T h e A f f o r... www.wvahc.org This publication was funded through a generous grant from the...

T h e A f f o r d a b l e C a r e A ct
www.wvahc.org
This publication was funded through a generous grant from the Claude Worthington Benedum Foundation
Goals of the Affordable Care Act
The Affordable Care Act (ACA) aims to ensure quality health care for all Americans
at a price they can afford. The new law is being phased in over several years.
The earliest provisions are already benefitting millions of Americans, especially
children, young adults, people with expensive illnesses, and seniors. By early 2014,
the major features of the ACA will be in place, with four overarching goals:
EmployerSponsored
Plans
Affordable
Individual
Plans
Medicare
Medicaid
and CHIP
1. Expand coverage. The ACA extends health coverage
to virtually all Americans. People who participate in
health plans through their employers will continue
to do so. Medicare will be enhanced, and Medicaid
will be expanded to more adults in states that take
advantage of new federal options and decide to fully
implement the law. New “health insurance exchanges”
will offer competitively-priced plans to individuals not
covered by employer or government-sponsored plans
and to small businesses. Significant tax credits will
be available to individuals and small businesses that
qualify to help make health coverage more affordable.
Ten essential benefits must be covered by all plans
offered through the health insurance exchanges
including: patient office visits; inpatient and
outpatient hospital services; maternity and newborn
care; mental health and substance use disorder
services, including behavioral health treatment;
prescription drugs; laboratory services; preventive and
wellness services; chronic disease management; and
pediatric services, including oral and vision care.
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West Virginians for Affordable Health Care
2. Reform insurance industry rules. New ACA rules
now require insurance companies to sell policies
that fully cover children with pre-existing conditions,
and this protection will be extended to adults in
2014. Other major changes include allowing young
adults to stay on their parents’ insurance policy until
age 26; prohibiting lifetime limits on benefits; and
limiting the percentage of money that an insurance
company can spend on administrative costs. Starting
September 23, 2012, insurance policies must be
written in plain language. And starting in 2014, the
ACA will prohibit new insurance plans from charging
women higher premiums than men for the exact
same policy.
3. Strengthen prevention. The ACA increases the
emphasis on keeping people well. Medicare and new
insurance policies must now cover more preventive
measures, and states have the option to extend these
preventive measures to their Medicaid programs with
additional federal funding to do so. These preventive
services are provided with no deductible, copayment
or coinsurance, and are based on what is clinically
appropriate for the patient.
4. Contain costs. Our current approach to health
care is fragmented and inefficient, and reimburses
medical providers for the quantity, versus quality, of
services they provide. The ACA begins to address these
problems by paying providers based on quality and
ensuring that patient care is coordinated.
West Virginians for Affordable Health Care
1544 Lee Street
Charleston, WV 25311
(304) 344-1673
www.wvahc.org
The Affordable Care Act:
What Health Reform Means for
Women and Families
The Affordable Care Act (ACA) takes historic steps to elevate the importance of
women’s health and health care. The new law improves coverage of essential
services for women, eliminates gender discrimination in the insurance industry,
and ensures access to affordable health plans, regardless of employment.
This report describes the provisions of the ACA in three
areas of particular concern to women:
I.
Preventive health care, including the expansion
of coverage for both general and gender-specific
services for adults, as well as preventive services for
children with no deductibles or co-payments.
II. Reproductive health care, including the
expansion of maternity coverage, improved
access to gynecologists and family planning, and
information on how the law applies to abortion.
III. Expanded coverage and equity improvements,
including expansion of Medicaid eligibility,
enhancements in Medicare coverage of preventive
services and prescription drugs, the end to
gender discrimination and pre-existing condition
limitations in health plans, and coverage of young
adults on their parents’ health plans. In addition,
the ACA strengthens offices that focus on women’s
health within the US Department of Health and
Human Services and other federal agencies.
The Affordable Care Act: What Health Reform Means for Women and Families
3
I. Preventive Health Care
The adage “an ounce of prevention is worth a pound of cure” is a centerpiece of
the ACA. The new law shifts the emphasis from a health system that responds
primarily to illness and injury to one that also focuses on keeping people healthy.
Women in particular will benefit from the preventive services that health plans are
required to cover under the ACA with no cost-sharing. These include evidencebased screenings, counseling, and procedures that over the course of a lifetime
may have a profound impact on the health of individuals and the nation as a whole.
