Thursday, July 26, 2012

Patient Protection and Affordable Care Act Summary 1

It’s important for me to know what the Patient Protection and Affordable Care Act actually says. I don’t want to get my information from biased sources so I am reading it myself. Several of my friends asked if I could provide a bullet point summary of what I’ve read. I’ve included it below. Now, the disclaimer. This is what I understand as I read it. I tried to just simplify the language from the Act but there may be some things lost in translation. This is the link I used to access the Act if you would like to read it in whole or in part yourself.

I am going to post them in 40-50 page summary increments when I have the chance to read and summarize!! (Because any more than 50 pages and my head would explode!!!)

Patient Protection and Affordable Care Act (PPACA)

  • No lifetime limits on the dollar value of benefits for participant/beneficiary
  • Up until 2014, insurance can set limits but the Secretary shall insure that access to benefits is made available with minimal impact on premiums.
  • Insurance can put a “per beneficiary” limit on covered benefits as long as they are not considered essential health benefits.
  • Insurance cannot rescind benefits once a participant is on a plan unless the participant commits fraud or intentional misrepresentation. Insurance must notify participant of cancellation.
  • Insurance cannot impose cost sharing on preventative services, immunizations, infant/child/adolescent/women (breast cancer, mammography) preventative care.
  • Secretary shall establish the minimal interval allowed for preventative services.
  • Secretary may develop guideline for Insurance to utilize value-based insurance designs.
  • A child can be covered under parent’s insurance until 26 years old, but insurance is not required to provide coverage to a child of the child receiving dependent coverage.
  • The Secretary shall define dependents eligible for this coverage but the definition will not modify the IRS’s definition of dependent.
  • Within 12 months of the enactment of the PPACA, the Secretary in consultation with the National Association of Insurance Commissioners shall develop standards for use by group health providers and health insurance issuers.
  • Summary of benefits and coverage will be presented in a standard form, no more then 4 pages long with print no smaller than 12 point font;
    • language shall be appropriate and easily understandable by the average plan enrollee;
    • uniform definitions of standard insurance terms and medical terms;
    • description of coverage including cost sharing;
    • exceptions, reductions and limitations on coverage;
    • cost sharing provisions including deductible, coinsurance and co-payment obligations;
    • the renewability and continuation of coverage provisions;
    • a coverage facts label that would include examples to illustrate common benefits scenarios (i.e. pregnancy) and related cost sharing;
    • a statement of whether the plan provides minimum coverage (defined by IRS code) and ensures the plan or coverage share of the total allowed coverage is not less than 60;
    • a statement that the outline is a summary of coverage and the coverage document itself should be consulted for all details;
    • a contact number for the patient to call and a website address where the coverage document can be reviewed.
    • Secretary will periodically review and update the standards developed under this section
  • Insurance must provide the above to patients within 24 months of the PPACA being enacted in either paper or electronic form. Modifications to above must be provided to patients at least 60 days before the modification takes effect.
  • The standards developed will preempt any state standards that require less information to be provided to the patient.
  • A fine of $1,000 will be charged for each failure of insurance to provide the information to its patients.
  • Secretary will develop standard definitions for insurance related terms (i.e. out-of-pocket limit, preferred provider, etc.); medical terms (hospitalization, durable medical equipment, etc.); insurance not offered through an Exchange is only required to submit the required information to the Secretary and the State Insurance Commissioner and make such information available to the public.
  • Insurance cannot discriminate in favor of highly compensated individuals (as defined by IRS code).
  • Within 2 years of enactment of PPACA, the Secretary in consultation with experts in health care quality and stakeholders will develop reporting requirements for use by insurance.
    • Improve health outcomes by care coordination, chronic disease management, etc.
    • Implement activities to prevent hospital readmission through a comprehensive hospital discharge program including comprehensive discharge planning, post discharge reinforcement by appropriate health care professional, etc.
    • Implement activities to improve patient safety and reduce medical errors through best clinical practices, etc.
    • Implement wellness and health promotion activities.
  • Insurance will submit an annual report to the Secretary and the plan enrollees explaining whether the benefits under the plan satisfied the topics above. The report should be made available to enrollees during open enrollment and to the public through a website. The secretary can impose penalties for non-compliance and can provide exemptions to reporting requirements if insurance substantially meet above goals.
  • Health and wellness programs may include quitting smoking; weight management, etc. No wellness program can impinge on Second Amendment Gun Rights nor can data be collected or stored regarding lawful ownership of guns or ammunition.
Next summary to follow...