Obama Care, New Health Care Provisions, Tea Party, Conservatives, Reputlicans, Democrats, Liberals,


Obama Care has become a rallying point in the upcoming off year elections for a great number of Tea Party, Republican, and Conservative  Candidates --- as they say it does too little for too much cost.


I have noted that most of their “talking points” contain very little substance or facts, and instead rely upon broad generalities.


Ironically, Democrat and Liberal Candidates have not filled in that gap by outlining key points of Health Care Reform, that many if not most of the electorate would be in favor of implementing.


Here is a partial list of benefits that are coming on line, and how they will affect virtually all of us, either directly or indirectly.  You can find out more on the new provisions on www.healthcare.gov, from which I obtained the facts contained here. The portions in italics are my own overview explanations:




We are all growing older, and modern medicine is making its greatest strides in the development of new and better drug treatments.  That is good news for those who can afford those drugs, and the new provisions on the Donut Hole will benefit those on Medicare.  Especially the middle class retirees on a very fixed pension and social security.

What is the “Donut Hole”?

Most Medicare drug plans have a coverage gap. This means that after you and your plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your drugs (up to a limit). This is known as the “Donut Hole” in drug coverage.


Filling the Donut Hole after 2011

Starting in 2011, if you have high prescription drug costs that put you in the donut hole, you’ll get a 50% discount on covered brand-name drugs while you’re in the donut hole. Between 2010 and 2020, you’ll get continuous Medicare coverage for your prescription drugs.



Appealing Health Plan Decisions

Currently there is very little patients can do when their insurer denies coverage for a needed procedure.  As most health insurance plans are now “for profit” organizations, it is to their benefit to deny as much as possible, and until now, most consumers or patients had very little recourse.

If your health plan was created after March 23, 2010, the Affordable Care Act ensures your right to appeal, or to ask that your plan reconsider its decision to deny payment for a service or treatment. New rules, now in effect, govern how your plan itself must handle your initial appeal. If your plan upholds its decision after its internal review, the law permits you to appeal to an independent reviewer who does not work for your health plan.

What This Means for You:

  • When an insurance plan denies payment for a treatment or service, you can appeal to the plan to review its own decision. Your plan must explain how to appeal when it informs you of the denial.
  • When you appeal, your plan must give you its decision within:
    • 72 hours for denials of urgent care.
    • 30 days for denials of non-urgent care you have not yet received.
    • 60 days for denials of service you have already received. 
  • If the plan still denies your request, it must explain why and tell you how to appeal for an independent review of the decision. In some cases involving urgent care, you may be able to have the internal and external review take place at the same time.

Some Important Details:

  • The appeals provision applies to all health plans created or purchased after March 23, 2010 and affects each plan as that plan starts a new “plan year” or “policy year” on or after September 23, 2010.
  • How much the law will change your appeal rights depends on the State you live in and the type of plan you have.  
  • Some employers’ plans may have more than one internal review before you’re allowed to seek an external review.


Insurance Protections for Children in the Affordable Care Act

Even if you are an empty nester, this new protection for children may just save the life of your grandchild, or make his or her life better with treatment and medication, that insurance companies often denied in the past based upon pre-existing conditions.

What This Means for You:

Until now, plans could refuse to accept anyone because of a pre-existing health condition, or they could limit benefits for that condition. Now, under the new law, health plans that cover children can no longer exclude, limit, or deny coverage to your child under age 19 solely based on a health problem or disability that your child developed before you applied for coverage. This new rule applies to all job-related health plans as well as individual health insurance policies issued after March 23, 2010. The rule will affect your plan as soon as it begins a “Plan Year”” or “policy year” on or after September 23, 2010.

Some Important Details:

  • This rule applies whether or not your child’s health problem or disability was discovered or treated before you applied for coverage.
  • The new rule doesn’t apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family (and is not a job-related health plan) on or before March 23, 2010 (the date that the new law was passed).
  • These protections will be extended to Americans of all ages starting in 2014.


On October 1, 2010, Sally purchased a new individual health policy for herself and her 13-year-old child, Miranda, who has been treated for asthma in the past. The new health policy excludes coverage for treatment of pre-existing conditions for all enrollees. On November 1, 2010—one month after coverage began for Sally and Miranda—Miranda is hospitalized for an asthma attack. Her insurance company denies payment for the hospitalization, because under the policy Miranda’s asthma is considered a pre-existing condition.

Under the new law, the insurer can’t deny payment for the hospitalization based on Miranda’s pre-existing asthma condition. Miranda is under the age of 19; Sally’s policy is new and therefore subject to the pre-existing condition rules of the new health care reform law. Sally’s policy year began after September 23, when the law’s rules on pre-existing conditions began to take effect.



