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It’s National Women’s Health Week, So Naturally, the GOP is Voting Yet Again to Repeal Obamacare!

May 13, 2013 7:22 pm / Leave a Comment

— by Kathleen Sibelius, Secretary–Dept. of Health & Human Services

This week, starting with Mother’s Day,  we celebrate National Women’s Health Week. As a nation, we honor the women in our lives – our mothers, grandmothers, aunts, sisters, cousins, friends, and colleagues – by encouraging them to make their health a priority and to take steps to live healthier, happier lives.

Women are frequently the health care decision-makers in their families. We take time off from work to drive a parent to the doctor. We hold our children’s hands while they get their vaccinations. We make the appointments for our spouses’ checkups – and then make sure they actually go. We stretch and re-work our family budgets to pay the doctor’s bills. And too often, we put our own health last.

But the truth is unless we take care of ourselves first, we cannot really take care of our families. That means we have to eat right, exercise, and get the care we need to stay healthy. Unfortunately, preventive care has not always been easily accessible or affordable for everyone, including young women.

But the health care law is helping to usher in a new day for women’s health. The Affordable Care Act is making it easier for women to take control of their own health.  For many women, preventive services like mammograms, Pap smears, birth control, and yearly well-woman visits are now available without cost sharing. The health care law improves women’s access to appropriate preventive health screenings, which can help detect diseases early, when treatment is most effective and least costly.

Starting next year, insurance companies will no longer be allowed to refuse us coverage just because we’re battling breast cancer or have another pre-existing condition – and they won’t be allowed to charge us more just because we are women.

If you’re one of the millions of women who are uninsured or who buy insurance on their own, more options are on the way because of the Affordable Care Act. Starting October 1, 2013, you will be able to visit a new Health Insurance Marketplace where you can compare and choose from a range of plans to find one that best fits your needs and budget. All of these plans must cover a package of essential health benefits, including maternity and newborn care.

To get more information about the Marketplace and to sign up for email and text updates to get ready for October, visit HealthCare.gov.

Being healthy starts with each of us taking control. So Monday on National Women’s Checkup Day, and during National Women’s Health Week, I encourage you to sit down with your doctor or health care provider and talk about what you can do to take control of your health.

There’s no better gift you can give yourself – or your loved ones.

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“Profit-Motive” Is Negatively Impacting Your Healthcare: Medicare Provider Charge Data

May 8, 2013 9:19 am / Leave a Comment

As part of the Obama administration’s work to make our health care system more affordable and accountable, data are being released by HHS (Health & Human Services) that show significant variation across the country, even within communities as to what hospitals charge for common inpatient services.

“Currently, consumers don’t know what a hospital is charging them or their insurance company for a given procedure, like a knee replacement, or how much of a price difference there is at different hospitals, even within the same city,” Secretary Sebelius said. “This data and new data centers will help fill that gap.”  For example,

  • In Dallas, Las Colinas Medical Center billed Medicare an average of $160,832 for a lower joint replacement. The price was $42,632 five miles away, at Baylor Medical Center.
  • Average inpatient charges for services for a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.
  • Average inpatient hospital charges to treat heart failure range from a low of $21,000 to a high of $46,000 in Denver, Colo., and from a low of $9,000 to a high of $51,000 in Jackson, Miss.
  • Ventilator: $115,00 George Washington University vs. $53,000 at Providence (just 5.4 miles apart)
  • Lower limb replacement: $117,000 at Richmond CJW Medical Center vs. 25,600 at Winchester Medical Center
  • Pneumonia: $124,051 in Philadelphia vs. $5,093 in Water Valley, Mississippi.

According to Ron Pollack, executive director of Families USA, hospital pricing is “the craziest of crazy quilts.” He went on to say, ”It is absurd — and, indeed, unconscionable — that the people least capable of paying for their hospital care bear the largest, and often unaffordable, cost burdens.”

