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Affordable Care Act Summary Table of 45 Key Provisions

| June 20, 2013
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Now that the ACA has turned 2 years old, here is a Primer, thanks to MCOL (http://www.mcol.com)

  • Accountable Care Organizations

                The Act requires the Centers for Medicare & Medicaid Services (CMS) to establish a shared savings program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs.  Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an Accountable Care Organization, also called an ACO. Refer tohttps://www.cms.gov/sharedsavingsprogram/ The CMS Innovation Center established by the Act has also developed the Pioneer ACO program. Refer tohttp://www.hhs.gov/news/press/2011pres/12/20111219a.html

Status: In effect with 32 Pioneer ACOs under contract in 2012; Final rules for MSSP released October 2011

 

  • Administrative Simplification

                The Act will institute a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information.

Status: First regulation effective January 1, 2012. Refer tohttp://1.usa.gov/wqkSP1

 

  • Affordable Insurance Exchanges

                The Act establishes a competitive private health insurance market through the creation of Affordable Insurance Exchanges. These State-based, competitive marketplaces, which launch in 2014, will provide individuals and small businesses with “one-stop shopping” for affordable coverage. They will also provide the sole venue where Members of Congress will get their health insurance. DHHS will administer exchanges for states not opting to establish their own exchange. Refer tohttp://cciio.cms.gov/programs/exchanges/index.html

Status: Effective January 1, 2014. Thirty-three States, including the District of Columbia have received at total of nearly $670 million in Exchange Establishment Grants

 

  • Annual Limits on Insurance Coverage

                For plan years starting between September 23, 2010 and September 22, 2011, plans may not limit annual coverage of essential benefits such as hospital, physician and pharmacy benefits to less than $750,000.  The restricted annual limit will be $1.25 million for plan years starting on or after September 23, 2011, and $2 million for plan years starting between September 23, 2012 and January 1, 2014. For plans issued or renewed beginning January 1, 2014, all annual dollar limits on coverage of essential health benefits will be prohibited. Refer to:http://cciio.cms.gov/programs/marketreforms/annuallimit/index.html

Status: Regulation of limits in effect. Elimination of limits effective plan years starting 1/1/2014.

 

  • Appealing Insurance Company Decisions

                The Act ensures consumers right to appeal health insurance plan decisions, and specifies how plans must handle appeals. If plans deny payment after considering an appeal, consumers may have an independent review organization decide whether to uphold or overturn the plan’s decision. Refer tohttp://1.usa.gov/p1c5jE
Status: In effect

 

  • Bundled Payments for Care Improvement initiative

                A national pilot program to align payments for services delivered across an episode of care, such as heart bypass or hip replacement, rather than paying for services separately.  Bundled payments are designed to give doctors and hospitals new incentives to coordinate care, improve the quality of care and save money for Medicare. Refer to http://1.usa.gov/pP19cM

Status: To start on rolling basis during 2012

 

  • Center for Medicare & Medicaid Innovation

                The Act establishes the Innovation Center to develop new payment and delivery models within parameters of the Act. Refer tohttp://www.innovations.cms.gov/

Status: In effect with 17 initiatives launched to date.

 

  • Children’s Health Insurance Program (CHIP) Funding

                States will receive two more years of funding to continue coverage for children not eligible for Medicaid.

Status: Effective October 1, 2013.

 

  • CLASS Voluntary Options for Long-Term Care Insurance

                The law provided for a voluntary long-term care insurance program – called CLASS — with cash benefits to adults who become disabled.

Status: Not being implemented per DHHS postion taken 10/14/2011

 

  • Clinical Trials Coverage

                Insurers will be prohibited from dropping or limiting coverage because an individual chooses to participate in a clinical trial.  Applies to all clinical trials that treat cancer or other life-threatening diseases.

Status: Effective January 1, 2014.

 

  • Community Care Transitions Program

                The Community Care Transitions Program tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries.  The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high risk beneficiaries, and to document measurable savings to the Medicare program. Refer to http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/index.html

Status: In effect.

 

  • Community First Choice Option

                The Community First Choice Option allows states to offer home and community based services to disabled individuals through Medicaid rather than institutional care in nursing homes. This option provides a 6 % increase in Federal matching payments to States for expenditures related to this option. Refer to http://bit.ly/H76m8K

Status: In effect.

 

  • Community Health Centers

                The Act established the Community Health Center fund that provides $11 billion over a 5-year period for the operation, expansion, and construction of health centers throughout the Nation. $9.5 billion is targeted to:  Support ongoing health center operations; Create new health center sites in medically underserved areas; Expand preventive and primary health care services, including oral health, behavioral health, pharmacy, and/or enabling services, at existing health center sites. $1.5 billion will support major construction and renovation projects at community health centers nationwide. Refer tohttp://1.usa.gov/n8g8mW 

Status: In effect.

 

  • Consumer Assistance Program Grants

                The Consumer Assistance Program grants provide nearly $30 million in new resources to allow States, who are in some cases partnering with local non-profits, to help strengthen and enhance ongoing efforts to educate consumers about their health coverage options and new programs, empower consumers to avail themselves of new protections, ensure consumers have access to accurate information, and help consumers navigate the system to find the most affordable and secure coverage that meets their needs. Refer tohttp://www.healthcare.gov/news/factsheets/2010/10/cap-grants.html

Status: Grants Awarded.

