The Affordable Care Act


About the Law

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.

Coverage

  • 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.
  • Keeps Young Adults Covered: If you are under 26, you may be eligible to be covered under your parent's health plan.
  • Ends Arbitrary Withdrawals of Insurance Coverage: Insurers can no longer cancel your coverage just because you made an honest mistake.
  • Guarantees Your Right to Appeal: You now have the right to ask that your plan reconsider its denial of payment.

Costs

  • Ends Lifetime Limits on Coverage: Lifetime limits on most benefits are banned for all new health insurance plans.
  • 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.

Care

  • Covers Preventive Care at No Cost to You: You may be eligible for recommended preventive health services. No copayment.
  • Protects Your Choice of Doctors: Choose the primary care doctor you want from your plan's network.
  • Removes Insurance Company Barriers to Emergency Services: You can seek emergency care at a hospital outside of your health plan's network.


Key Features of the Affordable Care Act By Year


On March 23, 2010, President Obama signed the Affordable Care Act. The law puts in place comprehensive health insurance reforms that will roll out over four years and beyond. Use the links below to learn about what's changing and when:

OVERVIEW OF THE HEALTH CARE LAW

2010: A new Patient's Bill of Rights goes into effect, protecting consumers from the worst abuses of the insurance industry. Cost-free preventive services begin for many Americans.

2011: People with Medicare can get key preventive services for free, and also receive a 50% discount on brand-name drugs in the Medicare "donut hole."

2012: Accountable Care Organizations and other programs help doctors and health care providers work together to deliver better care.

2013: Open enrollment in the Health Insurance Marketplace begins on October 1st.

2014: All Americans will have access to affordable health insurance options. The Marketplace allows individuals and small businesses to compare health plans on a level playing field. Middle and low-income families will get tax credits that cover a significant portion of the cost of coverage. And the Medicaid program will be expanded to cover more low-income Americans. All together, these reforms mean that millions of people who were previously uninsured will gain coverage, thanks to the Affordable Care Act.

2010

NEW CONSUMER PROTECTIONS

  • Putting Information for Consumers Online. The law provides for where consumers can compare health insurance coverage options and pick the coverage that works for them. Effective July 1, 2010.
  • Prohibiting Denying Coverage of Children Based on Pre-Existing Conditions. The health care law includes new rules to prevent insurance companies from denying coverage to children under the age of 19 due to a pre-existing condition. Effective for health plan years beginning on or after September 23, 2010 for new plans and existing group plans.
  • Prohibiting Insurance Companies from Rescinding Coverage. In the past, insurance companies could search for an error, or other technical mistake, on a customer's application and use this error to deny payment for services when he or she got sick. The health care law makes this illegal. After media reports cited incidents of breast cancer patients losing coverage, insurance companies agreed to end this practice immediately. Effective for health plan years beginning on or after September 23, 2010.
  • Eliminating Lifetime Limits on Insurance Coverage. Under the law, insurance companies will be prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays. Effective for health plan years beginning on or after September 23, 2010.
  • Regulating Annual Limits on Insurance Coverage. Under the law, insurance companies' use of annual dollar limits on the amount of insurance coverage a patient may receive will be restricted for new plans in the individual market and all group plans. In 2014, the use of annual dollar limits on essential benefits like hospital stays will be banned for new plans in the individual market and all group plans. Effective for health plan years beginning on or after September 23, 2010.
  • Appealing Insurance Company Decisions. The law provides consumers with a way to appeal coverage determinations or claims to their insurance company, and establishes an external review process. Effective for new plans beginning on or after September 23, 2010.
  • Establishing Consumer Assistance Programs in the States. Under the law, states that apply receive federal grants to help set up or expand independent offices to help consumers navigate the private health insurance system. These programs help consumers file complaints and appeals; enroll in health coverage; and get educated about their rights and responsibilities in group health plans or individual health insurance policies. The programs will also collect data on the types of problems consumers have, and file reports with the U.S. Department of Health and Human Services to identify trouble spots that need further oversight. Grants Awarded October 2010.