Medicare has begun paying providers based on quality rather than just the quantity of services they furnish by implementing new programs, such as value-based purchasing and re-admissions reductions.  HHS awarded $170 million to states to enhance their rate review programs, and since the passage of the Affordable Care Act (ACA), the proportion of insurance company requests for double-digit rate increases fell from 75 percent in 2010 to 14 percent so far in 2013.

The ACA also makes available many tools to help ensure consumers, Medicare, and other payers get the best value for their health care dollar.  To make data from these tools useful to consumers, HHS is also providing funding  to data centers to collect, analyze, and publish health pricing and medical claims reimbursement data.  The data centers’ work helps consumers better understand the comparative price of procedures in a given region or for a specific health insurer or service setting. Businesses and consumers alike can use these data to drive decision-making and reward cost-effective provision of care.

Data are available in Microsoft Excel (.xlsx) format and comma-separated values (.csv) format.

Inpatient Charge Data, FY2011, Microsoft Excel version
Inpatient Charge Data, FY2011, Comma Separated Values (CSV) version

Hospitals determine what they will charge for items and services provided to patients and these charges are the amount the hospital bills for an item or service. The Total Payment amount includes a Medicare Severity Diagnosis Related Group (MS-DRG) amount, bill total per diem, beneficiary primary payer claim payment amount, beneficiary Part A coinsurance amount, beneficiary deductible amount, beneficiary blood deducible amount and DRG outlier amount.

Data provided by CMS (Centers for Medicare/Medicaid Services) include hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the MS-DRG for FY2011.

DRGs represent almost 7 million discharges or 60 percent of total Medicare IPPS discharges. Average charges and average Medicare payments are calculated at the individual hospital level. Users will be able to make comparisons between the amount charged by individual hospitals within local markets, and nationwide, for services that might be furnished in connection with a particular inpatient stay.

There is some debate about how much patients, insurance providers and the government actually end up paying. “It’s true that Medicare and a lot of private insurers never pay the full charge,” said assistant professor at the University of California at San Francisco Medical School, Renee Hsia, “You have a lot of private insurance companies where the consumer pays a portion of the charge. But, for uninsured patients, they face the full bill. In that sense, the price matters.”

To view the new hospital dataset, please go to: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html.

To access the funding opportunity announcement, visit: http://www.grants.gov, and search for CFDA # 93.511.

For more information on HHS efforts to build a health care system that will ensure quality care, please see the fact sheet “Lower Costs, Better Care: Reforming Our Health Care Delivery System,” athttp://www.cms.gov/apps/media/press/factsheet.asp?Counter=4550.

To read a fact sheet about the Medicare data showing variation in hospital charges, please see:http://www.cms.gov/apps/media/fact_sheets.asp.

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Holding Insurance Companies Accountable for High Premium Increases

March 27, 2013 11:18 am

— by Kathleen Sebelius, Secretary of Health and Human Services

The Affordable Care Act (ACA) prohibits some of the worst insurance industry practices that have kept affordable health coverage out of reach for millions of Americans.  It provides families and individuals with new protections against discriminatory rates due to pre-existing conditions, holds insurance companies accountable for how they spend your premium dollars, and prevents insurance companies from raising your insurance premium rates without accountability or transparency.

For more than a decade before the ACA health insurance premiums had risen rapidly, straining the pocketbooks of American families and businesses.  Oftentimes, insurance companies were able to raise rates without explanation to consumers or public justification of their actions.

One of the provisions of the ACA is that insurance companies must now reveal the percentage of premium dollars they actually spend on health care and how much they spend on administration (e.g., salaries and marketing. Prior to ACA, this type of information was a closely held secret and insurance companies pocketed a good percentage of your premium dollars. With ACA in place, that’s no longer the case. If an insurance company spends less than 80% of premiums on medical care and quality (or less than 85% in the large employer, large group market), it must rebate the portion of premium dollars that exceeded this limit. This 80/20 rule is commonly known as the Medical Loss Ratio (MLR) rule

Chart showing the percent of rate filings that requested increases of 10 percent or more. 2009: 72%, 2010: 75%, 2011: 51%, 2012: 34%, 2013: 14% Rate Review in Action
The ACA brought an unprecedented level of scrutiny and transparency to health insurance rate increases by requiring insurance companies in every state to publicly justify their actions if they want to raise rates by 10% or more.  Insurance companies are required to provide easy to understand information to their customers about their reasons for significant rate increases, and any unreasonable rate increases are posted online.

