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11 Consumer Friendly Provisions from Health Care Reform

Health Care Reform1. Men and women now pay the same amount for coverage.

Previously, insurers could charge individuals based on gender. Because they tend to visit the doctor more often, women typically paid higher premiums than men.  The Affordable Care Act (ACA) now requires that men and women are charged the same amount.

2. The medical loss ratio requires health insurers to spend at least 80 to 85 percent on medical care.

Under the Medical Loss Ratio (MLR), health insurance issuers must submit data proving the proportion of revenue spent on clinical services and quality improvement. This helps ensure that companies do not spend a substantial amount of consumers’ dollars on administrative and overhead costs. Companies failing to meet these standards are required to provide rebates to customers.

3. Individuals with pre-existing conditions can’t be turned down for coverage.

More than 50,000 Americans with pre-existing conditions have gained coverage through the new Pre-Existing Condition Insurance Plan. Under this provision, consumers with pre-existing conditions cannot be charged more for insurance, nor can they be dropped from a plan if they become sick.

In 2014, health insurers can no longer deny coverage to individuals with pre-existing conditions – allowing millions of Americans gain coverage on the individual market.

4. Young adults can stay on their health plans until the age of 26.

Young adults up to age 26 are now eligible to stay covered under a parent’s health insurance plan, making it easier and more affordable to get coverage.

5. Children can no longer be denied coverage due to pre-existing conditions.

Once the law was passed, this little known provision kicked in to provide any child under the age of 19 guaranteed coverage. Over 17.6 million children with pre-existing conditions no longer have to worry about being denied coverage. Unfortunately, many health insurers stopped offering child-only coverage so many states enacted open enrollment periods for children.

6. Preventive care now offered with no out-of-pocket cost.

The ACA ensures that most insurance plans provide coverage and eliminate cost-sharing for certain preventive health services including mammograms for women, colonoscopy screenings, flu shots and many more. This provision has given 71 million additional Americans preventive services coverage according to the U.S. Department of Health and Human Services.

7. Essential benefits covered in all health plans with no cap on coverage.

In establishing minimum coverage standards for health plans, the ACA maintains that a set of core benefits are included in health insurance plans. This includes emergency services, hospitalization, maternity and newborn care, prescription drugs and many more.

8. Older adults can’t be charged more than three times the amount a young adult is charged.

Older patients typically utilize more, and higher cost health care services than younger patients. To help ensure that coverage remains affordable for everyone is to use age rating bands that spread premium costs over a range of age groups.

9. Premium tax credits for individuals between 100 and 400 percent of the federal poverty level.

In effort to reduce monthly premiums for individuals earning up to 400 percent of the federal poverty level, tax credits are available to cover a share of monthly health premiums charged. The tax credits are structured according to income so that the premium an individual or family must pay does not exceed a specified percentage of his or her income.

10. Subsidies for individuals between 100 and 250 percent of the federal poverty level.

In order to offset the cost of health care, the ACA created tax subsidies for individuals and families to assist in paying for health insurance. The cost-sharing subsidies essentially increase an insurance company’s portion of covered benefits, resulting in reduced out-of-pocket spending for lower-income consumers.

11. Medicaid expansion to childless adults but individual states will determine whether or not to expand the program.

Medicaid will be expanded to include more adults. Each state has the option to receive additional federal funds to expand their Medicaid roles to include more families and single adults. If all 50 states chose to implement the Medicaid expansion, it would cover an estimated 21.6 million additional uninsured adults.

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