Patient protection and affordable care act ppaca pdf

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patient protection and affordable care act ppaca pdf

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The Affordable Care Act ACA [1] is divided into 10 titles [2] and contains provisions that became effective immediately, 90 days after enactment, and six months after enactment, as well as provisions phased in through to For simplicity, the amendments in the Health Care and Education Reconciliation Act of are integrated into this timeline.

The Patient Protection and Affordable Care Act

Note: President Trump and Republicans in Congress have pledged to repeal and replace the Affordable Care Act, and unsuccessfully advocated several proposals to do so in Congress in On Dec. The following summary of the law as originally enacted focuses on provisions to expand coverage, control health care costs, and improve health care delivery system. Effective January 1, These out-of-pocket reductions are applied within the actuarial limits of the plan and will not increase the actuarial value of the plan.

Require risk adjustment in the individual and small group markets and in the Exchange. Require qualified health plans to report information on claims payment policies, enrollment, disenrollment, number of claims denied, cost-sharing requirements, out-of-network policies, and enrollee rights in plain language. Require states to develop a single form for applying for state health subsidy programs that can be filed online, in person, by mail or by phone.

Permit Exchanges to contract with state Medicaid agencies to determine eligibility for tax credits in the Exchanges. Require Exchanges to submit financial reports to the Secretary and comply with oversight investigations including a GAO study on the operation and administration of Exchanges.

Abortion coverage Permit states to prohibit plans participating in the Exchange from providing coverage for abortions. Require plans that choose to offer coverage for abortions beyond those for which federal funds are permitted to save the life of the woman and in cases of rape or incest in states that allow such coverage to create allocation accounts for segregating premium payments for coverage of abortion services from premium payments for coverage for all other services to ensure that no federal premium or cost-sharing subsidies are used to pay for the abortion coverage.

Prohibit plans participating in the Exchanges from discriminating against any provider because of an unwillingness to provide, pay for, provide coverage of, or refer for abortions.

Effective dates Unless otherwise noted, provisions relating to the American Health Benefit Exchanges are effective January 1, Require the Secretary to define and annually update the benefit package through a transparent and public process.

Effective January 1, Require all qualified health benefits plans, including those offered through the Exchanges and those offered in the individual and small group markets outside the Exchanges, except grandfathered individual and employer-sponsored plans, to offer at least the essential health benefits package. Effective January 1, Abortion coverage Prohibit abortion coverage from being required as part of the essential health benefits package.

Requirement to report medical loss ratio effective plan year ; requirement to provide rebates effective January 1, Establish a process for reviewing increases in health plan premiums and require plans to justify increases. Require states to report on trends in premium increases and recommend whether certain plan should be excluded from the Exchange based on unjustified premium increases.

Provide grants to states to support efforts to review and approve premium increases. Effective beginning plan year Administrative simplification Adopt standards for financial and administrative transactions to promote administrative simplification.

Effective dates vary Dependent coverage Provide dependent coverage for children up to age 26 for all individual and group policies. Effective six months following enactment Insurance market rules Prohibit individual and group health plans from placing lifetime limits on the dollar value of coverage and prohibit insurers from rescinding coverage except in cases of fraud.

Prohibit pre-existing condition exclusions for children. Prior to January , plans may only impose annual limits on coverage as determined by the Secretary. Grandfather existing individual and group plans with respect to new benefit standards, but require these grandfathered plans to extend dependent coverage to adult children up to age 26 and prohibit rescissions of coverage.

Require grandfathered group plans to eliminate lifetime limits on coverage and beginning in , eliminate annual limits on coverage. Prior to , grandfathered group plans may only impose annual limits as determined by the Secretary. Require grandfathered group plans to eliminate pre-existing condition exclusions for children within six months of enactment and by for adults, and eliminate waiting periods for coverage of greater than 90 days by Effective six months following enactment, except where otherwise specified Impose the same insurance market regulations relating to guarantee issue, premium rating, and prohibitions on pre-existing condition exclusions in the individual market, in the Exchange, and in the small group market.

