Benefits of the Affordable Care Act (ACA) for Women & Our Families Presented by the Statewide Parent Advocacy Network SPAN Funding provided by the US Department of Health and Human Services, Office of Women’s Health

The Patient Protection and Affordable Care Act: How it will help you & your family

Why we needed to make changes in our health care system Families, especially c hildren with special healthcare needs (CSHCN), faced exclusion from coverage, rescission of coverage when we got sick, exhaustion of lifetime benefits (sometimes before they even started school), co-pays for preventive care, and unaffordable coverage.

Why we needed to make changes in our health care system Uncovered medical expenses Higher “routine” expenses Loss of employment income Crushing medical debt burden

The Patient’s Bill of Rights: Affordable Care Act (ACA)  Insurers cannot deny coverage to children with pre-existing conditions  Protects your child from being dropped by your insurer when s/he gets sick  Protects your choice of doctor  Ends bureaucratic hurdles to emergency services  No lifetime limits on coverage (but annual limits)  No cost-sharing for preventive care

Who is the ACA helping?  Children with pre-existing conditions  Children & adults with chronic conditions or catastrophic illnesses  Young adults without insurance  Small businesses  People with poor quality insurance  Seniors

Implementing the Affordable Care Act:  The ACA is being phased in from 2010 through 2014  Many children who need help are getting it right away  Some provisions in the law are being phased in to allow time for preparation

BETTER BENEFITS, BETTER HEALTH FOR WOMEN & OUR FAMILIES Summary of Major Provisions of the Affordable Care Act Most young adults can stay on parents’ family plan until 26 ◦ Even if they are married, living independently, not in school Most health plans can’t deny coverage to children under age 19 due to pre-existing conditions (this applies to adults starting in 2014) If you have been uninsured due to a pre-existing condition, like cancer or pregnancy, you may be eligible for the Pre- Existing Condition Insurance Plan

BETTER BENEFITS, BETTER HEALTH FOR WOMEN & OUR FAMILIES Summary of Major Provisions of the Affordable Care Act Insurance companies cannot charge you a deductible or co- pay for recommended preventive services like mammograms and flu shots You can choose the primary care doctor or OB-GYN in your insurer’s network without a referral Your insurer cannot cap the dollar amount of care you can receive in your lifetime Your insurer cannot drop your coverage when you get sick due to a mistake on your application

Rights & Protections: Patient’s Bill of Rights Summary of Benefits & Coverage & Uniform Glossary (easy to understand) Appeal of health plan decisions including external review process Prohibition on limiting or denying benefits to children <19 for pre-existing conditions Pre-existing condition plan for adults Young Adult coverage on parents’ plans Preventive care without cost/co-pay!

Decreasing Insurance Costs Increases the amount of premium dollar the insurance company must spend on care Insurance companies must justify any rate increases of 10% or more Ban on lifetime dollar limits on essential benefits like hospital stays or therapies (annual limits phased out by 2014) Prohibition against charging women higher premiums than men (effective 2014) Tax credits available to small businesses Affordable plans under new exchanges

Insurance Choices Pre-existing condition insurance plan Affordable insurance exchanges (including tax credits to help you afford coverage if your income for a family of 4 is less than $88,000/year or individual is less than $43,000/year; start by 2014) CO-OP Insurance Plans (Consumer Operated & Oriented Plan) Consumer Assistance Program to help you find & select coverage

Ensuring the right to choose your doctor

Choosing your doctor  If you are enrolled in a health plan that requires you to designate a specific primary care provider, you are guaranteed the right to choose that doctor from within the plan’s provider network, as long as s/he is accepting new patients like you. You must be informed of your right to pick your primary care provider. Until you do so, the plan may select one for you. You may designate a pediatrician as your child’s primary care provider.

The ACA helps children with pre-existing conditions

 Insurers cannot deny policies to children with pre-existing conditions  Insurers will have to accept everyone who wants to purchase a plan, regardless of their health status. Children with special health care needs can get insurance to treat their illnesses!

