BUSI 523 St Petersburg College Affordable Health Act Discussion and Responses
Explain the timeline of the ACA and the influence that it has on the quality of care that is delivered to the beneficiary, as well as the process for filing an appeal for healthcare-related services that are delayed and/or denied by the insurance company.
first response
n March 23, 2010, the Patient Protection and Affordable Care Act (PPACA) was signed and shortly after that renamed the Health Care Reconciliation Act of 2010 also referred to as the Affordable Care Act or Obama Care. The main goal was to expand coverage of health insurance and to reduce the Medicare expenditure. With many provisions and various effective dates there are 10 key components listed in the Act as a guide which can be summarized as “expand access to insurance, increase consumer protections, emphasize prevention and wellness, improve quality and system performance, expand the health workforce, and curb rising health care costs” (NCSL, 2011).
A timeline was created as to which parts of the Act would be implemented and expanded on from 2010 to 2015. (Medical Mutual of Ohio, 2021)
2010
Federal funding for Medicaid increased so states can provide coverage to more individuals.
Pre-Existing Condition Insurance Plan (also called a “high-risk pool”), a temporary program to provide health coverage to individuals with pre-existing medical conditions who have been uninsured for at least six months, created.
Coverage for preventive services like immunizations, annual physicals and screenings included on all new plans.
Dependent coverage extended to age 26 and children can stay on their parents’ plan until age 26 (the age limit varies from state to state).
2011
Free preventive services for Medicare recipients available, such as wellness visits, without a copay.
The Center for Medicare and Medicaid Innovation established to improve healthcare quality and affordability.
Community First Choice Options created to help states provide home- and community-based services to disabled individuals.
2012
Incentives given to physicians for forming Accountable Care Organizations (ACOs) for Medicare patients, which improve patient care by encouraging communication and coordination between doctors. ACOs tie the Medicare reimbursements doctors receive to metrics around the overall health of the Medicare patients they treat - healthier people mean a higher reimbursement.
Uniform summary of benefits and coverage (also called the Summary of Benefits and Coverage”) given to all applicants and enrollees by health insurance plans and presented in a consistent format across all insurance companies so it’s easy to compare plans from different carriers.
2013
Health benefit exchanges launched by states or the U.S. Department of Health and Human Services (HHS) so individuals and small businesses can buy affordable coverage (with January 1, 2014, and beyond effective dates)
2014
Individuals required to have health insurance or pay a tax. A similar penalty for employers delayed until 2015 or later, depending on group size.
Annual limits on essential health benefits eliminated.
Expanded Medicaid eligibility in some states, including Ohio, for all people not eligible for Medicare under age 65 with incomes up to 138 percent of the federal poverty level ($15,282 for an individual and $31,322 for a family of four)
2015
Quality will be the focus.
Physician payments tied to quality of care.
The quality of health care to many Americans, through the provisions of the ACA, have greatly been improved. “Investing in primary health care in medically underserved communities, coverage of clinical preventive services without cost sharing, Indian health care geared towards school-based health centers, oral health-care prevention activities, tobacco cessation programs for Medicaid-enrolled pregnant women, and the addition of personalized prevention planning to Medicare, and establishing “teaching health centers,” (Rosenbaum, 2011). Those are just a few ways the ACA is changing the way health care is delivered to patients. The main premise of the ACA is to improve access and quality care to all Americans.
One change that I know has helped many with sudden or chronic conditions is the ability to appeal a denial or adverse decision from the insurance company. Harrington (2021) tells us that one can appeal the denial by questioning the decision in writing (p.83). “You can appeal your insurance company’s decision through an “internal appeal”, in which you ask your insurance company to do a full and fair review of its decision. If your insurance company still denies payment or coverage, the law permits you to have an independent third party decide to uphold or overturn the plan’s decision. This final process is often referred to as an “external review” (ASPA, 2017). States may have a Consumer Assistance Program available to aide in filing an appeal or request a review of your health insurance company’s decision if you are not sure what steps to take. Insurance companies must also provide you with information about how to file an appeal and the appeals process when you were enrolled in coverage, which can usually be found on their website.
Ezekiel 34:16, “I will seek that which was lost, and bring again that which was driven away, and will bind up that which was broken, and will strengthen that which was sick: but I will destroy the fat and the strong; I will feed them with judgment” (KJV, 2021). I relate this scripture to the very essence of the ACA. Restoring the intention of health care, to care for all the sick and injured, making access to and quality of healthcare paramount, and limiting the overbearing and exclusion insurance companies created.
second response
COLLAPSE
Imagine a world where children are dying because parents are unable to provide the most basic healthcare. In this great Country of The United States, people have opportunities unlike anywhere else, yet there exist a population of people that cannot get medical treatment and medication to cure the most common conditions. Change was needed to reform the medical assistance program in the United States.
Tremendous need existed, to provide Americans with access to medical care. While Democracy allows for capitalism to thrive, we should never neglect those that are without. Class segmentation in our society creates undeserved segments of the population that deserve basic rights. The ACA was enacted in 2010 in an environment of divisiveness rarely seen in American Politics. From the halls of Congress to state capitols, according to,(Morris et al., 2019) dinner tables across the nation, differences of opinion about the ACA raged almost unchecked. Big media pushed enlightenment to inform the American population.
In the United States according to, (Shi & Singh, 2018)the Affordable Care Act (ACA) has expanded health insurance but not achieved universal coverage. Further, access to affordable health care is inadequate at both individual and national levels-a challenge for academics, health care professionals, and politicians alike. Historically Americans frown on government interference in individual liberties like healthcare which is considered personal preference area. President Barack Obama’s political agenda trumped economic constraints and led to the enactment of the Affordable Care Act (ACA; nicknamed “Obamacare”) in 2010 through ideological and political maneuvering. (Shi & Singh, 2018, p. 51)The Deep views on capitalism, independence and preventing government influence has slowed the progression of the reform.
Despite early debate stated, (Morris et al., 2019)centered around option of single -payer system, the ACA simply built on the existing combination of private insurance, Medicaid, and Medicare to deliver and pay for health care services. New implementations were placed like the mandate to purchase health insurance and a few different policies.
Important according to, (Morris et al., 2019) feature was given to states by the legislation giving states the authority to make several important decisions regarding the implementation of the ACA. The choices provided to states under the ACA are not accidental; they are very much the product of existing norms and definitions of federalism in the U.S. Our current understanding of federalism is a product of the presidency of Ronald Reagan and what is often termed “Reagan federalism” When Reagan was elected, he places a new relationship between federal government and states giving States more power to make decisions. The two policy while very different have common characteristics. States have the authority to operate the fund they receive for medicals programs as they choose.
If denied a claim for medical treatment according to, regulations 42 CFR 405.940-405.942, a party to redetermination may request that the contractor make a redetermination. A request for determination as stated by, (Harrington, 2021)must be filed within 120 days after receiving the notice of the initial determination. The appeal process has five levels finishing level before moving on to the next until all appeal rights are exhausted.
There is a river of life, and he showed me a pure river of water of life, clear as crystal, proceeding from the throne of God and of the Lamb. In the middle of its street, and on either side of the river, was the tree of life, which bore twelve fruits, each tree yielding its fruit every month. The leaves of the tree were for the healing of the nations. Revelations 22:1,2 imagine a time when water from a river provides life.