See new rating and market rules in Creation of insurance pooling mechanism. Effective January 1, Require all new policies except stand-alone dental, vision, and long-term care insurance plans , including those offered through the Exchanges and those offered outside of the Exchanges, to comply with one of the four benefit categories.

Existing individual and employer-sponsored plans do not have to meet the new benefit standards. See description of benefit categories in Creation of insurance pooling mechanism.

This deductible limit will not affect the actuarial value of any plans. Effective January 1, Limit any waiting periods for coverage to 90 days. Effective January 1, Create a temporary reinsurance program to collect payments from health insurers in the individual and group markets to provide payments to plans in the individual market that cover high-risk individuals. Effective January 1, through December Allow states the option of merging the individual and small group markets.

Effective January 1, Consumer protections Establish an internet website to help residents identify health coverage options effective July 1, and develop a standard format for presenting information on coverage options effective 60 days following enactment.

Develop standards for insurers to use in providing information on benefits and coverage. Compacts may only be approved if it is determined that the compact will provide coverage that is at least as comprehensive and affordable as coverage provided through the state Exchanges. Enroll newly eligible Medicaid beneficiaries into the Medicaid program no later than January states have the option to expand enrollment beginning in , coordinate enrollment with the new Exchanges, and implement other specified changes to the Medicaid program.

Maintain current Medicaid and CHIP eligibility levels for children until and maintain current Medicaid eligibility levels for adults until the Exchange is fully operational. Establish an office of health insurance consumer assistance or an ombudsman program to serve as an advocate for people with private coverage in the individual and small group markets.

Phase-in revised payments over 3 years beginning in , for plans in most areas, with payments phased-in over longer periods 4 years and 6 years for plans in other areas. Provide bonuses to plans receiving 4 or more stars, based on the current 5-star quality rating system for Medicare Advantage plans, beginning in ; qualifying plans in qualifying areas receive double bonuses.

Phase-in adjustments to plan payments for coding practices related to the health status of enrollees, with adjustments equaling 5. Cap total payments, including bonuses, at current payment levels. Reduce annual market basket updates for inpatient hospital, home health, skilled nursing facility, hospice and other Medicare providers, and adjust for productivity. Effective January 1, Establish an Independent Payment Advisory Board comprised of 15 members to submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds a target growth rate.

If so, beginning January 15, , the Board will submit recommendations to achieve reductions in Medicare spending. Beginning January , the target is modified such that the board submits recommendations if Medicare per capita spending exceeds GDP per capita plus one percent. The Board will submit proposals to the President and Congress for immediate consideration.

The Board is prohibited from submitting proposals that would ration care, increase revenues or change benefits, eligibility or Medicare beneficiary cost sharing including Parts A and B premiums , or would result in a change in the beneficiary premium percentage or low-income subsidies under Part D. Hospitals and hospices through and clinical labs for one year will not be subject to cost reductions proposed by the Board.

The Board must also submit recommendations every other year to slow the growth in national health expenditures while preserving quality of care by January 1, Effective upon enactment Allow providers organized as accountable care organizations ACOs that voluntarily meet quality thresholds to share in the cost savings they achieve for the Medicare program. To qualify as an ACO, organizations must agree to be accountable for the overall care of their Medicare beneficiaries, have adequate participation of primary care physicians, define processes to promote evidence-based medicine, report on quality and costs, and coordinate care.

Shared savings program established January 1, Create an Innovation Center within the Centers for Medicare and Medicaid Services to test, evaluate, and expand in Medicare, Medicaid, and CHIP different payment structures and methodologies to reduce program expenditures while maintaining or improving quality of care.

Payment reform models that improve quality and reduce the rate of cost growth could be expanded throughout the Medicare, Medicaid, and CHIP programs. Effective January 1, Reduce Medicare payments that would otherwise be made to hospitals by specified percentages to account for excess preventable hospital readmissions. Effective fiscal year Medicaid Increase the Medicaid drug rebate percentage for brand name drugs to Effective January 1, Extend the drug rebate to Medicaid managed care plans.

