Obamacare / Affordable Care Act
Understanding The Affordable Care Act
Some people are very detail oriented, in fact, we often get requests asking if we can provide an annotated version of the entire Affordable Care Act. At more than 1,000 pages, that is no easy accomplishment. That said, we strive to provide Americans with whatever information they might need in order to make an informed decision about Obamacare. So that is why we are literally providing an annotated summary of the entire Obamacare Bill for your reading pleasure.
H.R. 3590, which is entitled The Patient Protection and Affordable Care Act, or Obamacare as it is more commonly referenced socially, was passed into law on March 23, 2010. The 906 page document is full of legalize language, a confusing format and more information than any one person could possibly digest.
The goal of this article is to summarize each section, or span of related sections, very simply and broadly so that you can get a bird’s eye view of the entire Affordable Care Act bill. If a certain section is redundant or unimportant to the big picture, it will be skipped so that you are not spending any more time than you have to understanding the law.
Sections 1001 – 1004: Reforming the individual and group healthcare system
The ACA is designed to reform the healthcare industry so that it meets the actual needs of Americans. Under the ACA, insurance companies 1) cannot cap the annual or lifetime limits to claims submitted; 2) can not rescind coverage just because a person becomes sick; 3) must cover certain co-pay free preventative health services; 4) must allow children to remain on their parent’s health insurance policy until their 26th birthday; 5) insurance companies must provide participants with an explanation of their benefits and plan coverage; and 6) group insurance policies cannot discriminate based on salary to determine eligibility into a plan.
In addition, the ACA will require that a reporting system is created to ensure the quality of care being provided under the Act, that insurance companies are trying to bring down the costs of healthcare and the ACA requires insurance companies to create an appeals process for participants who have issues with claim coverage determinations.
The ACA will also provide in its budget grants to states to help implement and manage the requirements of the ACA.
The ACA will work with the states to create a process to review the implementation of the ACA’s requirements and to make recommendations to improve the system.
TITLE I: QUALITY, AFFORDABLE HEALTHCARE FOR ALL AMERICANS
Section 1101 – 1105: How the ACA will immediately preserve and expand coverage to Americans
The ACA created an insurance policy available immediately to people who met certain criteria as high risk and who were in immediate need of coverage even though open enrollment had not begun yet.
The ACA will create a program that will reimburse companies who continue to fund employees who retire early and are not yet eligible for benefits under Medicare.
The ACA will require the Department of Health and Human Services (HHS) to create a website that contains information about the requirements of the ACA and coverage options.
The ACA also requires that the program carry out the administration of the Act by following operating and compliance rules.
Section 1201: Major changes made to healthcare under the ACA
The ACA reformed healthcare in America so that: 1) it prohibits insurance companies from considering preexisting conditions and past medical history when determining eligibility; 2) it prohibits discrimination of any sort when calculating a premium; 3) insurance companies can only consider tobacco use, size of family, age demographic to a certain, specific degree when calculating the monthly premium for a policy; 4) insurance companies must make their policies available to every person in the state they cover so long as during open enrollment or a special enrollment period; 5) insurance companies must renew coverage and cannot cancel based on reasons like medical history, number of claims submitted, disabilities, etc.; 6) insurance companies cannot discriminate against their participants; 7) employee must not wait longer than 90 days after starting employment to get insurance through their employer.
Section 1251 – 1253: Miscellaneous provisions
The Act does not require any individual to change their health insurance policy if they do not want to. [We now know that this provision is not necessarily true unless the policy is grandfathered in or it already met the requirements of the ACA]
If any requirement or standard is created by a State due to the ACA, that new rule will apply to all insurance companies in that State uniformly.
Section 1301 – 1304: Qualified Health Plans
Under the ACA, all insurance policies must be considered Qualified Health Plans in order to be offered in the market to Americans. A Qualified Health Plan must 1) offer the ten essential health benefits; 2) must be offered by an insurance company that is in good standing with each State it conducts business in; 3) must offer participants at least a silver and gold level plan; and 4) must offer plans at the same cost no matter whether purchased through the exchange or the private market.
The ACA imposes limitations on deductibles for employer-sponsored plans.
The ACA recommends that insurance companies offer catastrophic, bronze, silver, gold and platinum level policies with increasing costs for increasing coverage.
Nothing in the Act shall be construed to require any plan to cover abortions.
Section 1311 – 1313: Creating competition through the health exchanges
The ACA can allot grants to States to set up their own marketplace exchanges to offer health insurance.
If a State chooses to implement the ACA through their own exchange, they must create a website that offers individuals plans and also provides a SHOP (Small Business Health Options Program) marketplace for group healthcare policies. The ACA will monitor and review the implementation and management and the state exchanges. The state exchanges must be non-profit entities.
The ACA will provide incentives and rewards to healthcare providers who improve the health outcomes of patients.
Individuals have the freedom to choose any qualified plan available to them in their state, whether from the marketplace or the private market and employers can choose to offer their employees whatever levels of coverage that they want to cover. Employees then have the freedom to choose whichever plan they want that their employer offers.
Members of Congress and their staffers must pick a policy offered through the Exchange.
Agents and brokers may help individuals and employers select policies under the ACA.
People who are incarcerated in jail or prison or who are not lawful residents of the United States are not permitted to sign up for healthcare under the ACA.
A company that has more than one full-time employee may use the exchange to shop for healthcare and will be required to comply with the employer mandates under the ACA.
The state and federal Exchanges shall keep accurate accounting of all activities and HHS may investigate or audit the records of the Exchange periodically if they want.