The ACA helps children with pre-existing conditions Health plans aren’t able to exclude coverage of pre-existing conditions from their policies. This means that health plans can’t refuse to cover your child’s treatment solely because s/he already had a health condition when s/he joined the plan.

Denial of specific treatments ◦ Your insurance company can still deny coverage of a particular treatment if your plan does not offer coverage of that specific treatment to anybody enrolled in the plan.

To whom does it apply – and when? ◦ These protections apply to everyone who gets coverage through work and to everyone who buys an individual or family plan after March 23, These protections may not apply to those who stay in individual insurance plans that they bought before March 23, 2010, unless that plan has made major changes in its coverage or substantially increased cost-sharing or deductibles.

Enrolling children with pre-existing conditions ◦ For plan years beginning on or after September 23, 2010, insurers have to cover all children who apply for a plan, regardless of their health status. However, insurance plans are not required to have new plans available for purchase year-round. Plans may choose to have “open enrollment periods” (that is, periods when they will take new applicants).

The ACA helps people with chronic conditions or catastrophic illness

 Health insurance companies can no longer place lifetime caps on coverage (but they can set annual limits until 2014)  Limits annual coverage limits  Creates a new, more affordable insurance option for people with chronic illnesses  No unfair rescission of benefits because your child’s care gets “too expensive”

Rescission of benefits  Insurance companies will only be able to rescind policies if you commit fraud (you knowingly and willfully misrepresent or omit a piece of information relevant to your plan)  You are protected if you stay in your current plan or if you buy or enroll in a new plan  You are entitled to 30 days advance written notice if the plan wants to rescind coverage, and you have the right to appeal

Rescission of benefits  Insurers can cancel your policy if:  You stop paying premiums  The insurer stops offering your insurance plan or leaves the insurance market in your area  You move away, and the location of your new residence is not in the insurer’s service area  You get your coverage through an association, and you end your association membership

The ACA helps people with chronic conditions or catastrophic illness  Protections apply to “essential benefits”  Ambulatory care (doctor & specialist visits)  Emergency services  Hospitalization  Preventive & wellness services  Chronic disease management  Laboratory services & prescription drugs  Maternity & newborn care  Pediatric services  Mental health & substance use disorder services  Rehabilitative & habilitative services & devices

The ACA helps people with chronic conditions or catastrophic illness  Annual limits apply on an individual basis  If your child reaches their annual limit, the essential medical care that you and other members of your family get will still be covered by your health plan  Some plans that have annual limits below $750,000 now can apply for a waiver from the Secretary of Health & Human Services if they would have to significantly decrease benefits or raise premiums to comply

The ACA helps ensure fair treatment for emergency care

 If you have an emergency medical condition (symptoms are severe enough that you would put your health in jeopardy or might be seriously harmed if you don’t get immediate attention), you can get emergency medical screening and treatment at a hospital

The ACA helps ensure fair treatment for emergency care  Your health plan CANNOT:  Require you to get preauthorization for emergency services  Make you go thru extra administration hurdles to get out-of-network emergency services covered  Charge you higher co-payments or co-insurance for out-of-network emergency services than it charges for in-network emergency services  Limit coverage for out-of-network emergency care more than it would limit care in-network

The ACA helps ensure fair treatment for emergency care  Balance billing:  If a health care provider is not in the plan’s network, that provider may not accept the plan’s payment rates for a service, and may bill you the difference between what the plan pays for the service and what s/he charges  Your plan must pay emergency provides the greatest of the amount it pays in-network providers, a payment based on the same method it uses to pay for other out-of- network services (such as a % of usual and customary fees), or the amount Medicare would pay for that service

Your Right to Appeal Photo: Creative Commons UBC Library GraphicsCreative Commons UBC Library Graphics

