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Key Aspects of the Affordable Care Act Which Protect Patients 

Written by: Victor E. Battles, M.D. 

In addition to making health insurance more affordable for most Americans, the Affordable Care Act, which is the short name for the Patient Protection and Affordable Care Act, contains key provisions for protecting patients. Some of those key patient-protective aspects of the law are worth reviewing and understanding.

The act makes it mandatory that health plans provide certain categorized basic coverage also known as essential health benefits. Those include outpatient services such as doctor visits, emergency services, laboratory testing services, mental health services, substance abuse treatment, maternity and newborn services, prescription drug coverage, rehabilitation, pediatric services and some preventive and wellness services. The law specifies that the preventive services must be free of charge and not subject to copayments, deductibles or coinsurance.

Probably the most heralded and conspicuous patient-protection provision of the ACC is the abolition of the pre-existing-condition concept which insurance companies have used as a pretext to deny, exclude, cancel, or inflate coverage. It has long been the financial Achilles’ heel of many individuals and families, but it will see its total demise by virtue of Obamacare as of January 1, 2014.  The first deathblow was delivered with the passage of the law on March 23, 2010 which, beginning on September 23, 2010, prohibited insurance companies from denying or excluding coverage of children under 19 due to pre-existing conditions in all individual policies except those that are grandfathered or were purchased before March 23, 2010.

A related provision of the law which has received much less press and fanfare is the prohibiting of insurance companies from canceling coverage because of honest application mistakes. This change is reminiscent of the days when almost immediately after submitting a claim for services provided to a new patient I would receive a request for old records from the insurance company, only to later find out that they were denying payment of the claim based on a pre-existing illness. The decision would be the result of a self-serving conclusion on the part of the insurance company in response to a question or questions on the application which the patient had answered “no” to, regarding having ever experienced signs or symptoms of certain disease(s). After reviewing the medical history and physical which I submitted, the insurance carrier then assumed that based on documented signs and symptoms in the report, the patient obviously had the condition prior to the date of coverage, when in fact it could not be proven, nor did the patient even know that those signs and symptoms can be associated with the condition(s) for which coverage was denied.

Another major area of patient protection afforded by the ACA is a limit on patients’ cost-sharing responsibility, known as annual out-of-pocket expenses, or the amount that patients have to pay for covered services and drugs in a calendar year before the insurance company picks up 100% of the charges. Out-of-pocket costs are generally perceived to be copayments, deductibles, coinsurance, or a combination of either, but some companies down through the years have excluded deductibles, which have increased out-of-pocket costs considerably. That practice will no longer be permitted, beginning in January 2014 because of the Affordable Care Act. The limit on out-of-pocket expenses for all healthcare plans sold in the United States beginning in 2014 will be $6350. Additionally, individuals whose incomes fall in the 100% to 200% of the federal poverty levels and those whose incomes are between 200% and 250% of the federal poverty level will have reduced annual cost-sharing responsibilities of $2225 and $5200 respectively beginning in 2014. Grandfathered plans, which are those that were in existence before March 23, 2010, and which have not substantially reduced benefits or raised premiums, are exempt from patient cost-sharing limits however.

The imposition of lifetime and annual dollar limits on covered benefits by insurance companies has been detrimental to many patients in the past, leaving many in positions of bankruptcy because of spiraling healthcare costs no longer covered by their policies. The Affordable Care Act made it illegal however, for insurance companies to permanently stop paying for most covered services because they had reached their spending limit for a policyholder. That aspect of the law took effect on September 23, 2010. The ACC currently limits the annual spending restriction that some companies still impose, but will do away with the limit altogether beginning in 2014.

Given the complexity of health insurance, the meager health and health-insurance literacy of the population in general, and the unscrupulous precedent set by many in the insurance industry, several of the provisions in the Patient Protection and Affordable Care Act are a breath of fresh air to many.

Victor E. Battles, M.D. is a board-certified internist with 30 + years of patient contact. He has been a principal investigator in several clinical research trials and is the founder of Proactive Health Outlet. Additionally, he has worked in the areas of quality assurance and utilization review.

To learn more about health insurance in this time of healthcare reform, check out other articles on health insurance.

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