And it’s working.  A new report released today shows that the health care law is helping to moderate premium hikes.  Since this rule was implemented, the number of requests for insurance premium increases of 10% or more has dropped dramatically, from 75% to 14%.  The average premium increase for all rates in 2012 was 30% below what it was in 2010. And available data suggest that this slowdown in rate increases has continued into 2013.

Moreover, when an insurer does decide to increase rates, consumers are seeing lower rate increases than what the insurers initially requested.  In the review of rate requests for 10% or more, over 50% resulted in customers receiving either a lower rate increase than requested or no increase at all.

States have received $250 million in Health Insurance Rate Review Grants to help strengthen and improve their rate review processes thanks to the Affordable Care Act.  Of the 44 states that received rate review grants, 40 have reported enhancements to their rate review websites.  These website enhancements include searchable rate filings, new public comment options, live streaming of rate hearings, and plain language explanations of rate review and rate filings.

The Effective Rate Review program is one of many in the health care law aimed at protecting consumers.  The rate review program works in conjunction with the 80/20 rule, which requires insurance companies to generally spend 80% of premiums on health care or provide rebates to their customers. Insurance companies that did not meet the 80/20 rule have provided nearly 13 million Americans with more than $1.1 billion in rebates. Americans receiving the rebate will benefit from an average rebate of $151 per household.

Additionally, today we issued a final rule that implements five key consumer protections from the Affordable Care Act, including protection against denial of health coverage because of a pre-existing condition.  This rule makes the health insurance market work better for individuals, families and small businesses, and it also increases the transparency brought to rate increases by directing insurance companies in every state to file all of their rate increase requests.

For more information about the Affordable Care Act, visit http://www.healthcare.gov/index.html.

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The ‘Freedom’ to Refuse Health Insurance

July 17, 2012 8:56 pm

Raise your hand if you don’t want any health insurance.

— By Mitchell Zimmerman

Mitchell ZimmermanAs the writer Anatole France once said, “The law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges.”

The right to refuse to have health insurance — something Republican leaders tout as a fundamental freedom — is a lot like the “right” to sleep under bridges. No one wants to exercise it.

GOP leaders are framing the requirement that every American get health insurance as the gravest assault on our liberty since the British burned the White House in 1814. But even the most hard-core teapartistas tend to freely choose the very insurance coverage whose imposition they decry as socialist tyranny. Few conservatives insist on paying their own medical expenses because they’re rugged individualists.

More than 50 million Americans have no health insurance and nearly 30 million more have such bad policies that they’re officially “underinsured.” Is the Affordable Care Act a dreadful imposition on them? Nearly all uninsured Americans wish they had medical coverage, and the underinsured wish they had more.

People are uninsured and underinsured for two reasons: Either they can’t afford coverage, or insurance companies refuse to insure them. “Choosing” not to have health insurance because you’d prefer to feed your children isn’t a real choice.

One cornerstone of President Barack Obama’s health care reform is that the government will offer subsidies to many people who face this dilemma. They won’t have to choose between hunger and health any longer.

And there’s nothing un-American about making people purchase health services or insurance. Consider these examples of how the government can legitimately force you to do the right thing:

Children must go to school, unless their parents are among the 3 percent who opt for home-schooling. And children must be vaccinated before they enter the classroom. That means the government makes you pay for a vaccine, or you get a subsidized one at a clinic. We consent because we don’t want the risk of epidemics. It’s not an assault on our liberty — just an illustration of how, because we live in society, we can be made to buy things when necessary for the wellbeing of society as a whole.