Ensuring the right to appeal health plan decisions If you disagree with your plan’s refusal to pay for care, the plan will have to review its decision If you are not satisfied with that decision, you will have the right to appeal that decision to an independent reviewer who is outside of the health plan (consumers who appeal outside of their insurance companies win their cases about 45% of the time) You can appeal a plan’s decision not to pay for a benefit, or to reduce or end a covered service, which must be provided in writing through formal notice, when the plan says any of the following:

Ensuring the right to appeal health plan decisions (1)The care is not medically necessary or appropriate (2)You are not eligible for the health plan or benefit (3)You have a pre-existing condition (for adults until 2014) (4)The care is experimental or investigational (5)Your coverage is being rescinded

The Appeal Process (1)Ask for an internal review by other people in the health plan not involved in the original decision. They must consult with appropriate medical experts, & give you the details of why the plan refused to pay for your care, and allow you to review your file, get the medical evidence used, and the plan’s guidelines about when it does and doesn’t pay for the type of care you requested, at no charge. You may present testimony and more evidence, and respond to any evidence the plan uses. You can ask a consumer assistance program or other advocate to help you,. The plan must expedite its review if the matter is urgent & you request it. The plan must give you a final decision notice that explains how you can get external, independent review.

The Appeal Process (2) If you are not satisfied, request an external appeal. You have a least 4 months to request an external review, to gather doctor statements, medical literature, and other evidence you might want to submit with your request for an appeal. After you submit your request, you will receive notice that you have 5 more business days to submit any additional information you want considered, and if the plan submits additional info, you may respond to it. The independent reviewer makes a decision within 45 days, or 72 hours (or sooner) if the matter is urgent. The plan must follow the reviewer’s decision.

The ACA helps young adults Photo: Creative Commons UBC Library GraphicsCreative Commons UBC Library Graphics

The ACA helps young adults  Young adults up to age 26 can remain on their parents’ health insurance (NJ already allows young adults up to age 30 to stay on their parents’ health insurance), even if they are not students, don’t live at home, and don’t live in the same state as their parents!  It will help young adults stay healthy and protect them in the case of an accident

Who is eligible? ◦ Their parent has coverage through their employer or buys family coverage in the individual market ◦ The plan provides “dependent coverage” (but the young adult does NOT have to be dependent on their parent(s), and does not have to live with their parent(s)) ◦ The young adult doesn’t have a plan that offers health coverage

Avoiding breaks in coverage It is especially important for young adults to avoid breaks in coverage of 63 days or more, because such gaps strip them of protections against pre-existing condition exclusions. For more information, see Your Guide to HIPAA Protections, sections 7 and 8, online at insurance/legal-rights/guide-to-hipaa- protections.html. insurance/legal-rights/guide-to-hipaa- protections.html

Tax implications Job-based health benefits for young adults on their parents’ health plans are NOT considered taxable income!

The ACA supports small businesses Photo: (CC) Larry D. Moore: (CC) Larry D. Moore

The ACA supports small businesses  The law provides tax credits to help small businesses afford coverage for themselves and their employees Making insurance affordable for small business owners will encourage development and expansion

The ACA protects you from “junk insurance”

 The ACA sets standards for policies, and eliminates co- pays for preventive care (Bright Futures standards for children’s preventive care)  Insurers have to use more of your premium dollars to provide care, and limit what goes to salaries and administrative costs  Insurance premium hikes are subject to scrutiny People will have peace of mind, knowing their insurance will be there for them when they need it.

