EFFECTIVE NOW
LOW INCOME, THOSE WITH
PRE-EXISTING ILLNESSES,
AND THE DISABLED
States can cover more
people through Medicaid
States can choose to receive
federal matching funds to child-
less adults with incomes up to 133
percent of the federal poverty
level, a higher threshold than
before.
Who benefits: Low-income
childless adults
Coverage for uninsured
people with pre-existing
conditions
A new temporary program pro-
vides coverage for people with
pre-existing medical conditions
who have been uninsured for at
least six months. States may set
up their own programs; if they
don’t, residents can apply for
coverage through a national plan.
When: National program is in
effect now
Who benefits: Uninsured people
with pre-existing conditions
CHILDREN AND ADULTS
UNDER 26 YEARS OLD
Kids with pre-existing
conditions can’t be
denied coverage
Insurers cannot deny coverage to
children under the age of 19 due
to a pre-existing medical condi-
tion.
Who benefits: Children with
pre-existing conditions
Who pays more: Insurance
companies
Extend coverage for
young adults
Young adults can stay on their
parents’ plan until they turn 26
years old.
Who benefits: Adults under 26
who can’t get insurance at work
Who pays more: Insurance
companies
SMALL BUSINESSES
Tax credits for buying
coverage
Up to 4 million small businesses
could get tax credits to help
provide health coverage to their
employees.
When: Starting now the first
phase provides a credit up to 35
2012
THE DISABLED
Providing new,
voluntary options
for long-term care
The law creates a volun-
tary long-term care
insurance program to
provide cash benefits to
disabled adults.
When: Government must
designate a benefit plan
by Oct. 1, 2012
Who benefits: Disabled
individuals
SENIORS
Medicare hospital
quality incentives
Hospitals’ Medicare pay
will be based on perform-
ance on certain quality
measures. Hospitals’
performance must be
publicly reported, begin-
ning with measures
relating to heart attacks,
heart failure, pneumonia,
surgical care, health-care
associated infections, and
patients’ perception of
care.
When: Effective Oct. 1,
2012
percent of the employer’s
contribution to employees’
health insurance; this ceiling
will increase to 50 percent in
2014. Also, small non-profit
organizations now may re-
ceive up to a 25 percent
credit, increasing to 35 per-
cent in 2014.
Who benefits: Small busi-
nesses with fewer than 25
employees
Who pays more: Federal
government
SENIORS
Expand coverage for
early retirees
A $5 billion reinsurance
program helps employment-
based plans extend coverage
to people who retire between
the ages of 55 and 65, as well
as their spouses and depen-
dents.
Who benefits: Early retirees
“Doughnut hole”
$250 rebate
Seniors who reach the
“Doughnut Hole” in Medicare
prescription coverage this year
— after their drug costs for
the year reaches $2,840 —
receive a $250 rebate.
Who benefits: Seniors in the
Medicare prescription gap
Who pays: Federal govern-
ment
SHORING UP THE
HEALTH CARE SYSTEM
Free preventive care,
wellness initiative
All new health plans must
cover preventive services such
as mammograms and co-
lonoscopies with no deducti-
ble, co-pay or coinsurance. A
$15 billion Prevention and
Public Health Fund will pay for
programs to help people get
healthy — from quitting
smoking to fighting obesity.
Who benefits: People
enrolled in job-related health
plans or individual health
plans created after March 23,
2010.
Restrictions on
canceling sick person’s
coverage
In the past, insurance compa-
nies could search for any error
on a consumer’s application
and use the error to deny
payment for services or
cancel coverage when the
insured got sick. Now insurers
must prove the effort was
fraudulent.
Who benefits: People with
individual health insurance
Who pays more: Health-
insurance companies
Who benefits: Medicare
patients, high-quality
hospitals
SHORING UP
THE HEALTH CARE
SYSTEM
Electronic health
records
A series of gradual
changes will require
health plans to keep and
exchange records elec-
tronically. The goal is to
reduce medical errors and
paperwork costs.
When: First regulation
effective Oct. 1, 2012
Who benefits: Health
care system, patients
Fees from
drug makers
The law imposes new
annual or biennial fees on
the pharmaceutical manu-
facturing industry.
When: Beginning with
$2.8 billion in 2012-2013
Who benefits: Taxpayers
Who pays more: Phar-
maceutical manufacturers
Reduce health
disparities
The law requires the
collection and reporting of
patients’ racial, ethnic,
language, and gender data
to identify and address
health disparities.