 The Affordable Care Act: Curbing Insurance Cancellations

Known as “rescission” many ill people who thought they had health coverage have received a rescission and cancellation of their policy --- Even After a Procedure that was authorized, if the Insurance Company finds something missing from your application.  IE. a fifty year old woman has a gall bladder operation with a total bill of $32,000, and her insurance company refuses to pay for it, based  upon the fact that she did not list on her application that she had her appendix removed when she was 12 years old!



 What This Means for You:

Before the Affordable Care Act, if your insurance company found that you’d made a mistake on your insurance application, the insurance company might “rescind” your benefits—that is, declare your policy invalid from the day it began. Your insurance company might also ask you to pay back any money already spent for your medical care.

Under the new law, an insurer cannot rescind your coverage simply because you made an honest mistake or left out information that has little bearing on your health.

Example: When her insurance application asked for “anything else relevant to your health that we should know about,” Katy forgot to mention two visits to a psychologist she had 6 years earlier. Katy was later diagnosed with breast cancer, and submitted claims to her insurance company for breast cancer treatment. After receiving Katy’s claim, her plan discovered the two psychologist visits. Before the new law, Katy’s mistake might have prompted her health insurer to rescind, or retroactively cancel her coverage. But under the new law, Katy’s insurance plan cannot rescind her coverage, because Katy did not intentionally misrepresent significant information.

Some Important Details:

  • This provision applies to all health plans, whether you get coverage through your employer or purchase it yourself.
  • This provision applies to “plan years” or “policy years” that begin on or after September 23, 2010. To find out when your plan year or policy year begins, ask your insurer or plan administrator.  
  • Your insurance company can still rescind your coverage if you intentionally put false or incomplete information on your insurance application, and it can cancel your coverage if you fail to pay your premiums on time.
  • Your insurance company must give you at least 30-days notice before it can rescind your coverage, so that during that time you may be able to appeal the decision or find new coverage.



Patient Protections in the Affordable Care Act

One of the criticisms of Obama care is that it will take away the choices of patients on their health care providers, over and above whatever their health plan is.  Quite simply, that is not true.



The Affordable Care Act helps preserve your choice of doctors by guaranteeing that you can choose the primary care doctor or pediatrician you want from your health plan’s provider network and that you can see an OB-GYN doctor without needing a referral from another doctor. The law also ensures that you can seek emergency care at a hospital outside your plan’s network without prior approval from your health plan.

What This Means for You:  

  • You select the doctor: The new rules permit you to choose any available participating primary care provider as your doctor and to choose any available participating pediatrician as your child’s primary care doctor.
  • No health plan barriers to OB-GYN services: The new rules also prohibit health plans from requiring a referral from a primary care provider before you can seek coverage for obstetrical or gynecological (OB-GYN) care from a participating OB-GYN specialist.
  • Access to out-of-network emergency room services: In the past, some health plans would limit payment for emergency room services provided outside of a plan’s preselected network of emergency health care providers, or they would require that you get your plan’s prior approval for emergency care at hospitals outside of its networks. This could mean financial hardship if you get sick or injured while away from home. The new rules prevent health plans from requiring higher copayments or co-insurance for out-of-network emergency room services. The new rules also prohibit health plans from requiring you to get prior approval before seeking emergency room services from a provider or hospital outside your plan’s network.

Some Important Details:

  • These rules apply to all group health plans and individual health insurance policies created or issued after March 23, 2010. These rules do not apply to “grandfathered health plans.”
  • If your health plan or health insurance policy was created or issued after March 23, 2010, your plan will be affected as soon as it begins a new “plan year” or “policy year” on or after September 23, 2010.
  • Please note that you still may be responsible for the difference between the amount billed by the provider for out-of-network emergency room services and the amount paid by your health plan.



The Affordable Care Act: Eliminating Limits on Your Benefits

Friends of mine had a granddaughter who was born pre-maturely.  Within the first month of treatment, her health costs easily exceeded the “lifetime” limit on most health care plans.  They were very lucky they were able to continue her treatments.

This is also an extremely important provision for those approaching retirement age, who can be wiped out financially within a few weeks of treatment for a condition or disease.  Many retirees have lost their nest eggs they saved over decades of time, due to the limits of their insurance plans, which have not kept pace with the increases in health care costs.



The Affordable Care Act prohibits health plans from putting a “lifetime” dollar limit on most benefits you receive. The Act also restricts and phases out the “annual” dollar limits a health plan can place on most of your benefits—and does away with these limits entirely in 2014.

What This Means for You:

Before the Affordable Care Act, many health plans set an annual limit -- a dollar limit on their yearly spending for your covered benefits. Many plans also set a lifetime limit —a dollar limit on what they would spend for your covered benefits during the entire time you were enrolled in that plan. You were required to pay the cost of all care exceeding those limits.