The ACA makes our country healthier Photo: Creative Commons edenpicturesCreative Commons edenpictures

The ACA makes our country healthier  More people (including children) will have health insurance – it makes health insurance more affordable and accessible to millions of people across the country  Free preventive care means more children and adults will be able to get their illnesses treated early before they become serious and costly  People will have peace of mind, since the law protects them from insurance company’s bad practices

Preventive Benefits for Women 22 preventive services provided without cost- sharing/co-pay (effective August, 2012) ◦ Well-woman visits ◦ Domestic & interpersonal violence screening & counseling ◦ Breast cancer mammography screenings every 1-2 years for women > 40 ◦ Breast cancer chemoprevention counseling for women at higher risk ◦ Breastfeeding support, supplies & counseling for pregnant & nursing women ◦ Tobacco use screening & intervention for all women, & expanded counseling for pregnant women

Screening for Pregnant Women Routine anemia screening Bacteriuria urinary tract or other infection screening Gestational diabetes screening for women weeks pregnant & those at high risk of developing it Hepatitis B screening at 1st prenatal visit Syphilis screening for all pregnant women & other women at increased risk Rh incompatibility screening for all pregnant women & follow up testing for women at higher risk

Contraception-Related Benefits Genetic testing counseling for women at higher risk FDA-approved contraceptive methods, sterilization procedures, & patient education & counseling Folic acid supplements for women who may become pregnant

Other Sexuality-Related Benefits HPV DNA testing every 3 years for women 30 & older Chlamydia infection screening for younger women & those at higher risk Gonorrhea screening for all women at higher risk Sexually transmitted infections counseling HIV screening & counseling for sexually- active women Cervical cancer screening for sexually-active women

16 Covered Preventive Services for all Adults (Women & Men) Immunization vaccines ◦ Hepatitis A & B ◦ Herpes Zoster ◦ Human Papillomavirus ◦ Influenza (flu shot) ◦ Measles, mumps, rubella ◦ Meningococcal ◦ Pneumococcal ◦ Tetanus, diptheria, pertussis

Screening Services Alcohol misuse screening Blood pressure screening Cholesterol screening Colorectal cancer screening (> 50) Depression screening Type 2 Diabetes screening for those with high blood pressure HIV screening for adults at higher risk Obesity screening Tobacco use screening Syphilis screening for adults at higher risk

Counseling services Alcohol misuse counseling Diet counseling for those at higher risk for chronic disease Obesity counseling STD prevention counseling for those at higher risk Tobacco cessation interventions for tobacco users

27 Preventive Children’s Services Fluoride chemoprevention supplements for children without fluoride in water Iron supplements for children 6-12 months at risk of anemia Gonorrhea preventive medication for the eyes of all newborns Height, weight, body mass index measurements for children (0-11 months, 1-4 years, 5-10 years, 11-14, 15-17)

Immunizations Diptheria, tetanus, pertussis Haemophilus influenza Type B & flu shot Hepatitis A & B Human Papillomavirus Inactivated poliovirus Measles, mumps, rubella Meningococcal Pneumococcal Rotavirus Varicella

Screening for Young Children Newborn screening for: ◦ Congenital hypothyroidism ◦ Hearing ◦ Hemoglobinopathies or sickle cell ◦ Phenylketonuria (PKU) Autism 18 & 24 months Developmental screening < 3 & surveillance throughout childhood Oral health risk assessment (0-11 months, 1-4 years, 5-10 years)

Screening for all children Behavioral assessments (0-11 months, 1-4, 5-10, , 15-17) Blood pressure (same age ranges) Dyslipidemia (for children at higher risk of lipid disorders, same age ranges) Hematocrit or hemoglobin Lead, for those at risk of exposure Tuberculin, for those at higher risk Obesity screening & counseling Vision Medical history for all children throughout development (at same age ranges)

Screening for Adolescents Alcohol & drug use assessments Cervical dysplasia screening for sexually active females Depression screening HIV screening for adolescents at higher risk Sexually transmitted infection prevention counseling & screening for adolescents at higher risk

Spread the word about how the Affordable Care Act helps NJ’s children! If you need more information, contact Family Voices-NJ/NJ Family to Family Health Information Center at , or go to

RESOURCES Family Voices: Families USA: or Catalyst Center: Community Catalyst: NJ Citizen Action: Kaiser Family Foundation: Commonwealth Fund: Reform/Health-Reform-Resource.aspx Reform/Health-Reform-Resource.aspx US Department of Health & Human Services: