Earlier this year, Congress passed and the President signed landmark health insurance reform legislation, the Patient Protection and Affordable Care Act (P.L. 111-148) and the Health Care and Education Reconciliation Act (P.L. 111-152), and Americans are already experiencing the benefits. These two laws, together referred to as the Affordable Care Act, put control over health care decisions in the hands of the American people, not insurance companies. Senate Democrats are committed to implementing health reform that holds insurance companies accountable, brings costs down for everyone, and provides Americans with the insurance security and choices they deserve. This fact sheet provides an overview of recent health reform implementation activity. Previous updates on health reform implementation and other information are available from the DPC. [DPC]
Protecting Consumers and Putting Patients Back in Charge
The Affordable Care Act protects consumers by ending some of the worst health insurance industry abuses. One way the Affordable Care Act protects consumers and puts patients back in charge of their health care is by requiring insurance companies to implement effective internal and external appeals processes. [P.L. 111-148; H.R.4872enr.txt.pdf" target="_blank">P.L. 111-152] Patients deserve the right to appeal coverage determinations and claims decisions made by their insurance plan. Sometimes an internal appeals process is adequate to address consumer concerns, and the Affordable Care Act ensures all new health plans have such a process. However, if an internal review is not adequate, the Affordable Care Act provides, for the first time, the right for all consumers, regardless of where they live, to appeal decisions made by their health plan to an outside, independent decision-maker.
Specifically, the Affordable Care Act requires new insurance plans, with plan or policy years beginning on or after September 23, 2010, to implement an effective internal appeals process of coverage determinations and claims and to comply with any applicable State external review process. Regulations issued by the Departments of Health and Human Services, Labor, and Treasury will standardize internal and external review processes, so that no matter what state consumers live in, they have access to clearly defined and impartial appeals that ensure necessary health care is covered by their plan. [Federal Register, 7/22/10] The Administration estimates that next year, approximately 31 million people in new employer plans and 10 million people in new individual plans will benefit from these new appeals protections, and that 88 million Americans will benefit by 2013. [HealthCare.gov, 7/22/10]
The Affordable Care Act also provides $30 million in grants to states to establish or expand offices of health insurance consumer assistance or health insurance ombudsman programs. [P.L. 111-148; H.R.4872enr.txt.pdf" target="_blank">P.L. 111-152] These independent offices will assist consumers with filing complaints and appeals, educate consumers on their rights and responsibilities, and collect, track, and quantify consumer problems and inquiries. All states and territories may apply for these grants to expand their consumer assistance efforts. More information is available at Grants.gov. [Grants.gov, 7/22/10]
Together, the enhanced appeals process and consumer assistance grants will provide Americans with more protection and control over their health insurance coverage and health care. For example, if your insurance company denies coverage of a test recommended by your doctor, or denies coverage of emergency care, or even decides to revoke your coverage completely, you will have the opportunity to appeal that decision to the plan, and if they still refuse coverage, you can appeal that decision to an external reviewer. If you need help understanding the insurance coverage options available to you, a state consumer assistance program will be able to provide the support you need.
Combating Obesity in Children and Families
The Affordable Care Act created a Prevention and Public Health Investment Fund to provide an expanded and sustained national investment in prevention and public health programs to improve health and help control the growth rate of health care costs. [P.L. 111-148; H.R.4872enr.txt.pdf" target="_blank">P.L. 111-152] Last week, the Department of Health and Human Services announced that $5 million of the Investment Fund is available via a competitive grant to establish the Prevention Center for Healthy Weight. [Grants.gov, 7/16/10] Any public or nonprofit entity may apply for grant funding to plan, implement, and manage a nationwide Healthy Weight Collaborative, serve as a gateway for information regarding the prevention and treatment of overweight and obesity, and promote family-centered, community-based, coordinated care for children and families.
Improving the Wellbeing of Children and Families
The Affordable Care Act included $1.5 billion for states, tribes and territories to develop and implement evidence-based Maternal, Infant, and Early Childhood Visitation models targeted at reducing infant and maternal mortality by improving prenatal, maternal, and newborn health, child health and development, parenting skills, school readiness, juvenile delinquency, and family economic self-sufficiency. [P.L. 111-148; H.R.4872enr.txt.pdf" target="_blank">P.L. 111-152] The Department of Health and Human Services (HHS) recently announced the allocation of $88 million to the 49 states, the District of Columbia, and the five territories that applied for funding. [HHS, 7/21/10] In addition, HHS recently posted on the Federal Register a notice and request for comment regarding criteria for evidence of effectiveness of home visiting models. [Federal Register, 7/23/10]
Support for Working, Nursing Mothers
The Affordable Care Act includes a requirement for employers with more than 50 employees to provide nursing mothers with reasonable break time and a private place to express milk during the first year after their child’s birth. [P.L. 111-148; H.R.4872enr.txt.pdf" target="_blank">P.L. 111-152] Studies demonstrate the health benefits of breastfeeding for both infants and mothers, and increasing the number of mothers who breastfeed their babies is a goal of the Healthy People 2010 initiative. [HHS, 11/00] This week, the Department of Labor (DOL) issued a fact sheet to provide some basic information on this provision for employers and employees. [DOL, 7/10] DOL will provide additional information in future guidance.
The Democratic Policy Committee has released six previous updates on health reform implementation, available on the DPC website here, with the following direct links:
In addition, DPC maintains a centralized listing of health reform implementation resources which is frequently updated and is available here.