Patient Protection & Affordable Care Act

The Patient Protection and Affordable Care Act

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The Patient Protection and Affordable Care Act will ensure that all Americans have access to quality, affordable health care and will create the transformation within the health care system necessary to contain costs. The Congressional Budget Office (CBO) has determined that the Patient Protection and Affordable Care Act is fully paid for, ensures that more than 94 percent of Americans have health insurance, bends the health care cost curve, and reduces the deficit by $118 billion over the next ten years and even more in the following decade. The Patient Protection and Affordable Care Act addresses essential components of reform:

Quality, affordable health care for all Americans The role of public programs Improving the quality and efficiency of health care Prevention of chronic disease and improving public health Health care workforce Transparency and program integrity Improving access to innovative medical therapies Community living assistance services and supports Revenue provisions

Title I. Quality, Affordable Health Care for All Americans The Patient Protection and Affordable Care Act will accomplish a fundamental transformation of health insurance in the United States through shared responsibility. Systemic insurance market reform will eliminate discriminatory practices by health insurers such as pre-existing condition exclusions. Achieving these reforms without increasing health insurance premiums will mean that all Americans must have coverage. Tax credits for individuals, families, and small businesses will ensure that insurance is affordable for everyone. These three elements are the essential links to achieving meaningful reform. Immediate Improvements. Implementing health insurance reform will take some time. However, many immediate reforms will take effect in 2010. The Patient Protection and Affordable Care Act will:

Eliminate lifetime and unreasonable annual limits on benefits, with annual limits prohibited in 2014

Prohibit rescissions of health insurance policies Provide assistance for those who are uninsured because of a pre-existing condition Prohibit pre-existing condition exclusions for children Require coverage of preventive services and immunizations Extend dependant coverage up to age 26 Develop uniform coverage documents so consumers can make apples-to-apples comparisons

when shopping for health insurance


Cap insurance company non-medical, administrative expenditures Ensure consumers have access to an effective appeals process and provide consumer a place to

turn for assistance navigating the appeals process and accessing their coverage Create a temporary re-insurance program to support coverage for early retirees Establish an internet portal to assist Americans in identifying coverage options Facilitate administrative simplification to lower health system costs

Health Insurance Market Reform. Beginning in 2014, more significant insurance reforms will be implemented. Across individual and small group health insurance markets in all states, new rules will end medical underwriting and pre-existing condition exclusions. Insurers will be prohibited from denying coverage or setting rates based on gender, health status, medical condition, claims experience, genetic information, evidence of domestic violence, or other health-related factors. Premiums will vary only by family structure, geography, actuarial value, tobacco use, participation in a health promotion program, and age (by not more than three to one). Available Coverage. A qualified health plan, to be offered through the new American Health Benefit Exchange, must provide essential health benefits which include cost sharing limits. No out-of-pocket requirements can exceed those in Health Savings Accounts, and deductibles in the small group market cannot exceed $2,000 for an individual and $4,000 for a family. Coverage will be offered at four levels with actuarial values defining how much the insurer pays: Platinum 90 percent; Gold 80 percent; Silver 70 percent; and Bronze 60 percent. A less costly catastrophic-only plan will be offered to individuals under age 30 and to others who are exempt from the individual responsibility requirement. American Health Benefit Exchanges. By 2014, each state will establish an Exchange to help individuals and small employers obtain coverage. Plans participating in the Exchanges will be accredited for quality, will present their benefit options in a standardized manner for easy comparison, and will use one, simple enrollment form. Individuals qualified to receive tax credits for Exchange coverage must be ineligible for affordable, employer-sponsored insurance any form of public insurance coverage. Undocumented immigrants are ineligible for premium tax credits. Federal support will be available for new non-profit, member run insurance cooperatives, and the Office of Personnel Management will supervise the offering by private insurers of multi-State plans, available nationwide. States will have flexibility to establish basic health plans for non-Medicaid, lower-income individuals; states may also seek waivers to explore other reform options; and states may form compacts with other states to permit cross-state sale of health insurance. No federal dollars may be used to pay for abortion services. Making Coverage Affordable. New, refundable tax credits will be available for Americans with incomes between 100 and 400 percent of the federal poverty line (FPL) (about $88,000 for a family of four). The credit is calculated on a sliding scale beginning at two percent of income for those at 100 percent FPL and phasing out at 9.8 percent of income at 300-400 percent FPL. If an employer offer of c a c 9.8 c a a c , ays less than 60 percent of the premium, the worker may enroll in the Exchange and receive credits. Out of pocket maximums ($5,950 for individuals and $11,900 for families) are reduced to one-third for those with income between 100-200 percent FPL, one-half for those with incomes between 200-300 percent FPL, and