And, if you want to drive, you must buy liability insurance. Our society recognizes you don’t have the right to be irresponsible — to do something inherently risky to others, like driving a vehicle, without being able to provide compensation if and when you cause an accident.

Health insurance is no different. The Affordable Care Act won’t let you behave irresponsibly at other people’s expense. You can theoretically “choose” not to have health insurance. But you can’t choose never to get cancer or have a heart attack, or never to incur crushing medical expenses. And since we’re not yet the kind of society that will let people die in the gutter outside of a hospital because they don’t have money or insurance, a “choice” not to be insured is really a choice to make others pay for the medical expenses you or your kids will very likely incur at some point.

We have a responsibility to pay our dues in a free society, and the government isn’t assaulting liberty by making us live up to our responsibilities. We don’t have the right to a free ride. But what else do you call the act of letting everyone else pay our medical bills — particularly when the collective burden of uninsured individuals and families imposes an enormous cost on our entire national medical system and a grave burden on our economy?

The truth is that no one wants to be without health insurance. The Affordable Care Act isn’t going to make it available to everyone — an estimated 26 million Americans will still be uninsured by 2020 — but it’s a big step in the right direction. The Supreme Court made the right choice when it upheld the law.

Mitchell Zimmerman is an attorney who lives in Northern California. He supplements his work as a Silicon Valley intellectual property lawyer with pro bono work on behalf of the underrepresented. Distributed via OtherWords (OtherWords.org)

Lest You Didn’t Know: What Obamacare Provides

July 9, 2012 9:15 am / 1 Comment

  1. Insurance companies can no longer impose lifetime coverage limits on your insurance.
  2. The lifetime cap and annual cap will be sharply limited, and ultimately eliminated in 2014.
  3. Children with pre-existing conditions are covered.  (Frankly, I never really understood how a newborn could have a pre-existing condition when the mother was covered before becoming pregnant, and the mother was covered then entire time she was pregnant.  Thus the new born was covered from conception to birth, yet at birth has a pre-existing condition????  How is that possible?)
  4. A temporary program will help adults with pre-existing conditions get coverage.  It expires in 2014, when the health insurance exchanges come on-line.  Then, all are covered, pre-existing condition or not.
  5. Insurance companies are not permitted to drop you when you get sick.
  6. Children can elect to stay on their parents’ health insurance until the age of 26.
  7. Senior citizens get $250 toward closing the “doughnut hole” in their prescription drug coverage.
  8. Medicare’s preventive benefits include a free visit to your primary care doctor every year to plan your preventive services.  No more co-pays for preventive services under Medicare.
  9. Small Businesses get BIG tax credits — up to 50% of the premium costs — for offering health insurance to their workers.
  10. Insurers with unusually high administrative costs have to offer rebates to their consumers if they fail to spend 80% of premiums collected on actual health care. Every insurance company has to reveal how much it spends on overhead (which contributes nothing to the actual health of those they insure).
  11. Free birth control and other preventive services for women, unless you work for a churches that oppose birth control.  And, in those circumstances, the insurance company itself, separate from the Church, will provide coverage for birth control at no cost to those women.

Bills Before Congress: July 9 -13

July 9, 2012 8:56 am

in the House

The Repeal of Obamacare Act
Would repeal the 2010 healthcare law. It’s the GOP response to the Supreme Court ruling on the law. The House Rules Committee is expected to consider this bill on Monday evening in an “emergency meeting” because the bill will be officially introduced on Monday by Majority Leader Eric Cantor (R-Va.). The House is expected to vote on the bill on Wednesday, July 11.

Republicans in the house have gone overboard this session mandating that each and every bill must specify “pay-fors.”  A repeal of “Obamacare” would pose a $230B increase in the budget deficit.  Watch to see if hypocrisy prevails and whether Rep. Eric Cantor (R-VA) identifies ANY “pay-fors” as part of his repeal effort that is going absolutely NOWHERE.  

