Incremental changes began to occur in 2010 to begin trying to improve regulation and access to insurance. The insurance reform implementation timeline culminated in many major changes occurring in 2014 when the health-insurance Marketplace opened and the “individual mandate” that individuals must purchase health insurance or face a monetary penalty (with few exceptions) took effect. The health-insurance reform law will continue on after 2014 to make incremental changes to insurance with final implementation of changes slated for 2020. Please note that the following is meant to be a summary and is not a comprehensive list of changes related to the ACA.
2010 Implemented changes such as:
- Children could not be denied insurance based on pre-existing conditions
- Young adults up to age 26 could remain on his/her parent’s policy
- Stopped rescissions or insurance policy cancellations based on technicalities, application mistakes, or other minor issues
2011 Implemented changes such as:
- An 80/20 rule for insurance company spending (i.e., the insurance company must spend at least 80% of the money they accept in premiums for health coverage on healthcare and quality-improvement measures). The percent of money which must be spent on medical care or quality-improvement measures is also sometimes called a MLR or Medical Loss Ratio. If the insurance company doesn’t meet their metrics, they may need to pay policy holders a rebate from paid premiums.
- Rate reviews that protect policy holders from unreasonable increases in insurance premiums. With few exceptions, insurance companies must now explain and be approved to increase their existing policy premiums by 10% or more.
- Individuals with Medicare received a financial rebate toward a portion of the part D “donut hole” to help reduce out-of-pocket expenses for their medications.
2012 Implemented changes such as:
- Increased covered preventative services for women such as breast cancer screenings, and contraception coverage (*note that free contraception coverage continues to be debated in the judicial system as some companies claim religious exemptions from needing to provide or offer coverage)
- Insurance companies were made to supply less confusing and more understandable paperwork. The paperwork must provide a short Summary of Benefits and Coverage (SBC) written in plain language and a Glossary to explain terms used in health coverage.
2013 Implemented one major change:
- The opening of the State, Federal, and hybrid State-Federally facilitated Marketplaces – these Marketplaces (Exchanges) are the platform through which people who are seeking to purchase an insurance policy can shop and compare available private insurance plans being sold in their state. The Marketplace can also screen out individuals who would be eligible to apply for their state Medicaid program or CHIP (Children’s Health Insurance Program).
- Open enrollment began on October 1, 2013.
2014 Implemented changes such as:
- Adults with pre-existing conditions can no longer be excluded from purchasing health insurance.
- Many states have expanded their Medicaid programs to include more individuals including increasing qualifying income limits and childless adults into their programs.
- Many individuals purchasing insurance in the Marketplace will qualify for premium and out-of-pocket savings for purchased plans.
- Insurance companies can no longer set yearly or lifetime caps on the amount of medical care a person can receive. Please note that the lifetime cap applies to all health policies, but some insurance plans do have a “grandfathered” status and may still place an annual benefits cap. (“Grandfathered” plans were in effect on March 23, 2010 and the policies have not been considered to be substantially changed in ways that cut benefits or increased costs for policy holders. If you have a “grandfathered” insurance plan, your insurance carrier needed to notify you of that).
- Essential health benefits (EHBs) are the minimum coverage requirements for all plans sold in the Marketplace; however, plans can choose to include additional benefits or coverage.
Essential health benefits (EHBs) include the following:
(You will need to review specific policy coverage to determine any differing policies as far as what may be covered under each identified service, as there may be minor differences from policy to policy.)
- Emergency services
- Ambulatory patient services (outpatient care)
- Maternity and newborn care
- Pediatric services
- Substance abuse services and mental health (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (these are services or devices which assist people with injuries, chronic conditions, or disabilities to gain or maintain mental and physical skills)
- Laboratory testing or services
- Many preventative care, wellness, and chronic disease management services offered with no cost sharing (see https://www.healthcare.gov/what-are-my-preventive-care-benefits/#part=1 for more specific information on adult preventative services).
More changes are slated to be phased in incrementally until 2020 when the full implementation of the Affordable Care Act is scheduled to occur. Some of these changes include:
- Gradual closing of the Medicare “donut hole” which will be considered closed in 2020 with Medicare recipients paying 25 percent of brand name and generic drugs during the “donut hole” or coverage gap.
- Some employers with over 50 full-time employees in 2015 may be required to pay the Employer Shared Responsibility Payment if they don’t offer insurance that meets certain minimum standards.
Now that I know more about the history and some of the changes which are occurring, what are my next steps?
Most Americans with manageable healthcare needs will find sufficient information regarding coverage options through state and federal resources; however, the MS community must be prepared to ask additional questions to ensure proper insurance coverage. Using the MSAA PLAN model will hopefully set you up for success.
Click the following to proceed to PLAN.