Section 1321 – 1324: Guidelines for the States Exchanges
If a State is implementing the requirements of the ACA on its own it must create an Exchange for individuals and for companies (SHOP Exchange). If a State is not going to implement the ACA on its own, it will use the federal Exchange.
The ACA will create a program to carry out and provide grants and loans to Consumer Operated and Oriented Plan (Co-Op) Programs, which are nonprofit health insurance companies. Any company that wants to create a Co-Op Program in a particular state must apply and be approved.
The ACA also allows for the creation of a Community Health Insurance Option, which is a voluntary program that a State may opt out of that is made up of health care providers that offer ACA compliant coverage to a large group of beneficiaries and is designed to reduce admin costs and complexity.
Section 1331 – 1333: States have flexibility to create other healthcare programs
So long as the health insurance plans offer at least the 10 essential health benefits and comply with the requirements of the ACA, a State may offer other insurance plans to create competition in the marketplace.
Section 1341 – 1343: States must offer reinsurance policies
States must contract with at least one reinsurance entity to offer reinsurance policies to participants. Reinsurance programs share the obligation of an insurance claim with a second company.
Section 1401 – 1402: Tax credit and cost-sharing reductions
The ACA will provide tax credits to individuals and families that qualify to help pay for the monthly policy premiums. Tax credits available to individuals or families that make between 100% and 400% of the federal poverty line.
Employers must offer affordable health insurance coverage and the employee’s portion to pay per month must not exceed 9.8% of their household income and the employer must cover at least 60% of the costs.
The ACA requires the Comptroller General to conduct a study on the affordability of health insurance in the United States since the requirements of the ACA were fully implemented.
The out-of-pocket costs of healthcare will be reduced for individuals and families who qualify for a tax credit by a standard proportion related to their poverty line percentage: if between 100% – 200% of FPL, then reduced by 2/3; if between 200% – 300% of FPL, then reduced by 1/2; if between 300% – 400% of FPL, then reduced by 1/3.
Section 1411 – 1415: Guidelines to determine eligibility
Application for insurance through Marketplace will ask questions to determine whether eligible for a tax credit or cost-sharing, eligible for health coverage through his/her employer or whether he or she is eligible for an exemption. The ACA may require documentation or other proof to substantiate eligibility or an exemption.
The information provided on the application for insurance is confidential.
Any person who provides false or fraudulent or improperly uses or discloses information could be liable for a civil penalty of more than $25,000.
The IRS has implemented a section with the Internal Revenue Code of 1986 (Section 36B) that concerns the guidelines for the tax credit for qualified taxpayers.
The Secretary of the ACA program will advance the payment for the tax credit or cost-sharing payment to the insurance issuer of a qualified health plan on a monthly basis or periodically, depending on the what is required. The health insurance issuer should charge the taxpayer for the remaining balance, provide proper and accurate billing statements that show the tax credit deduction, advise the Secretary of the ACA if the taxpayer does not pay their portion and allow a 3-month grace period for nonpayment before discontinuing a plan.
The ACA (Healthcare.gov) is supposed to create an application that will request all information necessary to streamline the process of determining whether an individual or family is eligible for Medicaid, CHIP or a federal subsidy (tax credit or cost-sharing). The states must create their own form that functions in the same way and can determine quickly whether a person is eligible for assistance or a special program.
HHS may request certain confidential information from other agencies to verify or obtain information that may be necessary to confirm to determine whether a person is eligible for a federal subsidy or a special program. This confidential information may only be used for this purpose though.
The ACA must follow strict guidelines to maintain the confidentiality of any personal disclosures made by applicants or obtained by other agencies.
Any federal subsidies received by the federal government will not be considered income for tax purposes.
Section 1421: Small Business Tax Credit
An eligible small business employers can receive a tax credit for each taxable year if they provide health insurance to their full-employees equal to 50% tax credit so long as the insurance policies are qualified health plans under the ACA and that the cost sharing (premium that the employer has to pay) complies with ACA rules.
The amount of the tax credit may change based on a specific formula.
The terms “eligible small business” is defined as having less than 25 full-time employees. In addition, the terms “full-time employee” and “employee” are all defined and explained in this section.
The tax credit and deduction is not available to eligible small business owners until the year 2014.
Section 1501 – 1502: Responsibility of individuals to keep health coverage
All individuals must maintain their health coverage, which meets the minimum essential coverage requirements. Any individual who does not maintain such coverage will be penalized with a tax per non-compliant adult and non-compliant child. The tax will be imposed on the individual’s or family’s federal tax returns for the year that they did not consistently maintain adequate health coverage.
There are categories of people who are exempt from obtaining health coverage. They are: 1) Americans who are exempt from filing a Federal Income Tax Return; 2) Native Americans receiving healthcare from a different governmental program; 3) Americans who have only been without health insurance for three months or less; 4) Americans that are imprisoned; 5) Americans that qualify for a religious exemption; 6) Americans that are under the age of 26 and are still on their parent’s health insurance policy; or 7) illegal immigrants living within the United States.
The Secretary of HHS will require individuals and employers who provide their employees with healthcare to report that healthcare coverage.
Section 1511- 1515: Employer Responsibilities under the ACA
Employees of large employer companies can be automatically enrolled in their employer’s healthcare program and notice of that employee’s healthcare compliance will be an automatic reporting process under the ACA’s guidelines.
The large employer must provide notice to their employees of the insurance plan’s offered, the shared costs and the benefits offered. If the employer’s policy covers less than 60% of the costs, the employee may be eligible for a tax credit to obtain healthcare on the Exchange.