The National Strategic and Critical Minerals Production Act (HR 4402)
Aimed at streamlining the process for approving mining rights, and addressing what many see as an increasingly U.S. reliance on imported rare earth minerals that are key to manufacturing and national security.

Several non-controversial bills will also be considered in the House this week:

The Veterans’ Compensation Cost-of-Living Adjustment Act (HR 4114)
Increases, effective as of Dec. 1, 2012, the rates of compensation for veterans with service-connected disabilities and the rates of dependency and indemnity compensation for the survivors of certain disabled veterans.

The Veteran Skills to Jobs Act (HR 4155)
Directs the head of each Federal department and agency to treat relevant military training as sufficient to satisfy training or certification requirements for Federal licenses.

HR 4367 amends the Electronic Fund Transfer Act to limit the fee disclosure requirement for an automatic teller machine to the screen of that machine.

The Hydropower Regulatory Efficiency Act (HR 5892)
Improves hydropower.

The Juvenile Accountability Block Grant Reauthorization and the Bullying Prevention and Intervention Act (HR 6019)
Enhances the use of Juvenile Accountability Block Grants for programs to prevent and address occurrences of bullying and to reauthorize the Juvenile Accountability Block Grants program.

in the Senate

The Small Business Jobs and Tax Relief Act (S 2237) – The Senate will hold a procedural vote on this bill Tuesday afternoon.
This bill (#6 on POPVOX) would reduce corporate taxes on the first $5 million in wages paid in 2012 over 2011.

The Haqqani Network Terrorist Designation Act (S 1959)
Requires a report on the designation of the Haqqani Network as a foreign terrorist organization.

The Former Charleston Naval Base Land Exchange Act (S 2061)
Provides for an exchange of land between the Department of Homeland Security and the South Carolina State Ports Authority.

Other Bills of Interest

The Supreme Court ruling in favor of the healthcare bill prompted the introduction of several bills to repeal the law, none of which appear likely to advance because of the pending House vote on Cantor’s bill.

Three of these similar bills made the top of POPVOX’s most-commented list last week:

The NObamacare Act (HR 6053)
Repeals the provisions of the Patient Protection and Affordable Care Act and the health-related provisions of the Health Care and Education Reconciliation Act of 2010 not declared unconstitutional by the Supreme Court from Rep. Connie Mack (R-Fla.).

The Healthcare Tax Relief and Mandate Repeal Act (HR 6048)
Amends the tax code to repeal the individual and employer health insurance mandates, from Rep. Michael Turner (R-Ohio) and more than 100 other cosponsors.

The NObamacare Funds Act (HR 6054)
Prohibits funding to implement any provision of the Patient Protection and Affordable Care Act or of the health-related provisions of the Health Care and Education Reconciliation Act of 2010, from Rep. Connie Mack (R-Fla.).

Corporations Score another Supreme Court Victory

July 6, 2012 1:07 pm / 2 Comments

The Affordable Care Act ruling won’t heal our ailing health system.

By Margaret Flowers

Margaret Flowers

As a physician, I find it very odd that the debate over the Affordable Care Act has focused on the effect the law will have on the presidential election rather than the impact it will have on patients, health professionals, and health outcomes.

The Supreme Court case reinvigorated the debate over the Obama administration’s 2010 health care reform law. But we’re still getting partisan talking points instead of an honest review of the changes that are in store. This will likely worsen as we get closer to Election Day.

The new law is based on concepts developed by the Heritage Foundation, a conservative think tank. Republican presidential candidate Mitt Romney passed a very similar law for his state when he was the governor of Massachusetts. So while most Democrats are celebrating the Supreme Court decision to uphold the Affordable Care Act and Romney is saying he’d repeal it, consider this: Had a Republican passed this federal law, we would have the opposite situation.

imageLet’s put politics aside and look at the law from a policy standpoint. The big winners of the Supreme Court decision are the corporations who are profiting from the current health system — private health insurers, pharmaceutical companies, and corporate-owned hospitals and medical practices.

