The Affordable Care Act and what it means for you and your family



In March 2010, President Obama signed a comprehensive health reform, the Patient Protection and Affordable Care Act (ACA), into law. The law’s intent is to make regular and preventive care more accessible and affordable. While some provisions of the law have already taken effect, many more will be implemented in the coming years.

While we’ve heard about the legislation, also referred to as Obamacare, and know changes are being made to our health care plans, for many of us, we may not be sure what that really means.

If you already have a health plan and are happy with your policy, you can keep it as is. But for those who are uninsured, or who are switching to new plans, you’ll notice some changes to the way health insurance plans have operated in the past.

Insurance companies will now need to compete with each other and, as a consumer; you will be able to do comparison shopping between the companies. The new Health Insurance Marketplace (healthcare.gov), allows people to compare costs for a variety of quality, affordable plans that best meet their health care needs. You will be able to pick out the best health care option from a list of providerswhile making sure that your family gets what it needs at a competitive rate.

According to the US Dept. of Health and Human Services, beginning Oct 1, you will be able compare qualified health plans (although New Hampshire currently only has one plan available through Anthem Blue Cross Blue Shield), get answers to questions, find out if you are eligible for lower costs for private insurance or health programs like Medicaid and the Children’s Health Insurance Program (CHIP) and enroll in health coverage.

How will the ACA change your health care?

ACA is designed to give the consumer as much control over their health care as possible. With the new rules you are able to:

Choose the primary care physician you want: ACA permits you to choose any available participating primary care provider as your doctor and to choose any available participating pediatrician as your child’s primary care doctor. This puts you in more control of who provides the health careyou want for you and your family.

Access to out-of-network emergency room services: In the past, some health plans would limit payment for emergency room services provided outside of a plan’s preselected network of emergency health care providers. Some would require you to get your plan’s prior approval for emergency care at hospitals outside its networks. In some cases, this meant tremendous financial hardship if you got sick or injured while away from home.

ACA prevents health plans from requiring higher copayments or co-insurance for out-of-network emergency room services. The new rules also prohibit health plans from requiring you to get prior approval before seeking emergency room services from a provider or hospital outside your plan’s network.

No health plan barriers to OB-GYN services: ACA prohibits health plans from requiring a referral from a primary care provider before you can seek coverage for obstetrical or gynecological (OB-GYN) care from a participating OB-GYN specialist.

Family planning is also covered under ACA, which defines contraceptive coverage as one of the essential benefits employers must provide free of charge to their subscribers.

Guarantees your right to appeal: If you do not agree with your treatment coverage you have the right to appeal to your health plan to challenge its decision to deny payment or restrict treatment.

How will ACA change how the insurance companies conduct business?

The ACA requires that insurance companies become more transparent in their handling of business finances. Consumers will have an opportunity to see how and where their insurance companies spend their money.

Reviews premium increases: The ACA requires that insurance companies must now justify any unreasonable rate hikes. No longer can an insurance company arbitrarily raise its rates for any person or group. Going forward, any and all rate increases must be fully explained to consumers.

Money from subscribers goes to subscribers: The ACA requires that at least 80 percent of health insurance premium dollars pay for health care and not for things like salaries or administrative costs. According to a recent July 2013 White House Press release, one of the many parts of the health care law already benefitting middle class and working Americans is this very provision requiring insurance companies to spend at least 80 percent of premium dollars on medical care and health care quality improvement.

If the insurance companies don’t spend the correct amount of money in this way, they must provide a refund to their customers. Consumers can receive these refunds in several ways: a refund check in the mail; a lump-sum reimbursement to the same account that they used to pay the premium if by credit card or debit card; a reduction in their future premiums; or their employer providing one of the above, or applying the refund in another manner that benefits its employees, such as more generous benefits.

How does ACA expand insurance health care coverage?

Eliminates pre-existing condition exclusions for children: When my sister knew her husband was going to switch jobs, she stocked up on her daughter’s asthma inhalers anticipating they would have to wait six months before a new health plan would cover doctor visits for the pre-existing condition. With ACA, insurance companies can no longer deny or limit coverage to anyone with a pre-existing condition.

This means parents of children with chronic illnesses or pre-existing conditions no longer have to be concerned about interruption of medical treatment when health plans change, or if a job is lost and a new policy needs to be found. People with existing conditions will get continued care.

Covers your child until age 26: Under some health plans, students were aging out of their parent’s policies while they were still in school, and before they had jobs that provided a health plan. This was leaving open a serious gap in health coverage for many young people. With ACA, children are covered by their parent’s insurance policy until they are 26 years old, at which time they are considered ready to get a full time job with health benefits of their own.

Bans annual and lifetime limits: The ACA bans annual and lifetime limits. If you happen to have an accident or have a devastating illness that requires extensive treatment (i.e., cancer), health plans can no longer limit the amount of medical care they will cover. With ACA, your treatment, even if it is extensive and long-term, will be covered.

How does ACA help with preventive health services?

The U.S. Department of Health and Human Services released national and state data (February 2012) revealing that 45 million additional people are receiving preventative health services as a direct result of the Affordable Care Act. The health law requires insurance plans to provide coverage for and eliminate cost-sharing on certain recommended preventive health services. The report estimates that in New Hampshire, 279,000 people are benefiting from these new preventative services.

Preventive screenings: Believing that screening and early treatment for health issues is a cost-effective approach in health care, the ACA provides coverage for preventative services at no cost (no copayment) to consumers. These services include:

  • Immunizations
  • Screening for diabetes and depression
  • Autism screenings for children at 18 and 24 months
  • Developmental screening for children under age 3
  • Behavioral assessments throughout childhood
  • Well child visits with assessments and individualized prevention plans

Creates the Prevention and Public Health fund: The ACA creates a grant program to support the delivery of evidence-based and community-based prevention and wellness services. As a result, you’ll be hearing more about health issues and how you can maintain your health on a state and, in some cases, local level. More information and programs will become available. As a result you’ll have better access to information about things like exercise and diet programs that could potentially help you to keep your family healthy.

Wendy Thomas of Merrimack was recently voted Executive Director of The New Hampshire Challenge. She attended the New Hampshire Family Support Services conference in May, where this topic was addressed. Contact her at wethomas@gmail.com.

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