Large employers who do not offer their full-time employees and their dependents health coverage that meets the minimum essential coverage requirements for any month and/ or at least one full-time employee is forced to pay for coverage on the Marketplace Exchange with a federal subsidy because coverage is insufficient under the law or does not cover enough of the financial costs, will have to pay a penalty.
Large employers must offer new full-time employees health coverage under their employer-sponsored healthcare plan within 30 days of their start date or else they will have to pay a penalty.
The terms “applicable larger employer” is defined as having more than 50 full-time employees. This section also explains other rules for determining the size of the employer and defines “full-time employee”.
The large employer is responsible to provide reporting to the Secretary of HHS which employees are receiving employer-sponsored healthcare.
Section 1551 – 1563: Miscellaneous provisions
Nothing in the ACA permits discrimination upon a healthcare entity that may provide assisted suicide, euthanasia, mercy killing, abortion, etc.
The Secretary of HHS cannot create any regulations that would impede timely access to healthcare, create barriers or restrictions to obtaining healthcare or limit treatment needed by a patient based on their medical needs.
Insurance providers may not discriminate against individuals for any reason previously outlined in the ACA or under any federal law.
Employers may not discriminate or penalize (i.e. discharge) in any way an employee for any action that employee may take regarding the ACA.
TITLE II: ROLE OF PUBLIC PROGRAMS
Section 2001 – 2007: Access to Medicaid
The ACA requires that the eligibility requirements to enroll in Medicaid be expanded to include individuals who make less than 133% of the Federal Poverty Level. [This section was reviewed by the Supreme Court of the United States and was found to be unconstitutional. Accordingly, this section is only a recommendations and not a mandate.
Section 2201 – 2202: Simplifying Medicaid and CHIP enrollment
The ACA will provide rules to increase the support offered to the Medicaid and CHIP programs both financially and to increase enrollment.
The Marketplace Exchange website shall also provide applicants with information regarding whether they are eligible for Medicaid or CHIP.
Section 2301 – 2304: Improvements to Medicaid Services
These sections are only a recommendation due to the June 23, 2012 Supreme Court ruling.
Section 2401 – 2406: Options for states who provide long-term services
States may create programs to provide medical assistance for home and community-based attendant services and supports to people who have certain medical needs and who make less than 150% of the poverty line. The State may receive federal financial aid to support these programs.
Section 2501 – 2503: Medicaid Prescription Drug Coverage
These sections are also only a recommendation due to the June 23, 2012 Supreme Court ruling.
Section 2551 – 2801: Other Medicaid provisions
Again more of the same here. These sections are only a recommendation due to the June 23, 2012 Supreme Court ruling.
Section 2901 – 2902: Special rules and provisions regarding protecting American Indians and Alaska Natives
This section pertains to the right of native Americans and natives of Alaska to not have to comply with Obamacare and or the individual mandate.
Section 2951 – 2955: Healthcare services for Mothers and Children
The ACA wants the States to improve the services and initiatives in place that help mothers and children and promote healthy living and will provide federally-funded grants for certain programs.
TITLE III: IMPROVING THE QUALITY AND EFFICIENCY OF HEALTHCARE
Section 3001 – 3008: Incentivizing better quality outcomes of Medicare patients to payment
Hospitals that create value-based purchasing programs and that provide better quality to Medicare patients will be rewarded with financial incentives.
The Secretary wants to improve the physician feedback program and the regulations regarding quality reporting for long-term care hospitals and other inpatient rehab hospitals and hospice programs.
Section 3011 – 3015: National strategy for improving the quality of healthcare
The Secretary of HHS shall continue to create strategies to improve healthcare in the United States and to determine priorities of issues that need addressed within the system.
Section 3021 – 3027: Encouraging new patient care models and promoting innovations to the Center for Medicare and Medicaid Services (CMS)
The ACA wants a comprehensive review of the Medicare, Medicaid and CHIP social insurance programs to take place in order to find innovative ways to reduce expenses while improving the care provided under both programs. The ACA requires that CMS create a subgroup called the Center for Medicare and Medicaid Innovation (“CMI”) to carry out these duties and obligations. CMI should consult with and have an open door to representatives from Federal agencies, clinical and analytical medical experts and healthcare management professionals to brainstorm ideas and obtain input on ways to reform Medicare and Medicaid.
The ACA does make recommendations as to certain issues within the present Medicare and Medicaid models that need attention and reform. The ACA wants CMI to be its review process in 2011 and outlines the Treasury Department’s budget per year for these reviews and reforms. The ACA also requires CMI to submit a report to Congress starting in 2012 regarding the activities taken and changes effected in accordance with this section of the ACA.
The ACA also wants the Medicare program to create a Shared Savings Program whereby medical providers who enroll are rewarded for quality care and is designed to regulate the fee-for-service payment schedule so as to reduce excess and sometimes fraudulent expenditures.
The ACA also creates a National Pilot Program on Payment Bundling, which is a program that is designed to determine whether paying a bundled, lump sum for the care of a patient who is receiving multiple medical services at once, during one event, helps reduce costs to the Medicare program. This program is also examining the rate of improvement and quality of medical care provided to the patient by the hospital.
This section of the ACA also creates an Independent at Home Medical Practice Demonstration Program, which is designed to test whether providing Medicare care in the patient’s home improves the health and well-being of the patient, reduces the likelihood that the patient needs to be hospitalized and decreases costs for the hospital or medical facility.