The Court has deemed it constitutional for the government to require people to spend up to 9 percent of their income to purchase private insurance despite it being a defective product. People with insurance continue to face financial barriers to care. They delay and avoid necessary care because of the cost of co-pays and deductibles.

When patients have a serious medical condition, they risk financial ruin. Illness and soaring medical costs are the greatest causes of bankruptcy in the United States, even though four out of five people experiencing medical bankruptcy have health insurance. Purchasing private insurance is going to be subsidized with taxpayer dollars. It will cost Uncle Sam an estimated half a trillion dollars between 2014 and 2019 to pay that tab, according to the Congressional Budget Office. The insurance mandate and these subsidies will create corporate welfare on steroids.

What will the insurance companies do with all that money? They’ll hold onto as much as they can by denying and restricting payment for care. And they’ll use those dollars to weaken regulations meant to protect patients.

When national health care reform is fully implemented in 2019, 26 million people will still lack coverage. And health costs will continue to rise because the law lacks proven cost controls.

While the law does include a few positive provisions, it won’t stop the deterioration of our health care system. We’ll continue to see unnecessary suffering and preventable death. This is unacceptable when we are already spending nearly twice as much per person on care each year as other industrialized nations with universal health systems and much better health outcomes.

The truth is that we can solve our health care crisis. The fastest way to accomplish this is to drop just two words from the Medicare Act — "over 65" — and immediately expand Medicare to every person. That would create a system that’s about health care, not corporate profits. A universal Medicare system would control costs and improve the quality of patient care.

Let’s demand Medicare for all now. The longer we wait, the more people will suffer and die needlessly.

Margaret Flowers, MD is a pediatrician from Baltimore and co-director of ItsOurEconomy.US.  Distributed via OtherWords (OtherWords.org)

What’s Covered in the Affordable Care Act?

June 25, 2012 11:45 am

— BY KAREN Y.

The Stew steps through the crap the Right-Wing spews about ObamaCare (The Affordable Care Act) and breaks down what this landmark legislation actually means for average Americans.

AFFORDABLE CARE ACT (ACA) OF 2010

  1. Patient Rights and Protections
  2. Insurance Choices and Costs
  3. 65 and Older
  4. Small Business Tax Credits

The Affordable Care Act puts consumers back in charge of their health care. Under the law, a new “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health.

Patient’s Bill of Rights

  • Provides Coverage to Americans with Pre-existing Conditions: You may be eligible for health coverage under the Pre-Existing Condition Insurance Plan.
  • Protects Your Choice of Doctors: Choose the primary care doctor you want from your plan’s network.
  • Keeps Young Adults Covered: If you are under 26, you may be eligible to be covered under your parent’s health plan.
  • Ends Lifetime Limits on Coverage: Lifetime limits on most benefits are banned for all new health insurance plans. Before the health care law, many health plans set an annual limit — a dollar limit on their yearly spending for your covered benefits. Many plans also set a lifetime limit — a dollar limit on what they would spend for your covered benefits during the entire time you were enrolled in that plan. You were required to pay the cost of all care exceeding those limits.
  • Restricts Annual Dollar Limits on Coverage: Annual limits on your health benefits will be phased out by 2014.
  • Ends Pre-Existing Condition Exclusions for Children: Health plans can no longer limit or deny benefits to children under 19 due to a pre-existing condition.
  • Ends Arbitrary Withdrawals of Insurance Coverage: Insurers can no longer cancel your coverage just because you made an honest mistake.
  • Reviews Premium Increases: Insurance companies must now publicly justify any unreasonable rate hikes.
  • Helps You Get the Most from Your Premium Dollars: Your premium dollars must be spent primarily on health care – not administrative costs. Starting July 2012, The percentage of your premium dollars that an insurance company spends on providing you with health care and improving the quality of your care (as opposed to what it spends on administrative, overhead, and marketing costs) is known as “medical loss ratio.”

