Patient Protection and Affordable Care Act (PPACA)

Last year, the launch of the Affordable Care Act affected Americans nationwide.  Now it’s making its way into the business world.  Beginning in 2015, the “employer mandate” of President Obama’s Affordable Care Act (“ACA”) will take effect.  The provision, titled 4980H, was supposed to start in 2014 but was postponed by the IRS for another year.  Under the mandate, “large” companies will have to reevaluate the coverage they provide to their full-time employees.  In just another year, the same provision will apply to companies deemed “mid-size.”

I previously discussed the core components of the patient centered medical home delivery care model (PCMH). The post prompted numerous inquiries from health care professionals regarding what the financial benefits are in becoming recognized as a PCMH medical practice.

I researched the issue in more detail and found varying reports regarding reimbursement payment models by federal, state, and private payers that support PCMH recognized health care providers.

Read on to learn more about how proposed payment models may affect the financial aspects of a PCMH medical practice.

The Patient-Centered Primary Care Collaborative (PCPCC) states that the “medical home” (also referred to as the “patient-centered medical home”) is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It is now a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the simplest to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination, instead it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient's needs.

The highly anticipated launch of the state and federal health insurance “exchange” - sometimes used interchangeably with “marketplace” - was met with dismal reviews. Several concerns were raised by consumers regarding the technical problems associated with both state and federal exchanges in addition to a much needed clarification regarding the tax penalty provisions effective January 1, 2014. Lawmakers are now scrambling to address the public’s concern regarding the exchanges and the tax penalty provisions.

Read on to learn more about the health insurance exchanges and what state and federal agencies are doing to help the general public easily access health insurance information in order to obtain health care coverage before the tax penalty deadline.

What is the Health Insurance Exchange?

Before PPACA passed, health insurance companies had a broad range of options in determining the types of policies they issue to consumers and the costs of that health care coverage. In particular, companies could limit or deny insurance coverage to consumers that had pre-existing conditions and raise health care premiums, without justification, subject to certain state law limitations.

After PPACA, insurance companies must work within clearly defined standards that greatly impact who will receive insurance coverage, the types of coverage they will receive, and the costs of such coverage. For instance, insurance companies will no longer be able to raise insurance premiums solely for profit based reasons or disproportionately benefit from such higher premiums. If premiums are raised, insurance companies will now have to justify any rate increase greater than 10% to the states in which they operate in and disclose the information to their customers.

Read on to learn more about how the PPACA is impacting insurance companies and individuals.

The Patient Protection and Affordable Care Act (ACA) will provide several benefits and opportunities for small businesses to increase access to affordable health care coverage options.  The parts of the ACA that most directly affect small businesses are:  (1) the new state insurance exchanges; (2) tax credits; and (3) the employer mandate. The insurance exchanges and tax credits will take effect as planned on January 1, 2014.  The employer mandate will be put off for an additional year until 2015.

Read on to learn more about the parts of the ACA that directly affects businesses.

One of the most significant and impactful changes contained in the 2010 Patient Protection and Affordable Care Act (PPACA), requires health insurance companies to meet minimum medical loss ratio (MLR) targets of 80% for small group and individual plans and 85% for large group plans.  Pre-PPACA, the average, large health plan spent between 18 and 21 cents on administrative costs. Post-PPACA, spending 85 cents of every dollar on medical and quality leaves 15 cents for administrative costs.