  • Under the new law, lifetime limits on most benefits are prohibited in any health plan or insurance policy issued or renewed on or after September 23, 2010.
  • The new law restricts and phases out the annual dollar limits that all job-related plans, and those individual health insurance plans issued after March 23, 2010, can put on most covered health benefits. Specifically, the law says that none of these plans can set an annual dollar limit lower than:
    • $750,000—for a “plan year” or “policy year” starting on or after September 23, 2010 but before September 23, 2011.
    • $1.25 million—for a plan year or policy year starting on or after September 23, 2011 but before September 23, 2012.
    • $2 million—for a plan year or policy year starting on or after September 23, 2012 but before January 1, 2014.
  • No annual dollar limits are allowed on most covered benefits beginning on January 1, 2014.

Some Important Details:

  • Be aware that plans can put an annual dollar limit and a lifetime dollar limit on spending for health care services that are not “essential.”
  • If the new rules apply to your plan, they will affect you as soon as you begin a new plan year or policy year on or after September 23, 2010. (For example, if your policy has a calendar plan year, the new rules would apply to your coverage beginning January 1, 2011).
  • If you have a “grandfathered” individual health insurance policy, your health plan is not required to follow the new rules on annual limits. (A grandfathered individual health insurance policy is a plan that you bought for yourself or your family; that you did not receive through your employer; and that was issued on or before March 23, 2010). If you’re not sure whether your plan is grandfathered, ask your insurance company.
  • The ban on lifetime dollar limits for most covered benefits applies to every health plan—whether you buy coverage for yourself or your family, or you receive coverage through your employer.
  • Some plans may be eligible for a waiver from the rules concerning annual dollar limits, if complying with the limit would mean a significant decrease in your benefits coverage or a significant increase in your premiums.


Pre-Existing Condition Insurance Plan

It has been quite a Catch 22 that someone who really needs health insurance, and has lost theirs due to a job change, layoff, or out-sourcing / off-shoring of their job, would often not be able to get health insurance, due to a pre-existing condition, that was covered on their previous plan.



The law creates a new program – the Pre-Existing Condition Insurance Plan -- to make health insurance available to you if you have been denied coverage by private insurance companies because of a pre-existing condition.  

The Pre-Existing Condition Insurance Plan (PCIP), which is administered by either your state or the U.S. Department of Health and Human Services, will provide a new health coverage option for you if you have been uninsured for at least six months, you have a pre-existing condition or have been denied health coverage because of your health condition, and are a U.S. citizen or are residing here legally. 

This program may be able to help you, if you’ve been locked out of the insurance market, until 2014.  In 2014, you will have access to affordable health insurance choices through a new competitive marketplace called an Exchange.

A new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Exchanges will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, Members of Congress will be getting their health care insurance through Exchanges and you will be able buy your insurance through Exchanges too.


.  You can no longer be discriminated against based on a pre-existing condition.  

The Pre-Existing Condition Insurance Plan will be available in every state—but the program may vary depending on your state.   For years, many states have run programs – often called “high risk pools” – to offer insurance if you have a pre-existing condition.  To build on what states are already doing, states can either run the new program with resources made available by the Affordable Care Act, or rely on the U.S. Department of Health and Human Services to provide coverage.  

The program: 

  • Will cover a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs.  All covered benefits are available to you, even to treat a pre-existing condition.
  • Won’t charge you a higher premium just because of your medical condition. 
  • Doesn’t base eligibility on income.

The U.S. Department of Health and Human Services, with the help of the U.S. Office of Personnel Management and the U.S. Department of Agriculture’s National Finance Center, will run the Pre-Existing Condition Insurance Plan in some states.  The federal government is contracting with a national insurance plan to administer benefits in those states. Other states have requested that they run the program themselves.  The program may vary depending on what state you live in.



The Affordable Care Act’s New Rules on Preventive Care and You

 Contrary to the false hype that some politicians are putting out, that women will no longer be able to get mammograms or other preventive health exams, this provision makes such preventive procedures mandatory at no cost to the patient.



What This Means for You:

If your plan is subject to these new requirements, you would not have to pay a copayment or co-insurance, or any deductible to receive preventive health services, such as recommended screenings, vaccinations, and counseling.

For example, depending on your age, you may have free access to such preventive services as:

  • Blood pressure, diabetes, and cholesterol tests;
  • Many cancer screenings, including mammograms and colonoscopies;
  • Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression, and reducing alcohol use;
  • Routine vaccinations against diseases such as measles, polio, or meningitis;
  • Flu and pneumonia shots;
  • Counseling, screening, and vaccines to ensure healthy pregnancies;
  • Regular well-baby and well-child visits, from birth to age 21.

