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Medicare
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Learn About the Affordable Care Act

Already in Effect

Some parts of the Affordable Care Act are in effect now. Here are some that may affect you:

Consumers

Everyone

  • People who have health problems can get health insurance through either:
  • Young adults can stay on their parents' insurance plan until they turn 26. It doesn't matter whether they are single, married, working, or students.
    • Note: Grandfathered plans do not have to provide coverage to adult children who are eligible for employer-sponsored coverage. These are plans in effect before March 23, 2010.
  • People who use indoor tanning services now pay a 10% tax.
  • Chain restaurants and vending machines must post how many calories are in their foods.

Medicare and Medicaid

  • Medicare and Medicaid plans:
    • Offer free preventive services including an annual wellness visit and personal prevention plans.
    • Pay for more programs to help members quit smoking.
  • New rules make it easier for people with both Medicare and Medicaid to coordinate care between their providers.
  • The Center for Medicare and Medicaid Innovation is studying better ways to provide health care. It's goal is to improve the health of people with Medicare and Medicaid.

Medicare Part B & C

  • The high-income threshold for Medicare Part B premiums will stay at the 2010 level through 2019. This is $85,000 for individuals and $170,000 for couples. Seniors below this threshold pay a set monthly premium. Seniors above this level pay based on their income.
  • In the past, Medicare payments to doctors increased with inflation. Now, the increase will be a little bit less than inflation to encourage more efficient medical care.
  • Primary care doctors and general surgeons who work in shortage regions are getting a 10% bonus on all payments from Medicare.
  • Medicare is paying Medicare Advantage plan providers at 2010 levels. These providers cannot make you pay a higher premium.
  • Medicare payments to a provider will be reduced when:

    • A patient is treated again for the same problem
    • The problem was preventable

Medicare Part D

  • Medicare members in the prescription drug coverage gap or "donut hole" get 50% off brand-name drugs, and14% off generic drugs while in the gap.

Medicare Quality Improvement

  • The Medicare Independence at Home program begins. It will study if home-based primary care services for Medicare patients with many health problems will:

    • Improve their outcomes, and
    • Lower costs by reducing hospital and emergency room visits.
    • Medicare Advantage plans will get bonuses if they:
      • Provide you with high-quality care, and
      • Reduce costs.
    Medicare will pay hospitals based on the quality of care they provide you.
  • Accountable Care Organizations will get a bonus if:
    • They provide high quality care to people with Medicare
    • They save Medicare money

The bonus will be a part of the money that was saved.

  • To understand and fix population health differences, health care providers will collect and report data on:
    • Race
    • Ethnicity
    • Primary language

Businesses

  • Tax credits will help small businesses provide insurance benefits to their workers. Most small businesses can get a credit up to 35% of their costs for employees' health insurance. Small non-profit organizations can get a credit of up to 25%. Click here to learn more.
  • From 2011 to 2015, small businesses can get grants to help them set up wellness programs for their employees.
  • The Early Retiree Reinsurance Program provides financial help to employers. The money will allow them to continue to provide insurance to workers who retire between 55 and 65. People become eligible for Medicare at 65. This program will end on January 1, 2014 when insurance exchanges become available.

Insurance Reforms

Apply to new and grandfathered health plans:

  • Insurers cannot cancel your health insurance when you get sick unless you lied when you signed up for coverage.
  • Insurers cannot deny coverage to children under age 19 due to a health problem.
  • There are no lifetime dollar limits on essential health benefits.
  • Annual limits on essential health benefits cannot be less than:
    • $750,000 for plans that start between Sept. 23, 2010 and Sept. 22, 2011
    • $1,250,000 for plans that start between Sept. 23, 2011 and Sept. 22, 2012
  • Only prescribed drugs (not over the counter drugs) can be paid for with Flexible Spending Accounts, Health Savings Accounts, Health Reimbursement Accounts, or Medical Savings Accounts.
    • There is a 20% tax on unpermitted purchases.
  • Insurers must submit rationale for unreasonable premium increases to:
    • Health and Human Services
    • Each state in which plan members live
    • The public by putting their reasons on their website
  • Insurers must give you some money back if they spend less than 80% (individual) or 85% (group) of the premiums on medical services.

Apply to new health plans only:

  • All new health plans must cover 100% of the cost of preventive services. This includes services like mammograms, colonoscopies and vaccinations. The list of services can be found here.
  • All new health plans give you the right to appeal your insurer's decisions to internal and external review groups. This includes claims denials and contract changes. Click here to learn more.

Improving Care

  • States received $46 million to improve their insurance premium reviews. Learn more about these grants here.
  • New scholarships and loans can help:
    • People who want to work in health care afford to go to school
    • Increase the workforce to serve the newly insured.
  • The new Patient-Centered Outcomes Research Institute will look at how different treatments improve the quality of care.
  • The new National Health Care Workforce Commission will develop a strategy to recruit and train more doctors, nurses and health care workers. The goal will be to help communities and rural areas that need health care workers the most.
  • The new National Prevention, Health Promotion and Public Health Council will develop strategies to improve the delivery of health care services, patient health, and overall public health.
  • Beginning July 1, 2011, the federal government will not pay providers for treating avoidable health care complications. The provider must care for you and cannot charge you for this.
  • Community-based Collaborative Care Networks will be formed. These groups will involve hospitals, community health centers, and other providers. They will agree to work together to coordinate better care for low-income, uninsured, and underinsured patients.
  • A new trauma center program will help strengthen emergency departments and trauma centers.
  • Work will begin to develop more and larger community health centers, school-based health centers, and nurse-managed health clinics.

Medical Malpractice

  • States can receive grants to develop alternatives to medical malpractice lawsuits. The goal is to resolve more disputes about injuries caused by health care providers.

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