How the Patient Protection and Affordable Care Act Helps Pennsylvania

application/pdf iconACA Timeline and Summary (Jan 2012).pdf
application/pdf iconACA Summary Brochure.pdf

The Affordable Care Act puts the health of our families first. It makes sure that all of us have affordable, quality choices; it stops insurance companies from denying us care or charging us excessive and unfair rates; and it sees that we all have the tools we need to keep ourselves well. 

The new law puts an end to some of the worst insurance company abuses and makes health coverage more secure by making sure no one is denied care over a pre-existing condition, and that affordable, quality choices will be available to our families regardless of our income, health or employment status.

How and when will this affect you? Follow the timeline to find out! 

2010

For young adults: Option to stay covered on parents’ insurance

  • Effective Sept. 1, all young adults can remain on their parents’ health insurance plan until age 26. The young adult does not have to be a legal dependent or a student, and they can also be married or live in another state. Learn more at: http://cciio.cms.gov/resources/files/adult_child_faq.html. 

For early retirees: Support to help employers maintain retiree coverage

  • Early Retiree Reinsurance Program: If you are between age 55-64, check with your employer to see if they’ve taken advantage of new funding available to help offset the cost of offering continuing coverage to early retirees. This program, which will run between now Jan. 1, 2014, offers tax-free reimbursements to companies for medical claims of early retirees. For a list of participating employers in PA, see: http://www.healthcare.gov/law/features/employers/early-retiree-reinsurance-plan/pa.html.

For people with pre-existing health conditions: New coverage options

  • PA Fair Care: This is a comprehensive, affordable insurance plan available to anyone with a pre-existing health condition. This option will be available until Jan. 1, 2014 when it will be illegal for insurers to deny coverage or charge you more because of your gender or health status. Learn more at: www.pafaircare.com or by calling PHAN at (412) 512-9225. 

For all of us: New tools to keep health insurance rates reasonable

  • Beginning in 2010, the Department of Health and Human Services will work with states to create a process where insurers will have to publicly disclose and justify any rate hikes above 10% annually. This will bring more transparency and help keep rates affordable. Requested rate increases will be tracked and posted by HHS at: http://companyprofiles.healthcare.gov/. Pennsylvania will work to strengthen our oversight of rate hikes as well.

For seniors struggling with prescription drug costs: New Rx drug discounts

  • Effective Sept. 1, all seniors caught in the prescription drug coverage gap (the ‘donut hole’) received a $250 rebate check. In 2011, any senior who enters the donut hole will receive a 50% discount on brand drugs (7% on generics). The coverage gap will be eliminated by 2020, and discounts will increase each year, saving seniors money. Learn more at: http://www.healthcare.gov/law/features/65-older/.

For small businesses who would like to offer coverage: New tax credits

  • Effective Sept. 1, small businesses will receive a new tax credit to help with the cost of offering coverage to their employees. To qualify, a business must cover at least half of their employees’ premiums and have less than 25 full-time workers with average annual wages below $50,000. Small employers can deduct 35% from what it costs them to cover each employee, until 2014, when the credit rises to 50%. Learn more at: http://www.smallbusinessmajority.org/hc-reform-faq/. 

For people with private health insurance: Free preventive care

  • Effective Sept. 1, anyone enrolled in an insurance plan created on or after March 23, 2011 will be able to access preventive care with no cost-sharing or deductibles. These services include: a flu shot and other vaccinations, birth control, blood pressure and cholesterol tests, and many cancer screenings. View the full list of free preventive services at: http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html. 
  • Insurance plans (such as large group employer-provided plans) in effect prior to the law’s passage are considered to be “grandfathered” and are not required to offer free preventive services--but, a plan can lose its grandfathered status and be subject to the requirements of new plans if it: 
  • significantly increases co-payments or deductibles, raises co-insurance, reduces or eliminates covered benefits, makes annual limits more restrictive or adds new annual limits, or significantly decreases the share of premiums that employers contribute for their workers. 

For a detailed description of what standards grandfathered plans must meet, visit: http://www.familiesusa.org/assets/pdfs/health-reform/Grandfathered-Plans.pdf.