IMPROVING QUALITY AND LOWERING COSTS

  • Providing Small Business Health Insurance Tax Credits. Up to 4 million small businesses are eligible for tax credits to help them provide insurance benefits to their workers. The first phase of this provision provides a credit worth up to 35% of the employer's contribution to the employees' health insurance. Small non-profit organizations may receive up to a 25% credit. Effective now.
  • Offering Relief for 4 Million Seniors Who Hit the Medicare Prescription Drug "Donut Hole." An estimated four million seniors will reach the gap in Medicare prescription drug coverage known as the "donut hole" this year. Each eligible senior will receive a one-time, tax free $250 rebate check. First checks mailed in June, 2010, and will continue monthly throughout 2010 as seniors hit the coverage gap. Learn more about the "donut hole" and Medicare.
  • Providing Free Preventive Care. All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Effective for health plan years beginning on or after September 23, 2010. Learn more about preventive care benefits. See the full list of covered preventive services.
  • Preventing Disease and Illness. A new $15 billion Prevention and Public Health Fund will invest in proven prevention and public health programs that can help keep Americans healthy - from smoking cessation to combating obesity. Funding begins in 2010. See prevention funding and grants in your state.
  • Cracking Down on Health Care Fraud. Current efforts to fight fraud have returned more than $2.5 billion to the Medicare Trust Fund in fiscal year 2009 alone. The new law invests new resources and requires new screening procedures for health care providers to boost these efforts and reduce fraud and waste in Medicare, Medicaid, and CHIP. Many provisions effective now.

INCREASING ACCESS TO AFFORDABLE CARE

  • Providing Access to Insurance for Uninsured Americans with Pre-Existing Conditions. The Pre-Existing Condition Insurance Plan provides new coverage options to individuals who have been uninsured for at least six months because of a pre-existing condition. States have the option of running this program in their state. If a state chooses not to do so, a plan will be established by the Department of Health and Human Services in that state. National program effective July 1, 2010.
  • Extending Coverage for Young Adults. Under the law, young adults will be allowed to stay on their parents' plan until they turn 26 years old (in the case of existing group health plans, this right does not apply if the young adult is offered insurance at work). Check with your insurance company or employer to see if you qualify. Effective for health plan years beginning on or after September 23.
  • Expanding Coverage for Early Retirees. Too often, Americans who retire without employer-sponsored insurance and before they are eligible for Medicare see their life savings disappear because of high rates in the individual market. To preserve employer coverage for early retirees until more affordable coverage is available through the new Exchanges by 2014, the new law creates a $5 billion program to provide needed financial help for employment-based plans to continue to provide valuable coverage to people who retire between the ages of 55 and 65, as well as their spouses and dependents. Applications for employers to participate in the program available June 1, 2010. For more information on the Early Retiree Reinsurance Program, visit www.ERRP.gov.
  • Rebuilding the Primary Care Workforce. To strengthen the availability of primary care, there are new incentives in the law to expand the number of primary care doctors, nurses and physician assistants. These include funding for scholarships and loan repayments for primary care doctors and nurses working in underserved areas. Doctors and nurses receiving payments made under any state loan repayment or loan forgiveness program intended to increase the availability of health care services in underserved or health professional shortage areas will not have to pay taxes on those payments. Effective 2010.
  • Holding Insurance Companies Accountable for Unreasonable Rate Hikes. The law allows states that have, or plan to implement, measures that require insurance companies to justify their premium increases will be eligible for $250 million in new grants. Insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new health insurance Exchanges in 2014. Grants awarded beginning in 2010.
  • Allowing States to Cover More People on Medicaid. States will be able to receive federal matching funds for covering some additional low-income individuals and families under Medicaid for whom federal funds were not previously available. This will make it easier for states that choose to do so to cover more of their residents. Effective April 1, 2010.
  • Increasing Payments for Rural Health Care Providers. Today, 68% of medically underserved communities across the nation are in rural areas. These communities often have trouble attracting and retaining medical professionals. The law provides increased payment to rural health care providers to help them continue to serve their communities. Effective 2010.
  • Strengthening Community Health Centers. The law includes new funding to support the construction of and expand services at community health centers, allowing these centers to serve some 20 million new patients across the country. Effective 2010.