The new law limits how much of your premium dollar your insurer can spend on things other than providing health care and improving its quality. If your insurance company spends less than 80% of your premium on health care, it must provide a rebate of the difference.

  • Removes Insurance Company Barriers to Emergency Services: You can seek emergency care at a hospital outside of your health plan’s network.

Since the Patient’s Bill of Rights was enacted, the Affordable Care Act has provided additional rights and protections.  The health care law:

  • Covers Preventive Care at No Cost to You: You may be eligible for recommended preventive health services. No co-payment.
  • Guarantees Your Right to Appeal: You now have the right to ask that your plan reconsider its denial of payment.

Flexible Spending Account Changes

An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year.

  • There is no carry-over of FSA funds. This means that FSA funds you don’t spend by the end of the plan year can’t be used for expenses in the next year. An exception is if your employer’s FSA plan permits you to use unused FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year.
  • As of January 1, 2011, the costs of over-the-counter medications will be reimbursed under a Flexible Spending Account (FSA), Health Savings Account (HSA), or Health Reimbursement Account (HRA) only if the medications are purchased with a doctor’s prescription. These restrictions do not apply to the purchase of insulin.

Note: Flexible Spending Accounts are sometimes called Flexible Spending Arrangements. Health Reimbursement Accounts are sometimes called Health Reimbursement Arrangements.

Summary of Benefits and Coverage (SBC)

Starting September 23, 2012 or soon after, health insurance issuers and group health plans will be required to provide you with an easy-to-understand summary about a health plan’s benefits and coverage. The new regulation is designed to help you better understand and evaluate your health insurance choices.

Consumer Assistance Programs

  • Many states offer help to consumers with health insurance problems. The Affordable Care Act improves these services with grants that help states start or strengthen Consumer Assistance Programs (CAPs). The states and territories that applied for these grants have received funds provide residents direct help with problems or questions about health coverage.
  • Whether or not your state has a Consumer Assistance Program, you have rights under the health care law, including the right to appeal decisions made by your health insurance provider.
  • If your state does not have a Consumer Assistance Program, some state and federal government offices may still be able to help you determine your rights and solve problems.

Appealing Health Plan Decisions

The Affordable Care Act ensures your right to appeal health insurance plan decisions – to ask that your plan reconsider its decision to deny payment for a service or treatment. New rules that apply to health plans created after March 23, 2010 spell out how your plan must handle your appeal (usually called an “internal appeal”). If your plan still denies payment after considering your appeal, the law permits you to have an independent review organization decide whether to uphold or overturn the plan’s decision. This final check is often referred to as an “external review.”

Covered Preventive Services

Note: Services marked with an asterisk ( * ) must be covered with no cost-sharing in plan years starting on or after August 1, 2012.

Under the Affordable Care Act, you and your family may be eligible for some important preventive services — which can help you avoid illness and improve your health — at no additional cost to you.

