The Patient Protection and Affordable Care Act of, often called Affordable Care Act (ACA), is a federal law ruling aiming to protect individuals who previously didn’t have healthcare coverage but didn’t qualify for Medicaid.
It is a federal statute enacted by President Barack Obama in 2010, hence it is often referred to by the colloquial name Obamacare. The Act includes provisions to take effect between 2010 and 2020, although most took effect on January 1st, 2014
The Affordable Care Act protects individuals from arbitrary decisions by commercial insurance payers, including cancellation of coverage due to an honest mistake, and gives patients the right to request reconsideration if a claim is denied.
Under the ACA, health insurance plans can no longer deny benefits to children under age 19 for pre-existing conditions. Young adults under age 26 are also allowed to be covered under a parent’s health plan.
Other features include a ban on lifetime coverage limits for new health insurance plans and a requirement that insurance companies do not make unreasonable rate increases.
Consumers can buy these policies through the Health Insurance Marketplace (also known as Exchanges) during open enrollment, which occurs annually from November 15 through February 15 each year.
Special enrollment is also available outside this period for people who experience life-changing events, such as the birth of a child, the death of a spouse, and other examples. As a coder, you need to learn about the plans being offered in your state. Many of the plans function like HMOs, and only providers who have enrolled with the plan are eligible for claim payment.
If a patient is enrolled in a plan covered under the Affordable Care Act, this does not necessarily mean your office may accept a plan. It will depend if the provider is considered out of network if it isn’t enrolled as a provider in that plan.
From a practice management perspective, knowing who your payers are is important when scheduling appointments. The front office team should be educated in the difference between a commercial insurance plan such as PPO or HMO, and an ACA plan. Sometimes these plans can be the product of the same insurance company.
As a rule, any Affordable Care Act plan card has a slightly different filing instruction (it may say that non-emergency services should be provided within the state, and so forth), and it may not have a group number and/ or employer name like commercial cards.
When scheduling appointments for consumers withAffordable Care Act cards, it is a good idea to probe a bit in order to identify who the actual payer is.
