Healthcare Reform Summary

The Affordable Care Act sets forth provisions governing health insurance plans and issuers, including:

1. Exempting grandfathered health insurance coverage from requirements of this Act
2. Prohibiting pre-existing condition exclusions for dependent children under the age of 19 starting in 2010
3. Prohibiting pre-existing condition exclusions for everyone starting in 2014
4. Providing for guaranteed coverage to all individuals and employers and automatic renewal of coverage
5. Prohibiting premium variances, except for reasons of age, area or family enrollment
6. Prohibiting rescission of health insurance coverage without clear and convincing evidence of fraud
7. Prohibiting insurers from imposing lifetime limits on benefits.

The Act further requires qualified health benefits plans to provide essential benefits: 

1. Lifetime limits are prohibited on the dollar value of in-network and out-of-network covered services that constitute “Essential Health Benefits."
2. "Essential Health Benefits" include hospitalization, emergency services, prescription drugs, mental health services, preventive services, maternity and newborn care, as well as children's dental, vision, and hearing services and equipment.

The Act designates the responsible organizations: 

1. Establishes the Health Choices Administration as an independent agency to be headed by a Health Choices Commissioner
2. Establishes the Health Insurance Exchange within the Health Choices Administration in order to provide individuals and employers access to health insurance coverage choices, including a public health insurance option

Requires the Commissioner to:  

1. Contract with entities to offer health benefit plans through the Exchange to eligible individuals
2. Establish a risk-pooling mechanism for Exchange-participating health plans
3. Provides for an affordability premium credit and an affordability cost-sharing credit for low-income individuals and families participating in the Exchange

Requires employers to: 

Employers with 50 or more Full Time Employees are subject to the following rules:

1. If the employer does not offer minimum health coverage to all full-time employees and any one employee receives tax-subsidized coverage through an individual exchange, the employer must pay a $2,000 penalty for every full-time employee. (Not including the first 30 employees)
2. Employers who offer coverage but whose employees receive tax credits must pay $3,000 for each worker receiving a tax credit up to an aggregate cap of $2,000 per full-time employee.

Amends the Internal Revenue Code to impose a tax on:  

1. An individual without coverage under a health benefits plan; and
2. An employer that fails to satisfy health coverage participation requirements for an employee. Imposes a surtax on individual modified adjusted gross income exceeding $350,000

Amends title XVIII (Medicare) of the Social Security Act to revise provisions relating to payment, coverage, and access, including:  

1. Reduce payments to hospitals to account for excess readmissions
2. Limit cost-sharing for Medicare Advantage beneficiaries
3. Reduce the coverage gap under Medicare Part D (Voluntary Prescription Drug Benefit Program)
4. Provide for increased payment for primary health care services
5. Prohibit cost-sharing for covered preventive services

Requires the Secretary of Health and Human Services (HHS) to: 

1. Provide for the development of quality measures for the delivery of health care services in the United States
2. Establish a Center for Comparative Effectiveness Research within the Agency for Healthcare Research and Quality, financed by a tax on accident and health insurance policies, to conduct and support health care services effectiveness research

Amends title XIX (Medicaid) of the Social Security Act to:

1. Set forth provisions to reduce health care fraud
2. Expand Medicaid eligibility for low-income individuals and families
3. Require coverage of additional preventive services
4. Increase payments for primary care services

Sets forth provisions relating to the health workforce, including:  

1. Addressing health care workforce needs through loan repayment and training
2. Establishing the Public Health Workforce Corps
3. Addressing health care workforce diversity
4. Establishing the Advisory Committee on Health Workforce Evaluation and Assessment

Sets forth provisions to: 

1. Provide for prevention and wellness activities
2. Establish the Center for Quality Improvement
3. Establish the position of the Assistant Secretary for Health Information
4. Revise the 340B drug discount program (a program limiting the cost of covered outpatient drugs to certain federal grantees)
5. Establish a school-based health care program
6. Establish a national medical device registry

Implementation Timeline 

OTC Drug changes effective 1/1/2011 

Letter of Medical Necessity for OTC Drug Change 

Preventive Services Covered under Healthcare Reform