 

  • Consumer Web Site

                The law provides for website where consumers can compare health insurance coverage options and select coverage.  Refer tohttp://finder.healthcare.gov/

Status: In effect.

 

  • CO-OP: Consumer Operated and Oriented Plans

                The Act provides for the establishment of the Consumer Operated and Oriented Plan (CO-OP) Program, which will foster the creation of qualified nonprofit health insurance issuers to offer competitive health plans in the individual and small group markets. Refer tohttp://cciio.cms.gov/programs/coop/index.html

Status: To-date, seven non-profits intending to offer coverage in eight states have been awarded more than $638 million in developmental loans

 

  • Early Retiree Coverage

                Until the new Exchanges are available in 2014,  a program is created to provide needed financial help for employment-based plans to continue to provide coverage to people who retire between the ages of 55 and 65, as well as their spouses and dependents.  Refer to http://www.errp.gov/

Status: ERRP has provided participating employers $5 billion in reinsurance payments to provide benefits, impacting an estimated 19 million early retirees, spouses and dependents.

 

  • Employee Opt-Out of Employer Plan to Exchange

                Workers meeting certain requirements who cannot afford the coverage provided by their employer may take whatever funds their employer might have contributed to their insurance and use these resources to help purchase a more affordable plan in the new health insurance Exchanges.

Status: Effective January 1, 2014.

 

  • Fraud, Waste & Abuse

                increases the federal sentencing guidelines for health care fraud offenses by 20-50 percent for crimes that involve more than $1 million in losses. The law establishes penalties for obstructing a fraud investigation or audit and makes it easier for the government to recapture any funds acquired through fraudulent practices. The law also makes it easier for the Department of Justice (DOJ) to investigate potential fraud or wrongdoing at facilities like nursing homes.  An additional $350 million in funding is provided over 10 years to ramp up anti-fraud efforts. Refer to http://1.usa.gov/zDBH0S

Status: In effect.

 

  • Gender or Health Status Based Premium Rate Prohibition

                The Act eliminates the ability of insurance companies to charge different premium rates due to gender or health status.

Status: Effective January 1, 2014.

 

  • Hospital Value Based Purchasing

                The Value-Based Purchasing Program will begin paying 3,500 hospitals nationwide based on care quality, rather than solely relying on the quantity of services provided. Additionally, value-based purchasing in other Medicare programs is currently being developed. Refer tohttps://www.cms.gov/Hospital-Value-Based-Purchasing/

Status: In FY 2013, an estimated $850 million will be allocated to hospitals based on performance .  The size of the fund will gradually increase over time.

 

  • Independent Payment Advisory Board

                The IPAB is to be comprised of a 15 member independent panel, appointed by the president and confirmed by the Senate, charged with enforcing a limit on Medicare spending growth.  The board will have broad authority to craft and execute new Medicare policies (including changes to provider reimbursement) with limited Congressional input.  The first IPAB proposal must be submitted to Congress and the president beginning in 2014.

Status: Administrative funding initiated.  Bill to eliminate IPAB passed House in March 2012

 

  • Individual Mandate

                The Act requires most individuals to obtain basic health insurance coverage or pay a fee. If affordable coverage is not available to an individual, he or she will be eligible for an exemption.

Status: Effective January 1, 2014.

 

  • Individual Tax Credits

                Tax credits will become available for people with income between 100% and 400% of the poverty line who are not eligible for other affordable coverage. The tax credit is advanceable and refundable, allowing moderate-income families can receive the full benefit of the credit. These individuals may also qualify for reduced cost-sharing (copayments, co-insurance, and deductibles).

Status: Effective January 1, 2014.

 

  • Medicaid Increased Access

                Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in subsequent years.

Status: Effective January 1, 2014.

 

  • Medicaid Preventive Health Coverage

                The Act provides new funding to state Medicaid programs that choose to cover preventive services for patients at little or no cost.

Status: Effective January 1, 2013.

 

  • Medicaid Primary Care Physician Payment Increases

                The Act requires states to pay primary care physicians no less than 100% of Medicare payment rates in 2013 and 2014 for Medicaid primary care services. The increase is fully funded by the federal government.

Status: Effective January 1, 2013.

 

  • Medical Loss Ratio Requirements

                The Act requires insurers selling policies to individuals or small groups to spend at least 80% of premiums on direct medical care and efforts to improve the quality of care.  Insurers selling to large groups (usually 50 or more employees) must spend 85% of premiums on care and quality improvement. This rule does not apply to employers who operate what is called a self-insured plan. Refer to http://www.healthcare.gov/law/features/costs/value-for-premium/index.html

Status: In effect.

 

  • Medical School Grants for Physician Underserved Rural Recruitment

                The Act establishes a grant program to help medical schools recruit students most likely to practice medicine in underserved rural communities, provide rural-focused training and experience, and increase the number of medical graduates who practice in underserved rural communities. Authorizes $4 million for each of the fiscal years 2010-2013.