When: Effective March
2012
Who benefits: Patients
HEALTH CARE
REFORM
The Democrats’ overhaul of the nation’s health care
system will unfold over the next 10 years. Here are the
changes taking place now and in the next few years.
Right to appeals
claims denials
Consumers have the right
to appeal coverage claims
denials to their insurance
company and then, if
necessary, to an external
reviewer.
When: Effective for some
health plans now
Who benefits: People
with private health insur-
ance (Employer sponsored
or individual plans)
No lifetime
dollar limits
Health plans can no longer
impose lifetime dollar limits
on what they will pay for
essential benefits, like
hospital stays. Annual
dollar limits will also be
restricted.
When: Now. Annual dollar
limits will be phased out by
2014, with some excep-
tions.
Who benefits: People
with private health insur-
ance
Curb rate hikes
States that require insur-
ance companies to justify
their premium increases
will be eligible for $250
million in new grants.
Insurance companies with
unjustified premium in-
creases may not be able to
participate in the new
health insurance exchanges
in 2014.
When: Grants are awarded
now.
Who benefits: People
with private health
insurance
LATER YEARS
LOW INCOME AND
THOSE WITH PRE-
EXISTING ILLNESSES
Extend preventive care
for state Medicaid
programs
The law provides a one-
percentage-point increase in
federal matching Medicaid
funds for preventive services
to states that cover certain
preventive services at little or
no cost to patients.
When: Effective Jan. 1, 2013
Who benefits: Medicaid
recipients
Who pays more: Federal
government
Guaranteed availability
of insurance
Insurers cannot refuse to sell
coverage or renew policies
because of an individual’s
pre-existing medical condi-
tion. Also, in the individual
and small-employer markets,
it will be illegal to charge
higher rates because of
gender or health status.
When: Effective Jan. 1, 2014
Who benefits: Individuals
with pre-existing conditions
or poor health
Who pays more: Insurance
companies
Thinkstock photos
Rebuild primary
care workforce
Expand the number
of primary care
doctors, nurses and
physician assistants
through incentives
such as scholarships
and loan repayments
for primary care
doctors and nurses
working in under-
served areas.
Strengthen
health centers
New funding will pay
for construction and
service expansions of
community health
centers, enabling
these centers to
serve some 20
million new patients.
Who benefits:
Uninsured and low-
income people.
Who pays more:
Federal government
More pay for
rural health
care providers
Sixty-eight percent of
medically under-
served communities
in the U.S. are in rural
areas. Increased
payments to rural
health-care providers
could help attract
and retain medical
professionals to
these areas.
Who benefits: Rural
residents and health-
care professionals.
Who pays more:
Federal government
More access
to Medicaid
Americans who earn less than
133 percent of the poverty
level (about $14,000 for an
individual and $29,000 for a
family of four) will be eligible
for Medicaid. States will
receive 100 percent federal
funding for the first three
years to support this expan-
sion, phasing to 90 percent in
subsequent years.
When: Effective Jan. 1, 2014
Who benefits: Low-income
individuals and families
Who pays more: Federal
government
Help for health care
costs
Tax credits will be available for
people with incomes above 133
percent but below 400 per-
cent of poverty (about
$43,000 for an individual and
$88,000 for a family of four in
2010) to help them buy insur-
ance, if they not eligible for or
offered other affordable cov-
erage.
When: Effective Jan. 1, 2014
Who benefits: Low-income
individuals, families
Who pays more: Federal
government
NEXT YEAR
THE DISABLED
Home care
for the disabled
The new Community First
Choice Option allows state
Medicaid programs to offer
home- and community-based
services to disabled individu-
als rather than nursing-home
care.
When: Effective Oct. 1, 2011
Who benefits: Disabled
individuals
Who pays more: Federal
government and states
SENIORS
Prescription drug
discounts
Drug manufacturers must
provide a 50% discount on
brand-name prescriptions for
seniors with Medicare drug
plans who reach the “dough-
nut hole” coverage gap. Also,
federal subsidies begin for
generic prescriptions filled
during that coverage gap.
When: Effective Jan. 1, 2011.
Over the next 10 years, dis-
counts will increase until the
coverage gap is closed in
2020.
Who benefits: Medicare
drug-plan members who
reach the “doughnut hole”
Who pays more: Drug
manufacturers, federal gov-
ernment
Free preventive care
for seniors
The law provides certain free
preventive services for Medi-
care recipients, such as
annual wellness visits and
personalized prevention plans.