2011

IMPROVING QUALITY AND LOWERING COSTS

  • Offering Prescription Drug Discounts. Seniors who reach the coverage gap will receive a 50% discount when buying Medicare Part D covered brand-name prescription drugs. Over the next ten years, seniors will receive additional savings on brand-name and generic drugs until the coverage gap is closed in 2020. Effective January 1, 2011. Download a brochure to learn more (PDF - 1 MB)
  • Providing Free Preventive Care for Seniors. The law provides certain free preventive services, such as annual wellness visits and personalized prevention plans for seniors on Medicare. Effective January 1, 2011. Learn more about preventive services under Medicare.
  • Improving Health Care Quality and Efficiency. The law establishes a new Center for Medicare & Medicaid Innovation that will begin testing new ways of delivering care to patients. These methods are expected to improve the quality of care, and reduce the rate of growth in health care costs for Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). Additionally, by January 1, 2011, HHS will submit a national strategy for quality improvement in health care, including by these programs. Effective no later than January 1, 2011. Learn more about the Center for Medicare & Medicaid Innovation.
  • Improving Care for Seniors After They Leave the Hospital. The Community Care Transitions Program will help high risk Medicare beneficiaries who are hospitalized avoid unnecessary readmissions by coordinating care and connecting patients to services in their communities. Effective January 1, 2011.
  • Introducing New Innovations to Bring Down Costs. The Independent Payment Advisory Board will begin operations to develop and submit proposals to Congress and the President aimed at extending the life of the Medicare Trust Fund. The Board is expected to focus on ways to target waste in the system, and recommend ways to reduce costs, improve health outcomes for patients, and expand access to high-quality care. Administrative funding becomes available October 1, 2011. Learn more about strengthening Medicare.
  • INCREASING ACCESS TO AFFORDABLE CARE
  • Increasing Access to Services at Home and in the Community. The Community First Choice Option allows states to offer home and community based services to disabled individuals through Medicaid rather than institutional care in nursing homes. Effective beginning October 1, 2011.
  • HOLDING INSURANCE COMPANIES ACCOUNTABLE
  • Bringing Down Health Care Premiums. To ensure premium dollars are spent primarily on health care, the law generally requires that at least 85% of all premium dollars collected by insurance companies for large employer plans are spent on health care services and health care quality improvement. For plans sold to individuals and small employers, at least 80% of the premium must be spent on benefits and quality improvement. If insurance companies do not meet these goals, because their administrative costs or profits are too high, they must provide rebates to consumers. Effective January 1, 2011.
  • Addressing Overpayments to Big Insurance Companies and Strengthening Medicare Advantage. Today, Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than is spent per person in Traditional Medicare. This results in increased premiums for all Medicare beneficiaries, including the 77% of beneficiaries who are not currently enrolled in a Medicare Advantage plan. The law levels the playing field by gradually eliminating this discrepancy. People enrolled in a Medicare Advantage plan will still receive all guaranteed Medicare benefits, and the law provides bonus payments to Medicare Advantage plans that provide high quality care. Effective January 1, 2011. Learn more about Medicare and the Affordable Care Act.

2012

IMPROVING QUALITY AND LOWERING COSTS

  • Linking Payment to Quality Outcomes. The law establishes a hospital Value-Based Purchasing program (VBP) in Traditional Medicare. This program offers financial incentives to hospitals to improve the quality of care. Hospital performance is required to be publicly reported, beginning with measures relating to heart attacks, heart failure, pneumonia, surgical care, health-care associated infections, and patients' perception of care. Effective for payments for discharges occurring on or after October 1, 2012.
  • Encouraging Integrated Health Systems. The new law provides incentives for physicians to join together to form "Accountable Care Organizations." These groups allow doctors to better coordinate patient care and improve the quality, help prevent disease and illness and reduce unnecessary hospital admissions. If Accountable Care Organizations provide high quality care and reduce costs to the health care system, they can keep some of the money that they have helped save. Effective January 1, 2012.
  • Reducing Paperwork and Administrative Costs. Health care remains one of the few industries that relies on paper records. The new law will institute a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information. Using electronic health records will reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care. First regulation effective October 1, 2012.
  • Understanding and Fighting Health Disparities. To help understand and reduce persistent health disparities, the law requires any ongoing or new federal health program to collect and report racial, ethnic and language data. The Secretary of Health and Human Services will use this data to help identify and reduce disparities. Effective March 2012.

INCREASING ACCESS TO AFFORDABLE CARE

  • Providing New, Voluntary Options for Long-Term Care Insurance. The law creates a voluntary long-term care insurance program - called CLASS -- to provide cash benefits to adults who become disabled. Note: On October 14, 2011, Secretary Sebelius transmitted a report and letter to Congress stating that the Department does not see a viable path forward for CLASS implementation at this time. View a copy of the CLASS report.