2010 Preventive Measures
All new insurance policies issued after September 2010
must cover clinically appropriate preventive measures,
with no deductible, copayment or coinsurance.
Appendix A provides a complete list of the 2010
preventive measures that must be covered for
women, men and children at no additional cost.
Examples include:
• Women are covered for mammography every
one to two years after age 40; pap smears; and
osteoporosis screenings for women over 60,
depending on risk factors.
• Pregnant women are covered for expanded
counseling for tobacco and alcohol use; folic acid
supplements; and screenings for iron deficiency
and anemia.
• Both women and men are covered for cholesterol
screening, depending on health risk factors;
colorectal cancer screening for adults over 50;
1 This also applies to enrollees who have individual (non-employment based) policies.
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West Virginians for Affordable Health Care
depression screening; type two diabetes for
adults with high blood pressure; diet counseling
for adults at risk for chronic disease; flu
vaccination and other immunizations; and
obesity screening and counseling.
Patients should use an in-network provider to avoid
additional charges, and may have to pay for an office
visit if the preventive measure is not the primary
purpose of the health care visit.
Not all insurance plans are required to cover these
preventive measures. “Grandfathered” plans are
exempt. Grandfathered plans are plans that were in
existence on March 23, 2010, when the ACA was signed
into law, and have not made significant changes to
the costs paid by employees1 or the services covered.
The Public Employees Insurance Agency (PEIA), for
example, has increased costs to employees over the
last several years, and has lost its grandfathered status.
See Appendix B for a detailed explanation on changes
that insurance plans can make and what impact these
changes will have on their grandfathered status.
Estimates vary on how many policies will retain
their grandfathered status. Some reports project that
66 percent of small employers and 45 percent of large
employers would lose their grandfathered status by
2014. Others are projecting that 80 percent of employers
will have at least one insurance plan option that will
no longer be grandfathered by 2014. Over time, fewer
insurance plans will be grandfathered, and once they
lose their grandfathered status, they will be required to
cover preventive services with no cost sharing.
Some insurance companies have voluntarily added
these preventive measures as a covered benefit.
Highmark Blue Cross Blue Shield of West Virginia has
added these preventive measures with no deductible or
copayment to the covered services that they provide to
their fully insured customers. So, regardless of whether
a plan is grandfathered or not, these preventive
measures will be covered by those companies that
are fully insured by Blue Cross Blue Shield. Other
insurance companies may have added these preventive
measures. You should consultant your plan manager
administrator to see if these are covered services.
Under the ACA, more than 250,000 West Virginia women will
gain access to all FDA approved contraceptive measures with
no deductible or copayments. Removing the financial barrier to
contraceptives will allow more women to space their pregnancies
and avoid unwanted pregnancies.
2012 Preventive Measures
In August 2011, the US Department of Health and
Human Services (HSS) adopted eight additional
preventive measures for women that were
recommended by the Institute of Medicine. These
services must be provided with no deductible,
copayment or coinsurance when a new plan year
begins after August 1, 2012.2
Appendix A provides a complete list of these
2012 additional preventive services for women.
Examples include:
• Well-woman visits to obtain recommended
preventive services for women under age 65;
• Comprehensive breastfeeding support and
counseling from trained providers, as well
as breastfeeding supplies for pregnant and
nursing women;
• Domestic violence screening and counseling
for all women; and
• All Food and Drug Administration-approved
contraceptive methods, sterilization procedures,
and patient education and counseling.
2 For most women a new plan year will begin January 1, 2013. For women covered by PEIA, it will begin July 1, 2013.
The Affordable Care Act: What Health Reform Means for Women and Families
5
As with the 2010 preventive measures, grandfathered
insurance plans are exempt from providing these
additional preventive measures.
Preventive Health Care for Children
Women with children also will be interested in
the numerous preventive measures for infants,
children and adolescents that now must be covered
by new insurance policies without any deductible
or copayment.
Under the ACA, Bright Future Guidelines will provide children
with the gold standard for preventive care.
Abortifacient (abortion-inducing) drugs are not
contraceptives, and therefore are excluded from
coverage.
