Understanding Health Care Reform
| The Patient Protection and Affordable Care Act (PPACA) is part of health care reform that is aimed at decreasing the number of uninsured individuals and reducing the overall cost of health care. PPACA has a number of health insurance and health care changes that either have been implemented already or will be in the near future.
To help you better understand what this means for you whether you’re a member, a consumer, an employer, an agent or a health care professional, we’ve put together the following information and goals. Because many of these changes are still being clarified, we’ll add new information as it become available.
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Essential Health Benefits
In 2014, individual and small group plans inside and outside of the Exchange must offer a comprehensive package of items and services known as essential health benefits. Learn more.
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Regulations by Topic:
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Benefit Changes
Extension of Adult Dependent Coverage
All health plans that provide dependent coverage must extend coverage to single and married adult children up to age 26 who do not have access to employer-based coverage. Beginning in 2014, dependent coverage must extend to all single and married adult children up to age 26 regardless of their access to other coverage.
Learn more.
Preventive Care
Health plans must cover certain preventive services without a copayment, coinsurance or deductible when provided by in-network providers. (Grandfathered plans are exempt for as long as they remain grandfathered.)
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View the list of Preventive Services Covered under the Affordable Care Act
Lifetime Limits on Coverage/Annual Limits on Coverage*
Health plans will be prevented from placing lifetime and annual dollar limits on coverage.
Learn more.
Coverage for Pre-Existing Conditions*
Health plans must provide coverage to those with pre-existing conditions at an affordable price.
Learn more.
Costs
Health Insurer Fee
All health plans are required to pay this fee to help fund the cost of implementing provisions of PPACA.
Reinsurance Assessment Fee
All health plans will pay a reinsurance assessment fee until the end of 2016 to help fund a reinsurance program designed to reimburse companies that insure high-cost individuals within the individual health insurance market.
Federal Exchange User Fee
Any health plan that wants to offer plans through the federal health insurance exchanges will need to pay this fee to help play the administrative expense of running the program to stabilize premiums in the individual and small group market.
Patient Centered Outcomes Research Institute (PCORI) Fee
All health plans are required to pay this fee until the end of 2019 to help fund the comparative effectiveness research that will be conducted by PCORI, a non-profit organization established by PPACA.
Purchasing Insurance
Health Insurance Exchanges
Health Insurance Exchanges will offer individuals and families and small employer groups a place to compare health plan options and enroll for coverage.
Individual Mandate
This mandate will require all individuals to be enrolled in a health plan or pay an assessment.
Learn more.
Guaranteed Issue**
Health plans must permit individuals to enroll regardless of health status, age, gender or other factors that might predict the use of health services.
Rating Requirements***
Health plans will only be allowed to vary premiums based on policy type (individual or family), geographic area, age and tobacco use.
Tax Credit for Employee Health Insurance Expenses of Small Employers
This offers a tax credit to certain small employers that provide health insurance coverage to their employees.
Learn more.
Tax Credits for Individuals (Advanced Premium Tax Credits)
In 2014, individuals who enroll in qualified health plans through the Exchange may receive premium tax credits based on their income.
The tax credits will be available for individuals with household incomes between 100% and 400% of the Federal Poverty Level. For example, a household of four with an income of 100% of the Federal Poverty Level is $23,050 and the same household with an income of 400% of the Federal Poverty Level is $92,200.
Individuals who are eligible for the tax credits may use some of it, all of it or none of it when they purchase their plan from the Exchange.
Those who are eligible for affordable coverage through their employer will not be eligible for the tax credits.
Process Changes
Appeals/Grievance Process
A Wisconsin insurer offering group or individual health insurance coverage must comply with Federal internal appeal and external review standards.
Learn more about Unity's Appeal Process.
Summary of Benefits and Coverage (SBC)
Health plans are required to provide an easy-to-understand summary about a health plan’s benefits and coverage. The standard form helps to compare different health plan options.
View a sample Summary of Benefits and Coverage.
*Not applicable to Grandfathered Individual Plans
**Not applicable to Grandfathered Individual Plans. Effective January 1, 2014, this will also be applicable to Grandfathered Group Plans.
***Not applicable to Large Group, Grandfathered Small Group, or Grandfathered Individual Plans
Please Note: Information on other requirements will be added as it becomes available.
