The Affordable Care Act Part I: “Understanding How the ACA Impacts Insurance in the United States”

by Davina Fankhauser
President - Fertility Within Reach

The Affordable Care Act Part I:  “Understanding How the ACA Impacts Insurance in the United States”

There is much discussion taking place about the Affordable Care Act (ACA) and how it impacts Americans.  Fertility Within Reach has been researching the ACA and how it impacts infertility benefits.  So we will do a two part blog series; Understanding How the ACA Impacts Insurance in the United States and Understanding how the ACA Impacts Infertility Health Benefits.

History: The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) or “Obamacare” (a term we will not use in these blogs), is a United States federal statute signed into law by President Barack Obama on March 23, 2010.  The Affordable Care Act was passed with a goal that every American would have affordable health insurance.  On June 28, 2012, the United States Supreme Court upheld the constitutionality of the ACA’s individual mandate in the case National Federation of Independent Business v. Sebelius.

The Process:
At the federal level:  The ACA includes regulations that set standards for insurance, some specified in the law, others subsequently established by the Secretary of Health and Human Services.  The Secretary of Health and Human Services created 10 Essential Health Benefits (EHB).  Everyone was encouraged to provide feedback on the initial ten recommendations.  Due to public outreach, changes were made to the original 10 (one example is there are now benefits for Autism).  Once an opportunity for public feedback was provided.  Overall, these EHBs cover: “ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.”  It was up to the states to determine which insurance plans fulfill the EHBs.

At the state level:  The state Department of Health and Human Services was given the task to work with various state departments to select its state “benchmark plan”.  The benchmark plan, at a minimum, had to meet the essential health benefits.  The states had the option of selecting its benchmark plan from one of 10 current insurance plans within their state or not go through the process and select a federal plan to be their benchmark.   The 10 insurance plans under consideration came from large group, small business, and federal plans.

If your state had mandated health benefits as of December 31, 2012, those benefits were automatically grandfathered into the benchmark plan selected.

Every state participating in the process allowed opportunities for their residents to participate in hearings and/or submit feedback on the 10 insurance plans the state was considering.  If a state did not participate in the process and chose a default federal plan, state residents were not provided the chance to express their needs/preferences.

From the insurer:  The insurance companies may need to alter their plans in terms of their policies and benefits.  They must, at a minimum, offer the benefits within the benchmark plan selected by the state.  They will also need to meet new federal requirements such as, no pre-existing conditions, children are allowed to be covered under their parent’s plan until they are 26 years old, and insurers cannot drop consumers if they become sick.

What to expect:  Because insurers and states had to create new plans, you will likely be unenrolled from the old (inadequate) plan and have it replaced with options that meet the new requirements.  This is all about paperwork and tracking (for the government and the insurance companies).  Note: most benefits offered previously should be offered in future plans because they were grandfathered in (coming from the plan, selected by the state, to be the state benchmark).

Every State Could Have Two Benchmark Plans:
1. There is a benchmark plan for commercial insurance (large group, small business, non-group/individual policies).
2.  Each state also needs to select a benchmark plan for their Exchange plans (plans provided to the state population that qualifies for more affordable insurance or subsidies to help them afford health insurance).
The benchmark plan for the state Exchange plans may be the same or may be different than the commercial benchmark plan.

Who Qualifies for State Exchange Plans and Subsidies:
To qualify for one of the state Exchange insurance plans, you must meet certain criteria.
1.  If your yearly insurance premiums adds up to 9.5% or more of your individual income
2.  If you make less than 400% of the federal poverty level

If you qualify for state insurance, you can drop your insurance through your employer. (This is an incentive for employers to offer competitive insurance plans). Individuals with incomes between 100% and 400% of the federal poverty level who purchase insurance plans via an exchange will be eligible to receive federal subsidies to help pay premium costs.

Change after the government shutdown:  Prior to the shut down the law said individuals could estimate what their income would be in the coming year.  If the individual made less, their subsidy would increase.  If they made more than projected, their subsidy would be less.  One change since the shutdown is that people must show what their previous income was to determine if they quality.  This could be a tricky for individuals who are unemployed (newly or previously).

FWR Thoughts:
Fertility Within Reach is based in Massachusetts.  The Affordable Care Act is modeled after the health care program in our state.  Massachusetts currently has 98% of adults with health benefits, 99% of children with health benefits, and our premiums are going down.  The premiums decreasing is largely due to the work of the state legislators.  They passed a cost containment bill as well as established a cap on how much the insurance companies could increase premiums.

The Affordable Care Act afforded many opportunities to each state to control the impact of change on its residents.  Each state has the ability to ensure there is not a dramatic increase to the premiums which accompany the updated plans.  If you are finding your premiums are significantly higher, you can:
1. See if you qualify for one of your state Exchange plans
2.  Communicate with your employer to find a more affordable option (employers often receive insurance policy options via insurance brokers)
3.  Ask your legislator to establish a bill and/or vote to pass legislation that limits the premium increases established by insurance companies.
4.  VOTE for the legislators who will work for you and your needs.  If you are not sure, call their office and ask questions or read the websites.


A detailed summary of the PPACA can be found on the Wikipedia website:



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Davina Fankhauser

President - Fertility Within Reach

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