2013

IMPROVING QUALITY AND LOWERING COSTS

  • Improving Preventive Health Coverage. To expand the number of Americans receiving preventive care, the law provides new funding to state Medicaid programs that choose to cover preventive services for patients at little or no cost. Effective January 1, 2013. Learn more about the law and preventive care.
  • Expanding Authority to Bundle Payments. The law establishes a national pilot program to encourage hospitals, doctors, and other providers to work together to improve the coordination and quality of patient care. Under payment "bundling," hospitals, doctors, and providers are paid a flat rate for an episode of care rather than the current fragmented system where each service or test or bundles of items or services are billed separately to Medicare. For example, instead of a surgical procedure generating multiple claims from multiple providers, the entire team is compensated with a "bundled" payment that provides incentives to deliver health care services more efficiently while maintaining or improving quality of care. It aligns the incentives of those delivering care, and savings are shared between providers and the Medicare program. Effective no later than January 1, 2013.

INCREASING ACCESS TO AFFORDABLE CARE

  • Increasing Medicaid Payments for Primary Care Doctors. As Medicaid programs and providers prepare to cover more patients in 2014, the Act requires states to pay primary care physicians no less than 100% of Medicare payment rates in 2013 and 2014 for primary care services. The increase is fully funded by the federal government. Effective January 1, 2013. Learn how the law supports and strengthens primary care providers.
  • Open Enrollment in the Health Insurance Marketplace Begins. Individuals and small businesses can buy affordable and qualified health benefit plans in this new transparent and competitive insurance marketplace. Effective October 1, 2013.

2014

NEW CONSUMER PROTECTIONS

  • Prohibiting Discrimination Due to Pre-Existing Conditions or Gender. The law implements strong reforms that prohibit insurance companies from refusing to sell coverage or renew policies because of an individual's pre-existing conditions. Also, in the individual and small group market, the law eliminates the ability of insurance companies to charge higher rates due to gender or health status. Effective January 1, 2014. Learn more about protecting Americans with pre-existing conditions.
  • Eliminating Annual Limits on Insurance Coverage. The law prohibits new plans and existing group plans from imposing annual dollar limits on the amount of coverage an individual may receive. Effective January 1, 2014. Learn how the law will phase out annual limits by 2014.
  • Ensuring Coverage for Individuals Participating in Clinical Trials. Insurers will be prohibited from dropping or limiting coverage because an individual chooses to participate in a clinical trial. Applies to all clinical trials that treat cancer or other life-threatening diseases. Effective January 1, 2014.

IMPROVING QUALITY AND LOWERING COSTS

  • Making Care More Affordable. Tax credits to make it easier for the middle class to afford insurance will become available for people with income between 100% and 400% of the poverty line who are not eligible for other affordable coverage. (In 2010, 400% of the poverty line comes out to about $43,000 for an individual or $88,000 for a family of four.) The tax credit is advanceable, so it can lower your premium payments each month, rather than making you wait for tax time. It's also refundable, so even moderate-income families can receive the full benefit of the credit. These individuals may also qualify for reduced cost-sharing (copayments, co-insurance, and deductibles). Effective January 1, 2014.
  • Establishing the Health Insurance Marketplace. Starting in 2014 if your employer doesn't offer insurance, you will be able to buy it directly in the Health Insurance Marketplace. Individuals and small businesses can buy affordable and qualified health benefit plans in this new transparent and competitive insurance marketplace. The Marketplace will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, Members of Congress will be getting their health care insurance through the Marketplace, and you will be able buy your insurance through Marketplace too. Learn more about the Health Insurance Marketplace.
  • Increasing the Small Business Tax Credit. The law implements the second phase of the small business tax credit for qualified small businesses and small non-profit organizations. In this phase, the credit is up to 50% of the employer's contribution to provide health insurance for employees. There is also up to a 35% credit for small non-profit organizations. Effective January 1, 2014. Learn more about the small business tax credit.

INCREASING ACCESS TO AFFORDABLE CARE

  • Increasing Access to Medicaid. Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in subsequent years. Effective January 1, 2014.
  • Promoting Individual Responsibility. Under the law, most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. If affordable coverage is not available to an individual, he or she will be eligible for an exemption. Effective January 1, 2014.