Status: In effect.

 

  • Medicare Advantage Payment Reduction to Private Plans

                The Act modifies payments to Medicare Advantage plans in several ways, for a projected savings of $117 billion in federal expenditures for Medicare between fiscal years 2010 and 2019.

Status: In effect.

 

  • Medicare Bonus Payment for Rural/ Underserved Physicans

                The Act provides 10% Medicare Bonus payments to applicable physicians in rural/underserved areas

Status: In effect.

 

  • Medicare Prescription Drug “Donut Hole” Rebates and Discounts

                Each eligible senior will receive a one-time, tax free $250 rebate check in 2010. Starting with 2011. seniors who reach the coverage gap will receive a 50% discount when buying Medicare Part D covered brand-name prescription drugs. Over this decade, discounts apply until the coverage gap is closed in 2020.

Status: In effect through 2020. Discounts were estimated to save seniors $2.1 billion in 2011.

 

  • National Health Service Corps

                The Act provides additional funding to enhance the number of clinicians who practice in underserved communities through the National Health Service Corps. Refer to http://www.nhsc.hrsa.gov/

Status: In effect.

 

  • Pre-Existing Condition Coverage Denial Prohibition for Children

                Insurance companies prevented from denying coverage to children under the age of 19 due to a pre-existing condition.

Status: In effect.

 

  • Pre-Existing Condition Insurance Plan

                The Pre-Existing Condition Insurance Plan provides coverage options to individuals who have been uninsured for at least six months because of a pre-existing condition until coverage is available through Exchanges. States had the option of  running this program in their state, otherwise DHHS established the plan.  Refer to https://www.pcip.gov/

Status: Estimated 50,000 currently covered under program

 

  • Premium Rate Review for Increases Exceeding 10%

                The law allows states that have, or plan to implement, measures that require insurance companies to justify their premium increases will be eligible for $250 million in new grants. Insurance companies determined to have excessive or unjustified premium increases may not be able to participate in the new health insurance Exchanges in 2014. Refer to http://bit.ly/o3jFWs

Status: State grants awarded beginning in 2010, with more than $154 million awarded to fund rate review development/activities

 

  • Prevention and Public Health Fund

                A new $15 billion Prevention and Public Health Fund has been established for prevention and public health programs. Refer tohttp://1.usa.gov/mODwxv 

Status: In effect. The Administration allocated $500 million in 2010, $750 million in new funds in 2011 and $1 billion in 2012.

 

  • Preventive Care for Commercial/Individual plans

                All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Refer tohttp://www.healthcare.gov/law/features/rights/preventive-care/index.html

Status: In effect.

 

  • Preventive Care for Seniors

                Key preventive services available with no co-pay or deductibles, such as annual wellness visits and personalized prevention plans for seniors on Medicare.  Refer to http://www.medicare.gov/welcometomedicare/visit.html

Status: An estimated 32.5 million+ seniors have already received one or more free preventive services, including the new Annual Wellness Visit, since taking effect 1/1/2011

 

  • Primary Care Access Funding

                The Act provides funding for scholarships and loan repayments for primary care doctors and nurses working in underserved areas. Doctors and nurses receiving payments made under any state loan repayment or loan forgiveness program intended to increase the availability of health care services in underserved or health professional shortage areas will not have to pay taxes on those payments.

Status: In effect.

 

  • Racial, Ethnic and Language Disparity Identification

                The Act requires any ongoing or new federal health program to collect and report racial, ethnic and language data, to help identify and reduce disparities.

Status: Effective March 2012.

 

  • Rescinding Coverage

                In the past, insurance companies could retroactively deny coverage due to errors on a customer’s application, which is now prohibited. Refer tohttp://www.healthcare.gov/law/features/rights/cancellations/index.html

Status: In effect.

 

  • Small Business Health Insurance Tax Credits

                Small businesses that have fewer than 25 employees and provide health insurance qualify for a tax credit of up to 35% (up to 25% for non-profits) to offset the cost of insurance. This credit will increase in 2014 to 50% (35% for non-profits). Refer to http://1.usa.gov/nrDz6r

Status: 360,000 small employers received credit in 2011. Tax credits increase in 2014.

 

  • Summary of Benefits and Coverage and Uniform Glossary

                Plan will be required to provide standardized information about health plan benefits and coverage. Specifically, the rules ensure consumers receive two key forms: A short, easy-to-understand Summary of Benefits and Coverage (or “SBC”); and a list of definitions (called the “Uniform Glossary”) that explains terms commonly used in health insurance coverage. These forms were developed by the DOL, DHHS, and the Treasury, based primarily on model forms created through a public process led by the National Association of Insurance Commissioners (NAIC) and a working group of consumers and others. Refer tohttp://1.usa.gov/oovGw1

Status: Effective Plan Years starting 9/23/2012

 

  • Young Adults Coverage

                Young adults are allowed to stay on their parents’ plan until they turn 26 years old (in the case of existing group health plans, this right does not apply if the young adult is offered insurance at work).

Status: In effect. Estimated 2.5 million additional young adults covered.

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