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Important provisions of the ACA

March 13, 2014

Article published in Duncan Banner March 12, 2014.I

There are two aspects of the Patient Protection and Affordable Care Act that have received limited or no public dissemination. First, the Affordable Healthcare Act expands treatment for people with cerebral palsy, autism and other developmental disabilities. Second, the Affordable Care Act only marginally impacts those TRICARE beneficiaries (active-duty, reservists and retired members of the U.S. military).
Under the law, individual and small group plans sold on or off the health insurance marketplaces (exchanges) include rehabilitative and habilitating services and devices. Health plans purchased before enactment of the ACA typically covered only rehabilitative services for people due to accidents or illnesses. Prior to the law, coverage for habilitating purposes – helping people learn to maintain functional skills, rather than regaining them – was not covered. The insurance companies’ rationale was that the individual was recovering a function such as speech by having to learn to speak again. Thus, insurance companies classified these functions as educational issues.
Large employer group plans do not have this requirement. Hopefully, future tweaks to the Affordable Care Act, rather than eliminating it completely, will cover these aspects.
As reported January 14, 2014 in Kaiser Health News, “Under the ACA health law, each state had to identify a benchmark plan that would serve as a basis for defining the essential health benefits offered there. In the final Essentials Health Benefits Rule, HHS (Health and Human Services) said that if the states’ benchmark plan does not define the habilitation benefit, states may choose to do so themselves. If they do not set specific rules, they can either require insurance plans to cover those benefits as ‘parity’ with rehabilitative services so that they are similar in scope, amount and duration, or leave it to the insurers to determine how to cover the benefit and report that to HHS. Regulators will review the rules in 2016.”
The plan you select needs to be carefully scrutinized to make sure it does not shortchange patients who need habilitation services by reducing such coverage in favor of more extensive benefits for rehabilitative services. Enhanced rehabilitative services may be good for some customers; and the substitution is allowed under the law as long as it remains in the same essential health benefit category.
The Patient Protection and Affordable Care Act will have limited impact on TRICARE beneficiaries. The biggest change they will notice may be an extra letter in their mailbox each January and an extra box to check on their tax forms every April.
Beneficiaries who receive TRICARE benefits, whether at no cost, electing to pay an enrollment fee, or by paid monthly premiums, have minimum essential coverage under the Affordable Care Act. This includes TRICARE Prime, Prime Remote and Standard, TRICARE Reserve Select, TRICARE Young Adult, TRICARE Retired Reserve and the Continued Health-Care Benefit Program.
Eligibility alone for premium-based TRICARE benefit plans – TRS, TYA, TRR and CHCBP – does not constitute minimum essential coverage. Eligible beneficiaries must purchase, and be in good standing by paying their coverage-in-force premiums, in order for these TRICARE programs to qualify as minimum essential coverage. There are two groups of TRICARE beneficiaries who do not meet the minimum essential coverage requirement. They are those getting care for line-of-duty-only related conditions and those only eligible to receive care in military hospitals or clinics.
Because the information sent to the IRS is generated using beneficiaries’ Social Security Numbers, it is essential for sponsors to make sure their families’ Defense Enrollment Eligibility Reporting System (DEERS) information is correct and up to date.
Department of Defense will send every TRICARE beneficiary the same information it sends the Internal Revenue Service, which will detail whether sponsors and their dependents had minimum essential coverage during the previous year. Sponsors can then use this information when they file their tax forms. (TRICARE Information Courtesy of the Defense Health Agency and USAF Afterburner)





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