What is the Affordable Care Act (Obama Care)?
About a 7 min. read
Read more about the Affordable Care Act below, as changes are likely to come with a new Administration and a fresh challenge in the Supreme Court.
Also, please read my books— available for $0.99, $6.99 & $11.99
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As we move forward toward a new administration and a new Congress, one of the important issues on many people’s agenda is healthcare. It is almost certain that the Democrats and the new White House will make proposals for expanding healthcare coverage for millions of Americans, but what is the current law and what might have to be changed?
Some important provisions of the Patient Protection and Affordable Care Act (often called, Obama Care) are listed below. For a complete reading of the law, visit Congress’ website here.
No Lifetime or Annual Limits
In General.--A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish--
(1) lifetime limits on the dollar value of benefits for any participant or beneficiary; or
(2) unreasonable annual limits (within the meaning of section 223 of the Internal Revenue Code of 1986) on the dollar value of benefits for any participant or beneficiary.
➤No lifetime limits on the benefits offered in terms of dollar value and no unreasonable annual limits in terms of dollar value.
Prohibition of Rescissions
``A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage involved,….
➤No health plan should rescind coverage, except in cases of fraud.
Coverage of Preventive Services
``(a) In General.--A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for--
``(1) evidence-based items or services that have in effect a rating of `A' or `B' in the current recommendations of the United States Preventive Services Task Force;
``(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and
``(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.
``(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.
``(5) for the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009.
➤Health plans should cover: evidence-based services, immunizations for individuals as recommended by the Advisory Committee in the CDC (Will COVID vaccinations will fall under this guideline?), immunizations for infants and children and mammographies, as well as breast cancer prevention and screening techniques.
Extension of Dependent Coverage
``(a) In General.--A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age. Nothing in this section shall require a health plan or a health insurance issuer described in the preceding sentence to make coverage available for a child of a child receiving dependent coverage.
➤Your children can stay on your health plan until they are 26.
Prohibition of Discrimination Based on Salary
``(a) In General.--The plan sponsor of a group health plan (other than a self-insured plan) may not establish rules relating to the health insurance coverage eligibility (including continued eligibility) of any full-time employee under the terms of the plan that are based on the total hourly or annual salary of the employee or otherwise establish eligibility rules that have the effect of discriminating in favor of higher wage employees.
``(b) Limitation.--Subsection (a) shall not be construed to prohibit a plan sponsor from establishing contribution requirements for enrollment in the plan or coverage that provide for the payment by employees with lower hourly or annual compensation of a lower dollar or percentage contribution than the payment required of similarly situated employees with a higher hourly or annual compensation.
➤Health plans cannot discriminate based on the salary of an employee in terms of their eligibility for coverage, but can establish contribution requirements that are of a lower dollar amount for employees as noted above.
Prohibition of Exclusions of People with Preexisting Conditions
``(a) In General.--A group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage.’'
➤Insurers cannot deny coverage to people with preexisting conditions.
African Americans make up a significant percentage of the population in states where Medicaid has not been expanded.
Guaranteed Availability of Coverage
``(a) Guaranteed Issuance of Coverage in the Individual and Group Market.--Subject to subsections (b) through (e), each health insurance issuer that offers health insurance coverage in the individual or group market in a State must accept every employer and individual in the State that applies for such coverage.
``(b) Enrollment.--
``(1) Restriction.--A health insurance issuer described in subsection (a) may restrict enrollment in coverage described in such subsection to open or special enrollment periods.
``(2) Establishment.--A health insurance issuer described in subsection (a) shall, in accordance with the regulations promulgated under paragraph (3), establish special enrollment periods for qualifying events (under section 603 of the Employee Retirement Income Security Act of 1974).
``(3) Regulations.--The Secretary shall promulgate regulations with respect to enrollment periods under paragraphs (1) and (2).
➤Insurers must accept employers and individuals who apply for coverage in an individual or group market.
Prohibition of Discrimination Against Individuals Based on Health-Related Statuses
``(a) In General.--A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan or coverage based on any of the following health status-related factors in relation to the individual or a dependent of the individual:
``(1) Health status.
``(2) Medical condition (including both physical and mental illnesses).
``(3) Claims experience.
``(4) Receipt of health care.
``(5) Medical history.
``(6) Genetic information.
``(7) Evidence of insurability (including conditions arising out of acts of domestic violence).
``(8) Disability.
``(9) Any other health status-related factor determined appropriate by the Secretary.
➤Insurers cannot base eligibility rules on genetic information, evidence of your insurability (or documentation of your great health)—including things that arise from domestic violence, etc.
Health Insurance Exchanges or Marketplaces
“Health Insurance Marketplace — also known as the Health Insurance Exchange — is the place where people without health care insurance can find information about health insurance options and also purchase health care insurance. Information can also be found regarding eligibility for help with paying premiums and reducing out-of-pocket costs. Each year the Marketplace has an open enrollment period.
In addition to the federally-facilitated Marketplace, HealthCare.gov, there are also state-based Marketplaces. Whether you use the federally-facilitated Marketplace or a state-based Marketplace depends on the state in which you live. If you visit HealthCare.gov, you will be asked to provide your ZIP code.
