The Affordable Care Act, or Obamacare, was enacted in 2010 to provide health insurance to all Americans and to decrease healthcare costs. The purpose of the Act is to spread the cost of health care insurance by having as many people as possible pay for it.
The Act creates an "individual mandate" for all Americans to purchase healthcare insurance, effective 2014. Those without insurance can purchase insurance through online "marketplace insurance exchanges" set up by either the state or federal government. If an individual does not have enough to purchase insurance, he or she may qualify for a federal insurance subsidy.
The Affordable Care Act seeks to cover previously uninsured Americans by making it illegal for health care insurance companies to deny coverage based on pre-existing conditions and by expanding Medicare eligibility for low-income individuals.
However, that provision of the Affordable Care Act was declared optional for the states by the United States Supreme Court. As a result, many states, including Texas, Florida, Mississippi, Louisiana, and South Carolina have declined to expand Medicare in their states.
What is the Current Status of the ACA?
As of October 2017, the Affordable Care Act is still an enforceable law. However, the Trump administration has opted not to provide Obamacare subsidies to insurance companies to help fund certain insurance plans. Several states are suing to overturn the executive order, but as of the time of this writing it is unknown whether the states or the administration will prevail.
The Trump administration has also revoked two contraceptive mandates established previously. The first rule revoked is a mandate whereby employers must include birth control in their insurance plans, except if the employer has a religious or moral objection. The second revoked rule waives costs of birth control for consumers, shifting the cost to insurance companies and/or employers.
Why Has My Insurance Policy Been Cancelled?
Under the Affordable Care Plan, health-care insurance plans must meet a minimal standard of coverage. In order for an insurance plan to legal under the Affordable Care Act, the insurance plan must contain essential health benefits and it must have limited cost-sharing. If a plan does not meet either of those requirements, that plan is subject to cancellation.
What Are Essential Health Provisions?
The essential health provision requires that the insurance plan must at least contain the following benefits:
- Ambulatory Care
- Emergency Care
- Maternity Care
- Substance Abuse Treatment/ Rehabilitate Services
- Laboratory Services
- Prescription Services
- Children’s Dental and Vision Care
- Mental Health Care
- Preventative Services and Chronic Disease Management
- Coverage of Hospitalization
The Affordable Care Act requires that all preventative services be covered with no out-of-pocket costs and that the mental health and substance abuse treatments meet federal standards. In addition, insurance companies cannot impose annual dollar limits on the coverage of any benefit considered "essential."
Many of these "essential" benefits are actually unnecessary for many patients. Men typically do not want maternity care; some people will never have children, while some patients will never abuse substances. Many state plans do not include a benefit or two even though the benefit is considered "essential." If you feel that an "essential" benefit is not needed, you can either seek a grandfather plan exception or move to another state.
What Is Cost-Sharing?
Under the Affordable Care Act, an insurance plan must cover at least 60% of out-of-pocket expenses. In other words, all insurance plans must, at a minimum, pay for 60% of all services while the patient, at a minimum, is responsible for 40% of all services. Insurance plans are free to cover a higher percentage, but it must cover at least 60% under the Affordable Care Act.
However, the Affordable Care Act imposes a limit on out-of-pocket expenses. Even if the insurance plan only covers the minimum 60%, individuals cannot pay more than $6,250 in out-of-pocket costs and families cannot pay more than $12,500 in out-of-pocket costs.
What Are Grandfathered Plans?
Grandfathered plans are plans which were implemented before March 23, 2010. If the insurance plan was implemented before March 23, 2010, you may be able to keep the plan even though it’s not in compliance with the essential benefits and cost-sharing requirements of the Affordable Care Act.
Job-based plans implemented after the 2010 date may be able to maintain their grandfather status if the plan has not substantially cut costs or benefits since implementation. "Job-Based" means the insurance plan was provided by the employer rather than purchased by the patient him or herself.
Regardless of how the patient obtained the plan, the insurance company itself must notify the patient that the plan is a grandfather plan. If an insurance company decides to cancel a grandfather plan, the company must provide at least 90 days notice.
How Does the Ban on Pre-Existing Condition Discrimination Work?
Under the Affordable Care Act, insurance companies cannot refuse to sell or renew policies to anyone with a pre-existing condition. Under the Affordable Care Act, "pre-existing condition" is defined as:
- Genetic information
- Health status
- Medical condition
- Claims experience
- Medical history
- Receipts of other health care plans
- Evidence of insurability
Any other health-related status determined appropriate by the Secretary of Health and Human Services
Do I Need a Lawyer If I Am Being Denied Insurance or Benefits?
The goal of the Affordable Care Act is to provide expanded minimal standard of health care for those who were previously uninsured. If an insurance company or a health care provider is refusing a health care service, then the Affordable Care Act has been violated. An experienced personal injury attorney who specializes in health care can fight for your legal rights.