied away from prescribing defined, national standards for “essential health benefits” or covered treatments offered in insurance plans. Instead, regulators opted to give states more flexibility in defining “essential health benefits” or covered treatments. Regulators recognize the coverage that is appropriate for one state may not be appropriate for the majority of residents in another state. Florida, for example, is home to many more seniors than most other states. States directed insurers to develop insurance plans that cover treatments/diseases in the 10 minimum categories. States had four choices from which insurance packages could be designed: one of the three largest state employee health plans (by enrollment); one of the three largest federal employee health plan options; the largest HMO offered in the state; or one of the three largest small-group plans in the state. This means that there can be restrictions on items/services covered, such as a limit on number of office visits. States that did not choose one of the four options for defining an “essential benefits package” had one selected for them by federal regulators. Federal regulators used the benefits offered by the small-group plan with the largest enrollment in that state. States had to develop the “essential benefits package” as part of their work to establish State Health Insurance Exchanges – or online insurance marketplaces. These opened October 1, 2013. New York State selected Oxford EPO as the state’s benchmark plan. In addition to the selection of a benchmark plan, New York has indicated the coverage areas in which benefits will be supplemented in order to meet ACA requirements. For more details, go to the state’s exchange website http://healthcarereform.ny.gov/health_insurance_exchange/. (Update added 10/5/12)

On April 12, 2012, Governor Cuomo issued an executive order establising New York’s health care insurance exchange. This put the state in compliance with the ACA. The marketplace is now open and operates under the Department of Health in consultation with the Department of Financial Services and other agencies. Regional advisory groups consisting of consumer advocates, health providers, insurers, and unions advised the state on the design of the marketplace.

Commercial health insurers must provide consumers with clear, consistent, and comparable summary information about their health plan benefits and coverage. The new forms became available on September 23, 2012. Key feature is a standardized plan comparison tool called “coverage examples,” similar to the Nutrition Facts label required for packaged food. (Update added 2/15/12)

In June 2013, the healthcare.gov website was re-vamped and is now more consumer-focused and offers a 24/7 consumer call center 1-800-318-2596/TTY: 1-855-889-4325. Also offers online CHAT feature. (Updated 7/3/13)

In July 2013, New York State notified the Nassau-Suffolk Hospital Council (NSHC) that it was selected as a Navigator Agency for the exchange for the Long Island region - Nassau and Suffolk counties. The NSHC has state trained and certified enrollers ready to assist individuals, families, and businesses in understanding the insurance options offered on the exchange and in purchasing insurance. The navigators screen individuals via their income for eligibility for subsidies that will help them afford insurance or whether their income places them in the Medicaid insurance program. The navigators also help small business owners determine if they are eligible for any tax credits. Seniors and disabled in the Medicare program will continue to be covered under the Medicare insurance program. (Update added 11/22/13)

Building on the announcement from 2013 that the administration will allow individual insurance policies cancelled because of their inability to meet federal minimum coverage requirements an extension for one year, a subsequent rule change allowed these cancelled policies to be renewed for coverage through 2017. This two-year extension applies to both individual and small group policies that began on or before October 1, 2016. Granting of the extension is at the discretion of each state’s insurance commissioner and then private insurers have the option to renew or not renew these policies for a one-year time period. New York State has not granted extensions. However, on December 19, 2013, the Department of Health and Human Services said consumers whose coverage is cancelled because it does not meet minimum ACA requirements can buy catastrophic coverage if all other coverage on marketplace is too expensive. (Update added 3/13/14)

The new national initiative “From Coverage to Care” (C2C) is designed to help answer questions that people may have about their new health insurance coverage and to help them make the most of their new benefits, including taking advantage of primary care and preventive services. The initiative’s Roadmap to Better Care and You includes eight steps to help consumers and health care providers become informed about the diverse benefits available through insurance coverage and how to use the coverage appropriately to access primary care and preventive services. Go to http://marketplace.cms.gov/help-us/c2c.html (Updated 6/1814)

All patient categories listed below benefit from the Affordable Care Act provisions noted above (except where noted), as well as these additional provisions:

Uninsured

  • Most importantly, U.S. citizens and legal immigrants who are uninsured will become insured either through an insurance program provided by their employer, an insurance plan purchased in the State Health Insurance Exchange, or through a Basic Health Program (BHP) offered outside of the Exchange. In New York, the BHP is called the Essential Health Plan. The plan offers affordable insurance options to those whose incomes are above the Medicaid limit, but who still cannot afford the premiums of other marketplace plans. Depending on income, the monthly premium for the Essential Plan is either $0 or $20 per month. The Essential Plan covers all major medical needs and is only available through the New York State of Health marketplace. Further, the Essential Health Plan must meet a medical loss ratio of at least 85 percent. This ratio requires large insurers to spend at least 85 cents of every premium dollar on health services. For insurers covering the individual and small group market the ratio is 80 cents of every premium dollar. New York had medical loss ratio legislation in place before the Affordable Care Act provision kicked in. (Updated 8/5/16)

Young Adults

  • As of September 2010, adult children can remain on their parent’s insurance until age 26 (29 according to New York’s law).
  • The State Health Insurance Exchange must offer a catastrophic coverage plan for individuals under the age of 30 for whom coverage is unaffordable.
  • In December 2013, the U.S. Department of Health and Human Services said consumers whose coverage cancelled because it did not meet minimum federal requirements could buy catastrophic level coverage if all other coverage on the marketplace is determined to be too expensive. This level coverage had been available only to those aged 30 and under. (Update added 2/26/14)

Seniors/Disabled

  • Effective January 1, 2011, Medicare beneficiaries are entitled to an annual wellness visit and personalized prevention plan, that includes some screening tests, with no co-payment or deductible.
  • The “donut hole” (coverage gap) for prescription drugs will phase out by 2019.
  • Seniors and disabled in the Medicare program will continue to be covered under the Medicare insurance program and will never need to purchase insurance through the Exchange. (Update added 7/23/13.)