2015

IMPROVING QUALITY AND LOWERING COSTS

  • Paying Physicians Based on Value Not Volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide higher value care will receive higher payments than those who provide lower quality care. Effective January 1, 2015


Pre-Existing Conditions


Under the Affordable Care Act, health insurance companies can't refuse to cover you or charge you more just because you have a "pre-existing condition" - that is, a health problem you had before the date that new health coverage starts. They also can't charge women more than men.

These rules went into effect for plan years beginning on or after January 1, 2014.

What This Means for You

Health insurers can no longer charge more or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer. They cannot limit benefits for that condition either. Once you have insurance, they can't refuse to cover treatment for your pre-existing condition. Learn more about coverage for pre-existing conditions.

One Exception: Grandfathered Plans

The pre-existing coverage rule does not apply to "grandfathered" individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family on or before March 23, 2010 that has not been changed in certain specific ways that reduce benefits or increase costs to consumers.

Pre-Existing Condition Insurance Plan (PCIP) Coverage

The Pre-existing Condition Insurance Plan (PCIP) ended on April 30, 2014. The PCIP program provided health coverage options to individuals who were uninsured for at least six months, had a pre-existing condition, and had been denied coverage (or offered insurance without coverage of the pre-existing condition) by a private insurance company. Now, thanks to the Affordable Care Act, health insurance plans can no longer deny anyone coverage for their pre-existing condition, and so PCIP enrollees can transition to a new plan outside of the PCIP program. Learn more about your health insurance options at HealthCare.gov.


Young Adult Coverage


Under the Affordable Care Act, if your plan covers children, you can now add or keep your children on your health insurance policy until they turn 26 years old.

What This Means for You

Before the health care law, insurance companies could remove enrolled children usually at age 19, sometimes older for full-time students. Now, most health plans that cover children must make coverage available to children up to age 26. By allowing children to stay on a parent's plan, the law makes it easier and more affordable for young adults to get health insurance coverage.

Children can join or remain on a parent's plan even if they are:

  • Married
  • Not living with their parents
  • Attending school
  • Not financially dependent on their parents
  • Eligible to enroll in their employer's plan

When Someone Turns 26

Under-26 coverage ends on a child's 26th birthday. When a child loses coverage on their 26th birthday, they qualify for a Special Enrollment Period. This lets them enroll in a health plan outside Open Enrollment.


Lifetime & Annual Limits


The Affordable Care Act prohibits health plans from putting annual or lifetime dollar limits on most benefits you receive.

Lifetime Limits

Thanks to the Affordable Care Act, lifetime limits on most benefits are prohibited in any health plan or insurance policy. Previously, many plans 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.

Annual Limits

The Affordable Care Act bans annual dollar limits that all job-related plans and individual health insurance plans can put on most covered health benefits. Before the health care law, many health plans set an annual limit - a dollar limit on their yearly spending for your covered benefits. You were required to pay the cost of all care exceeding those limits.

Exceptions

  • Plans can put an annual dollar limit and a lifetime dollar limit on spending for health care services that are not considered essential health benefits.
  • Grandfathered individual health insurance policies are not required to follow the rules on annual limits.


Preventive Care


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.

Preventive Services Covered Under the Affordable Care Act

If you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, the following preventive services must be covered without your having to pay a copayment or co-insurance or meet your deductible. This applies only when these services are delivered by a network provider.

  • Covered Preventive Services for Adults
  • Covered Preventive Services for Women, Including Pregnant Women
  • Covered Preventive Services for Children


15 Covered Preventive Services for Adults

  1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  2. Alcohol Misuse screening and counseling
  3. Aspirin use for men and women of certain ages
  4. Blood Pressure screening for all adults
  5. Cholesterol screening for adults of certain ages or at higher risk
  6. Colorectal Cancer screening for adults over 50
  7. Depression screening for adults
  8. Type 2 Diabetes screening for adults with high blood pressure
  9. Diet counseling for adults at higher risk for chronic disease
  10. HIV screening for all adults at higher risk
  11. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary
  12. - Hepatitis A
    - Hepatitis B
    - Herpes Zoster
    - Human Papillomavirus
    - Influenza (Flu Shot)
    - Measles, Mumps, Rubella
    - Meningococcal
    - Pneumococcal
    - Tetanus, Diphtheria, Pertussis
    - Varicella
  13. Obesity screening and counseling for all adults
  14. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  15. Tobacco Use screening for all adults and cessation interventions for tobacco users
  16. Syphilis screening for all adults at higher risk


22 Covered Preventive Services for Women, Including Pregnant Women

The eight new prevention-related health services marked with an asterisk ( * ) must be covered with no cost-sharing in plan years starting on or after August 1, 2012.