Tis section of the ACA also establishes the Hospital Re-admissions Reduction Program, which is designed to decrease rushed patient discharge orders from a hospital in order to receive the discharge compensation amount from the Medicare program. This is achieved by decreasing the actual discharge compensation amount, which should decrease the incentive to the hospital to prematurely discharge a patient in order to receive compensation.
The Qualify Improvement Program is a program that is focused on hospitals with high readmission rates and is designed to decrease that readmission rate by working with patient safety organizations who will help suggest and implement change.
The Community-Based Care Transitions Program is designed to financially reward and fund community-based programs that provide care services to Medicare recipients and to hospitals with high readmission rates for improving the care to Medicare recipients with multiple chronic diseases and illnesses to decrease their need to be hospitalized
Section 3101 – 3114: Improving the Medicare program for patients and providers and ensuring that the patient has access to medical care and services.
This section of the ACA makes adjustments, amendments and clarifications to the language of various Social Security Act (SSA) provisions including but not limited to payment to physicians for Medicare services rendered and extending the deadlines of some existing SSA provisions to the year 2010 and beyond.
This section also creates a twelve-month special enrollment period for recipients of TRICARE healthcare (healthcare for active and retired military members and their families).
This section also provides Medicare medical coverage and payment for bone mass and density tests, treatments and scans.
This section also sets up a project whereby the Secretary of the Department of Health and Human Services (HHS) will pay for certain complex diagnostic lab test Medicare claims in order to promote medical and scientific advancement.
Section 3121 – 3129: Extensions and improvements to other Medicare programs and provisions under the Social Security Act
Section 3131 – 3143: Improving payment accuracy to save the Medicare program money
This section adjusts the payment amount reimbursed to medical providers for home healthcare under the Social Security Administration’s Medicare program.
This section also requests that the Secretary of the Department of Health and Human Services to conduct studies on the different costs associated with Medicare care to determine whether reform efforts would help reduce financial waste to the program.
The ACA also wants reform to hospice care and the financial costs associated with hospice care and has asked the Secretary of HHS to review hospice care and costs and make recommendations.
The ACA also wants to fix the disproportionate share of payments made to hospitals that is causing financial waste to the Medicare program. Payments will be decreased by a certain percentage in 2015 and then adjusted based on specific factors.
The ACA also wants the Secretary of HHS to periodically review the code values for specific physician fee schedules to determine whether the code values are accurate or inflated. The purpose of this review is to adjust the code values to ensure that physicians are being paid a fair amount of money for the services rendered to avoid unnecessary financial waste to the Medicare program.
This section of the ACA also made modifications and amendments to the following provisions of the Social Security Act: Section 1848, subsection 4, which regards rules for imaging services; Section 1834, subsection (a)(7)(A), which regards payment for power-driven wheelchairs; Section 1833 regarding treatment of certain cancers in hospitals; Section 8147A regarding payment for bio-similar, biological products.
This section also wants reform and change to the hospital wage index as it relates to Medicare care and wants the Secretary of HHS to plan those reform efforts.
This section and HHS will also establish a program called the Medicare Hospice Concurrent Care Demonstration Program, which is designed to improve and measure the level of improvement of patient care, quality of life and costs associated with the hospice services.
HHS will also conduct a study on whether Medicare-dependent hospitals that provide inpatient hospital services in an urban geographic region need more funding.
Section 3201 – 3210: Amendments and improvements to provisions within the Social Security Act that regard Medicare Part C (Medicare Advantage)
The ACA amended, added, deleted or otherwise changed specific language within the following sections of the Social Security Act’s provisions on Medicare Part C (Medicare Advantage):
Within Section 1853(j), the language is amended regarding how to compute certain Medicare Advantage benchmark amounts;
Within Section 1853(d), which relates to the Medicare Advantage local plan service areas; adding a section regarding performance bonuses to certain programs that improve the health and provide unique care opportunities to Medicare Advantage recipients;
Within a number of sections relating to the competitive bidding process;
Within Section 1852, which regards the different cost sharing funding for particular Medicare Advantage services in comparison to reimbursement under Original Medicare;
Within Section 1854, which regards how a medical facility can apply for a rebate or bonus for services;
Within Section 1853, which regards how hospitals code different services to receive payment from the Medicare Advantage plan; within Section 1851, which regards simplifying the dis-enrollment transition period and process;
Within Section 1859, which regards an extension of specialized Medicare Advantage plans for recipients with special needs;
Within Section 1859 the ACA is adding a section on special rules for senior housing facility plans; within Section 1854, which regards rejecting an insurance carrier’s bid to offer a particular Medicare Advantage plan;
Within Section 1882, which regards tasking the National Association of Insurance Commissioners to develop new standards and rules for Medigap plans.
Section 3301 – 3315: Amendments and improvements to provisions within the Social Security Act that regard Medicare Part D
The ACA amended, added, deleted or otherwise changed or improved specific language within the following sections of the Social Security Act’s provisions on Medicare Part D (Prescription Drug Coverage):
Within Section 1860D, which regards adding a paragraph that covers the conditions imposed on manufacturers who want Medicare Part D to cover their prescription drugs;
Within Section 1860D, the Secretary shall create a Medicare coverage gap discount program for Part D recipients to help lower costs;
Within Section 1860D, language is amended to clarify this section on Part D low income benchmarks to determine premiums;
Within Section 1860D, the language is amended to allow for the waiver of nominal premiums assigned to individuals that are eligible for financial subsidies;
Within Section 1860D, language regarding special rules for widows and widowers receiving low-income assistance is added;
Within Section 1860D, the section regarding access to information on subsidy eligibility and providing, funding outreach and assistance programs on part D plans and limiting access to subsidies to higher income participants is amended and improved;
Within Section 1860D, the formula to categorize classes of prescription drugs will be improved;
Within Section 1860D, the language is amended to add a section on how to reduce wasteful dispensing of prescription drugs to long-term care facility patients;
Within Section 1860D, the language regarding the section on costs incurred by AIDS drug assistance programs and Indian Health services is amended as well;
This section also adds a system whereby people can report complaints against their prescription drug plan and amends within Section 1860D the exception and appeals process for participants.
