Know What You’d be Giving Up—or What the GOP is Trying to Take Away

Posted on by vlrock

What is The Affordable Care Act? — The Affordable Care Act (ACA), officially titled The Patient Protection and Affordable Care Act (PPACA) and sometimes called ObamaCare (a nickname popularized by the GOP), is a US law that reformed both the healthcare and health insurance industries throughout America.  It was signed into law by President Barack Obama on March 23, 2010, upheld by the Supreme Court on June 28, 2012 and has overcome many GOP repeal attempts as well as a few other major court cases. While the law is not ‘perfect,’ in the years since the PPACA become a law, it has provided healthcare protection to more than 100 million Americans and has helped to reduce the uninsured rate nationally.

It came into existence as a first attempt to remedy a number of abusive issues within the insurance industry that created some serious access and financial issues for individuals and families across our nation.  As enacted, the PPACA:

Under the PPACA, all plans must offer a specified minimum level of TEN essential benefits that apply to employer plans, exchange plans, Medicaid and Medicare  (Note: There were a number of grandfathered plans that may not have included all of these 10 essential benefits, but those were permitted to continue unchanged under the PPACA only until 2015.)

  • Ambulatory patient services (Outpatient care). Care you receive without being admitted to a hospital, such as at a doctor’s office, clinic or same-day (“outpatient”) surgery center. Also included in this category are home health services and hospice care (note: some plans may limit coverage to no more than 45 days).
  • Emergency Services (Trips to the emergency room). Care you receive for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness. Typically, this is a trip to the emergency room and includes transport by ambulance. You cannot be penalized for going out-of-network or for not having prior authorization.
  • Hospitalization (Treatment in the hospital for inpatient care). Care you receive as a hospital patient, including care from doctors, nurses and other hospital staff, laboratory and other tests, medications you receive during your hospital stay, and room and board. Hospitalization coverage also includes surgeries, transplants and care received in a skilled nursing facility, such as a nursing home that specializes in the care of the elderly (note: some plans may limit skilled nursing facility coverage to no more than 45 days).
  • Maternity and newborn care. Care that women receive during pregnancy (prenatal care), throughout labor, delivery, and post-delivery, and care for newborn babies.
  • Mental health services and addiction treatment. Inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance abuse disorder. This includes behavioral health treatment, counseling, and psychotherapy. (NOTE: some plans may limit coverage to 20 days each year. Limits must comply with state or federal parity laws. Read this document for more information on mental health benefits and the Affordable Care Act).
  • Prescription drugs. Medications that are prescribed by a doctor to treat an illness or condition. Examples include prescription antibiotics to treat an infection or medication used to treat an ongoing condition, such as high cholesterol. At least one prescription drug must be covered for each category and classification of federally approved drugs; however, limitations do apply. Some prescription drugs can be excluded. “Over the counter” drugs are usually not covered even if a doctor writes you a prescription for them. Insurers may limit drugs they will cover, covering only generic versions of drugs where generics are available. Some medicines are excluded where a cheaper equally effective medicine is available, or the insurer may impose “Step” requirements (expensive drugs can only be prescribed if a doctor has tried a cheaper alternative and found that it was not effective). Some expensive drugs will need special approval.
  • Rehabilitative services and devices – Rehabilitative services (help recovering skills, like speech therapy after a stroke) and habilitative services (help developing skills, like speech therapy for children) and devices to help you gain or recover mental and physical skills lost to injury, disability or a chronic condition (this also includes devices needed for “habilitative reasons”). Plans have to provide 30 visits each year for either physical or occupational therapy, or visits to the chiropractor. Plans must also cover 30 visits for speech therapy as well as 30 visits for cardiac or pulmonary rehab.
  • Laboratory services. Testing provided to help a doctor diagnose an injury, illness or condition, or to monitor the effectiveness of a particular treatment. Some preventive screenings, such as breast cancer screenings and prostrate exams, are provided free of charge.
  • Preventive services, wellness services, and chronic disease treatment. This includes counseling, preventive care, such as physicals, immunizations, and screenings, like cancer screenings, designed to prevent or detect certain medical conditions. Also, care for chronic conditions, such as asthma and diabetes.
  • Pediatric services. Care provided to infants and children, including well-child visits and recommended vaccines and immunizations. Dental and vision care must be offered to children younger than 19. This includes two routine dental exams, an eye exam and corrective lenses each year.