HHS exempted churches and other houses of worship
that objected on religious grounds from paying for
or providing contraceptives. HHS did not exempt
affiliated church organizations such as Catholic
hospitals or religious social service agencies. However,
HHS is considering alternative methods of financing
of contraceptives for these organizations. Alternatives
being considered include having contraceptives be
provided directly by the organization’s insurance
company, through a rebate from a pharmaceutical
company, or through an arrangement with a drug
company doing business with the Federal Employee
Health Benefits program.
A decade of work by government agencies,
professional organizations and experts in infant,
child and adolescent health has created the Bright
Futures Guidelines as the “gold standard” for
preventive services for children and youth. The ACA
incorporates the guidelines of Bright Futures in its
preventive services for children and youth.
Appendix A provides a complete list of preventive
measures that must be covered for children at no
additional cost. Examples include periodic well baby
and well child visits; vision and hearing screening;
assessment of developmental and behavioral progress;
physical examination; and oral health screening.
Additionally, childhood immunizations must be
covered by all new insurance policies without a
deductible or copayment. These immunizations
include hepatitis B, diphtheria, tetanus and pertussis,
measles, mumps and rubella, and annual flu shots
for children over six months of age.3
3 As note above, patients should use an in-network provider to avoid additional charges; may be charged for an office visit if the preventive measure is
not the primary purpose of the health care visit; and grandfathered plans are exempt from the requirement that they provide these preventive measures
without a deductible or copayment.
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West Virginians for Affordable Health Care
With the adoption of the ACA virtually all insurance policies will cover maternity care in the future
II. Reproductive Health Care
Maternity Coverage
The ACA requires ten “essential health benefits” be
covered by all health insurance plans sold through the
health insurance exchanges and all new individual and
small group policies sold outside the health insurance
exchanges beginning on January 1, 2014. One of the
required essential health benefits is maternity and
newborn services. Additional provisions in the ACA that
will benefit women during and after pregnancy include:
• Pregnancy-tailored counseling from a doctor that
will help pregnant women quit smoking and avoid
alcohol use;
• Requiring Medicare to pay nurse midwives
the same reimbursement that physicians receive.
Although Medicare pays for very few deliveries, its
payment structure is often adopted by Medicaid
and private insurance companies;
• Requiring large employers (50 or more employees)
to provide new mothers a private place and break
time to express breast milk for one year after the
birth of a child;
• Increased education and support to women with
postpartum depression and increased funding to
research the cause and treatment for postpartum
depression; and
The ACA has provided more than $4 million to support maternal,
infant and early childhood home visitation programs in West Virginia
• Grants for maternal, infant and early childhood
home visiting programs for at risk families. West
Virginia already has received $4.2 million in grant
monies for these programs.
Grandfathered plans are not required to provide
essential health benefits, including maternity and
newborn care. However, the Pregnancy Discrimination
Act requires all employers with 15 or more employees
to cover pregnancy-related conditions on par with
other medical conditions. This means that after January
2014, virtually all health insurance policies will cover
maternity and newborn care.
The Affordable Care Act: What Health Reform Means for Women and Families
7
Abortion
The ACA reinforces current federal laws on coverage of
abortion services, including limiting the use of federal
funds to cases of rape, incest or to protect the life of the
pregnant woman (known as the Hyde limitations). The
ACA does not pre-empt state law regarding abortion.
States may include policies in their state health
insurance exchanges that cover abortions beyond the
Hyde limitations, and must include at least one policy
that does not.
Under the ACA, West Virginia has received more than $1 million in
grants to reduce teen pregnancies and sexually transmitted diseases.
Access to Gynecologists
The ACA prohibits new insurance plans from requiring
a woman to obtain approval from her primary care
provider in order to see a gynecologist. Additionally, the
ACA allows a woman to select her own gynecologist. In
the past, some HMOs automatically assigned women
to gynecologists and primary care providers, and their
children to pediatricians. Women will now be able to
select their gynecologists, primary care providers and
their children’s pediatricians. The health providers must
be in the insurance company’s network and accepting
new patients. Grandfathered plans are exempt from
this requirement.
Family Planning
New insurance plans that renew after August 2012 must
cover all FDA-approved contraceptives with no cost
sharing. The ACA also includes two grants for programs
to reduce teen pregnancies. The State Personal
Responsibility Education Program (PREP) funds
evidence-based sex education to reduce the rate of
teen pregnancies and sexually transmitted infections.
The Abstinence Education Grant program funds
“abstinence only until marriage” programs. During
2010 and 2011, West Virginia organizations received
$550,000 in PREP grants and $600,000 in Abstinence
Education Grants.