two-thirds for those with income between 300-400 percent FPL. Credits are available for eligible citizens and legally-residing aliens. A new credit will assist small businesses with fewer than 25 workers for up to 50 percent of the total premium cost.

Shared Responsibility. Beginning in 2014, most individuals will be responsible for maintaining minimum essential coverage or paying a penalty of $95 in 2014, $495 in 2015 and $750 in 2016, or up to two percent of income by 2016, with a cap at the national average bronze plan premium. Families will pay half the amount for children up to a cap of $2,250 for the entire family. After 2016, dollar amounts will increase by the annual cost of living adjustment. Exceptions to this requirement are made for religious objectors, those who cannot afford coverage, taxpayers with incomes less than 100 percent FPL, Indian tribe members, those who receive a hardship waiver, individuals not lawfully present, incarcerated individuals, and those not covered for less than three months. Any individual or family who currently has coverage and would like to retain that coverage can do so

a a a . T c a individual responsibility to have health coverage. Similarly, employers that currently offer coverage are permitted to continue offering

c c a a a c . Employers with more than 200 employees must automatically enroll new full-time employees in coverage. Any employer with more than 50 full-time employees that does not offer coverage and has at least one full-time employee receiving the premium assistance tax credit will make a payment of $750 per full-time employee. An employer with more than 50 employees that offers coverage that is deemed unaffordable or does not meet the standard for minimum essential coverage and but has at least one full-time employee receiving the premium assistance tax credit because the coverage is either unaffordable or does not cover 60 percent of total costs, will pay the lesser of $3,000 for each of those employees receiving a credit or $750 for each of their full-time employees total.

Title II. The Role of Public Programs The Patient Protection and Affordable Care Act expands eligibility for Medicaid to lower income persons and assumes federal responsibility for much of the cost of this expansion. It provides

a c a C H a I a c P a , M ca a CHIP enrollment, improves Medicaid services, provides new options for long-term services and supports, improves coordination for dual-eligibles, and improves Medicaid quality for patients and providers. Medicaid Expansion. States may expand Medicaid eligibility as early as April 1, 2010. Beginning on January 1, 2014, all children, parents and childless adults who are not entitled to Medicare and who have family incomes up to 133 percent FPL will become eligible for Medicaid. Between 2014 and 2016, the federal government will pay 100 percent of the cost of covering newly-eligible individuals. In 2017 and 2018, states that initially covered less of the newly- b a ( O S a ) will receive more assistance than states that covered at least some non-elderly, non-pregnant adults ( E a S a ). S a will be required to maintain the same income eligibility levels through December 31, 2013 for all adults, and this requirement would be extended through September 30, 2019 for children currently in Medicaid.


Child en Heal h In ance P og am. States will be required to maintain income eligibility levels for CHIP through September 30, 2019. The current reauthorization period of CHIP is extended for two years, to September 30, 2015. Between fiscal years 2016 and 2019, states would receive a 23 percentage point increase in the CHIP federal match rate, subject to a 100 percent cap. Simplifying Enrollment. Individuals will be able to apply for and enroll in Medicaid, CHIP and the Exchange through state-run websites. Medicaid and CHIP programs and the Exchange will coordinate enrollment procedures to provide seamless enrollment for all programs. Hospitals will be permitted to provide Medicaid services during a period of presumptive eligibility to members of all Medicaid eligibility categories. Community First Choice Option. A new optional Medicaid benefit is created through which states may offer community-based attendant services and supports to Medicaid beneficiaries with disabilities who would otherwise require care in a hospital, nursing facility, or intermediate care facility for the mentally retarded. Disproportionate Share Hospital Allotments. S a a e share hospital (DSH) allotments are reduced once a a uninsured rate decreases by 45 percent. The initial reduction for States that spent 99.90 percent of their allotments over the five-year period of 2004 through 2008 would be 50 percent, unless they are defined as low DSH states, in which case they would receive a 25 percent reduction. The initial reduction for states that spent greater than 99.90 percent of their allotments would be 35 percent, or 17.5 percent for low DSH states in this category. As the uninsured rate continues to c , a DSH allotments would be reduced by a corresponding amount. At no