  1. Anemia screening on a routine basis for pregnant women
  2. Bacteriuria urinary tract or other infection screening for pregnant women
  3. BRCA counseling about genetic testing for women at higher risk
  4. Breast Cancer Mammography screenings every 1 to 2 years for women over 40
  5. Breast Cancer Chemoprevention counseling for women at higher risk
  6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*
  7. Cervical Cancer screening for sexually active women
  8. Chlamydia Infection screening for younger women and other women at higher risk
  9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*
  10. Domestic and interpersonal violence screening and counseling for all women*
  11. Folic Acid supplements for women who may become pregnant
  12. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*
  13. Gonorrhea screening for all women at higher risk
  14. Hepatitis B screening for pregnant women at their first prenatal visit
  15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women*
  16. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older*
  17. Osteoporosis screening for women over age 60 depending on risk factors
  18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  19. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
  20. Sexually Transmitted Infections (STI) counseling for sexually active women*
  21. Syphilis screening for all pregnant women or other women at increased risk
  22. Well-woman visits to obtain recommended preventive services*


26 Covered Preventive Services for Children

  1. Alcohol and Drug Use assessments for adolescents
  2. Autism screening for children at 18 and 24 months
  3. Behavioral assessments for children of all ages Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  4. Blood Pressure screening for children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  5. Cervical Dysplasia screening for sexually active females
  6. Congenital Hypothyroidism screening for newborns
  7. Depression screening for adolescents
  8. Developmental screening for children under age 3, and surveillance throughout childhood
  9. Dyslipidemia screening for children at higher risk of lipid disorders Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  10. Fluoride Chemoprevention supplements for children without fluoride in their water source
  11. Gonorrhea preventive medication for the eyes of all newborns
  12. Hearing screening for all newborns
  13. Height, Weight and Body Mass Index measurements for children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  14. Hematocrit or Hemoglobin screening for children
  15. Hemoglobinopathies or sickle cell screening for newborns
  16. HIV screening for adolescents at higher risk
  17. Immunization vaccines for children from birth to age 18 -doses, recommended ages, and recommended populations vary: ?Diphtheria, Tetanus, Pertussis
  18. - Haemophilus influenza type b
    - Hepatitis A
    - Hepatitis B
    - Human Papillomavirus
    - Inactivated Poliovirus
    - Influenza (Flu Shot)
    - Measles, Mumps, Rubella
    - Meningococcal
    - Pneumococcal
    - Rotavirus
    - Varicella
  19. Iron supplements for children ages 6 to 12 months at risk for anemia
  20. Lead screening for children at risk of exposure
  21. Medical History for all children throughout development Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  22. Obesity screening and counseling
  23. Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
  24. Phenylketonuria (PKU) screening for this genetic disorder in newborns
  25. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
  26. Tuberculin testing for children at higher risk of tuberculosis Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  27. Vision screening for all children


Affordable Care Act Rules on Expanding Access to Preventive Services for Women


Before the health care law, too many Americans did not get the preventive care they need to stay healthy, avoid or delay the onset of disease, and reduce health care costs. Often because of cost, Americans used preventive services at about half the recommended rate.

Yet chronic diseases - which are responsible for 7 of 10 deaths among Americans each year and account for 75 percent of the nation's health spending - often are mostly preventable. Cost sharing (including copayments, co-insurance, and deductibles) reduces the likelihood that preventive services will be used. Especially concerning for women are studies showing that even moderate copays for preventive services such as mammograms or Pap smears result in fewer women obtaining this care.

The Affordable Care Act, the health care legislation passed by Congress and signed into law by President Obama on March 23, 2010, helps make prevention affordable and accessible for all Americans. The Affordable Care Act requires most health plans to cover recommended preventive services without cost sharing. In 2011 and 2012, 71 million Americans with private health insurance gained access to preventive services with no cost sharing because of the law.

