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]
Six Months of Health Reform and a Patient’s Bill of Rights
On the six-month anniversary of the Affordable Care Act’s enactment, Senate Democrats celebrate the Patient’s Bill of Rights included in the law, which ends some of the worst insurance industry abuses. While Republicans continue their efforts to repeal these critical consumer protections, Senate Democrats remain 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.
For health insurance policies issued or renewed after September 23, 2010, Americans can depend upon the following protections:
· No lifetime limits on coverage. Insurers are prohibited from imposing lifetime limits on benefits. This provision applies to all new and existing plans in all markets.
· No coverage rescissions when Americans get sick. Insurers are prohibited from rescinding health coverage when a beneficiary gets sick as a way of avoiding paying that person’s health care bills. This provision applies to all new and existing plans in all markets.
· Extended coverage for young adults. Young adults may stay covered on their parents’ or guardians’ health insurance policy until their 26th birthday. This provision applies to all new and existing plans in all markets.
· Coverage for children with pre-existing conditions. Insurers are prohibited from denying coverage to children who have pre-existing conditions. This provision applies to all new plans and to existing plans in the group market.
· Regulated annual limits on coverage. Insurance plans’ use of annual limits are tightly regulated to ensure access to needed care. This provision applies to all new plans and existing employer plans, until 2014, when the Exchanges are operational and use of any type of annual limit will be banned for all new plans and existing employer plans.
· Required coverage of preventive care with no cost-sharing. Insurers are required to provide coverage of preventive health care services without imposing deductibles or cost-sharing. This provision applies to all new plans in all markets.
· Right to Choose Your Doctor and Access Emergency Care. Patients’ rights are protected by allowing health insurance plan members to choose any participating primary care provider, or in the case of children, any participating pediatrician, prohibiting insurers from requiring prior authorization before a woman sees an ob-gyn, and ensuring access to emergency care. This provision applies to all new plans in all markets.
· Fair opportunity to appeal coverage and claims decisions. Health insurers are required to develop an appeals process that, at a minimum, provides beneficiaries with a notice of internal and external appeals processes and allows beneficiaries to review their file and present evidence in their appeal. This provision applies to all new plans in all markets.
More information on these critical consumer protections is available from the DPC. [DPC, 9/22/10]
Advancing Research to Improve Patient Care
Earlier this week, the Government Accountability Office announced the appointment of 19 members to the Board of Governors for the Patient-Centered Outcomes Research Institute. [GAO, 9/23/10] The Affordable Care Act establishes this independent, non-profit Institute governed by public and private sector representatives to provide for research that helps inform the decisions of patients and providers regarding the clinical effectiveness of different medical treatments and services available for the same condition. [H.R.3590enr.txt.pdf" target="_blank">P.L. 111-148; H.R.4872enr.txt.pdf" target="_blank">P.L. 111-152] Public or private entities will conduct the research agenda, and findings will be disseminated through the Agency for Healthcare Research and Quality. The Institute is funded with contributions from public payers and an assessment on health insurance plans. The individuals named to the Board of Governors will play a critical role in advancing high quality health care by ensuring that patients and health care providers have access to important information regarding various treatment options.
Improving Public Health and Preventive Care
The Affordable Care Act includes a Prevention and Public Health Investment Fund to provide an expanded, sustained national investment of $15 billion over ten years for prevention, wellness, and public health activities to improve health and help restrain the rate of growth in private and public sector health care costs. [H.R.3590enr.txt.pdf" target="_blank">P.L. 111-148; H.R.4872enr.txt.pdf" target="_blank">P.L. 111-152] Of the $2.3 trillion the United States annually spends on health care, only four cents out of every dollar is invested in prevention and public health, despite studies showing that disease prevention can effectively reduce health care spending. [CMS, accessed 9/13/10; Brookings, 4/07; Trust for America's Health, accessed 9/13/10]
This week, the Centers for Disease Control and Prevention announced $42.5 million in funding for 94 projects at state, tribal, local, and territorial health departments to improve delivery of public health services. [HHS, 9/20/10] CDC also announced $6.8 million in funding for eight national, non-profit professional public health organizations to provide technical assistance, training, and information to health departments to improve public health infrastructure and the delivery of public health services. Finally, CDC also announced $26.4 million to increase epidemiology, laboratory, and health information systems capacity at health departments in all 50 states, two territories, and the six largest local jurisdictions, to improve response to disease outbreak, improve disease monitoring, and strengthen information sharing among jurisdictions. [HHS, 9/24/10]
Additional prevention and public health grants announced this week include $3.8 million to help states reduce tobacco use, $5 million to create a Prevention Center for Healthy Weight at the National Initiative for Children’s Healthcare Quality, and $26.2 million to support and improve primary care and behavioral health services for individuals with mental illnesses or substance use disorders. [HHS, 9/24/10]
Combating Health Care Fraud
Even as the Affordable Care Act begins to deliver for American families, criminals continue to attempt to defraud the health care system. The health reform law is one step ahead of them with its strong anti-fraud provisions. This week, the Centers for Medicare & Medicaid Services (CMS) proposed rules called for by the Affordable Care Act to fight fraud in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). [HHS, 9/20/10; Federal Register, 9/23/10] The law calls for CMS to implement a provider screening program to ensure only legitimate providers, and not those who intend to defraud the government and taxpayers, are permitted to participate in Medicare, Medicaid and CHIP. [HealthCare.gov, accessed 9/23/10] The Affordable Care Act also provides CMS with new authority to withhold payments to providers who are subject to credible allegations of fraud. This new tool will prevent fraudulent payments from occurring in the first place, rather than attempting to recoup payments after the fact. Finally, the rules also provide for enhanced information sharing, so that when a fraudulent actor is removed from one program, they are removed from other taxpayer funded health programs.
Maintaining Access to Medicare Advantage Plans
This week, CMS released the Medicare Advantage Landscape, which announces Medicare Advantage Plan options for the upcoming year. Despite the rhetoric by opponents of health reform, Medicare beneficiaries will continue to have access to private plan options. In 2011, virtually all Medicare beneficiaries (99.7 percent) will continue to have access to a Medicare Advantage plan, and enrollment is expected to grow by five percent. [CMS, 9/21/10] In addition, those plans will be more beneficiary-friendly. CMS announced that on average, premiums will decline by one percent and benefits will remain unchanged.
Improving Health Information Technology
The Affordable Care Act requires the development of standards and protocols to promote the interoperability of systems for enrollment of individuals in Federal and state health and human services programs, with the goal of allowing for electronic eligibility determinations and enrollment in appropriate programs. The Secretary of Health and Human Services recently adopted recommendations made by the Health Information Technology (HIT) Policy Committee and HIT Standards Committee to encourage adoption of electronic systems and processes that allow individuals to obtain and maintain appropriate health coverage and other human services benefits. [HHS, 9/19/10]
How Health Reform Helps Your State
This week, the White House posted information on the benefits of the Affordable Care Act in each state and the District of Columbia. [The White House, accessed 9/23/10] State-by-state fact sheets are also available from the DPC. [DPC, 6/22/10]
The Democratic Policy Committee has released nine previous updates on health reform implementation, available on the DPC website here. In addition, DPC maintains a centralized listing of health reform implementation resources which is frequently updated and is available here.