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West Virginians for Affordable Health Care
Plans sold through health insurance exchanges that
offer abortion coverage above the Hyde limitations
(medically necessary abortions, for example) cannot
use federal tax credits for these abortion services.
Insurance companies that provide access to abortion
beyond the Hyde limitations will have to separate funds
received from federal tax credits from private premium
payments to comply with this requirement.
Insurance companies may not discriminate against
any provider or health care facility based on their
willingness or unwillingness to perform or provide
referrals for abortions. Also, the Pre-Existing Conditions
Insurance Plans, which guarantee access to a high riskpool for people with pre-existing conditions, cannot
cover abortion services beyond the Hyde limitations.
Abortion Coverage in the
Health Insurance Exchanges
Guaranteed
Optional
Restricted
At least one
plan does
not include
coverage of
abortion
beyond
the Hyde
limitations.
A plan(s)
that includes
abortion
coverage
beyond
the Hyde
limitations.
Use of
federal funds
(i.e. subsidies)
for abortion
coverage
beyond
the Hyde
limitations.
An estimated 63,000 uninsured West Virginia women will receive health coverage if the state fully implements the ACA’s
option to expand Medicaid.
III.Expanded Coverage
and Equity Improvements
Medicaid Expansion
Since women earn less than men on average, the
expansion of Medicaid eligibility in 2014 will principally
benefit women. Currently, the state’s Medicaid program
only covers parents who earn less than 35 percent of
the federal poverty level, about $6,700 for a family of
three. Childless adults in West Virginia do not qualify
regardless of income. In 2014, the ACA will cover all
individuals and families who earn less than 138 percent
of the federal poverty level or about $26,300 for a
family of three if West Virginia takes advantage of new
federal options and decides to fully implement the new
law. Of the estimated 115,000 uninsured women in
West Virginia, 55 percent – about 63,000 women – will
become eligible for Medicaid, according to the Kaiser
Family Foundation.
More than 236,000 West Virginia Medicare members received free
preventive services under the ACA in 2011.
mammograms, pap smears and colorectal cancer
screens due to the ACA.
Changes in Medicare
More than half (56 percent) of all Medicare members
are women. There are two important improvements in
Medicare as a result of the ACA.
• In addition to having access to all clinically
appropriate preventive measures, Medicare
members are also eligible for an annual wellness
benefit. The additional preventive measures
and wellness visit are being provided without a
deductible or copayment. In 2011, more than
236,000 West Virginians with Medicare coverage
received free preventive services such as
• Medicare members have an improved prescription
drug benefit to reduce the gap in prescription
drug coverage referred to as the “doughnut hole.”
In 2012, Medicare members in the doughnut hole
are receiving a 50 percent discount on brand name
drugs and a 14 percent discount on generic drugs.
During the first two years of the ACA, West Virginia
Medicare members have received more than
$45 million in assistance when they were in the
doughnut hole. The ACA closes the doughnut hole
entirely by 2020.
The Affordable Care Act: What Health Reform Means for Women and Families
9
End to Discrimination Based
on Pre-existing Conditions
New health insurance policies cannot deny a child a
policy because the child has a pre-existing condition or
issue a policy that excludes coverage of the pre-existing
condition. This provision currently applies to children
up to their 19th birthday. Beginning on January 1, 2014,
this provision is extended to adults.
Until 2014, young adults who have employer-sponsored
health insurance available to them are not eligible
for their parent’s policy. After 2014, they can choose
between the employer-sponsored insurance and their
parents’ policy. Young adults who are married and/or
have dependent children are eligible for their parent’s
policy, but their dependent children are not.
End of Gender Discrimination
In the individual market, insurance companies can
continue to charge children a higher premium for a
pre-existing condition. However, in group plans, which
is where most West Virginians receive health insurance
coverage, individuals with pre-existing conditions
cannot be charged a higher premium, although
employers with higher than average claims can be
charged higher premiums. This additional cost cannot
be passed on to individuals who have a pre-existing
condition or higher than average claims.
All plans sold in the health insurance exchanges will be
new plans and will be prohibited from discriminating
against both people with pre-existing conditions and
small businesses based on the health status of their
employees. This means that insurance companies can
no longer charge higher premiums to people with preexisting conditions or to small businesses with higherthan-average claims.
