Health Care Reform Benefits

Health Care Reform

The Patient Protection and Affordable Care Act (PPACA) is a United States federal statute signed into law by President Barack Obama on March 23, 2010. The law (along with the Health Care and Education Reconciliation Act of 2010) is the principal health care reform legislation of the 111th United States Congress. PPACA reforms certain aspects of the private health insurance industry and public health insurance programs, increases insurance coverage of pre-existing conditions, expands access to insurance to over 30 million Americans, and increases projected national medical spending while lowering projected Medicare spending.

Provisions that have taken effect as of January 2012

Seniors in Medicare who reach the coverage gap receive 50% discount on Part D covered brand name drugs.

Seniors in Medicare will receive increasing Part D brand name drug savings until coverage gap is closed in 2020.

Young adults are allowed to stay on their parent’s health insurance plan until they turn 26.

Pre-existing Condition Insuranace Plan (PCIP) available for those who have been denied coverage and without insurance for 6+ months.

Small buisinesses can receive tax credit up to 35% of their employer contribution towards employee health insurance benefits.

Non profits can receive tax credit up to 25% of their employer contribution towards employee health insurance benefits.

Federal matching funds were increased for states to expand Medicaid program to cover more low income families.

Additional resources have been allocated to reduce fraud and waste in Medicare, Medicaid and CHIP. $2.5 billion was returned in 2009.

Enhanced enrollment and screening requirements to detect fraud on the part of Medicare providers.

New requirements for suppliers of Medicare Durable Medical Equipment to reduce fraud

Extra help for employment based plans to continue affordable health insurance for people who retire before 65.

More information on line to help people compare health insurance coverage at

All new plans include preventive office visits at no charge.

A policy can only be rescinded (canceled) if the member intentionally misrepresents facts on the application.

There are no longer lifetime dollar limits on key benefits like hospital stays or treatment.

Children under 19 can get health insurance even if they have a pre-existing condition or illness before applying.

Certain preventative services like vaccines are covered 100% in network.

Adult Preventive Services covered in all health plans without having to pay any cost sharing, deductible or co-payment for office visits:


Abdominal Aortic Aneurysm

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Alcohol misuse, sceening and counseling

Aspirin use for men and women of certain age

Blood Pressure screening for adults

Cholesterol screening for adults of certain age and risk

Colorectal Screening screening for adults over 50

Depression screening for adults

Type 2 Diabetes screening for adults with high blood pressure

Diet counseling for adults at risk for chronic disease

HIV screening for adults at high risk

Immunizations, covers a spectrum of ages and types

Obesity screening and counseling

Sexually Transmitted Infection prevention counseling for adults

Tobacco Use cessation and intervention

Anemia screening for pregnant women

Breast Cancer Mammography, women over 40, every 2 years.

Breast Cancer Chemoprevention, counseling for women at risk

Cervical Cancer screening for women

Chlamydia Infection for younger and women at risk

Folic Acid supplements for women who might become pregnant

Gonorrhea screening for women at risk

Hepatitus screening for pregnant women at their first prenatal visit

Osteoporis screening for women over 60 at risk

Syphilis screening for women at risk


Additional Women’s Preventive Services effective in policies issued after August 1, 2012:

Well Women visits

Gestational diabetes screening

Human Papillomavirus testing for high risk and normal cytology results

Counseling for sexually transmitted infections and HIV

Contraceptive Methods including sterilization, counseling

Breastfeeding Support supplies and counseling

Interpersonal and Domestic Violence screening and counseling

 No charge preventive services for children


Alcohol and Drug use assessments in adolescents

Autism screening 18 to 24 months

Blood pressure screening at various age ranges

Cervical Dysplasia screening for sexually active females

Congenital Hypothyroidism screening for new borns

Depression screening for adolescents

Dyslipidemia screening for children at high risk of lipid disorders

Fluoride Chemoprevention supplements for children

Gonorrhea preventive medication for the eyes of all new borns

Hearing screening for all new borns

Hematocrit or Hemoglobin screening for all children

Immunizations from birth to 18 for a variety of diseases

Iron supplements for children 6 – 12 months at risk of anemia

Lead screening for children at risk of exposure

Obesity screening and counseling

Oral Health risk assessment

Phenylketonuria (PKU) screening for this genetic disorder in new borns

Sexually Transmitted Infection prevention for adolescents at risk

Tuberculin testing for children of higher risk of tuberculosis

Vision screening for all children

Members may be eligible for a rebate if plan doesn’t spend at 80% of premiums on medical care and quality improvement during the year.

HSA money can only be spent on over-the-counter if plan member has a prescription.

2012 Reforms

Benefit summaries will start to use standard format that makes it easier to compare plans.

Accountable Care Organizations, in these groups, doctors can better coordinate patient care and improve the quality

Value-Based Purchasing program (VBP) in Original Medicare. This program offers financial incentives to hospitals to improve the quality of care

Standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information

Medicare Shared Savings program, allowing ACOs to contract with Medicare

2013 Reforms

Requires states to pay primary care physicians no less than 100% of Medicare payment rates in 2013 and 2014 for primary care services

National pilot program, bundling payments, to encourage hospitals, doctors, and other providers to work together to improve the coordination and quality of patient care

States will receive two more years of funding to continue coverage for children not eligible for Medicaid

2014 Reforms

Affordable Insurance Exchanges, competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans.

