The Affordable Care Act (ACA) includes many provisions to ensure patients with liver disease have private insurance and are able to access needed care. Once the insurance provisions in the law are fully implemented, people with liver disease will no longer be denied insurance or be forced to pay more for coverage simply because of their condition. The law includes new rights and protections for patients including the following •
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Summary of Benefits and Coverage and Glossary: As of September 2012, health insurers must provide beneficiaries with a plan English summary of the plan’s benefits and coverage. This will make it easier for all individuals to compare their insurance options, which is especially critical for liver patients to make informed decisions about their coverage. Consumer Assistance Program: The ACA improved existing state-‐based consumer assistance services through grants to create new or strengthen programs. These programs help patients file complaints and appeals, enroll in coverage and their about their rights as consumers. Patients can find consumer assistance in their state here. Appealing Health Plan Decisions: The ACA provides patients with a right to appeal health insurance plan decisions to deny payment for services for plans created after March 23, 2010. These rights do not apply to grandfathered health plans created prior to the passage of the ACA. Preventive Care: Health plans will be required to cover recommended preventive health services without the patient being required to pay a copayment, co-‐insurance, or deductible. A list of the covered preventive services can be found here. This may not apply to grandfathered health plans. Patient’s Bill of Rights: The ACA outlines a new patients bill of rights that is outlined here. Doctor Choice and ER Access: Consumers have the right to choose their primary care doctor or pediatrician from the insurance plan’s provider network. Women are able to see an OBGYN without being required to have a referral. Consumers are not required to have prior approval to seek emergency treatment at a hospital outside of the plan’s network. Grandfathered Health Plans: Under the ACA, patients retained the right to keep the health insurance plan they had on the day the law was enacted. These plans
American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org
are exempt from some of the law’s consumer protections and are referred to as grandfathered health plans. • No Pre-‐Existing Condition Exclusion for Children: Children with liver disease can not be excluded by job based health plans or new individual plans on the basis of having a pre-‐existing condition. • No Dropping the Sick: Insurers are prohibited from rescinding or diluting coverage to avoid paying medical bills when a person is diagnosed with liver disease or other conditions as long as the policyholder pays his premium in full. Besides enumerating a patient’s rights and protections, the ACA reformed how individuals insurance plans and markets must operate. • Coverage Options for Individuals with Pre-‐existing Conditions: Uninsured individuals with liver disease are able to access insurance through high risk pools in every state designed to make coverage available for people with pre-‐existing conditions. These high risk pools will be available until the provision banning discrimination based on pre-‐existing conditions is fully implemented in 2014 when insurers will not be able to refuse to sell or renew policies based on the fact that a person has liver disease or any other pre-‐existing condition regardless of their age. • Lifetime and Annual Limits: Lifetime limits on benefit coverage are now prohibited and annual plans will be phased out completely in 2014. • Coverage of Young Adults: Children with liver disease will be able to stay on their parents’ insurance plan until age 26. • Health Plan Premiums: The ACA limits the amount plan premiums can vary. Under the law, they may vary 3 to 1 based on age, geographic area, 1.5 to 1 based on tobacco use and family size. • Medical Loss Ratio: As of last year, insurance companies were required to spend 80 to 85 percent of premium dollars on medical care and health care quality improvement, rather than administrative expenses. Insurance companies who do not meet that threshold are required to provide a rebate to their customers. This provision ensures that liver patients received better value for their premium dollars and create greater transparency and accountability in the insurance market place. • Health Insurance Exchanges (HIE): Beginning in 2014, individuals will be able to buy insurance through state-‐based exchanges. Exchanges will be insurance American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org
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marketplaces where all insurance plans will be certain benefit and cost standards. Premium subsidies will be provided to families without access to other coverage and with incomes 100-‐400 percent of the poverty level. Cost-‐ sharing subsidies will also be available to people with incomes between 100-‐250 percent of the poverty level to limit out-‐of-‐pocket spending. Essential Health Benefits: All small group and individual plans, including those offered through state-‐based Health Insurance Exchanges, must offer a minimum set of health benefits including coverage of preventive and wellness services and chronic disease management. For more information, see the Essential Health Benefits bulletin released last year by the Center for Medicare and Medicaid Services (CMS).
American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org