This section also tasks the Office of the Inspector General to conduct studies and issue reports the prices of drugs and of the formulas used by Part D plans to include a drug in the plan
Section 3401 – 3403: Ensuring Medicare Sustainability
This section updates the requirements for the years 2012 and beyond, decreases the payments received from the Medicare program, increases the required rate level of productivity and decreases the rate of discharges allowed in a fiscal year for patients who were admitted for an inpatient stay, skilled nursing facilities, long-term care hospital, inpatient rehab facility, home health agencies, psychiatric hospitals, hospice care, dialysis facilities, outpatient hospitals and a few others. This is designed to lessen the incentive to discharge a patient before they are ready and promote better healthcare for the patient while admitted into the hospital facility.
This section also applies the temporary adjustments of Part B premiums based on a person’s income for the year 2010 to the years 2011-2019. This ensures that this income-based relief carries on for many years.
This section also creases an “Independent Medicare Advisory Board” that is designed to monitor the growth of the Medicare recipient pool, project future population and make recommendations and proposals to decrease costs, reduce fraud and carry out the other obligations made by the ACA on the Medicare program. This section also outlines how the Board’s proposals will be reviewed and implemented if approved and also the appeal process if denied. Each Board Member will have a 6 year term and can be reappointed for another term.
Section 3501 – 3511: Healthcare Quality Improvements
This section mandates that a “best practices” guide be created, which will be utilized by healthcare professionals to improve the quality, safety and value of healthcare to Americans.
This section also requires that the Center for Quality Improvement and Patient Safety, which is under the Agency for Healthcare Research and Quality carry out research projects and conduct or support activities that promote the “best practices” and redesign and reform the healthcare system. The Center should also identify healthcare professionals that are carrying out the “best practices” and are providing high quality care to Americans.
This section also mandates that the Center will conduct research to determine whether the healthcare delivery system and its tools can be improved and further developed to improve the quality, safety and efficiency of those healthcare delivery services. Some of these tool improvements can be provided in the form of technical support and innovations or grants and contracts to third-party entities to carry out those improvements on the Center’s behalf.
This section also requires HHS to create Community Health Teams, which is categorized as an interdisciplinary and interprofessional team that will receive grants and contracts to support primary care practices and providers. These Health Teams must either be state or state-designated entities or Indian tribe or tribal organizations.
HHS will also create a program that provides grants and contracts to entities to implement medication management to licensed pharmacists and other professionals to help treat chronic disease. This is designed to improve the quality of care and reduce the costs of treatment.
This section also requires grants to be awarded to entities that can manage projects that will reform emergency care and trauma systems in healthcare. The purpose of these reforms is to ensure that patients are taken to and treated by a medically appropriate facility and to ensure that hospital resources are being properly tracked and are not overextended.
HHS will also create a program that is administered by several government agencies to conduct research to improve the basic science of emergency medicine, the model of service and delivery, transitioning research conclusions into practice and the general improvement of emergency services and medicine.
Another program that is established by this section will issue grants to qualified public or Indian tribal nonprofits or trauma centers that are designed to offset uncompensated care costs and to fund trauma services so that they can continue to function. This section also permits grants to go directly to states that will then provide to trauma centers to improve or maintain their services.
This section also recommends the creation of a program that will promote a collaborative decision-making process between patients, their families and caregivers or their authorized representatives and their doctors in order to determine a course of treatment, other treatment options. This collaborative effort will take into account the patient and family’s beliefs and preferences. This process should eliminate duplicated efforts and will streamline the process of establishing the care plan. This section also provides for grants to facilities to carry out this shared decision-making program if needed.
This section also wants HHS to determine whether adding a summary regarding the risks and benefits of a particular prescription drug to the label or the advertising of the drug would be beneficial to physicians, patients and consumers.
HHS may also issue grants to schools to carry out an education program to teach healthcare-related students how to improve the quality and safety of healthcare services.
HHS also wants an office on women’s health to be created that would focus solely on healthcare concerns of women and would create programs, provide grants, conduct studies and implement steps to improve healthcare and healthcare services given to women.
Section 3601: Nothing in the ACA shall be construed as a reduction of the mandatory benefits given to Americans under the Social Security Act regarding the Medicare program.
TITLE IV: PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH
Section 4001 – 4004: Modernizing Disease Prevention and the Public Health Systems
President Obama will establish under HHS, a counsel called the “National Prevention, Health Promotion and Public Health Counsel”, which shall be made up of the Surgeon General and several Secretaries, Directors and Administrators of other government agencies. The Counsel will promote and lead the country in prevention, wellness and better health practices, provide recommendations to the President and Congress concerning important health issues and appropriate federal legislation or policy to combat those issues.
The President will also appoint no more than 25 non-Federal, healthcare professionals and practitioners with expertise in a variety of different healthcare-related fields including community services, preventative medicine, health coaching and education, rehab medicine and work site healthcare, to be a part of an Advisory Group that will report to the Surgeon General and will function under HHS. This Advisory Group will review the healthcare system and make recommendations for public programs and strategies that would improve healthcare in the U.S.
