Learn the 12 things important, but often overlooked, facts about the Affordable Care ActThe Affordable Care Act (ACA) is an historic effort by the government to extend medical insurance coverage to all Americans, increase the quality of care, increase accountability, and reduce cost. It’s been said that the ACA changes the relationship between government, health care providers and all who receive health care in the U.S. However, at this time little is generally known about the program. Several interesting facts about the ACA follow:

  1. To help people make educated decisions when shopping for medical insurance, the ACA mandates that health insurers provide an easy to understand summary of a health plans benefits and coverage. This is called a Summary of Benefits and Coverage (SBC).
  2. Effective January 1, 2014, health plans cannot limit or deny coverage based upon “pre-existing conditions,” i.e., health problems that existed before the applicant applied for insurance coverage. Since this prohibition against denying coverage due to pre-existing conditions applies to developmental disabilities and other childhood disabilities, special needs planning for the purpose of securing health insurance may be eliminated. It is possible to foresee many cases in which payback 1st party special needs trusts will be completely unnecessary.
  3. The ACA allows the patient to choose his or her primary care provider from the health plan’s provider network.
  4. The ACA mandates that the patient may seek emergency care at a hospital outside the plan’s network without prior approval, and prevents health plans from requiring higher co-payments or co-insurance for out-of-network emergency room services.
  5. The ACA ensures a patient’s right to appeal health insurance plan decisions which deny payment for a treatment or service. Patients can appeal decisions internally and, if the decision denying coverage is affirmed, can request review by an independent review organization.
  6. The ACA prohibits health plans from imposing lifetime dollar limits on benefits. Before the ACA, many health plans set a dollar limit on spending for covered benefits during the time the patient was enrolled in a plan.
  7. Parents can now cover children under the parent’s health plan until the child attains age 26 even is the child is married, mot living with the parent, attending school, not financially dependent on the parent, or eligible to enroll in their own employer’s plan.
  8. Under the ACA, people are eligible for preventive services, at no additional cost. Preventative services, designed to help avoid illness and improve health, include blood pressure, diabetics and cholesterol tests, cancer screenings, counseling, routines vaccinations, flu and pneumonia shots and the like.
  9. The ACA has no impact on the existing Medicare system.
  10. Under the ACA, Americans must secure health coverage by January 1, 2014, Those who do not will pay a penalty. Penalties will be phased in through 2016. In 2014, the penalty for individuals is $95, or 1% of taxable income, whatever is greater. By 2016, the penalty will be $695, or 2.5% of taxable income.
  11. Effective January 1, 2014, Medicaid will be expanded to include individuals between the ages of 19 and 65 with incomes of up to 133% of the federal poverty limit. Medicaid expansion does not affect people over the age of 65. Medicaid expansion does not affect recipients of nursing home Medicaid benefits or recipients of community Medicaid programs such as those which pay assisted living facilities and home health aides. Medicaid expansion affects indigent people below age 65 who are not eligible for Medicare. (Medicare recipients under age 65 are not eligible for Medicaid expansion.)
  12. The long-term care component of the ACA, the ACA program designed to pay for nursing home care, community services and the like, called the Community Living Assistance Services and Supports, or CLASS, was dropped from the ACA in 2011. CLASS was found to be “financially untenable.”

(This blog post is adapted from an article entitled “Overview of the Affordable Care Act for Disability and Elder Law Attorneys” by Scott Sclkoff, Esq., and presented on March 22, 2014 at the Seventh Annual Meeting of the Academy of Special Needs Planners (ASNP). Mr. Vanarelli is a founding member of the ASNP.) 

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