Healthcare Reform Insurance Provisions

                           U.S. Healthcare Reform Insurance Provisions


Reform Provision

Effective Dates


Pre-existing Medical Condition

Interim coverage via high-risk insurance pools

June, 2010 to 12/2013


Insurers barred from rejecting applicants due to pre-existing conditions

1/1/2014 via Health insurance exchanges

Insurance Limits on Coverage

Insurers barred from selling policies with lifetime limits

Sept., 2010


Insurers barred from selling policies with annual limits


Medicare Beneficiaries

Improved medication coverage:

$250 federal reimbursement for those paying for medications in Medicare drug “doughnut hole”;

Drug companies required to give 50% discount on brand name drugs for prescriptions filled in “doughnut hole” (out-of-pocket)





       Mandated Insurance Out-of-pocket “doughnut hole” payments eliminated;Medicare Advantage (private plan) frozen in 2011 and cut back over time, reducing benefits like free eyeglasses and hearing aids;Free screenings for colon, prostate, & breast cancer (  for complete list; large employer plans and plans operating before 3/23/10 exempt unless plans change terms). Penalties for failure to buy qualified insurance (x 50% for individuals in household < age 18):

  • Greater of $95 or 1% of   income per individual;
  • Greater of $325 or 2% of income per individual;
  • Greater of $695 or 2.5% of income per individual;
  • Total household penalty may not exceed $2,085.
                       By 2020

By 2018

(in high-cost parts of U.S.)



1/1/11 Medicare/Medicaid

                     1/1/2014                        1/1/2014                      1/1/2015                      1/1/2016

Young Adults Those under 26 years old can stay on parent’s health insurance if not offered health insurance via work.


Premium Subsidies Eligible individuals & families include those with incomes between 133% and 400% of federal poverty levels, = $14,404-$43,320 for individuals and $29,326-$88,200 for families of four (sliding scale)                     1/1/2014
Medicaid Eligibility Expands in 2014:Low-income adults, including with no children, eligible if income <133% of federal poverty level, = $14,404 for individuals and $29,326 for family of four using 2010 income guidelines.                     1/1/2014

Source: Technical Explanation of the Revenue Provisions of the “Reconciliation Act of 2010”, As Amended, In Combination with the “Patients Protection and Affordable Care Act”, Joint Committee on Taxation, 3/21/10;  Consumers Guide to Health Reform. Kaiser Health News, 4/1/3/2010.

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