“Gender rating” is the insurance company’s practice
of charging women a higher premium than men for
the exact same policy. Currently, women often pay a
higher premium than men in the individual market.
However, in the group market, most employers (those
covered by Title VII of the Civil Rights Act of 1964)
cannot discriminate against women by charging them
a higher premium than similarly situated men. This
does not prevent insurance companies from charging a
higher premium to companies with a high percentage
of women such as child care centers, nonprofit
organizations, dentist offices, etc.
Gender rating is prohibited by the ACA in both the
individual market and the small group market for all
new plans effective January 1, 2014. All plans sold in
the health insurance exchanges beginning on January
1, 2014 will be new plans, and therefore, prohibited
from charging women higher premiums than men.
Grandfathered plans are exempt from the prohibition
on gender rating.
Additionally, the ACA prohibits discrimination in
health programs that receive federal dollars. For
example, insurance companies that participate in the
health insurance exchanges, where they will receive
federal subsidies for insuring moderate- and middleincome families, will be prohibited from discriminating
based on gender.
Federal Offices Will Focus
on Women’s Health
16,000 young adults in West Virginia were able to stay on their
parents’ policy in 2011, and that number is projected to increase.
Young Adult Coverage
Young adults can now stay on their parents’ health
insurance policy until their 26th birthday. The young adult
can be in school or out of school; married or unmarried;
living with his or her parents or living separately; listed
as a dependent on his or her parent’s IRS filing or filing a
separate tax return; and still qualify for coverage under his
or her parent’s health insurance policy.
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West Virginians for Affordable Health Care
The new law strengthens offices that will focus on
women’s health within US Department of Health and
Human Services, Food and Drug Administration,
Centers for Disease Control and Prevention, Health
Resources and Services Administration, and other
agencies. The purposes of these Offices of Women’s
Health are to provide information on women’s unique
health care needs and establish goals and priorities
for improvements in women’s health. Although
these Offices of Women’s Health are in the executive
branch of government, they cannot be eliminated or
reorganized without the approval of Congress.
APPENDIX A
Preventive Measures for Women,
Pregnant Women, Adults and Children
Women-Specific
Preventive Measures
Effective Date
for Most Women4 Preventive Measure
January 2011
Mammography every one to two years for women over 40
January 2011
Cervical cancer screening for sexually active women
January 2011
Osteoporosis screening for women over 60, depending on risk factors
January 2011
Chlamydia infection screening for younger women and others at higher risk
January 2011
Breast cancer (BRCA) counseling about genetic testing for women at higher risk
January 2011
Breast cancer chemoprevention counseling for women at higher risk
January 2011
Gonorrhea screening for all women at higher risk
January 2011
Syphilis screening for all pregnant women or other women at increased risk
January 2013
Well-woman visit to obtain recommended preventive services for women under 65
January 2013
Domestic violence screening and counseling for all women
January 2013
Human immunodeficiency virus (HIV) screening and counseling for sexually active women
January 2013
Human papillomavirus (HPV) DNA test: high risk HPV DNA testing every three years for women
with normal cytology results who are 30 or older
January 2013
Sexually transmitted infections (STI) counseling for sexually active women
January 2013
All Food and Drug Administration-approved contraceptive methods, sterilization procedures, and
patient education and counseling.
4 The benefits listed as having an effective date for most women of January 2011 technically went into effect when a new plan year began after September 23, 2010.
For most women that was January 1, 2011. The benefits listed as having an effective date of January 2013 will actually have an effective date when a new plan year
begins after August 1, 2012. For most women that will be January 1, 2013.