Members of Congress will be getting their health care insurance through Exchanges

All plans must included certain “essential health benefits”

Plans must cover at least 60% of costs for in-network covered services.

Plans must fit into five categories that cover between 60% to 90% of all costs

A ‘catostrophic coverage’, least expensive, will be available for people under 30 or with financial hardship.

Most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans

If affordable coverage is not available to an individual, he or she will be eligible for an exemption

Workers meeting certain requirements who cannot afford the coverage provided by their employer may take whatever funds their employer might have contributed to their insurance and use these resources to help purchase a more affordable plan in the new Affordable Insurance Exchanges

Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid

Tax credits to help the middle class afford insurance will become available for those with income between 100% and 400% of the poverty line who are not eligible for other affordable coverage

Insurers will be prohibited from dropping or limiting coverage because an individual chooses to participate in a clinical trial

The law prohibits new plans and existing group plans from imposing annual dollar limits on the amount of coverage an individual may receive

“Guarantee Issue” will prohibit insurance companies from refusing to sell coverage or renew policies because of an individual’s pre-existing conditionsPlans may not charge higher premiums due to gender or health status.

Small business tax credit for employer contribution to employee health insurance will increase to 50%

Non-Profit tax credit for contribution to the employee health insurance will increase to 35%.

2015 Reforms

Physician payments will be tied to the quality of care they provide

For more information and a complete list of benefits visit

Questions and Answers

Aren’t Colonoscopies Free under Healthcare Reform Law? Kaiser Health News explains some of the situations

  • pcip

    Great little timeline and projection into what to expect with reform.

  • FreeMktMonkey

    Ah, the comforting illusion of free or almost free!!! Daignostic Services should always be paid directly as they are gateway transactions most likely to be discounted. Pep Boys recognized this by offering to diagnose that check engine light for FREE! Let the free market work by moving away from 3rd party payment and the poison it is to it’s proper function. If there ever is a mandate it should be to direct a % of income to an HSA, never to purchase insurance products that are not in the best interest of most who purchase them.

    • Kevin Knauss

      I agree that there is no free lunch. In this case, the no cost preventive office visits are built into the premiums.

      But more importantly is the application of the adage “An ounce of prevention is worth a pound of cure”. Both insurance providers and public assistance programs realize this.

      It is far less costly to treat cancer in the early stages than when detection is late stage. From the government perspective, we need only look to Medi-Cal in California to see the 100’s of millions of tax dollars spent on patients in skilled nursing facilities.

      My father spent 5 years in a skilled nursing facility, 4 on Medi-Cal to the tune of $250,000+. It is very possible that had he had access to early screening for certain health conditions, his debilitating stroke could have been avoided. $80 office visit versus $250k in tax payer money, I think it speaks for itself.

  • seo new york

    I’m going to school for Ultrasound and was wondering how the Health Care Reform will affect the salary of the workers in those fields. No, money is not the reason I am choosing Ultrasound, I have been interested in it for years (I’m 22), but if you want to have a successful life, with a house and children in the future you have to weigh all of the pros and cons. Anyway, do you think that this reform will affect the salaries? Thank you.

    • Kevin Knauss

      There will be winners and losers with health care reform. Because of the Medical Loss Ratio (MLR) regulations, commissions to agents and brokers has been severely reduced. Medical technicians wages will still be governed by supply and demand. As more people are covered by health insurance there will be an increase in demand for services. If there is a shortage of trained medical staff, hospitals and physician groups will bid up the wages to attract qualified employees. Eventually, more people will enter the field and any temporary spike in wages will be smoothed away by inflation.

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  • Teese Powell

    Thank you for breaking down the actually terms of Heath Care Reform. President Obama doesn’t do a good job getting the specifics out there. While I know it wasn’t all “death panels” and “everyone will be on a 2 year waiting list for a check-up, I didn’t know exactly what was being implemented. Good job!!

    • Kevin Knauss

      When I realized how many important changes were happening under Healthcare Reform and NOT being reported, I decided I had to try and get the word out.

  • vince phillips

    Lots of benefits and everything is free…NOT! Few would disagree with merits of free benefits but the costs do not go away. The insurers have to eat the cost of first-dollar preventive care services and how do they recoup their new expenses? What other choice do they have besides raising premiums. Or, in the case of expanding medicaid or subsidizing Health insurance exchanges up to a family income of $80,000 a year means that we taxpayers pay for it. It is easy to be Obama or one of his defenders and promise things for free but free ain’t free.

    • Kevin Knauss

      True, nothing is free. The last two wars were not free. Had you been given a yearly bill for the Iraq war, would you have felt different about it?

      Health insurance has become the de facto gatekeeper to healthcare services. Without insurance you can’t get comprehensive care. The big question is how much of your healthcare decisions do you want dictated by business? Is it “OK” for an insurance company to deny a life saving procedure because it would cost them too much money?

      Much of the ACA is centered around preventive medicine. There is no argument that catching cancer early has better partient outcomes and cost les money. Yes, this costs money. But we shouldn’t be tripping over dollars to pick up a dime.

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