It also waives the Medicare
deductible for colorectal
cancer screening tests.
When: Effective Jan. 1, 2011
Who benefits: Medicare
recipients
Who pays more: Federal
government
Medicare premiums
for higher-income
beneficiaries
The income threshold for
higher Medicare Part B premi-
ums will be frozen at 2010
levels for 2011 through 2019,
resulting in more people
paying the higher premiums.
Also, the premium subsidy for
Medicare prescription drug
coverage will be reduced for
those with incomes above
$85,000/individual and
$170,000/couple.
When: Effective Jan. 1, 2011
Who benefits: The Medicare
budget
Who pays more:
Higher-income Medicare
SHORING UP THE
HEALTH CARE SYSTEM
Medicare tax increase
Increases the Medicare Part A
(hospital insurance) tax rate on
wages, to 2.35% from 1.45%, on
earnings over $200,000 for
individual taxpayers and
$250,000 for married couples
filing jointly; imposes a 3.8%
assessment on unearned in-
come for higher-income taxpay-
ers.
When: Effective Jan. 1, 2013
Who benefits: The Medicare
budget
Who pays more: Higher-
income taxpayers.
Individual requirement
to have insurance
Most individuals who can afford
it will be required to obtain
basic health insurance coverage
or pay a fee to help offset the
costs of caring for uninsured
Americans. If affordable cov-
erage is not available to an
individual, he or she will be
eligible for an exemption.
When: Effective Jan. 1, 2014
Who benefits: Uninsured
people, health-care providers
Who pays more: Previously
uninsured individuals
Employer requirements
Employers with more than 50
employees that don’t offer
health coverage will be as-
sessed per-employee fees if
they have at least one full-time
employee who receives a tax
credit for buying his or her own
health coverage.
When: Effective Jan. 1, 2014
beneficiaries
Reducing payments
to Medicare
Advantage insurers
The law gradually eliminates
the extra amount that
Medicare pays per person to
private insurers’ Medicare
Advantage plans compared
with outlays under tradition-
al Medicare. The law also
prohibits Medicare Ad-
vantage plans from impos-
ing higher cost-sharing
requirements than tradition-
al Medicare for some cov-
ered services.
When: Effective Jan. 1, 2011
Who benefits: The Medi-
care budget
Who pays more: In effect,
health insurers because
they’ll receive less
Cuttings costs to
preserve Medicare
The Independent Payment
Advisory Board will propose
ways to reduce the growth
in Medicare spending and
extend the life of the Medi-
care Trust Fund.
When: Funding available
Oct. 1, 2011
Who benefits: Medicare
recipients
SHORING UP THE
HEALTH CARE SYSTEM
Minimum medical
spending by insurers
The law requires health
plans to report the propor-
tion of premium dollars
spent on clinical services
and quality measures, as
opposed to administrative
costs. If that proportion is
less than 85% for large-
employer plans and 80% for
plans sold to individuals and
small employers, consumers
would be due rebates.
When: The rebate program
takes effect Jan. 1, 2011.
Who benefits: Consumers
with health insurance
Who pays more: Health
insurance companies
Improving Medicare,
Medicaid
A new Center for Medicare
& Medicaid Innovation will
test new ways to deliver
care and pay providers. The
goal is to reduce the growth
in costs for Medicare,
Medicaid, and the Children’s
Health Insurance Program
while maintaining or improv-
ing the quality of care.
When: Effective Jan. 1, 2011
Who benefits: Medicare,
Medicaid and CHIP
recipients
Who benefits: The federal
budget
Who pays more: Mid-size and
large employers that don’t
provide health coverage
Health insurance
exchanges
New state-based health insur-
ance marketplaces called ex-
changes will be established,
through which individuals and
small businesses can choose
from among health plans meet-
ing benefit and cost standards.
Members of Congress will be
getting their health coverage
through these exchanges.
When: Effective Jan. 1, 2014
Who benefits: Individuals and
small businesses needing more
affordable coverage
Apply employers’ funds
to other coverage
Some workers who can’t afford
the coverage offered at work
will be able to take whatever
amount their employer would
have paid toward their insurance
and use it to buy a more afford-
able plan though the new health
insurance exchanges.
When: Effective Jan. 1, 2014
Who benefits: Low- and
moderate-income workers
Fees from health
insurers
The law imposes new annual or
biennial fees on the health
insurance industry.
When: Beginning with $8
billion in 2014
Who benefits: The federal
budget
Who pays more: Health
insurers