OBAMACARE_AND_YOU by xiuliliaofz


The bill will come out in installments

   Some start 90 days from the bill
    (June 23rd, 2010)
   Many start in six months (September 23rd, 2010)
   Some start in 2011
   Some start in 2012
   Some start in 2013
   Most start in 2014
   A few start in 2016
   And the rest start in 2018
   Many of these initiatives are still works in
   In many cases the insurance companies are still
    working out the details
   Some facets are questionable
        We’re not sure what they mean or how they can be

     Updates are coming out constantly

    Today we are going to go over what we know
   Essential Benefits         Prescription drugs
                              Rehabilitative services
                              Habilitative services and
   Ambulatory patient
    services                    devices
                              Laboratory services
   Emergency services
                              Preventive and wellness
   Hospitalization
   Maternity and new born
                              Chronic disease
   Mental health and
                              Pediatric services
    substance abuse care
                                including vision and oral
   Behavioral health           care
                             List by Blue Cross Blue Shield
                                of Georgia
   Prior authorization and increased cost sharing
    for emergencies is no longer allowed

    Old plans can be grandfathered
   June 1- $5 billion has been set aside for a
    reinsurance plan to be set up for employer’s
    coverage for early retirees over 55. This is to
    cover 80% of the claims between $15,000 and

    This is to go away in 2013
By July 1, each state is to have an Internet portal
  for individuals and small businesses to shop
  for insurance
   June 21- $5 billion has been set aside for the
    states to create a high risk pool for adults with
    pre existing conditions who can not get health
    insurance now and have been uninsured for 6

   In Georgia, the Department of HHS will set this
    up. In most other states the Insurance
    Commissioners Office is setting these up.

   This will go away in 2013
   September 23- New policies must cover the
    full cost of preventive care as recommended by
    the US Preventive Task Force
   This includes immunizations, preventive care
    for children through adolescents and
    preventive care for women

    Old plans can be grandfathered
    Colonoscopies unknown at this time
   September 23- New appeals process
       Plans will be required to have external review
       Must provide participants with notice of the internal
        and external appeals process
       Must allow participant to review files and present
        evidence and testimony as part of appeals
       Must be able to maintain insurance through appeals

    Old plans can be grandfathered
   September 23- Nondiscrimination rules that
    apply to self funded plans will now extend to
    fully insured plans

   These rules prohibit employee’s eligibility to be
    based on hourly pay or salary pay

    Can be grandfathered
   September 23- Plans may no longer contain
    lifetime limits on coverage of essential benefits

   Annual limits will be restricted by the
    Department of Health and Human Services
   September 23- No rescissions are allowed
    unless proof of fraud or misrepresentation
   Insurer must provide prior notice of

Cannot be grandfathered
   Primary care doctors can be chosen as long as
    they are in network and taking new patients
   Plans may no longer require pre authorization
    or referrals to OB/GYNs

    Old plans can be grandfathered
    Probably does not affect Georgia
   Plans can no longer favor highly compensated

    This is under scrutiny as many plans today are
    set up as manager’s carve outs. It is unknown
    if this will make a difference depending on the
    compensation of the managers
   September 23- Plans may no longer carry pre
    existing condition exclusions for children
    under 19 years of age

    This cannot be grandfathered
   Children who do not have access to group
    health insurance through their employer, can
    stay on their parent’s plan to age 26, even if
   Any employer contributions to the premiums
    are a tax deductible business expense and not
    taxable income for the member

    Insurance companies are jumping on this now
   Beginning in 2010, small businesses with fewer
    than 25 employees and average wages of less
    than $50,000 will receive a tax credit for their
    contributions to buying health insurance for
   The credit starts at 35% and increases to 50% in
    2014, when the exchange becomes operational
   A tax credit may be available to small
    businesses with fewer than 10 employees
    whose annual wages average less than $25,000
   January 1- Employers will be required to
    disclose the value of health insurance benefits
    on the employee’s annual W-2 form
   This can exclude employer’s contribution to
   This will probably not be taxed just disclosed

    Not specified if this is to disclose the year 2010
    or 2011
   January 1- Insurers must publicly report the
    medical loss ratio and it must be 80% for small
    groups and individuals and 85% for large
   Small groups are those with under 100
    employees, but states can make it 50 starting in
   Any excess money over the 80% or 85% must
    be paid back to those insured as rebates
   Health Spending Accounts, Flexible Spending
    Accounts and Health Reimbursement Accounts
    can no longer pay for over the counter drugs,
    unless they are prescribed by a doctor

