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The Achievement of a Lifetime

People who like their employer-provided health plan and doctors can keep them, plus it will be easier for Americans to get and keep coverage. Changes begin with plans starting or renewing on or after Sept. 23, 2010.

For Employees With Coverage at Work

People who like their employer-provided health plan and doctors can keep them, plus it will be easier for Americans to get and keep coverage. Changes begin with plans starting or renewing on or after Sept. 23, 2010. Reforms will apply once the current collective bargaining agreement ends. For more, visit the Kaiser Family Foundation at

  • Insurance companies can’t deny coverage for pre-existing conditions.
  • If you get sick, your insurance company can’t drop you.
  • Children with pre-existing conditions can’t be denied coverage. Children covered by a parent’s plan can’t be denied treatment for a pre-existing condition.
  • Provided they’re not eligible for their own employer-sponsored coverage, children can stay on a parent’s plan until age 26.
  • No more lifetime caps (the dollar limit that insurance companies pay to a bene-ficiary over a lifetime) for “essential health benefits.”
  • Coverage limits — the dollar amount an insurer will pay a beneficiary each year — will no longer be set by insurers, and won’t be used to block access to needed care. By 2014, annual limits will be eliminated.
  • Co-payments and deductibles for preventive services, including certain immunizations and screenings, will be eliminated.
  • Waiting periods before a person can be insured will not exceed 90 days.
  • The impact of an excise tax on high-cost health care plans ($10,200 for individuals and $27,500 for families) is significantly reduced by postponing its implementation until 2018. The threshold is higher where a workforce is older than average or includes more women than average. There are also adjustments for retirees.
  • The new law reduces the U.S. deficit by $143 billion in the first 10 years by holding down the growth of health care spending, and by revenue-raising measures.

For Employees Without Coverage at Work

It will be easier for people who don’t have cov-erage through their employers to get it. Once insured, they will have the same safeguards that will protect people who get coverage through work. Here’s how the new law applies to those who don’t have employer-provided coverage:

  • Under the new law, 32 million Americans who have no insurance now will be able to afford it on their own more easily. Reform means 95 percent of Americans will be insured.
  • Those without employer-provided coverage will have access to state-run buying pools or “exchanges” that will offer commercial and nonprofit health insurance plans. Many AFSCME home and child care providers, early retirees and part-timers are likely to obtain coverage through the exchange and to qualify for tax credits to help cover the cost.
  • Until 2014, when insurance companies can no longer deny coverage to people with pre-existing conditions, those under the age of 65 with pre-existing medical conditions who are refused coverage by insurance companies will be able to get subsidized coverage through a temporary national high-risk pool.
  • Beginning in 2014, Medicaid becomes available to all persons under age 65 with income of up to 133 percent of the poverty level.
  • Employers who have more than 50 workers and don’t offer basic health insurance coverage will be fined.
  • Community health centers will get $11 billion from the federal government starting in 2011. AFSCME members without employer coverage can utilize these services.
  • To make it easier for them to provide more affordable health care options for their employees, small businesses will receive approximately $40 billion in tax credits.
  • In an effort to bring insurance companies under control, rates will be subject to federal regulation to ensure they are justified and that at least 80 percent of premiums are used for medical care.

For Retirees, Much to Like

Neither Medicare taxes nor trust funds will be used for reform, and there will be no cuts in guaranteed Medicare benefits. In fact, older Americans are among the chief beneficiaries of the Patient Protection and Affordable Care Act. Here’s why:

What Happens Now

  • Seniors who fall in the Medi-care Part D “donut hole” in prescription drug coverage will receive a $250 rebate this year and a 50 percent discount on brand name drugs beginning in 2011. The hole will be completely closed by 2020.
  • Co-payments and deductibles for Medicare preventive services, such as annual check-ups and cancer screenings, will be eliminated starting next year.
  • The Act creates a $5 billion federal re-insurance program for employer plans that cover retirees age 55 to 64 (workers who retire before they are eligible for Medicare). This will help offset the costs of expensive premiums for employers and retirees and will help preserve benefits.

What Happens Over Time

  • The law adds nearly a decade of financial solvency to Medi-care by reforming payments to hospitals and reducing unnecessary and costly hospital readmissions.
  • Savings from new efforts to crack down on fraud as well as reductions in the big subsidies paid to Medicare Advantage (MA) private insurance plans will strengthen Medicare’s stability over the long term.
  • The Class Act — a voluntary, employment-based program — will provide cash benefits for participants who need long-term care services in their homes.
  • Improvements to care coordination will enhance quality and eliminate wasteful duplication of Medicare-covered services.

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