ACA Basics: What You Should Know...But Still Might Not



Starting January 1, 2014, everyone in the U.S. (except for some exceptions) will be required to have health insurance. It is estimated that there will be 30 million to 35 million U.S. citizens who will be required to have health insurance who didn’t have it before this law went into effect.

Those who are not insured by their employer or through Medicaid or Medicare can buy health insurance from the newly established exchanges, or marketplaces, being formed in each state. Depending on the state, these marketplaces are being managed in one of three ways—by the state itself, by the federal government, or by the state and federal government in partnership—or in a variation of one of these formats.

Plans sold on the public exchanges will be presented in five categories—bronze, silver, gold, platinum and catastrophic. In addition, private exchanges are also being established to sell health insurance.

Each health insurance plan must provide the minimum of 10 essential health benefits, which, in addition to including pediatric vision as well as dental care, also include outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, and preventive and wellness services and chronic disease management.

Other mandates of the Affordable Care Act include disallowing the denial of coverage for an individual with a pre-existing medical condition, allowing children up to 26 years of age to stay on their parents’ health insurance policies, and the elimination of lifetime spending limits.

Financial incentives have also been legislated to encourage medical practitioners to use electronic health records. This is in part due to the fact that ultimately practitioners are intended to communicate over health information exchanges and the use electronic health records helps facilitate that.

While these are just some of the basics about the Affordable Care Act that everyone should have familiarized themselves with by now, at thousands of pages, the full extent of the law goes far beyond the scope of this small collection of articles. Assuredly, its impact and implications will be revealed and ultimately reflected in health care in general and vision care specifically as the law continues being put into practice.

Following is a glossary of terms related to health care reform and the Affordable Care Act:

Accountable Care Organization (ACO):
a group of health care providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get. The organization's payment is tied to achieving health care quality goals and outcomes that result in cost savings.

Affordable Care Act (ACA, also known as the Patient Protection and Affordable Care Act): the comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.

Care Coordination: the organization of treatment across several health care providers. Medical homes and accountable care organizations are two common ways to coordinate care.

Children’s Health Insurance Program (CHIP): insurance program jointly funded by state and federal government that provides health coverage to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but can’t afford to purchase private health insurance coverage.

Defined Benefit Health Care Plan: when employers agree to offer their employees a predetermined dollar amount each year to put toward health insurance premiums.

Essential Health Benefits: a set of health care service categories that must be covered by certain plans, starting in 2014. The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the health insurance marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. Insurance policies must cover these benefits in order to be certified and offered in the health insurance marketplace. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid.

Federally Qualified Health Center: federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally qualified health centers provide primary care services regardless of ability to pay. Services are provided on a sliding scale fee based on ability to pay.

Federal Employee Dental and Vision Insurance Program (FEDVIP):
dental and vision benefits available to Federal employees, retirees and their dependents; used by the U.S. Department of Health and Human Services as a state’s benchmark pediatric insurance plan for dental and/or vision when one was not available in a particular state’s benchmark insurance plan.

Health Insurance Marketplace: (also known as health insurance exchange) a resource where individuals, families and small businesses can learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. The marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the marketplace, and information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). The marketplace encourages competition among private health plans and is accessible through websites, call centers and in-person assistance.

Health Information Exchange:
an organization that provides services to enable the electronic sharing of health-related information.

Medical Loss Ratio: a basic financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees. A medical loss ratio of 80 percent indicates that the insurer is using the remaining 20 percent to pay overhead expenses, such as marketing, profits, salaries, administrative costs and agent commissions. The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws.

Medicaid Expansion: the Affordable Care Act expands Medicaid coverage to millions of low-income Americans, upgrades both Medicaid and the Children’s Health Insurance Program, and creates a minimum Medicaid income eligibility level across the country. Beginning in January 2014, individuals under 65 years of age with income below 133 percent of the federal poverty level will be eligible for Medicaid.

Navigator: an individual or organization that’s trained and able to help consumers, small businesses and their employees as they look for health coverage options through the marketplace, including completing eligibility and enrollment forms.

Qualified Health Plan: under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the health insurance marketplace, provides essential health benefits, follows established limits on cost-sharing (such as deductibles, copayments, and out-of-pocket maximum amounts) and meets other requirements. A qualified health plan will have a certification by each marketplace in which it is sold.