Require the Secretary to develop a methodology to distribute the DSH reductions in a manner that imposes the largest reduction in DSH allotments for states with the lowest percentage of uninsured or those that do not target DSH payments, imposes smaller reductions for low-DSH states, and accounts for DSH allotments used for waivers. Effective October 1, Prohibit federal payments to states for Medicaid services related to health care acquired conditions. Effective July 1, Prescription drugs Authorize the Food and Drug Administration to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed.

Effective upon enactment Waste, fraud, and abuse Reduce waste, fraud, and abuse in public programs by allowing provider screening, enhanced oversight periods for new providers and suppliers, including a day period of enhanced oversight for initial claims of DME suppliers, and enrollment moratoria in areas identified as being at elevated risk of fraud in all public programs, and by requiring Medicare and Medicaid program providers and suppliers to establish compliance programs.

Develop a database to capture and share data across federal and state programs, increase penalties for submitting false claims, strengthen standards for community mental health centers and increase funding for anti-fraud activities. The Institute will be overseen by an appointed multi-stakeholder Board of Governors and will be assisted by expert advisory panels. Findings from comparative effectiveness research may not be construed as mandates, guidelines, or recommendations for payment, coverage, or treatment or used to deny coverage.

Effective upon enactment Medical malpractice Award five-year demonstration grants to states to develop, implement, and evaluate alternatives to current tort litigations. Preference will be given to states that have developed alternatives in consultation with relevant stakeholders and that have proposals that are likely to enhance patient safety by reducing medical errors and adverse events and are likely to improve access to liability insurance.

Funding appropriated for five years beginning in fiscal year Medicare Establish a national Medicare pilot program to develop and evaluate paying a bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care that begins three days prior to a hospitalization and spans 30 days following discharge.

If the pilot program achieves stated goals of improving or not reducing quality and reducing spending, develop a plan for expanding the pilot program. Establish pilot program by January 1, ; expand program, if appropriate, by January 1, Create the Independence at Home demonstration program to provide high-need Medicare beneficiaries with primary care services in their home and allow participating teams of health professionals to share in any savings if they reduce preventable hospitalizations, prevent hospital readmissions, improve health outcomes, improve the efficiency of care, reduce the cost of health care services, and achieve patient satisfaction.

Effective January 1, Establish a hospital value-based purchasing program in Medicare to pay hospitals based on performance on quality measures and extend the Medicare physician quality reporting initiative beyond Reports to Congress due January 1, Dual eligibles Improve care coordination for dual eligibles by creating a new office within the Centers for Medicare and Medicaid services, the Federal Coordinated Health Care Office, to more effectively integrate Medicare and Medicaid benefits and improve coordination between the federal government and states in order to improve access to and quality of care and services for dual eligibles.

Effective March 1, Medicaid Create a new Medicaid state plan option to permit Medicaid enrollees with at least two chronic conditions, one condition and risk of developing another, or at least one serious and persistent mental health condition to designate a provider as a health home.

Effective January 1, Create new demonstration projects in Medicaid to pay bundled payments for episodes of care that include hospitalizations effective January 1, through December 31, ; to make global capitated payments to safety net hospital systems effective fiscal years through ; to allow pediatric medical providers organized as accountable care organizations to share in cost-savings effective January 1, through December 31, ; and to provide Medicaid payments to institutions of mental disease for adult enrollees who require stabilization of an emergency condition effective October 1, through December 31, Create processes for the development of quality measures involving input from multiple stakeholders and for selecting quality measures to be used in reporting to and payment under federal health programs.

National strategy due to Congress by January 1, Establish the Community-based Collaborative Care Network Program to support consortiums of health care providers to coordinate and integrate health care services, for low-income uninsured and underinsured populations.