For all of us: New comparison tools

  • In July, the Department of Health and Human Services took some of the headache out of searching for private insurance in launching www.HealthCare.gov, a user-friendly resource where anyone can go to get side-by-side comparisons of the benefits and costs for plans in their area. The comparison tool allows folks to make smart choices using accurate, unbiased information.

2011 to 2013

For seniors enrolled in original Medicare: Free preventive care

  • Beginning Jan. 1st, all seniors in Traditional Medicare will receive new preventive care benefits for free. This means that a senior can get: an annual flu shot, dementia screening, nutrition counseling, a mammogram or colonoscopy or many other important preventive services -- all with no co-pays or cost-sharing. For a full list of preventive benefits now available for free for seniors, see: http://www.healthcare.gov/law/features/65-older/medicare-preventive-services/index.html. 

For people with private health insurance: New protections to see that insurers use your money on actual medical care!

  • Right now, there is very little transparency or accountability for how insurance companies use our premium dollars. They can use them for advertising, lobbying, CEO salaries and board member perks--things that have nothing to do with the quality or value of our coverage. Starting in 2011, the law puts a stop to this bad behavior by requiring insurance companies to spend at least 85% of policyholders’ premium dollars on actual health care--giving all of us more bang for our buck. If a company doesn’t meet this standard, they have to give all policyholders a rebate for the difference at the end of that policy year. This also applies to Medicare Advantage plans--starting in 2014. 

For kids: CHIP’s funding extended to keep kids covered

  • The Children’s Health Insurance Program (CHIP), which provides federal funding to states to make sure all kids up to age 19 have health coverage is reauthorized and funded for an additional two years -- until 2015. 

For seniors enrolled in Medicare Advantage: Bonus payments to highly-rated plans

  • Effective Jan. 1st, 2012 Medicare Advantage plans that are rated at least 4 of 5 stars by the Center for Medicare and Medicaid Services (CMS) will receive a 10% bonus payment. This bonus will incentivize insurers to offer high-quality, comprehensive, affordable choices to seniors by rewarding the best plans. To compare Medicare Advantage plans in your area, and view plan ratings, visit: www.medicare.gov/find-a-plan/questions/home.aspx or call 1-800-MEDICARE (1-800-633-4227). 

For seniors on medicare: Bonus payments to primary care physicians

  • Beginning Jan. 1st, and lasting through 2015, all primary care physicians accepting Medicare patients will receive a 10% bonus payment on top of their regular reimbursement rate to reward doctors in this critically important field. 

For all of us: Bonus payments to primary care physicians and general surgeons practicing in shortage areas

  • Beginning Jan. 1st, and lasting through 2015, all primary care physicians and general surgeons practicing in shortage areas will receive a 10% bonus payment on top of their regular reimbursement rate to incentivize more practitioners to serve areas in need. 

For Folks on Medicaid: Better Reimbursements for Primary Care Physicians

  • On Jan. 1st, primary care doctors treating Medicaid patients will be reimbursed at Medicare payment rates to ensure that physicians in this growing field are well-compensated.

Relieving the Paperwork Burden on Doctors: Electronic Medical Records

  • Beginning Oct. 1st, insurers will be required to simply and standardize their billing forms to relieve the administrative burden on doctors and hospitals. Health plans will also begin preparing to upgrade and make your health records more secure by moving to an electronic record-keeping system. This will reduce medical errors, cut costs and give your doctor more time to spend with you, the patient. 

2014: A New Day in Health Care

From this year on, all Americans will enjoy the security and peace of mind that comes with having stable, affordable, high-quality health coverage, regardless of their health or employment status. Here’s how it works:

Insurers Cannot Deny You Coverage or Charge You More Due to Your Health Status or Gender:

The days when an insurance company can deny you coverage because you have a health condition, or charge you higher rates because you happen to be female, are over. Insurers must offer coverage to everyone who seeks it, and cannot refuse to pay for treatments related to an illness you had before signing up for that plan. 

You Can Rest Assured That Quality Coverage Will Be There When You Need It:

If you’re facing a layoff, struggling to find full-time work with benefits or thinking about starting your own business, you no longer have to face the threat of being uninsured. Beginning Jan. 1st, you can secure coverage through a new, competitive state-based insurance marketplace, choosing from the same plans available to your Member of Congress. 