Through the Affordable Care Act, women's preventive health care services - such as mammograms, screenings for cervical cancer, and other services - are already covered with no cost sharing under some health plans. The Affordable Care Act also makes certain recommended preventive services free for people on Medicare. The law also recognizes the need to take into account the unique preventive health needs of women throughout their lifespan.

On August 1, 2011, HHS adopted new Guidelines for Women's Preventive Services (Guidelines) - including well-woman visits, contraception, and domestic violence screening and counseling. These preventive services are required to be covered without cost sharing in most non-grandfathered health plans starting with the first plan or policy year beginning on or after August 1, 2012.1 The Guidelines were recommended by the independent Institute of Medicine (IOM) and based on scientific evidence. Beginning August 1, 2012, about 47 million women gained guaranteed access to additional preventive services without paying more at the doctor's office.

With the addition of these new benefits, the Affordable Care Act continues to make wellness and prevention services affordable and accessible for more and more Americans.

Women and Preventive Health

When it comes to health, women are often the primary decision-maker for their families and the trusted source in circles of friends. They are also key consumers of health care. Women have high rates of chronic disease, including diabetes, heart disease, and stroke. In addition, women have unique preventive health needs to ensure they are healthy throughout every stage of life.

While women are more likely to need preventive health care services, they often have less ability to pay. On average, they have lower incomes than men and a greater share of their income is consumed by out-of-pocket health costs. A report by the Commonwealth Fund found that in 2009 more than half of women delayed or avoided necessary care because of cost. Removing cost-sharing requirements lets women decide which preventive services they will use and when. In fact, one study found that the rate of women getting a mammogram went up as much as 9 percent when cost sharing was removed. In addition to saving lives by catching cancer early, mammograms can also protect families from skyrocketing medical bills that result from treating the advanced stages of the disease.

New Comprehensive Coverage for Women's Preventive Care

The Affordable Care Act helps make prevention affordable and accessible for all Americans by requiring most health plans to cover and eliminate cost sharing for preventive services recommended by the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices, and the Bright Futures Guidelines recommended by the American Academy of Pediatrics.

The law also requires insurers to cover additional preventive health benefits for women. In 2011, HHS adopted new guidelines recommended by the IOM for women's preventive services to fill the gaps in current preventive services guidelines for women's health. The Guidelines help ensure a comprehensive set of preventive services for women. IOM conducted a scientific review and provided recommendations on specific preventive measures that meet women's unique health needs and help keep them healthy. HHS based its Guidelines for Women's Preventive Services on the IOM report issued July 19, 2011.

The eight additional women's preventive services that are covered without cost-sharing requirements include:

  • Well-woman visits: This includes an annual well-woman preventive care visit for adult women to obtain the recommended preventive services, and additional visits if women and their health care providers determine they are necessary to deliver those services. These visits will help women and their health care providers determine what preventive services are appropriate, and set up a plan to help women get the care they need to be healthy.
  • WGestational diabetes screening: This screening is for women 24 to 28 weeks pregnant, and those at high risk of developing gestational diabetes. It will help improve the health of mothers and babies because women who have gestational diabetes have an increased risk of developing type 2 diabetes in the future. In addition, the children of women with gestational diabetes are at significantly increased risk of being overweight and insulin-resistant throughout childhood.
  • WHPV DNA testing: Women who are 30 or older have access to high-risk human papillomavirus (HPV) DNA testing every three years, regardless of Pap smear results. Early screening, detection, and treatment have been shown to help reduce the prevalence of cervical cancer.
  • WSTI counseling: Sexually active women have access to annual counseling on sexually transmitted infections (STIs). These sessions have been shown to reduce risky behavior in patients, yet only 28 percent of women aged 18-44 years reported that they had discussed STIs with a doctor or nurse.
  • WHIV screening and counseling: Sexually active women have access to annual HIV screening and counseling on HIV. Women are at increased risk of contracting HIV/AIDS. From 1999 to 2003, the Centers for Disease Control and Prevention reported a 15 percent increase in AIDS cases among women, and a 1 percent increase among men.
  • WContraception and contraceptive counseling: Women with reproductive capacity have access to all Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider. Abortifacient drugs are not included. Contraception has additional health benefits like reduced risk of cancer and improving the health of mothers-to-be.
  • WBreastfeeding support, supplies, and counseling: Pregnant and postpartum women have access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment. Breastfeeding is one of the most effective preventive measures mothers can take to protect their health and that of their children, according to the Centers for Disease Control and Prevention (CDC). One of the barriers for breastfeeding is the cost of purchasing or renting breast pumps and nursing related supplies.
  • WInterpersonal and domestic violence screening and counseling: Screening and counseling for interpersonal and domestic violence will be covered for all adolescent and adult women. An estimated 25 percent of women in the United States report being targets of intimate partner violence during their lifetimes. Screening is effective in the early detection and effectiveness of interventions to increase the safety of abused women.