Funds appropriated for five years beginning in FY Financial disclosure Require disclosure of financial relationships between health entities, including physicians, hospitals, pharmacists, other providers, and manufacturers and distributors of covered drugs, devices, biologicals, and medical supplies.

Report due to Congress April 1, Disparities Require enhanced collection and reporting of data on race, ethnicity, sex, primary language, disability status, and for underserved rural and frontier populations. Also require collection of access and treatment data for people with disabilities. Require the Secretary to analyze the data to monitor trends in disparities. Effective fiscal year Establish a grant program to support the delivery of evidence-based and community-based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas.

Funds appropriated for five years beginning in FY Coverage of preventive services Eliminate cost-sharing for Medicare covered preventive services that are recommended rated A or B by the U. Preventive Services Task Force and waive the Medicare deductible for colorectal cancer screening tests. Authorize the Secretary to modify or eliminate Medicare coverage of preventive services, based on recommendations of the U.

Preventive Services Task Force. Preventive Services Task Force and recommended immunizations with a one percentage point increase in the federal medical assistance percentage FMAP for these services. Effective January 1, Authorize Medicare coverage of personalized prevention plan services, including a comprehensive health risk assessment, annually. Require the Secretary to publish guidelines for the health risk assessment no later than March 23, , and a health risk assessment model by no later than September 29, Effective January 1, Provide incentives to Medicare and Medicaid beneficiaries to complete behavior modification programs.

Effective January 1, or when program criteria is developed, whichever is first Require Medicaid coverage for tobacco cessation services for pregnant women. Effective October 1, Require qualified health plans to provide at a minimum coverage without cost-sharing for preventive services rated A or B by the U.

Preventive Services Task Force, recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screenings for women. Effective six months following enactment Wellness programs Provide grants for up to five years to small employers that establish wellness programs.

Funds appropriated for five years beginning in fiscal year Provide technical assistance and other resources to evaluate employer-based wellness programs.

The Patient Protection and Affordable Care Act

Note: President Trump and Republicans in Congress have pledged to repeal and replace the Affordable Care Act, and unsuccessfully advocated several proposals to do so in Congress in On Dec. The following summary of the law as originally enacted focuses on provisions to expand coverage, control health care costs, and improve health care delivery system. Effective January 1, These out-of-pocket reductions are applied within the actuarial limits of the plan and will not increase the actuarial value of the plan. Require risk adjustment in the individual and small group markets and in the Exchange. Require qualified health plans to report information on claims payment policies, enrollment, disenrollment, number of claims denied, cost-sharing requirements, out-of-network policies, and enrollee rights in plain language.


numbers assigned to sections in PPACA are specified in brackets after the [For continuous pagination in electronic, PDF version, add 19 pages]. Page. Patient Protection and Affordable Care Act (Public Law –).


Affordable Care Act

PPACA directly regulates healthcare providers, insurance companies, individuals, and employers. The law is quite broad, affecting insurance companies, hospitals, individuals, and employers. The employer mandates, or rules in PPACA which require employers to provide certain levels of coverage to certain employees, went into effect in Since PPACA regulates a number of different areas regarding healthcare coverage, it naturally contains a number of separate provisions.

This page contains resources and information to help you understand this complex law and its impact on fire departments. The Task Force has focused on the PPACA's impact on the three general issues of the volunteer fire service, emergency medical services, and the cost of employer provided health insurance. The legislation is now in the Senate where it is awaiting action. This legislation would codify the IRS' decision to exempt volunteer fire departments from the PPACA's requirement for certain employers to offer health insurance to full-time employees.

The health care law, sometimes known as "Obamacare," was signed March 23, And, so long as you visit a doctor in your health plan's provider network, you won't have to pay a copay, co-insurance or deductible for annual wellness exams or immunizations. See if you'll save. Washington, D. Contact Shasta Community Health Center's Outreach and The key reforms in the Affordable Care Act were designed to significantly decrease barriers to obtaining health coverage as well as accessing needed health care services.

The Patient Protection and Affordable Care Act

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