Essentially, the ACA protects insurance coverage for the uninsured. It eliminates lifetime limits on benefits for any participant or beneficiary. (ACA, Sec. 2711) and provides coverage for pre-existing conditions (ACA Sec. 2705). No longer can people be denied coverage for the following factors:
1. Health status/medical condition
2. Claims experience
3. Medical history
4. Genetic information
Insurance companies must now cover ‘essential health benefits’ (ACA, Sec. 1320) to at least include the following:
1. Ambulatory patient services (out care received without being admitted to a hospital)
2. Emergency Services
3. Hospitalizations, example surgeries.
4. Maternity and newborn care
5. Prescription drug coverage
6. Laboratory services
7. Pediatric services
8. Preventive and wellness services
9. Rehabilitative and habilitative services
10. Mental Health & Substance Abuse Disorders (Added February, 2013, by Sec. Sibelius of Dept. HHS.
Think of the ACA insurance coverage as simply extending Medicare type coverage to almost everyone in the U.S. (see above for who is covered). But be careful….the because many of the services can have frequency caps which would prohibit your clients from getting the necessary treatment they truly need.
What does the ACA mean for an attorney’s practice?
• Now almost all present and future claimants, including those catastrophically injured and disabled, can get insurance coverage.
• It allows attorneys to determine maximum client out of pocket costs for future treatment for most injuries since policies have maximum annual out of pocket limits.
• It reduces claimant fear about the future and how much they will need for care.
• Most claimants will be able to qualify for federal premium assistance.
• Do not let the Defense bar use the ACA to minimize your client’s life care plans future damages as we live in New York State with the Collateral Source Rule (CPLR 4545) where discussing health insurance is off limits to our jurors to attack future life care plans.
• Many expenses that are staples of Life Care Plans are not covered by any health insurance including the ACA plans or are capped such as long term care, nursing care, home care, continuous physical therapy(capped), occupational therapy (capped).
I am hearing defendants make arguments at mediations using the ACA and I am sure they are sharpening their spears as the ACA’s implementation progresses to dispense with the collateral source rule.