Prior to the passage of the PPACA, many plans offered sub-par coverage as a way to keep premium costs down. This would seem attractive until one needed care. Provisions like this led to many cases of Americans paying for plans for years and then finding that they did not have access to the care they needed or they hit a dollar limit and were denied treatment when they needed it most. Today, under PPACA, all plans cover essential health benefits to ensure that we all get the care we need.

Depending on the plan you may have selected some Essential Benefits include no out-of-pocket costs (no cost sharing), but all Essential Benefits offer no annual or lifetime limits and have minimum cost sharing limits.

  • No Cost Sharing on Some Preventive Services — Essential Health Benefits include annual wellness visits and many types of preventive services including immunizations and screenings at no out of pocket costs. The Affordable Care Act has a major focus on wellness and prevention to help increase early detection and catch sickness before it starts increasing wellness and decreasing the need for costly treatments. Note: For preventive care to have no out-of-pocket expense it must be delivered by a network provider.
  • No Annual Limits on Essential Health Benefits — There are no dollar limits on Essential Benefits. Before annual and lifetime limits were enacted, over 60% of bankruptcies in the US were medical bankruptcies. Eliminating dollar limits on essential care ensures that patients won’t have to stop treatment or go broke when they reach their dollar limit.
  • A Minimum Actuarial Value on All Coverage — The PPACA places a cap on out-of-pocket costs on all plans that cover Essential Benefits. Plans offering Essential Benefits must cover at least 60% of covered out-of-pocket expenses, on average, and must have reasonable out-of-pocket maximums.  Some plans may also have what’s called a “stop-loss” provision such that once they reach the plan’s stated out-of-pocket maximums, the plan pays 100% of their extra costs.  (Note: Stop-Loss limits never include your premium, balance-billed charges, or health care your health insurance or plan doesn’t cover. However, all cost-sharing you’re charged for Essential Benefits does count toward your out-of-pocket stop-loss limit.)
    • Bronze plans cover 60% on average of covered out-of-pocket expenses,
    • Silver plans generally cover 70% of covered out-of-pocket expenses,
    • Gold plans generally cover 80% of covered out-of-pocket expenses, and
    • Platinum plans generally cover 90% of covered out-of-pocket expenses.

The PPACA did define some limits and exceptions.  Those are:

  • Insurance companies can still put a yearly dollar limit and a lifetime dollar limit on spending for health care services that are not considered essential health benefits.
  • Some health insurance plans may have received a temporary waiver from the rules on yearly dollar limits. Yearly limit waivers end with plan or policy years beginning in 2015 (2014 in some States).
  • All non-grandfathered health plan must limit the total out-of-pocket costs enrollees pay for in-network.
  • Health plans can still set limits on the number of times you can receive a certain treatment.
  • Large Group (employer) markets and self-funded (ASOs) don’t need to offer Essential Benefits.

Quick Facts about Essential Benefits defined under the PPACA (Obamacare):/

  • Cost sharing (co-pays and amounts you’re required to pay) for Essential Health Benefits count towards your maximums.
  • Aside from the Essential Health Benefits, one or more of the plans from which you’re able to select may offer a number of additional benefits.
  • Some plans may offer better cost-sharing options on benefits subject to out-of-pocket cost-sharing. Generally speaking, the more valuable the ‘metal’ (bronze, silver, gold, platinum), a higher the percentage of out-of-pocket costs will be covered by your insurer.
  • Essential Health Benefits include the most commonly used health services like preventive services and annual wellness visits with no cost sharing (co-pays).
  • Essential Health Benefits include preventive care and treatments you need should you get sick. This includes ongoing treatment for common serious sicknesses like cancer.
  • Before the PPACA over 60% of all bankruptcies in the US were medical related, many due to the cost of treatment exceeding annual and lifetime dollar limits.Under the PPACA, there are NO annual or lifetime limits on Essential Health Benefits.
  • The annual cost to society of substance use disorders alone is approximately $200 billion, yet only a fraction ($15 billion) is spent on treatment. The PPACA included parity treatment mental health and substance use disorders services is projected to balance these numbers and reduce healthcare costs.
  • Plans offered by large employers are required to offer only “Minimum Essential Coverage” without the act defining what that looks like. This has caused some companies to adopt “skinny plans” with very limited coverage. There are no requirements for limits on out-of-pocket cost for services not covered under such employer plans.

Want to know more?  Obamacarefacts.com has a wealth of information about the Patient Protection and Affordable Care Act that you can glean through at your leisure.