Affordable Care Act Part 2



A little over four months ago, I began working at a locally owned, not-for-profit health insurance company. Although the patient-care centered aspects of this business  weren’t foreign to me, there has been a pretty steep learning curve with regards to the health insurance side of things. I touched on a few of the upcoming ACA changes in  my last blog post; however, there are a few additional topics that I would like to discuss. These subjects include Nevada Health Link, Grandfathered Plans, The Patient Bill  of Rights, Medical Loss Ratios, and Cost-Sharing.


Nevada Health Link is Nevada’s version of the Health Insurance Marketplace. The ACA requires a new Health Insurance Exchange be established in every state beginning  January 2, 1014. These online portals are a new way for individuals and small businesses to purchase health insurance. As of February 12th, the Nevada exchange has  enrolled only 23, 686 members which are well short of its goal of 118,000 by March 31st [1].


Prior to beginning my current employment, the term Grandfathered Plans was a complete mystery to me. A Grandfathered plan is any plan in effect on March 23, 2010, the date that the ACA became law. These plans do not have to follow some health insurance reform provisions, such as the requirement to cover all preventive care services without cost sharing, for as long as they remain grandfathered.


On the surface, the Patient Bill of Rights helps children (and eventually all Americans) with pre-existing conditions gain coverage and keep it, protect all Americans’ choice of doctors, and end lifetime limits on the care consumers receive [2].


Under the health care reform law, health insurers are required to spend at least 80% (for individuals and small groups) or 85% (for large groups) of their policy premiums in a given state on claims. This percentage is called their Medical Loss Ratio or MLR. If their MLR (claims over premiums) is less than the required percentage, the difference has to be paid to individual and group policyholders as a rebate.


Finally, cost-sharing. Some cost-sharing limits that apply to non-grandfathered plans beginning with 2014 plan years are outlined below:


–        In-network out-of-pocket (OOP) maximums cannot exceed $6,350/individual and $12,700/family. All copays, deductibles and coinsurance for EHBs must count toward the OOP maximum.


–        Mental health/substance abuse benefits must count toward the medical plan’s OOP maximum, even if the benefits are provided by a different vendor.


–        For insured small group plans only, (no more than 50 employees), in-network deductibles cannot exceed $2,000 individual and $4,000 family.


This blog series, by no means is intended to be comprehensive. However, as we can see, there is a lot more to the ACA than we may read or hear about from local media members. I encourage all of you to examine your health insurance plan documents and see if you can tell where the Affordable Care Act has taken effect.




Posted on February 16, 2014, in Uncategorized and tagged , , , . Bookmark the permalink. Leave a comment.

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