  • Screenings for adults: abdominal aortic aneurysm, alcohol misuse screening and counseling, Aspirin use for men and women of certain ages, Blood Pressure screening for all adults, cholesterol screening for adults of certain ages or at higher risk, colorectal cancer screening for adults over 50, depression screening for adults, Type 2 Diabetes screening for adults with high blood pressure, diet counseling for adults at higher risk for chronic disease, HIV screening for all adults at higher risk, immunization vaccines for adults (doses), Obesity screening and counseling for all adults, sexually transmitted infection (STI) prevention counseling for adults at higher risk, tobacco use screening for all adults and cessation interventions for tobacco users, syphilis screening for all adults at higher risk.
  • Covered Preventive Services for Women, Including Pregnant Women: Anemia screening on a routine basis for pregnant women, bacteriuria urinary tract or other infection screening for pregnant women, BRCA counseling about genetic testing for women at higher risk, breast cancer mammography screenings every 1 to 2 years for women over 40, breast cancer chemoprevention counseling for women at higher risk, breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*, cervical cancer screening for sexually active women, chlamydia infection screening for younger women and other women at higher risk, Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*, domestic and interpersonal violence screening and counseling for all women*, folic acid supplements for women who may become pregnant, gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*, gonorrhea screening for all women at higher risk, Hepatitis B screening for pregnant women at their first prenatal visit, Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women*, Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older*, osteoporosis screening for women over age 60 depending on risk factors, Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk, tobacco use screening and interventions for all women, and expanded counseling for pregnant tobacco users, sexually transmitted infections (STI) counseling for sexually active women*, syphilis screening for all pregnant women or other women at increased risk, well-woman visits to obtain recommended preventive services for women under 65*.
  • Covered Preventive Services for Children: Alcohol and Drug Use assessments for adolescents, autism screening for children at 18 and 24 months, behavioral assessments for children of all ages, blood Pressure screening for children, Cervical Dysplasia screening for sexually active females, Congenital Hypothyroidism screening for newborns, Depression screening for adolescents, developmental screening for children under age 3, and surveillance throughout childhood, dyslipidemia screening for children at higher risk of lipid disorders, Fluoride Chemoprevention supplements for children without fluoride in their water source, gonorrhea preventive medication for the eyes of all newborns, hearing screening for all newborns, Height, Weight and Body Mass Index measurements for children, hematocrit or hemoglobin screening for children, hemoglobinopathies or sickle cell screening for newborns, HIV screening for adolescents at higher risk, immunization vaccines for children from birth to age 18 (doses, recommended ages, and recommended populations vary), iron supplements for children ages 6 to 12 months at risk for anemia, lead screening for children at risk of exposure, medical history for all children throughout development, obesity screening and counseling, oral health risk assessment for young children, Phenylketonuria (PKU) screening for this genetic disorder in newborns, sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk, tuberculin testing for children at higher risk of tuberculosis, vision screening for all children.

65 or Older
The Affordable Care Act strengthens Medicare, offers eligible seniors a range of preventive services with no cost-sharing, and provides discounts on drugs when in the coverage gap known as the “donut hole.”

  • Medicare Preventive Services: Under the Affordable Care Act, if you have Original Medicare, you may qualify for a yearly wellness visit and many preventive services for free. Medicare provides preventive benefits to keep you healthy including a yearly wellness visit, tobacco use cessation counseling, and a range of no-cost screenings for cancer, diabetes, and other chronic diseases.
  • Medicare Drug Discounts: The Affordable Care Act includes benefits to make your Medicare prescription drug coverage (Part D) more affordable. It does this by gradually closing the gap in drug coverage known as the “Donut Hole.”
  • Strengthening Medicare: Over $4 billion in Medicare fraud recovered in 2010. Under the Affordable Care Act, the life of the Medicare Trust Fund will be extended to at least 2024 as a result of reducing waste, fraud, and abuse, and slowing cost growth in Medicare. This will provide you with future cost savings on your premiums and co-insurance.

Small Business Employers
Tax credits and new programs are now available to small businesses. Learn how the law helps make care more affordable for employers, employees, and early retirees:

  • Small Employer Tax Credits: Tax credits for small businesses and non-profits help you bring down the cost of providing insurance. If you have fewer than 25 employees and provide health insurance, you may qualify for a tax credit of up to 35% (up to 25% for non-profits) to offset the cost of your insurance. This credit will increase in 2014 to 50% (35% for non-profits). This will make the cost of providing insurance much lower.
  • Early Retiree Reinsurance Program (ERRP): If your company provides health insurance to retirees ages 55 to 64, it may be eligible for financial help through the Early Retiree Reinsurance Program. The Early Retiree Reinsurance Program provides much-needed financial relief for employers so retirees can get quality, affordable insurance.

Compiled by VeracityStew.com

Also by this author:  What’s in Dodd-Frank?

Published with permission.  Originally published on VeracityStew.com [http://veracitystew.com/2012/06/17/whats-covered-in-the-affordable-care-act/]