Chronic Disease Sufferers

  • The Affordable Care Act contains millions of dollars to fund pilot programs in disease prevention and other public health activities geared toward reducing obesity, diabetes, high blood pressure, tobacco addiction, asthma, and other common, but high-cost chronic diseases and conditions. It encourages public and private partnerships and programs at all levels of government and industry to work together to achieve a healthier America.
  • In December 2013, the U.S. Department of Health and Human Services said consumers whose coverage cancelled because it did not meet minimum federal requirements could buy catastrophic level coverage if all other coverage on the marketplace is determined to be too expensive. This level coverage had been available only to those aged 30 and under. (Update added 2/26/14)

Children

  • Children with pre-existing medical conditions cannot be excluded from obtaining health insurance.
  • The law provides grants for the establishment of school-based health centers.

Adults Under 65

  • Lifetime coverage limits no longer exist.
  • Annual coverage limits were eliminated in 2014.
  • The limitation on pre-existing medical conditions for all adults was eliminated in 2014.
  • Premium holders are entitled to rebates if commerical insurers fail to meet the medical loss ratio. This ratio requires large insurers to spend at least 85 cents of every premium dollar on health services. For insurers covering the individual and small group market the ratio is 80 cents of every premium dollar. New York had medical loss ratio legislation in place before the Affordable Care Act provision kicked in. In New York, millions have been refunded to premium holders since 2011. Effective August 1, 2012, the federal government required benefit plans to send out “medical loss ratio” rebates. Self-insured employers are exempt. Individuals who purchase their own insurance will receive checks. Employers can chose to apply the rebates toward future premium costs or distribute to employees. (Updated 8/25/14)
  • Regulatory approval is now required when insurers seek to raise premiums significantly. New York enacted prior approval authorization before the enactment of this provision in the Affordable Care Act.
  • High-risk pool for adults with pre-existing conditions, in New York known as the Bridge Plan, began in October 2010 and remained in operation until 2014, when the State Insurance Exchange opened.
  • A reinsurance program to subsidize early retiree coverage became effective in July 2010 and ended in 2014. This helped employers and employees reduce premium costs.
  • Employers are required to provide a reasonable break time and location for nursing mothers to express milk for her nursing child up to a year following the birth of the child.
  • Nutrition information for food that is standard on a menu must be listed, including caloric content. Applies to food establishments/chains with 20 or more locations.
  • Federal government awarded low interest loans to launch consumer-governed health insurance plans in eight states. Non-profit, co-op plans opened for business in 2014 and are designed for the individual and small-group insurance markets. In November 2015, the New York State Departmet of Health shut down Health Republic Insurance, New York’s only co-op plan, due to insolvency. (Update added 8/5/16)
  • On July 2, 2013, the Department of the Treasury announced that it would delay for one year, until January 2015, the Affordable Care Act mandate that employers (50+ employees) provide coverage for their workers or pay penalties. (Update added 7/23/13)
  • In December 2013, the U.S. Department of Health and Human Services said consumers whose coverage cancelled because it did not meet minimum federal requirements could buy catastrophic level coverage if all other coverage on the marketplace is determined to be too expensive. This level coverage had been available only to those aged 30 and under. (Update added 2/26/14)

Businesses

  • Federal grants for comprehensive workplace wellness programs are available to small businesses with less than 100 employees.
  • Businesses that pay part of the insurance premiums for their employees are entitled to rebates if commerical insurers exceed the medical loss ratio. This ratio requires large insurers to spend at least 85 cents of every premium dollar on health services. For insurers coverning the individual and small group market, the ratio is 80 cents of every premium dollar. New York had medical loss ratio legislation in place before the Affordable Care Act provision kicked in. Effective August 1, 2012, the federal government required benefit plans to start sending out “medical loss ratio” rebates. New York State businesses and individuals were refunded millions since 2011. Self-insured employers are exempt. Individuals who purchase their own insurance will receive checks. Employers can chose to apply the rebates toward future premium costs or distribute to employees. (Updated 8/25/14)
  • A reinsursance program to subsidize early retiree coverage became effective in July 2010 and it will end in 2014. This helped employers and employees reduce premium costs.
  • On July 2, 2013, the Department of the Treasury announced that it would delay for one year, until January 2015, the Affordable Care Act mandate that employers (50+ employees) provide coverage for their workers or pay penalties. (Update added 7/23/13)
  • Delay of employer mandate for businesses with between 50 and 100 employees took effect in 2016. This follows on initial change announced in 2013 that delayed the employer mandate for all employers until 2015. The administration essentially allowed for a phase in of the employer mandate over a two-year period, based on the size of the firm. The administration says it made these changes to help businesses adjust to the law. (Update added 8/5/16)
  • In December 2013, the U.S. Department of Health and Human Services said consumers whose coverage cancelled because it did not meet minimum federal requirements could buy catastrophic level coverage if all other coverage on the marketplace is determined to be too expensive. This level coverage had been available only to those aged 30 and under. (Update added 2/26/14)

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