Health Insurance Exchanges were created to help provide individuals with an opportunity to buy insurance on an exchange to meet their needs. 14 states and the District of Columbia run their own marketplaces, while 36 states utilize the federal marketplace.
Shared Responsibility Payments are, of course, now reduced to zero and this is the subject of a Supreme Court case, which will be decided in the spring.
The Supreme Court
The Supreme Court heard arguments, recently, on the Affordable Care Act on November 10, 2020 - It will decide on the case in 2021
The questions presented before the court center around the following:
“Congress passed the Patient Protection and Affordable Care Act ("ACA"), Pub. L. No. 111-148, 124 Stat. 119 (Mar. 23, 2010), with the express goal of achieving near- universal health-insurance coverage. To achieve that goal, Congress found it was "essential" to require healthy Americans to ensure that they have what Congress considered minimum essential coverage. In 2012, this Court held that "[t]he Federal Government does not have the power to order people to buy health insurance." Nat'l Fed'n of Indep. Bus. v. Sebelius ("NFIB"), 567 U.S. 519, 575 (2012) (op. of Roberts, C.J.). The Court upheld the minimum-essential-coverage requirement, however, because it was "fairly possible" to construe the mandate as a tax. In 2017, Congress eliminated that alternative construction by zeroing out any penalty. That legislative act rendered the individual mandate unconstitutional, as the court below correctly held.
➤Should the individual mandate be separated from the entire law or should the Affordable Care Act (Obama Care) be thrown out altogether because of this one individual provision?
Of course, this may be decided before, or after, a new health care law is proposed by Congress and the new administration, which come into their offices in January of 2021.
Expansion of Medicaid Coverage
Beginning January 1, 2014, Medicaid was expanded to cover adults who are below 65 years of age and whose income is at or below 133% (or 138%) of the Federal Poverty Level.
Note: There is a 5% disregard statement that effectively makes the cut off 138% of the Federal Poverty Level.
So, for Americans with lower incomes, the expansion of Medicaid coverage was designed to help them obtain health coverage and for Americans with slightly higher (more moderate) incomes, tax credits for insurance purchased through marketplaces are designed to help them obtain coverage.
Thus, for:
“Income between 100% and 400% FPL: If your income is in this range, in all states you qualify for premium tax credits that lower your monthly premium for a Marketplace health insurance plan.
“Income below 138% FPL: If your income is below 138% FPL and your state has expanded Medicaid coverage, you qualify for Medicaid based only on your income.
So, lower-income individuals would get coverage through the expansion of Medicaid, moderate-income individuals (as we have stated) would get tax (breaks) credits to help them purchase insurance through the marketplaces and individuals with higher incomes would be left to purchase the health insurance they need, on their own, or through their jobs.
That was the way it was supposed to work, but the Supreme Court’s decision essentially made it optional for states to participate in this expansion of Medicaid.
At least 12 states do not participate in this Medicaid expansion. In these states the median income level of a person with a child, or children, that qualifies them for Medicaid is 40% of the Federal Poverty Level ($8,532 for a family of three as of 2019) and adults without children, in these states, typically don’t qualify for Medicaid (Kaiser Family Foundation).
So, you end up with millions of people who don’t qualify for Medicaid in their states—they make too much to qualify. And, there are those who make below 100% of the Federal Poverty Level, so they don’t get tax credits for purchasing health insurance within the marketplaces.
What happens to those people who lose their jobs because of the COVID pandemic?
What if you have a gig job, or work part time, and you make too much to qualify for Medicaid and your state does not participate in the Medicaid expansion?
Will treatment and vaccinations become free for people with COVID infections, or for frontline workers and people in general? These are some of the questions that will have to be dealt with in the coming months and it is a good idea for you to know where your state stands and what your options are as they change the laws related to healthcare.
The following states, as of November 2020, have not adopted the Medicaid expansion under Obamacare/Affordable Care Act:
Florida
Georgia
Alabama
Mississippi
South Carolina
North Carolina
Tennessee
Kansas
Texas
Wyoming
South Dakota
Wisconsin
Make yourself familiar with the provisions of the law that are important to you, and with other aspects of health care-related issues, so that you can be an informed citizen when you voice your disapproval of, or support for, soon-to-come actions.
© Copyright 2020 Danita Smith, Red and Black Ink, LLC
References:
Burns, Joseph. "Check in on Health Insurance Open Enrollment.” New York Times. November 7, 2020. Accessed November 14, 2020. https://www.nytimes.com/2020/11/07/at-home/health-insurance-shopping.html
Patient Protection and Affordable Care Act, H.R.3590 — 111th Congress (2009-2010). https://www.congress.gov/bill/111th-congress/house-bill/3590/text and https://www.congress.gov/bill/111th-congress/house-bill/3590
Supreme Court—Texas v. California (19-1019) and California v. Texas (19-840)—consolidated. Heard Tuesday, November 10, 2020. https://www.supremecourt.gov/oral_arguments/argument_transcripts/2020/19-840_1a72.pdf
“The Health Insurance Marketplace”. Internal Revenue Service. Accessed November 2020.