This section also creates a Prevention and Public Health Fund under HHS, which is designed to invest in prevention and public health programs and to limit the increased costs of healthcare in the public and private sector. This section also outlines the amount of money dedicated to this fund, per year, from the Treasury’s budget.
This section also establishes independent Prevention Services Task Forces to review the cost and overall effectiveness of clinical and community preventative services and how those services can be improved.
Finally, this section creates a campaign to educate and conduct outreach to the public to stress the importance of taking preventative measures, promote wellness and mitigate chronic disease.
Section 4101 – 4108: Increasing the access that people can have to clinical preventive services.
HHS will promote and provide grants to entities that will establish school-based health centers to help children and adolescents that don’t have easy access to medical care. These school-based health centers shall provides services such as:
Medical services related to the diagnosis, referrals, treatment and follow-up of different types of medical conditions including chronic conditions, specialty care and oral healthcare; and
Mental health and substance use disorder counseling, assessment and treatment, including inpatient and outpatient programs and community support programs.
HHS is also requesting it coordinate with the CDC and national, professional oral health organizations to establish a 5-year, national public education campaign and program to promote oral healthcare prevention and education for children and adults. The campaigns should be targeted towards certain audiences (children, parents, elderly, racial minority populations, etc.) and should also incorporate science-based strategies such as community water fluoridation. This campaign was to take effect in 2012.
This section also requests that other oral healthcare programs be improved or altered according to the law.
This section also requests implementation of prevention and wellness services for Medicare recipients. This The Medicare program must now include in its coverage prevention services and annual wellness visits, which will include:
- Health risk assessments
- Taking routine measurements such as blood pressure, height, weight, body mass index, etc.
- Detecting cognitive impairments
- Screening of medical history, identification of possible risks and conditions and preventative physical examinations to determine whether risk factors are present
- Preventative counseling and personalized health advice
The Secretary of HHS must also create guidelines for health risk assessments of chronic diseases, injury risks, urgent health needs, which can be administered to individuals through web-based or telephonic means, through an in-person encounter with a doctor or through community-based programs. The guidelines must be created and implemented by 2011.
These programs will be managed and funded by Medicare Part B. This section also amends the section within the Social Security Act that regards an initial preventive physical examination to be permitted during the twelve-month period after the person’s Part B coverage begins.
There will be no coinsurance or other type of payment required from a patient for a preventive and wellness service as described in this section. These preventive and wellness services will be a deemed an Outpatient Department Service and the Medicare program will reimburse healthcare providers for the service but request no payment from the patient.
Any preventive service that is rated A or B will be 100% covered by Medicare. This also means that the annual deductible will not have to be paid before these claims can be covered. Preventive services such as screening and other services, initial preventive physical examinations and personalized prevention plan services are all rated A or B and will be covered entirely by Medicare.
These preventive, diagnostic, screening and rehabilitative services, including vaccines, are also covered entirely by the Medicaid program for adults.
This section also requests the inclusion of counseling, diagnostic and therapy services to help pregnant women stop using tobacco products. There will be no payment due for these services.
This section also requires the Secretary of HHS to award grants to States that carry out initiatives that incentivize and produce results from Medicaid recipients, who change their lifestyle to reduce health risks and outcomes and to prevent chronic disease. This section also outlines the evaluation and assessment standards for these State initiated programs.
Section 4201 – 4207: Programs and services that will create a healthier community of people
HHS will give out grants to State and local government agencies and community organizations that create and implement community-based programs that promote preventive health activities and actions to reduce chronic disease rates. These types of programs could be:
- Creating better and healthier school environments by improving food choices, physical activity and wellness programs and education
- Creating better access to nutritious food options.
- Creating programs and committees to support active living and health food intake
- Creating programs that would improve public safety, discourage smoking tobacco products, increase access to nutritional foods and promote physical activity.
- Improving work site wellness programs
- Encouraging health nutritional options at restaurants
- Addressing the wellness needs of different age groups, racial and ethnic groups, people with disabilities and people that live in both urban and rural areas
HHS will also award grants to State or local health departments that will implement a 5-year program that provides health interventions (such as improving nutrition, stop substance and tobacco use, improve mental health and promote a healthy lifestyle), screenings and clinical referrals to people who are between the ages of 55 and 64 in order to promote wellness.
This section also creates standards for the use of diagnostic equipment such as examination tables and chairs, weight scales, mammography equipment, x-ray machines and other radiological equipment, in a physician’s office, so that the equipment is accessible and usably by all individuals, despite their needs or restrictions.
This section also allows the Secretary of HHS to enter into contracts with the manufacturers of vaccines to purchase in bulk for adults. This section allows the States to purchase these vaccines direct from the manufacturer to provide to adults as well. The Secretary of HHS may issue grants to States that implement programs that promote vaccination and immunization of children, adolescents and adults. The grant money would be used to provide reminders to people to get vaccinated, to provide education, to reduce the out-of-pocket costs of these immunizations and vaccinations to families.
This section also provides a standard for nutritional labeling on menu items at chain restaurants. Any chain restaurant with 20 or more locations must provide the nutritional information for any item that is regularly on their item. The nutritional information must include: nutrition contents, calorie count, and a statement of suggested daily caloric intake.
This nutritional information must be placed close to the either the name of the food item if on a menu or near the physical location of the food if on a buffet or cafeteria bar so that the information is easily associated with the item.
If a company with 20 or more vending machines sells a food item through a vending machine, the calorie count must be placed on a sign that is near the food item.