   Penalties for early withdrawal of funds
    increases from 10% to 20% and Archer MSAs
    go from 15% to 20%
   January 1- The Department of Health and
    Human Services is to conduct a study on self
    funded plans and market characteristics of
    employers to determine how to make sure
    there is no adverse selection

    This may lead to additional reporting
   January 1- Grants will be available for small
    employers that establish wellness programs.
    There will be technical assistance and other
    resources to evaluate the program. Program
    must be new to qualify

Grants available for five years starting in 2011
   All employees will automatically be enrolled
    by employers into a Long Term Care program
    and begin to make payroll contributions
   This will provide a national insurance pool for
    Long Term Care for people who need in home
    care or care in a care center when they are

    Employees can choose not to purchase this
 March 23, 2011- HHS will create a Uniform
  Standards and Definitions Summary for each plan
  in accordance with the National Association of
  Insurance Commissioners.
These will explain coverage and benefits
       Highlights of plans
       No more than 4 pages
       Font no smaller than 12 pt.
       Includes coverage points
       Must include standardized definitions of terms

    Companies must begin to use these by March 23, 2012
   March 23- A 60 day notice must be provided
    for any summary material modification

Penalties for not providing summary or timely
  changes will be not more than $1000 for each
  willful failure, but each participant is counted

Applies to grandfathered plans
   A research fee of $1.00 per participant through
    2013 and $2.00 through 2019 will be collected to
    pay for a comparative effectiveness study
   Employee contributions to FSAs will be limited
    to $2500 a year

   The cap will be adjusted annually in
    accordance with the Consumers Price Index
   Employers will be required to notify employees
       About the exchange for new employees at the time
        of hire and for current employees by March 21, 2013
       They may be eligible for a subsidy under the
        exchange if employer’s contribution is less than 60%
        of the total allowed costs of benefits
       If employee purchases through the exchange he or
        she will lose employer’s coverage
   Large employers will have expanded form 5500
    reporting requirements which will include
    information on the health insurance coverage
    of their employees
   All individuals will have to carry health
    insurance or pay a penalty enforced by the IRS
   The penalty will be $95.00 or 1% of income
    which ever is greater in 2014. This amount will
    be phased up in later years
   Families will pay half the penalty for children
    with a cap of $2,085.00 per family
Religious Reasons      Members of Native
Individual no longer      American Indian
   lives here             Tribes
Incarceration          Hardship waivers
Tax payers who are     Can’t afford it
   under 100% of       No Income Tax Liability
   poverty level       (Some say religion based
   There can no longer be exclusions for pre
    existing conditions on group or individual
   All people who apply must be accepted for

    This does not apply to grandfathered plans
   There can no longer be any rate ups for new
    individual and fully insured small group plans
   There can no longer be increased premiums
    based on health status, claims history or gender

   Allowable rate increase:
       Age (3:1 ratio)
       Geography
       Family size
       Tobacco use (1:1.5 ratio)
   States can merge their small group and
    individual markets
   Routine patient care costs must be covered for
    a patient who engages in approved clinical
    trials for life-threatening illnesses such as

    Does not apply to grandfathered plans
   State health insurance Exchanges will be set up
    and running for small businesses and
    individuals to buy insurance.
   States can determine if they will allow large
    groups to buy here as well in 2017
   There are restrictions on plan designs
   They must all cover essential health benefits
   States can require additional benefits if they
    pay for them
   Large employers do not have to offer employee
    health insurance
   But most with over 50 employees will pay an
    assessment if they do not offer coverage, or the
    coverage isn’t affordable
   Both full time and part time employees are
    included when determining the number of
    employees (full time equivalency rules)
   Employers with 50+ employees who do not
    offer the minimum essential coverage will pay
    $2000 for each employee over the first 30 if one
    of their employees gets a tax subsidy to buy
    insurance on the exchange (full time equals 30
    hours, determined monthly). Certain seasonal
    workers are not included.
   Penalties are assessed monthly.
   Employers who do not offer plans with
    minimum essential coverage but have at least
    one employee who receives a subsidy on the
    exchange will pay the lesser of $3000 for each
    employee receiving credit, or $2000 for each
    full time employee
   Employers must provide “free choice”
    vouchers to employees with incomes below
    400% of poverty level if employees
    contribution to coverage is over 9.5% of the
    employees income and the employee chooses
    to purchase coverage in the exchange. No
    penalties will be imposed with respect to those
    who use these vouchers.