Some Important Details:

  • This preventive services provision applies to people enrolled in job-related health plans or individual health insurance policies created after March 23, 2010. If you are in such a health plan, this provision will affect you as soon as your plan begins its first new “plan year” or “policy year” on or after September 23, 2010.
  • If your plan is “grandfathered,” these benefits may not be available to you.
  • If your health plan uses a network of providers, be aware that health plans are only required to provide these preventive services through an in-network provider. Your health plan may allow you to receive these services from an out-of-network provider, but may charge you a fee.
  • Your doctor may provide a preventive service, such as a cholesterol screening test, as part of an office visit. Be aware that your plan can require you to pay some costs of the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit.


Tax Credit for Small Businesses that Insure Their Employees

What’s up with all those folks who say the new health care will destroy small businesses, when they are specific benefits for them, such as the new tax credit? 

The Affordable Care Act helps small businesses and small tax-exempt organizations afford the cost of covering their employees.

If you have fewer than 25 employees and provide health insurance you may qualify for a small business tax credit of up to 35% (up to 25% for non-profits) to offset the cost of your insurance. This will make the cost of providing insurance much lower.







Getting Value for Your Premium Dollar with the Affordable Care Act

Within my lifetime, health care institutions and insurers transformed from a primarily “non-profit” model to a “for profit” model.  Even the highly esteemed Blues (Blue Cross and Blue Shield) managed to become for profit companies --- despite all the years of non profit status (just why were they allowed to do so after years of building a clientele and business while receiving tax breaks as a non profit?).  This provision will help to ensure that insurance companies are actually in the business in providing health care insurance, and not just a funnel for millions of dollars in compensation to the CEO’s and other high executives.

What This Means for You:

To make sure your premium dollars are spent primarily on health care, the new law limits how much of your premium dollar your insurer can spend on administrative costs, marketing, and other non-health care-related costs. If your insurance company exceeds that limit, it must provide a rebate to you.

The law also requires your health insurer to justify unreasonable premium increases to your State regulator and the Secretary of the U.S. Department of Health and Human Services.

Some Important Details:

  • For certain large employer plans, the law requires that at least 85% of all premium dollars collected by insurance companies be spent on health care services and health care quality improvement. This rule affects you if you get your health benefits through an employer with more than 50 employees and your employer buys coverage from an insurer. If you’re not sure whether your plan matches this description, check your summary plan description or ask your employer.
  • This rule does not apply to large employer plans that are self-insured. If you’re not sure whether your plan matches this description, check your plan documents or ask your employer.
  • If you are in an individual or small employer plan, the law requires that at least 80% of the premium dollars be spent on benefits and quality improvement. You are in an individual plan if you buy insurance for yourself or your family directly from an insurance company, and not through your employer. You are in a small employer plan if you get health benefits from an employer with 50 or fewer employees.   
  • Your health insurance company must report yearly to the Secretary of Health and Human Services on the share of premium dollars spent on health care services and health care quality improvement in all “plan years” or “policy years.” Your insurer is required to provide reports and any rebates required for each plan year that starts after January 1, 2011. Details on the rebate program are being developed.


Coverage of Young Adults under Age 26

This aspect is a definite “win-win” provision.  On the one hand, it provides health care to a segment of the population that is often in a transition between school and work, and may not have access to affordable health care insurance.  While on the other hand, it generates premiums for a mostly young and healthy segment of the population that often needs little to no services, and that helps to balance the older segments of the population, that are in need of ever more health services.



Covering Young Adults under the Affordable Care Act, if your plan covers children, you can now add or keep your children on your health insurance policy until they turn 26 years old.

What This Means for You:

Until now, health plans could remove enrolled children usually at age 19, sometimes older for full-time students. Now, most health plans that cover children must make coverage available to children up to age 26. By allowing children to stay on their parents’ plan, the Affordable Care Act makes it easier and more affordable for young adults to get health insurance coverage.

Your adult children can join or remain on your plan whether or not they are:

  • married;
  • living with you;
  • in school;
  • financially dependent on you;
  • eligible to enroll in their employer’s plan, with one temporary exception: Until 2014, “grandfathered” group plans do not have to offer dependent coverage up to age 26 if a young adult is eligible for group coverage outside their parents’ plan.

Some Important Details:

  • Your plan is required to provide a 30-day period—no later than the first day of your plan’s next “plan year” or “policy year” that begins on or after September 23, 2010—to allow you to enroll your adult child. Your plan must notify you of this enrollment opportunity in writing.
  • If you enroll your adult child during this 30-day enrollment period, your plan must cover your adult child from the first day of that plan year or policy year.





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