c a a a t be reduced by more than 50 percent compared to its FY2012 allotment. Dual Eligible Coverage and Payment Coordination. The Secretary of Health and Human Services (HHS) will establish a Federal Coordinated Health Care Office by March 1, 2010 to integrate care under Medicare and Medicaid, and improve coordination among the federal and state governments for individuals enrolled in both programs (dual eligibles). Title III. Improving the Quality and Efficiency of Health Care The Patient Protection and Affordable Care Act will improve the quality and efficiency of U.S. medical care services for everyone, and especially for those enrolled in Medicare and Medicaid. Payment for services will be linked to better quality outcomes, and the Patient Protection and Affordable Care Act will make substantial investments to improve the quality and delivery of care and support research to inform consumers about patient outcomes resulting from different approaches to treatment and care delivery. New patient care models will be created and disseminated, rural patients and providers will see meaningful improvements, and payment accuracy will improve. The Medicare Part D prescription drug benefit will be enhanced and the coverage gap, or donut hole, will be reduced. An Independent Payment Advisory Board will develop recommendations to ensure long-term fiscal stability. Linking Payment to Quality Outcomes in Medicare. A value-based purchasing program for hospitals will launch in FY2013 to link Medicare payments to quality performance on common, high- cost conditions. The Physician Quality Reporting Initiative (PQRI) is extended through 2014, with


incentives for physicians to report Medicare quality data physicians will receive feedback reports beginning in 2012. Long-term care hospitals, inpatient rehabilitation facilities, certain cancer hospitals, and hospice providers will participate quality measure reporting starting in FY2014, with penalties for non-participating providers. Strengthening the Quality Infrastructure. The HHS Secretary will establish a national strategy to improve health care service delivery, patient outcomes, and population health. The President will convene an Interagency Working Group on Health Care Quality to collaborate on the development and dissemination of quality initiatives consistent with the national strategy. Encouraging Development of New Patient Care Models. A new Center for Medicare & Medicaid Innovation will research, develop, test, and expand innovative payment and delivery arrangements. Accountable Care Organizations (ACOs) that take responsibility for cost and quality of care will receive a share of savings they achieve for Medicare. The HHS Secretary will develop a national, voluntary pilot program encouraging hospitals, doctors, and post-acute providers to improve patient care and achieve savings through bundled payments. A new demonstration program for chronically ill Medicare beneficiaries will test payment incentives and service delivery using physician and nurse practitioner-directed home-based primary care teams. Beginning in 2012, hospital payments will be adjusted ba a a ac a c a ntially preventable Medicare readmissions. Ensuring Beneficiary Access to Physician Care and Other Services. The Act extends a floor on geographic adjustments to the Medicare fee schedule to increase provider fees in rural areas and gives immediate relief to areas affected by geographic adjustment for practice expenses. The Act extends Medicare bonus payments for ground and air ambulance services in rural and other areas. The Act creates a 12 month enrollment period for military retirees, spouses (and widows/widowers) and dependent children, who are eligible for TRICARE and entitled to Medicare Part A based on disability or ESRD, who have declined Part B. Rural Protections. The Act extends the outpatient hold harmless provision, allowing small rural hospitals and Sole Community Hospitals to receive this adjustment through FY2010 and reinstates cost reimbursement for lab services provided by small rural hospitals from July 1, 2010 to July 1, 2011. The Patient Protection and Affordable Care Act extends the Rural Community Hospital Demonstration Program for five years and expands eligible sites to additional states and hospitals. Improving Payment Accuracy. The HHS Secretary will rebase home health payments starting in 2014 to better reflect the mix of services and intensity of care provided to patients. The Secretary will update Medicare hospice claims forms and cost reports to improve payment accuracy and revise the underlying payment system to better reflect the cost of providing care to hospice patients. The Secretary will revise Disproportionate Share Hospital (DSH) payments to better account for hospital costs of treating the uninsured and underinsured, including adjustments to DSH payments to reflect lower uncompensated care costs resulting from increases in the number of insured patients. The bill also makes changes to improve payment accuracy for imaging services and power-driven wheelchairs. The Secretary will study and report to Congress on reforming the Medicare hospital wage index


