Last time we discussed some additional taxes you may or may not be paying as a result of PPACA.  This post addresses the considerable benefits of PPACA to you a health care consumer.  Next time we’ll discuss the effects of PPACA on your practice.

Free Preventive Care

I say “free”, but it really isn’t, since the insurance company is paying for it and you’ll likely be paying higher premiums for it.  But, that said, you are now allowed three visits to your primary physician per year and certain screening examinations such as mammograms, colonoscopies, pap smears and even an ultrasound to rule out AAA (only for older male smokers) without having to pay a co-pay or co-insurance.

Free Contraceptive Coverage

Insurers now can’t charge you a co-pay or co-insurance for birth control pills or an IUD.  Good luck getting them to pay for your condoms.

Stay on Parents’ Insurance Until Age 26

It is a little surprising to me just how popular this provision is.  I moved out of the house at 18 and aside for a month or two in the summers during college, never looked back.  I paid for my own health insurance and didn’t think it was that big of a deal, just part of being an adult.  There are apparently plenty of people out there who disagree with me though, so now you can stay on your parent’s plan until you turn 26.  I don’t know why 26 and not 36 or 46, but that’s the way it is.  It doesn’t matter if the kids are students, working, married, single, or smoking pot, as long as they don’t have coverage through their employer.  Lots of people have 2 or 3 kids by 26, but the kids can’t get onto the grandparent’s plan.

No Lifetime or Annual Limits

This is a provision I’m happy to see in the new law.  If nothing else, insurance needs to cover catastrophes.  Now your insurer can’t put a maximum lifetime limit on your coverage.  The “no annual limit” rule begins in 2014.

Pre-existing Condition Rule Changes

Another justifiably popular provision of the law prevents insurers from denying you coverage due to pre-existing conditions.  While this is obviously going to raise premiums for healthy people, I’m okay with that if it avoids the situation my wife and I once got into where we had to pay much higher premiums because she had a single episode of cystitis.  This doesn’t phase in fully until 2014, but until then you can buy insurance through a more expensive “Pre-existing Condition Insurance Plan.”  My aunt who was recently diagnosed with pancreatic cancer, only to learn that her employer-provided health insurance had an annual limit of something like $2000, was able to get insurance through a PCIP after her diagnosis.

PPACA requires insurers to use an adjusted community rating to determine premiums.  The insurer can charge more depending on your age, gender, and tobacco use, but that’s it.  All 50 year old male non-smokers in your community have to be charged the same premium.

Essential Health Benefits

PPACA requires insurers to pay for anything deemed an “essential health benefit.”  What are essential health benefits?  Here’s a list ( breast implants and abortions aren’t on it.)

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance abuse disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

Annual Cost Sharing Limits

A health insurance plan must have an annual out of pocket cost of no more than $5950 (individual) or $11,900 (family.)  No super high deductible plans allowed.

Choose Any Doc From Your Plan

There is a provision that allows you to see any doc in the plan, rather than having one assigned to you.  You can also see an OB/GYN without a referral.

Insurance Company Rebates

If an insurance company doesn’t spend 80-85% of premiums collected on actual health care, it must refund the difference.  This puts a limit on insurance company overhead as well as profits.

Standardized Coverage


Beginning in 2014, there will be much more standardization of health plans.  While all plans must cover the essential health benefits, they can offer different “actuarial levels.”  The least expensive plans, with the highest co-pays and co-insurance, will be the bronze level, in which the insurance company will pay 60% of all the health care costs incurred by a typical population on the plan.  Silver level will pay 70%, gold will pay 80%, and platinum will pay 90%.  If you’re healthy, you want a bronze plan.  If you’re not, you want a platinum plan.

Out of Network Emergency Care

If you go to an ED that is out of network, you no longer need pre-approval nor can the insurance company charge a higher co-pay or co-insurance.

Health Insurance Exchanges

States will be required to set up health insurance exchanges where individuals and small businesses can easily compare and purchase plans.  My state has had one for years.  It’s not that helpful.  It’s just a website.  But if you’re not very good with a search engine I suppose it’s nice.

Government Subsidies

The federal government will subsidize your health care if you make less than 400% of the federal poverty level.  That means a family of four currently gets a decreasing subsidy up until an income level of $88,200.  How much is the subsidy?  Well, a family of four making $29,000 would fork out less than $50 a month for health insurance and a family making $88,199 would have a maximum payment of about $700 a month.  This is unlikely to affect residents or employed docs, who generally have their health insurance as part of their work benefits.  Medical students with a working spouse, however, may easily qualify for a substantial subsidy.

Expansion of Medicaid

The federal government is mandating that states expand their Medicaid coverage to cover everyone up to 133% of the federal poverty line.  Many states now just cover pregnant women and children at low income levels.  That level is currently $14,404 for individuals and $29,327 for a family of four.  Barring a working spouse, that should cover any medical students whose parents don’t have a plan, or who are already 26.

Next time we’ll talk about how PPACA is going to affect your practice (and thus your salary.)