The Affordable Care Act: What Health Reform Means for Women and Families
11
Preventive
Measures for Pregnant Women
Effective Date
for Most Women Preventive Measure
January 2011
Anemia screening on a routine basis for pregnant women
January 2011
Hepatitis B screening for pregnant women at their first prenatal visit
January 2011
Folic Acid supplements for women who may become pregnant
January 2011
Bacteriuria urinary tract or other infection screening for pregnant women
January 2011
Rh (Rhesus) incompatibility screening for all pregnant women and follow-up testing for women at
higher risk
January 2011
Special, pregnancy-tailored counseling from a health care provider that will help pregnant women
quit smoking and avoid alcohol use
January 2013
Breastfeeding: comprehensive support and counseling from trained providers, as well as access to
breastfeeding supplies, for pregnant and nursing women
January 2013
Diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing
gestational diabetes
Preventive
Measures for Women and Men
12
Effective Date
for Most Adults
Preventive Measure
January 2011
Alcohol misuse screening and counseling
January 2011
Aspirin use for men and women of certain ages
January 2011
Blood pressure screening for all adults
January 2011
Cholesterol screening for adults of certain ages or at higher risk
January 2011
Colorectal cancer screening for adults over 50
January 2011
Depression screening for adults
January 2011
Type 2 Diabetes screening for adults with high blood pressure
January 2011
Diet counseling for adults at higher risk for chronic disease
January 2011
HIV screenings for all adults at higher risk
January 2011
Immunization vaccines for adults — doses, recommended ages, and recommended populations vary
• Hepatitis A
• Hepatitis B
• Influenza
• Measles, Mumps, Rubella
• Tetanus, Diphtheria, Pertussis
January 2011
Obesity screening and counseling for all adults
January 2011
Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
January 2011
Tobacco Use screening for all adults and cessation interventions for tobacco users
January 2011
Syphilis screening for all adults at higher risk
West Virginians for Affordable Health Care
• Herpes Zoster
• Meningococcal
• Varicella
• Human Papillomavirus (HPV)
• Pneumococcal
Preventive
Measures for Children and Adolescents5
Effective Date
for Most Children Preventive Measure
January 2011
Alcohol and drug use assessments for adolescents
January 2011
Autism screening for children at 18 and 24 months
January 2011
Behavioral assessments for children of all ages
January 2011
Blood pressure screening for children of all ages
January 2011
Cervical Dysplasia screening for sexually active females
January 2011
Congenital Hypothyroidism screening for newborns
January 2011
Depression screening for adolescents
January 2011
Developmental screening for children under age 3, and surveillance throughout childhood
January 2011
Dyslipidemia screening for children at higher risk of lipid disorders
January 2011
Fluoride Chemoprevention supplements for children without fluoride in their water source
January 2011
Gonorrhea preventive medication for the eyes of all newborns
January 2011
Hearing screening for all newborns
January 2011
Height, weight and body mass index measurements
January 2011
Hematocrit or Hemoglobin screening
January 2011
Hemoglobinopathies or sickle cell screening for newborns
January 2011
HIV screening for adolescents at higher risk
January 2011
Immunization vaccines for children from birth to age 18 -- doses, recommended ages, and
recommended populations vary
• Diphtheria, Tetanus, Pertussis
• Hepatitis A
• Hepatitis B
• Inactivated Poliovirus • Influenza
• Meningococcal
• Pneumococcal
January 2011
Iron supplements for children ages 6 to 12 months at risk for anemia
January 2011
Lead screening for children at risk of exposure
January 2011
Medical history for all children throughout development
January 2011
Obesity screening and counseling
January 2011
Oral health risk assessment for young children
January 2011
Phenylketonuria (PKU) screening for this genetic disorder in newborns
January 2011
Sexually transmitted infection (STI) prevention counseling for adolescents at higher risk
January 2011
Tuberculin testing for children at higher risk of tuberculosis
January 2011
Vision screening for all children
• Haemophilus influenzae type b
• Human Papillomavirus (HPV)
• Measles, Mumps, Rubella
• Rotavirus
• Varicella
5 A complete list of children’s preventive measures and when they should occur can be found at:
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf
The Affordable Care Act: What Health Reform Means for Women and Families
13
APPENDIX B
Explanation of “Grandfathered Plans”
Under the ACA
“New” insurance policies include all new policies and policies that are not
“grandfathered.” Grandfathered plans are plans that were in existence on
March 23, 2010, when the ACA was signed into law, and have not made
significant changes in the costs paid by employees or the services covered.
For example, the West Virginia Public Employees Insurance Agency (PEIA) was
in existence when the ACA became law, but because it has changed the costs
employees must pay by so much, it has lost its grandfathered status.
In order to maintain grandfathered status, plans may only make limited changes
in their health insurance policies that were in effect on March 23, 2010. Examples
of changes that will cause a health plan to lose its grandfathered status include:
• Significant Cut or Reduction in Benefits: For
example, if a plan decides to no longer cover care
for people with diabetes or HIV/AIDS.
