The Affordable Care Act in CT: What It Is and What It Means for Naturopathic Medicine

NEWTOWN, Conn. - Aug. 8, 2013 - PRLog --             We are now at the doorstep to monumental changes in healthcare, as the health insurance exchanges created under the of The Affordable Care Act are in the final stages of development before being opened to the public on October 2013; this has meant a flurry of activity for insurers, regulators, legislators, physicians, hospitals, business owners, professional associations and other interested healthcare stakeholders as compliance for these changes is sought.  As a way to address concerns, U.S. Senator Chris Murphy hosted a forum in Hartford on July 2^nd regarding this transition and was joined by U.S. Senator Richard Blumenthal and representatives from federal and state agencies involved with the process.  They brought up many new features of the law including the creation of accessible marketplaces for plans that meet a qualified minimum level of coverage, reforming industry practices like denials based on pre-existing conditions, incentives for consumer coverage as tax credits and penalties and increased protection under Medicare with expansion of Medicaid. Connecticut is also one of six “Early Innovator” states and has volunteered to develop its own exchange without relying on management from the federal Department of Health and Human Services (“HHS”).  This makes the changes happening in Connecticut particularly exciting, as they may forecast the feasibility of implementing similar programs through the rest of the country; and it is not without its rewards, the State has received $117,184,326 in grants for research, planning, information technology development, and implementation of the Affordable Care Act, with the expectation that Connecticut disseminates its design successes to other states in the coming years. 

A New Marketplace For Insurance

            The Patient Protection and Affordable Care Act of 2010, more commonly referred to as ‘The Affordable Care Act’ (“ACA”), requires the creation of two types of state-based health insurance exchanges, which must be in operation by January 1, 2014.  The American Health Benefit Exchanges for individuals will vary state to state and is being called “Access Health CT” in Connecticut, while the Small Business Health Options Program (“SHOP”) Exchanges will be for business owners to offer to employees.  Though the federal government will set minimum standards, primarily through HHS, the law makes primary responsibility for governance and operations that of the states.  Thus states have considerable flexibility in how they want to implement these programs and if they choose to partner with other states and form regional exchanges, or form multiple exchanges within their state, they are able to do so.  However, if HHS discovers that exchanges are not operational by the deadline, then HHS must operate the exchange or find a non-profit entity to do so. 

            The health insurance exchanges are intended to be more than just clearinghouses from which consumers choose plans, they also aim to improve the quality of these plans while controlling cost. Only “qualified” plans will be allowed to be offered on the exchange and they must meet several criteria.  All plans posted on the exchange must include a robust network of doctors and clinics and a minimum “essential health benefits” package which includes: emergency services, hospitalization, maternity and newborn care, mental health, substance abuse, prescription drugs, laboratory services, pediatric coverage and preventative services, as well as chronic disease management, among others.  Different levels in the plans vary by the percentage cost of care that they cover, ranging from bronze at 60%, through silver and gold, up to platinum at 90%.  Benefit levels are based on “actuarial value”, which is a summary measure of the amount of medical claims paid by the health plan (excluding a member’s  point-of-service cost sharing), expressed as a percentage of the total medical claims incurred for a standard population.  These statistical calculations are what insurance companies do when assessing risks and premiums, and are used in determining deductible amounts required on different plans.  The ACA seeks to set limits on the maximum annual deductible for health plans purchased by small employers so that the annual deductible may not exceed $2000 for single coverage or $4000 for family coverage, though these limits do not apply on the individual market, which has other parameters.   One of the enticing features of the exchanges is that “[n]o one will pay more than 9.5 percent of household income on health insurance and many will be capped at just two or three percent”, per the Access Health CT document ‘10 Things You Neeed to Know About Health Insurance Exchanges’.  The State is expecting to meet ambitious goals like this by using competition between the insurance companies in the new marketplace, as well as tax credit incentives, as ways of keeping costs down over time.  If enough people join the exchange in a given state, it has better odds of working and staying affordable, hence motivators like premium subsidies and tax credits are only available to people who have gotten health insurance through  a qualified plan within the exchange, and not through one of the grandfathered plans that exists outside of the exchange, which don’t have to offer a qualified benefits package.  Grandfathered plans, or plans that were in existence prior to the law’s enactment, are exempt from many of the new requirements, including the new rating rules and the requirement to offer a minimum essential benefit package.  Other plans, such as large-group or self-insured plans, are also exempt from many of the the new rules. 

Reforming the Insurance Industry  

            Beyond the exchanges, the ACA attempts to alter and reform entrenched health insurance practices both in and out of the exchange.  These include guaranteed issue and renewability of coverage, banning premium variation based on health status or gender, prohibiting pre-existing condition exclusions and annual or lifetime limits, requiring coverage of preventative health services without cost-sharing, and many others.  Among the changes, is the first-time creation of a mandated external appeals process for people in self-funded plans, so they have the right to an external review.

            Another significant change to the health insurance industry comes in the form of increased transparency and accountability.  To ensure premium dollars are spent primarily on medical care, the law’s “80/20” rule requires that at least 80% of premium dollars collected by insurance companies for individuals and small employers must be spent on benefits and quality improvement.  ...