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Healthcare Changes in 2011: How Healthcare Reform Will Affect the PH Community

May 2, 2011

In March 2010, the Affordable Care Act (ACA) was signed into law, drastically changing the healthcare industry in the United States. Although many of the changes will require up to 10 years to completely implement, the PH community has already started to feel the effects of the new law.

Listen as Gavin Lindberg, PHA’s Washington Representative, explains what provisions are included in the ACA, how these changes have already affected the PH community, and what to expect over the upcoming months and years.

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Additional Questions and Answers

The following questions were asked during the presentation. Because we were unable to provide immediate answers, we have listed both the questions and their respective answers below.

  • Do annual and lifetime caps apply to dental benefits as well as more traditional medical benefits?
    Retiree-only and “excepted health plans” such as dental plans, long-term care insurance, or Medigap, are exempt from the Affordable Care Act insurance reforms. Learn more

  • How will patients be penalized if they don’t elect to get mandatory coverage?
    Beginning in 2014, the Affordable Care Act requires most residents of the United States to obtain health insurance and imposes a financial penalty for being uninsured. That penalty will be the greater of a flat dollar amount per person that rises to $695 in 2016 and is indexed by inflation thereafter (the penalty for children will be half that amount and an overall cap will apply to family payments) or a percentage of the household’s income that rises to 2.5 percent for 2016 and subsequent years (also subject to a cap).

The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) have estimated that about 21 million nonelderly residents will be uninsured in 2016, but the majority of them will not be subject to the penalty. Unauthorized immigrants, for example, are exempted from the mandate to obtain health insurance. Others will be subject to the mandate but exempted from the penalty—for example, because they will have income low enough that they are not required to file an income tax return, because they are members of Indian tribes, or because the premium they would have to pay would exceed a specified share of their income (initially 8 percent in 2014 and indexed over time). Individuals may also be granted waivers from the penalty because of hardship and may be exempted from the mandate on the basis of their religious beliefs.

  • Is the pre-existing condition exclusion provision effective for young adults until their 19th birthday, or through the age of 19?
    The provision is effective for young adults until their 19th birthday (through the age of 18). Beginning September 23, 2010, group health plans cannot exclude enrollees (employees, spouses or dependents) under age 19 based on pre-existing conditions. For other plans, all pre-existing condition exclusions must be removed beginning in 2014.

Grandfathered group health plans receive no special protection and must comply once the provision becomes effective with respect to the plan. These rules apply equally to collectively bargained and non-collectively bargained plans.

A special rule applies to individual health insurance coverage. The pre-existing condition rules only apply to non-grandfathered individual health insurance plans.


Presenter Information

Gavin Lindbergh, PHA's Washington Representative

Gavin Lindberg
PHA's Washington Representative; Vice President, Health and Medicine Counsel of Washington

Gavin Lindberg is Vice President of the Health and Medicine Counsel of Washington, a government relations firm specializing in legislative and regulatory consulting services. The firm represents a variety of non-profit patient organizations, health professions schools, and biomedical research societies with an interest in federal appropriations issues. Gavin has been with the firm for 16 years and worked on Capitol Hill as a legislative aide prior to joining the company. He has represented PHA in Washington for 12 years.

Margaret Beardsworth, PHA's Insurance Program Manager

Margaret Beardsworth
PHA’s Insurance Program Manager

As PHA’s Insurance Program Manager, Margaret is the first point of contact for questions and comments about the insurance portion of PHA's website. In addition, she gathers patients' stories about their insurance challenges in order to help shape PHA's insurance policy agenda. Finally, Margaret works closely with PHA's medical and corporate partners in efforts to raise awareness about PH among insurance payers.

Katie Kroner, PHA's Director of Advocacy and Awareness

Katie Kroner
PHA's Director of Advocacy and Awareness

Katie coordinates PHA’s grassroots advocacy efforts, including the 435 Campaign. She maintains online action alerts, manages the advocacy email group and provides patients and supporters with tools and resources to build successful relationships with their elected officials. Katie is the first point of contact for information about PH Awareness Month in November, the Congressional Luncheon and the PH Resource Network Lobby Day.



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