Insurance companies will compete for your business based on plan quality and value. Insurers will have to provide you with a standardized, easy to understand description of what their plans cover and how much you can expect to pay for covered services so that you can make apples-to-apples comparisons and choose a plan that’s right for you and family -- or your and your small business. 

All plans offered in this new marketplace will have to meet high standards for quality and affordability, and must cover the “essential benefits” you need to stay well, including: ambulatory care, emergency care, hospitalization, prescription drugs, maternity and newborn care, mental health and substance abuse treatment, rehabilitative care, laboratory services, preventive and wellness services, chronic disease management, and pediatric services. If you work in a low-wage, low-benefit sector where you are “offered” a plan by your employer that’s too expensive and doesn’t cover what you need -- you don’t have to take your employer-based coverage. Instead, you can take the money your employer would have put toward your coverage and use it to sign up for a better, more affordable plan in the new marketplace.

You Are Protected Financially and Have the Right to Comprehensive Coverage You Can Afford:

Gone are the days of being pushed to the brink of financial ruin over health care costs. Gone are the days of languishing uninsured if you’re a low-income worker, or laid off. Now, if you earn between 133 and 400% of the federal poverty level in 2014 (for an individual in 2010 dollars--that’s $14,484 and $43,560--each year, these amounts will rise slightly) and purchase coverage in the new marketplace, you will get substantial tax credits to lower your monthly premiums (before you pay them!) and will benefit from caps limiting how much you have to pay in out-of-pocket for health care each year. If your employer offers you a plan that would cost more than 9.5% of your household income, or if it covers less than 60% of cost of covered benefits, you can reject that plan, choose a plan in the new marketplace, and receive the same tax credits as everyone else. Here’s how the tax credits and out-of-pocket caps work (in 2014 figures):

If you are purchasing a plan through the new marketplace, the amount you pay for your premiums is based on your household income, to make sure coverage is affordable for you. Out-of-pocket caps limit how much you have to pay for co-insurance and other co-pays, but does not include your monthly premium payments. You can calculate the value of your credits and out-of-pocket caps at: http://healthreform.kff.org/Subsidycalculator.aspx.

Keep in mind: This chart depicts the scenarios based on selecting a “silver” level benefit plan, with cost estimates provided the Congressional Budget Office, analyzed by the Kaiser Family Foundation. If you are currently covered by your employer, the out-of-pocket caps will not apply to your plan unless it does something to lose it’s “grandfathered” status like reduce your coverage or significantly raise your co-pays.

If you earn less than 133% of the poverty level, you will be able to get fully covered under Medicaid--whether or not you have children, and regardless of your health status. 

Protecting Our Families, Protecting Our Care

Our health, the health of our families is sacred. We all want to know that we and our loved ones can get the care we need, when we need it--at a price we can afford. That’s what the Affordable Care Act is all about. It puts the health of our families first and sees that we all have affordable, quality choices. It stops insurance companies from denying us care or charging us excessive and unfair rates; and it gives us the tools we need to keep ourselves well.

Unfortunately, many politicians continue to attack the new law to score political points. They don’t understand--or don’t care to look at--how it’s already giving peace of mind, security and stability to millions of working families, young adults, seniors and small businesses here in Pennsylvania. 

We all know folks in our lives who have struggled to find, afford or hang on to health coverage for themselves and their families. We can image the terror of looking at a loved one with cancer and telling them that there’s nowhere to turn for help. We feel, deep in our hearts, the injustice of watching folks who are doing everything right fall further and further behind. That’s why we have to move forward. We cannot allow big insurance giants and the politicians doing their bidding to take away these new rights, benefits and protections for our families. 

What can we all do to protect the Affordable Care Act and see that our families and communities feel its benefit?

You’ve already done the most important thing--educating yourself on what’s in the new law. You’re armed with good information--and now we need you to share it! Talk to your friends and neighbors, your family, and most importantly, your state legislators. Tell them you support this law and want to see its promise made real to all Pennsylvanians.

PHAN is always looking for good folks to help us get the word out about the benefits of the new law. We’re available to help folks who are recently laid-off, underinsured or struggling with health care costs to find coverage and access the care they need. And we’re looking to connect with folks who have or will be helped by the new law. If any of those describe you--please get in touch with us!