system and will establish a demonstration program to allow hospice eligible patients to receive all other Medicare covered services during the same period. Medicare Advantage (Part C). Medicare Advantage (MA) payments will be based on the average of the bids submitted by insurance plans in each market. Bonus payments will be available to improve the quality of care and will be ba a ca c a a ca a a , as well as achievement on quality rankings. New payments will be implemented over a four-year transition period. MA plans will be prohibited from charging beneficiaries cost sharing for covered services greater than what is charged under fee-for-service. Plans providing extra benefits must give priority to cost sharing reductions, wellness and preventive care prior to covering benefits not currently covered by Medicare. Medicare Prescription Drug Plan Improvements (Part D). In order to have their drugs covered under the Medicare Part D program, drug manufacturers will provide a 50 percent discount to Part D beneficiaries for brand-name drugs and biologics purchased during the coverage gap beginning July 1, 2010. The initial coverage limit in the standard Part D benefit will be expanded by $500 for 2010. Ensuring Medicare Sustainability. A productivity adjustment will be added to the market basket update for inpatient hospitals, home health providers, nursing homes, hospice providers, inpatient psychiatric facilities, long-term care hospitals and inpatient rehabilitation facilities. The Act creates a 15-member Independent Payment Advisory Board to present Congress with proposals to reduce costs and improve quality for beneficiaries. When Medicare costs are projected to exceed certain targets, the B a proposals will take effect unless Congress passes an alternative measure to achieve the same level of savings. The Board will not make proposals that ration care, raise taxes or beneficiary premiums, or change Medicare benefit, eligibility, or cost-sharing standards. Health Care Quality Improvements. The Patient Protection and Affordable Care Act will create a new program to develop community health teams supporting medical homes to increase access to community-based, coordinated care. It supports a health delivery system research center to conduct research on health delivery system improvement and best practices that improve the quality, safety, and efficiency of health care delivery. And, it support medication management services by local health providers to help patients better manage chronic disease. Title IV. Prevention of Chronic Disease and Improving Public Health T b a a ca a a a a , a of initiatives will provide the impetus and the infrastructure. A new interagency prevention council will be supported by a new Prevention and Public Health Investment Fund. Barriers to accessing clinical preventive services will be removed. Developing healthy communities will be a priority, and a 21st century public health infrastructure will support this goal. Modernizing Disease Prevention and Public Health Systems. A new interagency council is created to promote healthy policies and to establish a national prevention and health promotion strategy. A Prevention and Public Health Investment Fund is established to provide an expanded and sustained national investment in prevention and public health. The HHS Secretary will convene a national public/private partnership to conduct a national prevention and health promotion outreach and


education campaign to raise awareness of activities to promote health and prevent disease across the lifespan. Increasing Access to Clinical Preventive Services. The Act authorizes important new programs and benefits related to preventive care and services:

For the operation and development of School-Based Health Clinics. For an oral healthcare prevention education campaign. To provide Medicare coverage with no co-payments or deductibles for an annual wellness

visit and development of a personalized prevention plan. To waive coinsurance requirements and deductibles for most preventive services, so that

Medicare will cover 100 percent of the costs. To provide States with an enhanced match if the State Medicaid program covers: (1) any

clinical preventive service recommended with a grade of A or B by the U.S. Preventive Services Task Force and (2) adult immunizations recommended by the Advisory Committee on Immunization Practices without cost sharing.

To require Medicaid coverage for counseling and pharmacotherapy to pregnant women for cessation of tobacco use.

To award grants to states to provide incentives for Medicaid beneficiaries to participate in programs providing incentives for healthy lifestyles.

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