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January 25, 2018

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Medical Coding News Archives

Obamacare: Call It What It Is—Patient Protection and Affordable Care Act

November 29, 2012:

Brigid T. Caffrey, BA, BS, CCS, Manager, Clinical/Technical Editors

Maybe referring to the Patient Protection and Affordable Care Act by its formal name will help dispel some of the misinformation about the health care bill. A study by the bipartisan Congressional Budget Office concluded that this act, which will be in full effect by 2014, will lower the budget deficit by $143 billion over 10 years due to planned taxes and cost offsets.

With little more than a year to go to full implementation, let’s review some of the main aspects of ensuring that all Americans have insurance choices and access to health care services.

Patient protection:

  • Eliminates discriminatory practices:
    • Individuals cannot be denied due to pre-existing conditions
    • Individuals cannot be dropped due to illness
    • Individuals cannot be charged higher premiums because of health issues
    • Payers cannot limit/cap lifetime or annual benefits
    • Individuals cannot be made to pay higher premiums due to age, sex, geographical area
    • Individuals cannot be denied coverage due to eligibility rules based on financial status
  • Insures more Americans:
    • Allows children up to age 26 to be covered on their parents’ plans
    • Makes insurance available to those currently uninsured, either through incentives to employers, Medicaid, or tax credits and insurance exchanges
  • Guarantees coverage:
    • Provides for preventive and screening services without cost-sharing, such as blood pressure screening, colorectal cancer screening, immunizations, mammography, contraception, well-woman visits
  • Establishes an external appeals process:
    • Creates ombudsman programs to advocate for the beneficiary in cases of complaint, appeal, and administrative issues

Affordable care:

  • Reduces costs by making services available to those who now use visits to the emergency room as their primary health plan
  • Closes the coverage gap (donut hole) for the Medicare drug plan
  • Removes barriers to urgent care, such as referrals or physician approval, and saves the beneficiary from assuming the costs
  • Allows shopping for and purchasing of insurance through marketplace pools via health exchanges, thus using the combined buying power for individuals to afford private health insurance that may not exceed a percentage of an individual’s income
  • Provides tax credits to small businesses to cover up to 50 percent of their total employee premium payments
  • Requires insurance companies to spend at least 80 percent of the premium payments on medical services and not on advertising and executive salaries; those who fail to prove compliance must send rebates to policyholders

Costs of the act are offset by:

  • Requiring those who refuse health care insurance to pay a penalty in the form of a tax to contribute to the health care coverage for the rest of Americans
  • Lowering payments to hospitals
  • Increasing Medicare taxes on high-income households
  • Assessing penalties on large business employers who do not offer health care insurance
  • Assessing taxes on various health-related activities, such as assessing indoor tanning services at a 10 percent excise tax and elective cosmetic surgery at a 5 percent excise tax
  • Reducing overhead by consolidating the higher education loan program with the Pell Grant Program


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