This section also allows the Secretary of HHS to establish a program that would test the successfulness of sending an individualized wellness program to a person who utilizes a community health center and is part of an at-risk population of people. The individualized wellness program is designed to identify risk factors (such as weight, tobacco and alcohol use, blood pressure, etc.) for preventable conditions and help the person take action, such as through nutritional counsel, physical activity plans and stress management and dietary supplements.
This section also requires employers to provide a reasonable break time for an employee to pump breast milk for her nursing baby, for up to 1 year after childbirth. The employer must also provide a place that is not a bathroom for the employee to do this.
Section 4301 – 4306: Support for Prevention and Public Health Innovations
This section advises that HHS and the CDC will provide money to fund research projects regarding public health services and systems.
This section also mandates that any program that is funded by this section report data such as race, sex, language, etc. of the applicants, recipients and participants of the programs.
The Secretary of HHS must also coordinate a process to manage all of the data collected in order to analyze to detect and monitor trends in health and must make those reports accessible to different government agencies. The Secretary is also supposed to submit a report to Congress regarding recommendations for improving healthcare disparities among different groups of Americans.
The ACA will also revise the Employer-Based Wellness Program to include assistance from a government agency to employers to provide programs that promotion prevention and better health to employees. This assistance may include tools to measure participation by employees, suggestions to increase participation, assess changes that can be made to improve the programs and evaluating how certain programs affect employee productivity, workplace injury, overall medical costs, etc. This assistance will also include training for employers to evaluate their programs on their own.
This section also requires a national study and survey to be conducted of work site health policies and programs enacted by employers to promote healthy lifestyles for their employees. The study should result in a report that is submitted to Congress, which will recommend certain programs and policies that were successful and should be implemented on a larger level. These programs and policies are cannot be turned into requirements imposed on employers.
A provision of the Public Health Service Act is amended to include a provision allowing the Secretary of HHS and the Director of CDC to create a grant program that is designed to improve surveillance and response to infectious diseases and other conditions that are of great public importance. The grants would be used to strengthen the science, enhance lab practices, improve the exchange of information and strengthen national guidelines.
This section also requests that the Secretary of HHS coordinate with the Institute of Medicine (if they want to participate) to hold a conference on pain and pain care management to increase recognition of the problem and to evaluate the diagnosis, treatment and management of pain on certain groups of people of different ethnicity, ages, sex, races, etc.
The Public Health Service Act is also amended to include a provision requesting the Director of the National Institute of Health to come up with recommendations on pain research programs. Additionally, the Secretary of HHS will create a committee people to coordinate efforts with the government that relate to pain research.
The Secretary of HHS may also issues grants and contracts to health professional schools, hospices and private or public groups that carry out programs to educate and train healthcare professionals in pain care and management.
Finally, this section provides additional funding to Social Security Act’s provision on the childhood obesity project.
Section 4401 – 4402: Miscellaneous
Congress must work with the Congressional Budget Office to develop better ways to evaluate and score the progress of different prevention and wellness programs. The Secretary of HHS will conduct evaluations of these programs in relation to employee statistics such as their overall health, absenteeism, medical costs, productivity, fitness level, etc. to determine the success of these employer-based wellness initiatives.
TITLE V: HEALTHCARE WORKFORCE
Section 5001 – 5002: Purpose and Definitions of this Section
The purpose of this section of the law is to gather and assess data to determine and instruct the healthcare workforce ways to improve access to healthcare for all individuals, but particularly for lower income, the uninsured and minority people.
Section 5101- 5103: Improvements to the Healthcare Workforce
The law will create a 15-meber National Healthcare Workforce Commission that will provide information to the state and federal governments and the President. This Commission will work with government agencies to develop and evaluate education and training programs and to determine whether there is enough healthcare workforce (i.e. doctors, nurses, pharmacists, dentists, chiropractor, psychologists, etc.). The Commission should be made up of people who are actually in the healthcare workforce or are parts of groups of people who are affected by the healthcare workforce such as representatives of consumers, labor unions, employers, or education.
The Commission should also monitor the number of students coming up in the healthcare workforce and their educating and training levels, review the education loans and grants available to students and the effect of federal policies that related to healthcare on the healthcare workforce.
The overall purpose of the Commission is to ensure that the healthcare workforce is receiving the education and training that they require, that there are qualified people training to fill positions and that there are enough people working in the healthcare workforce to meet the needs of the people.
The Commission shall also review and provide reports on the State Healthcare Workforce Grant program and recommend people or groups to receive the grants. Grant recipients should partner with the states to create and carry out plans to develop and improve state and local healthcare workforces. This partnership would also analyze the healthcare labor market and ability for students to enter a career in healthcare, identify areas of healthcare where more people are needed and direct students in that direction, improve recruitment, education, training and retention of healthcare workers and identify barriers that people may face in entering the healthcare workforce and find ways to resolve them.
The Secretary of HHS will create a National Center for Health Workforce Analysis that will analyze healthcare workforce and other types of workforce issues. Any information or data that it creates from analyzing the workforces should be shared with other agencies. This group can also issue grants and enter into contracts with other entities in order to collect and analyze more data and information.
Section 5201 – 5210: Increasing the Supply of the Healthcare Workers
This section amends the statute regarding medical school loans and states that if a student takes a loan from the fund (a particular type of student loan dictated by 42.U.S. Code § and the student does not finish school in the time limit prescribed and practice in that field for at least 10 years or at least until the loan is paid off, an additional interest payment will be applied to the loan. This section also states that a student should be reviewed for this type of loan without inclusion of their parent’s financial information.