    This is called the “free ride” penalty
   Employers with more than 200 employees, that
    offer coverage, must automatically enroll new
    full time employees in coverage.

    Employees may opt out
   Subsidies to buy insurance in the exchange will
    be available in tax credits and cost sharing
    assistance, for people above Medicaid
    eligibility, but below 400% of Federal Poverty
   For small businesses
        All plans must incorporate essential benefits
        Deductibles are limited to $2000 for individuals and
        $4000 for families
       It does not specify if Qualified High Deductible
        Health Plans which are a necessary part of HSAs will
        have the benefits to qualify for essential benefits

        Does not include self funded plans or grandfathered
   Catastrophic plans will be available for those
    under 30 years of age

    Other restrictions will apply
   Waiting periods cannot exceed 90 days

    No penalty stated so far

    Cannot be grandfathered
   Wellness incentives can include up to 30% of
    the premiums and up to 50% with Department
    of Health and Human Services approval
   A reinsurance plan will be available for the
    individual market and will be funded by
    individual and small group plan assessments
   The penalty for people who chose not to buy
    health insurance will rise to $695 or 2.5% of
    income, which ever is greater

   States can join healthcare compacts which will
    allow insurers to sell individual policies in any
    state participating in the compact
   A new excise tax goes into effect for high value
    (Cadillac) plans. 40% tax for amounts over $10,200
    for individuals and $27,500 for families. This will
    include employee and employer contributions as
    well as contributions to FSAs, HSAs and HRAs,
    onsite clinics or wellness plans that are ERISA
    Not included are dental benefits, vision, accident,
    disability, long term care and after tax indemnity
    or specified disease plans. This will be paid by the
    insurance companies and plan administrators
   Employers and employees can keep the plans
    they had as of March 23rd, 2010, and are exempt
    from some reforms.

   Collectively bargained plans that were ratified
    prior to March 23rd, 2010 can be maintained in
    place until the next collective bargaining
    agreement related to healthcare coverage ends.
   Most new laws go into effect as plans renew
    after the stated dates
   The Department of Health and Human Services
    will adopt a single set of operating rules for
    electronic transactions to create uniformity.

   Group health plans will have to comply.
   Electronic claims will include:

     Health claims
     Physician encounter information
     Eligibility and claims status
     Enrollment and disenrollment
     Premium payments
     Referral authorization and precertification
   New employer administrator reporting

     Whether employer offers minimal essential benefits
      to full time employees
     Any waiting periods
     Monthly premium for lowest cost option in each
      enrollment category (If more than one is offered)
     Employer’s share of the total cost of benefits
      provided under the plan
   New Employer Administrator Reporting
    Responsibilities, continued:

       Number of full time employees each month
       Name, address and Social Security Number for each
        full time employee and the months they were
        covered under the employer’s plan
       Probably others as well

They will not be able to purchase insurance from
     the exchange even if they pay full price

       (reported in the AP, April 5, 2010)
   Beware!
New rights for employees to charge their employers
  with discrimination having to do with health
  benefits, based on federal laws such as the Age
  Discrimination Act, the Rehabilitation Act, the
  Civil Rights Act, the Fair Labor Standards Act, and
The acts amendment of the Fair Labor Standards Act
  prohibits an employer from discrimination in
  terms of exclusions from participation in or in
  denial of benefits under any health program or
   BEWARE!!
This bill also provides whistleblower protections
  for employees who provide information to, or
  cooperate with federal or sate government
  authorities concerning alleged violations of the

These new rights apply whether the employer’s
  health benefits plan is fully funded or self
Reports from
               Kathleen Sibelius
of the Department of Health and Human Services

  Beware of scam insurance
Currently 18 states have filed a lawsuit that this is

        We don’t know what will happen
   How do we pay for this????
       July 1, 2010- 10% tax on tanning business equals 2.7
        billion over 10 years
       In 2011- pharmaceutical industry will pay annual
        industry fees which will increase yearly to 2.8 billion by
       In 2013- medical device manufacturers will begin to pay
        an additional 2.3% tax on sales
       In 2013- Medicare payroll tax will increase by .9% for
        individuals who make over $200,000 and couples who
        make over $250,000 a year
       3.8% tax from income from interest, dividends, annuities,
        royalties and rents from those who make over $200,000
        and couples who make more than $250,000 a year
   In 2014- Insurers will pay a premium tax. It
    will pay out:
        8 billion in 2014
       11.3 billion in 2015
       13.9 billion in 2017
       14.2 billion in 2018
       It will then rise proportionate to the overall
        premium growth

To top