• Increase in Co-Insurance Charges: Typically,
co-insurance requires a patient to pay a fixed
percentage of a charge (for example, 20% of a
hospital bill). In order to maintain its grandfathered
status, a plan cannot increase this percentage.
• Significant Increases in Copayments: In order to
maintain its grandfathered status, a plan cannot
increase copayments by more than the greater of
$5 (adjusted annually for medical inflation) or a
percentage equal to the medical rate of inflation
plus 15 percentage points. For example, if a plan
raises its copayment from $30 to $50 over the next
two years, it will lose its grandfathered status.
• Significant Increases in Deductibles: In order
to maintain its grandfathered status, a plan
can increase deductibles by no more than a
percentage equal to the medical rate of inflation
plus 15 percentage points.
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West Virginians for Affordable Health Care
• Significant Reduction in Employer Contributions:
Grandfathered group plans (job-based coverage),
cannot decrease the percent of premiums the
employer pays by more than 5 percentage points.
For example, if a group plan decreases the
employer’s share of premium costs from 80% to
70%, it would lose its grandfathered status.
• Significant Increases in Annual Limits on Benefits:
Some insurers cap the amount that they will
pay for covered services each year. To maintain
its grandfathered status, a health plan cannot
decrease any annual dollar limits that were in place
as of March 23, 2010. Grandfathered plans that do
not have an annual dollar limit cannot add a new
one except in very limited situations.
• May Change Insurance Companies: An employer
with a group health plan can switch plan
administrators as well as buy insurance from
a different insurance company without losing
grandfathered status, provided the plan does not
make any of the above six changes to its cost or
benefits structure.
The Affordable Care Act:
What Health Reform Means
for Women and Families
Written by
Perry Bryant
Executive Director
West Virginians for Affordable Health Care
Edited by
Julie Pratt
Ridgeline:
Ideas in Action
Layout Design by
Renate Pore
Lydia Mitts
West Virginians for
Affordable Health Care
Families USA
Dave Love
The Phillips Group
This publication was funded through a grant from the Claude Worthington Benedum Foundation
This and other publications on the Affordable Care Act are available are on WVAHC’s web site: www.wvahc.org
WVAHC Board of Directors
Dan Foster, MD, President
Barbara Fleischauer
Margaret Chapman Pomponio
CAMC and West Virginia Senate
West Virginia House of Delegates
WV FREE
Sam Hickman, Vice President
Reverend Todd Garland
Craig Robinson
NASW West Virginia Chapter
Catholic Diocese of Wheeling-Charleston
Cabin Creek Clinic
David Forinash, Secretary
Brandon Merritt
Tom Sims
Retired health care administrator
Kanawha-Charleston Health
Department
AARP West Virginia
Reverend James Patterson
Northeastern University School of Law
Sally K. Richardson, Treasurer
WVU Institute for Health Policy Research
Beth Baldwin
West Virginia Nurses Association
Rachel Dash
Temple Israel
Partnership of African American
Churches
Kenny Perdue
West Virginia AFL-CIO
George Pickett, MD
Emily Spieler
Kathleen Stoll
Families USA
Gary Zuckett
West Virginia Citizen Action Group
Retired state public health director
WVAHC Board Advisors
WVAHC Staff
About WVAHC
Sue Coyle
Ashley Adams
WVU School of Nursing
Eastern Panhandle Regional
Coordinator
West Virginians for Affordable Health Care
is a tax-exempt, nonprofit organization
under IRS 501(c)(3) regulations. WVAHC
was organized in 2005 by a diverse group
of individuals concerned about the rising
cost of health care and insurance coverage.
We are funded by membership dues, public
donations, and grants. No member is paid
for serving on our Board of Directors.
Dolly Ford
Licensed Clinical Social Worker
Danny Scalise
Capital Resource Agency
Nancy Tyler
Nancy Tyler Healthcare
Chris Zinn
Lisa Diehl
North Central Regional Coordinator
Renate Pore
Director of Health Care Policy
Doris Selko
Southern Regional Coordinator
Hospice Nurse
West Virginians for Affordable Health Care
1544 Lee Street, Charleston, WV 25311
(304) 344-1673 • www.wvahc.org
The Affordable Care Act: What Health Reform Means for Women and Families
15
West Virginians for Affordable Health Care
1544 Lee Street
Charleston, WV 25311
(304) 344-1673
www.wvahc.org