This section also amends and increases the loan amounts that schools may give to nursing students.
This section also adds a loan program for pediatric specialty. The loan program says that individuals who agree to work full-time in the field for not less than 2 years are eligible for the student loan. This is a way to increase the number of people going into this field of medicine.
The Public Health Service Act is amended to create a loan repayment program to help people afford the training and schooling necessary to join the healthcare workforce. This is designed to help eliminate position shortages in the field as well. People who are presently receiving schooling in the field or have in the past ten years and are employed with a health agency or are in their fellowship and are a U.S. citizen can apply to join this repayment program. No applicant may have already received a loan reduction under some other statute. Any applicant must also promise to work in the field for a federal, state or tribal health agency or in a fellowship program for a particular period of time (minimally three-years). If the applicant is approved, a portion of their loans will be repaid on their behalf.
The Public Health Service Act also amends some of the language in the recruitment and retention program and the grants for state and local programs. In addition the Act also adds the ability for the Secretary of HHS to issue grants and enter into contracts with entities to issue scholarships to people entering degree or professional training programs. This section also provides the amount of money that shall be allotted for these grants per year.
This section also creates grants for health clinics that are managed by nurses and commissions the need for Ready Reserve Corps to help Commissioned Corps that may need help dealing with issues of routine or emergency public health response missions. This section also eliminates the cap on people who can part of the Commissioned Corps.
Section 5301 – 5315: Improving Healthcare Workforce Education and Training Opportunities
The Secretary of HHS can issue grants or enter into contracts with public or private hospitals, school of medicines or training programs in order to provide financial assistance to train or create more fellowships for students or professionals in the field, to develop and operate training or intern/residency programs and other types of programs that not only help teach but help find people to teach and train students and professionals.
The Public Health Service Act is also amended to add a section regarding training opportunities for direct care workers. The Secretary can issue grants to institutions that provide higher education and the grants must go towards providing new training opportunities to direct care workers that employed in long-term care programs like nursing homes or assisted living facilities
The Public Health Service Act is also amended to add a section on grants issued to schools of dentistry, public or private hospitals or other entities in order to create programs that will develop and promote training in general, pediatric and public health dentistry. The grants should also provide financial assistance to dental students and residents still in training.
This section also creates an alternative dental healthcare providers demonstration project, which allows the Secretary of HHS to issue grants to 15 eligible entities that will create a program to train and employ dental healthcare providers. This will increase the access that people will have to dental services in the community.
This section also creates a grant award for entities that operation geriatric education centers. The grants must be used to carry out short-term intensive courses on geriatrics, chronic care management, long-term care and other related medical issues.
This section will also allow grants to higher education institutions to support recruitment of students, education and clinical training in social work, psychology and mental health psychiatry. Part of these grants are designed for school that may traditionally get less funding because they are historically black colleges or universities or serve some other minority group.
This section also amends the language of the 42. U.S. Code § 293e, which relates to grants for health professions education and amends the language of 42 U.S. Code 296j, which relates to advanced nursing education grants.
This section also amends 42 U.S. Code 296p, which relates to nurse education, practice and quality grants. In particular, this section allows the Secretary to issue grants to entities to increase and improve their nursing workforce by creating retention programs. These programs would include career advancement, internships and residency programs, and providing additional education and training to nursing professionals. A grant could also be issued to an entity in order to improve nurse retention and patient care, which can be done by improving the relationships between nurses and other healthcare providers and creating a sense of community.
This section also amends certain language in the loan repayment and scholarships section and the nurse faculty loan program section of the Public Health Service Act. This section also amends the language of the Public Health Service Act to include the Eligible Individual Student Loan Repayment program, which provides better repayment of education loans to people who work full-time as faculty in an accredited school of nursing. This is designed to increase the number of qualified teachers in nursing schools.
This section also provides grants to entities that enlist community health workers to promote positive health behaviors and outcomes to people who live in communities that don’t have access to a lot of medical care.
This section also amends the Public Health Service Act that relates to Fellowship Training and allows the Secretary to carry out activities that deal with the shortages in the healthcare workforce related to lab science and epidemiology. Expanding the number of healthcare workers in these fields will promote medical advancement.
Finally, this section establishes the U.S. Public Health Sciences Track, which is a program that can grant advanced degrees to a certain number of medical students each year that will provide team-based service in the fields of public health, epidemiology and emergency preparedness and response.
Section 5401 – 5405: Efforts to Support the Existing Healthcare Workforce
This section amends the section of the Public Health Service Act related to allocation of funding for grants that are provided to health profession schools and other health or educational entities that provide health profession education to under-represented minority people.
This section also amends the Public Health Service Act and increases the amount of student loan debt that the federal government will pay for people who take a faculty position of health professional schools.
This section also provides awards to entities so that they can create or can continue to carry out healthcare workforce education programs (the Infrastructure Development Award) and to entities to maintain and improve the effectiveness of or to modify in order to improve their existing health education center programs.
This section also allows the Secretary to issue grants and enter into contracts with entities in order to improve healthcare increase the presence of minority faculty members in health profession schools and to improve the schooling environment and support offered to the schools.
This section also amends language in the section regarding Workforce Diversity Grants and the Primary Care Extension Program. The Primary Care Extension Program is amended to include the purpose of the program, which is to support and assist primary care providers through education on preventative medicine, chronic disease management, mental and behavior health services and different therapies. The Secretary can also provide grants to states that create these programs.
Update: More will be added to this soon so please check back for more information!