Protections in the Patient Protection and Affordable Care Act (ACA)

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on February 23rd, 2017.
Protections in the Patient Protection and Affordable Care Act (ACA)

If you think that any part of the ACA (sometimes called “Obamacare”) has helped you or anyone you know, contact the President and your members of Congress. Voice your support for provisions you value in any legislation that is introduced in Congress to replace the ACA.

How many of these provisions did you know that the Affordable Care Act includes?

  • Provides access to health insurance for citizens and legal immigrants through state-run exchanges or the federal-facilitated Marketplace.

  • Funds an online program and help-line ((800) 318-2596) to help people review their health insurance options.

  • Funds states to set up or expand counseling to help people navigate the private insurance system and find a plan that fits their needs and budgets.

  • Offers access to health insurance for those with pre-existing health problems (like kidney disease or transplant) on state exchanges and the Marketplace.

  • Requires all insurers to cover those with pre-existing conditions.

  • Limits how companies can set health insurance premiums. Only age (premiums for older people can be no more than 3 times those of young people), geographic area, and smoking can be used. In the past, women paid much more than men.

  • Requires premium hikes to be reviewed and approved. Plans must spend 80% of premiums on medical costs (not investment or marketing)—or give rebates to consumers.

  • Eliminates annual and lifetime limits on health insurance coverage.

  • Requires all health plans including Medicare to provide certain preventive services for free.

  • Allows children to stay on a parent’s health plan until age 26.

  • Lets states choose to expand Medicaid to those under 65 without Medicare who have incomes up to 138% of the federal poverty level (31 states did so). The federal government pays pays states’ costs at 95% in 2017, declining to 90% in 2020 and later for new enrollees who became eligible due to Medicaid expansion.

  • Offers a tax credit to help small businesses (50 or fewer employees) offer health insurance to their employees through the Small Business Health Options Program (SHOP).

  • Offers a tax credit to larger businesses (over 50 employees) to provide health insurance coverage—or they pay a penalty for not offering coverage.

  • Provides tax credits to those whose income is 100-400% of the federal poverty level no matter which “metal level” plan (bronze, silver, gold or platinum) they choose in states that didn’t expand Medicaid (income limits for tax credits are 138% to 400% of federal poverty in states that did expand Medicaid). A change that could help those with limited income would be to provide tax credits for those with incomes less than 100% of federal poverty who live in states that didn’t expand Medicaid and who don’t qualify for tax credits now.

    Note: Premiums tend to increase and out-of-pocket costs tend to decrease when going from a bronze to a silver to a gold to a platinum plan. Costs vary for deductibles, coinsurance and copayments from plan-to-plan.

Plan Category

Estimated Insurance Payment

Estimated Payment by Insured

Bronze

60%

40%

Silver

70%

30%

Gold

80%

20%

Platinum

90%

10%

  • Offers cost sharing subsidies to lower out-of-pocket costs for premiums, copays, and coinsurance for those who choose a silver level plan and whose income is 100-250% of the federal poverty level. Depending on their income within that range, their maximum out-of-pocket cost in 2017 is from $2,350 to $5,700 per individual or from $4,700 to $11,400 for two or more family members.

  • Limits the out-of-pocket maximum to $7,150 for an individual or $14,300 for two or more family members if the family’s income is higher than 250% of federal poverty or other than a silver plan is chosen.

  • Requires most people to enroll in a health plan or pay an income-based penalty of 2.5% of household income or $695 per adult through taxes, except those who qualify for an exemption.

  • Covers a set of “essential benefits” (see below) in state-run exchanges and the federal-facilitated Marketplace, as well as in most individual and group plans:

    • Ambulatory patient services (outpatient care you get without being admitted to a hospital)—including dialysis

    • Emergency services

    • Hospitalization (like surgery and overnight stays)—including inpatient dialysis

    • Pregnancy, maternity, and newborn care (both before and after birth)

    • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)

    • Prescription drugs

    • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)

    • Laboratory services

    • Preventive and wellness services and chronic disease management

    • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

Plans must also include the following benefits:

Centers for Medicare & Medicaid Services. How to pick a health insurance plan.

Kaiser Family Foundation. Summary of Coverage Provisions in the Patient Protection and Affordable Care Act. July 17, 2012

Resources:

Kaiser Family Foundation. Explaining Health Care Reform: Questions About Health Insurance Subsidies. November 1, 2016.

Kaiser Family Foundation. Status of State Action on the Medicaid Expansion Decision. January 1, 2017.

U.S. Department of Health & Human Services. Key Features of the Affordable Care Act by Year

Comments

  • amandap

    Mar 1, 10:24 PM

    It's really because if you can keep a population sick and broke you can more effectively oppress them and stay in power.

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  • amanda p

    Feb 23, 6:35 PM

    I think we should repeal paying for the golden health insurance benefits our legislature bestows on itself both on the state and federal levels.

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    • Beth Witten

      Mar 19, 1:53 PM

      I wasn't sure about state legislators so I searched and found this information on the National Conference of State Legislatures website. State legislators are considered state employees, but some states consider them part-time employees and offer optional coverage and couple of states don't offer them coverage at all. http://www.ncsl.org/research/health/state-employee-health-benefits-ncsl.aspx

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    • Beth Witten

      Mar 19, 1:44 PM

      Members of Congress (federal) get their healthcare through the ACA exchange for small businesses in DC (SHOP). Similar to other employer-provided health insurance plans, the employer (in this case, the federal government) pays part of the premium. If the congressperson purchases a gold plan, the government pays 72%. After he/she retires from Congress, he/she can get insurance the same way other federal employees are insured, which is under the Federal Employee Health Benefits Program. I found this information on Snopes which fact checks rumors. This was posted 3/15/17. http://www.snopes.com/members-congress-health-care/

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  • John Agar

    Feb 23, 4:48 PM

    Not that I think the ACA approaches the fairness, equity and access of the universal healthcare offered by most other western nations (ANZ, Canada, Scandinavian countries, and even the dear old but rather stretched NHS in the UK) ... it doesn't ... but, it still took a huge step in the fairness, equity and access direction. To regress back to a 'who know's what level of repeal' under Trump seems utter madness. It would certainly eliminate any vestige of move forward to fairness, equity and access that the ACA delivered. I simply can't understand their thinking. It's reptilian.

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