Most non-grandfathered private health plans started covering the additional women's preventive services with no cost sharing starting with the first plan or policy year beginning on or after August 1, 2012. The rules governing coverage of preventive services, which allow plans to use reasonable medical management to help define the nature of the covered service, also apply to the Guidelines for Women's Preventive Services. Plans will retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost sharing for branded drugs if a generic version is available and just as effective and safe.

The coverage of these preventive services gives Americans access to many of the services already offered to Members of Congress. Not only are these services similar to a list of preventive services recommended by the National Business Group on Health, but many private employers already cover these services.

In light of the religious concerns of certain religious organizations, the Guidelines exempt the health plans of certain religious employers from the requirement to cover contraceptive services. The administration also has established accommodations for certain other non-profit religious organizations (including non-profit religious institutions of higher education) so they will not have to contract, arrange, pay or refer for contraceptive coverage to which they object on religious grounds. Health insurance companies or third party administrators-rather than objecting non-profit religious organizations-will pay for contraceptive services used by women who otherwise receive health coverage under health plans offered by these organizations. In short, these final rules provide accommodations under which women in health plans offered by eligible non-profit religious organizations that object to contraceptive coverage on religious grounds have access to free contraceptive coverage, but such organizations do not have to contract, arrange, pay or refer such coverage.

What This Means for You

If your plan is subject to these new requirements, you may not have to pay a copayment, co-insurance, or deductible to receive recommended preventive health services, such as screenings, vaccinations, and counseling.

For example, depending on your age, you may have access - at no cost - to preventive services such as:

  • Blood pressure, diabetes, and cholesterol tests
  • Many cancer screenings, including mammograms and colonoscopies
  • Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression, and reducing alcohol use
  • Regular well-baby and well-child visits, from birth to age 21
  • Routine vaccinations against diseases such as measles, polio, or meningitis
  • Counseling, screening, and vaccines to ensure healthy pregnancies
  • Flu and pneumonia shots

Some Important Details

This preventive services provision applies only to people enrolled in job-related health plans or individual health insurance policies created after March 23, 2010. If you are in such a health plan, this provision will affect you as soon as your plan begins its first new "plan year" or "policy year" on or after September 23, 2010.

Top things to know about preventive care and services:

  • Grandfathered plans: If your plan is "grandfathered," these benefits may not be available to you.
  • Network providers: If your health plan uses a network of providers, be aware that health plans are required to provide these preventive services only through an in-network provider. Your health plan may allow you to receive these services from an out-of-network provider, but may charge you a fee.
  • Office visit fees: Your doctor may provide a preventive service, such as a cholesterol screening test, as part of an office visit. Be aware that your plan can require you to pay some costs of the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit.
  • Questions: If you have questions about whether these new provisions apply to your plan, contact your insurer or plan administrator. If you still have questions, contact your state insurance department.
  • Talk to your health care provider: To know which covered preventive services are right for you - based on your age, gender, and health status - ask your health care provider.


ER Access & Doctor Choice


The Affordable Care Act helps preserve your choice of doctors and opens access to out-of-network emergency services.

Your Doctor

  • You select the doctor: You can choose any available participating primary care provider as your doctor and choose any available participating pediatrician as your child's primary care doctor.
  • Visit your OB-GYN: You can seek coverage for obstetrical or gynecological (OB-GYN) care from a participating OB-GYN specialist without a referral.


Emergency Medical Services


Health plans cannot require

  • Higher copayments or co-insurance for out-of-network emergency room services
  • Approval before seeking emergency room services from a provider or hospital outside your plan's network

Exceptions

  • Grandfathered individual health insurance policies are not required to follow these rules.


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