The Patient Protection and Affordable Care Act (ACA)

Federal health care reform, officially known as the Patient Protection and Affordable Care Act (ACA), was passed into law in 2010 and upheld by the Supreme Court in 2012.

The Campaign for Modern Medicines is working alongside advocates across the country to ensure the ACA's implementation brings quality health care to the tens of millions of Americans who currently lack it, and improves the quality of care for those who already have it.

Access to care can help prevent disease, cure illnesses, and save lives. As the ACA is implemented, CMM will ensure that decision makers pay attention to the details and concentrate on what matters: the needs of patients.

The ACA left many specifics about implementation of the law in the hands of federal and state regulators. Both the U.S. Department of Health and Human Services (HHS) and the country's governors and legislators have many decisions to make that will determine how the ACA delivers health care to Americans. Debates about many of these issues are happening right now.

CMM is focusing on two components of the ACA which will have significant effects on the care patients receive in the coming years: the definition of essential health benefits and the implementation of health insurance exchanges.

Essential Health Benefits

A critical piece of the ACA is the requirement that most health insurance plans in states' individual and small group markets offer a minimum level of health insurance coverage as defined by HHS. This minimum is referred to as essential health benefits (EHB.) Most plans, including those offered through the new state health insurance marketplaces, will have to offer coverage that meets the essential health benefits criteria.

EHB prescribes minimum coverage in 10 categories of health care services, including hospitalizations, prescription drugs, and emergency services. CMM is particularly interested in the requirements for prescription drug coverage and has been closely watching the HHS regulatory process.

HHS released its final rule on essential health benefits in mid-February 2013 and the decision on prescription drug coverage was mostly positive. Health care plans will be required to cover at least one drug per category, or cover the number of drugs per category in the state's chosen benchmark plan, whichever is greater. Additionally, the final ruling includes a strengthened requirement that insurers must set up procedures that allow patients to get access to prescription medications that are not covered by their plan, if those medications are appropriate for the patient.

The final ruling leaves a number of important details about essential health benefits up to the states. As states make these decisions, we will work with advocates to ensure that they focus on providing individuals in their state with access to the robust prescription drug coverage they deserve.

Implementation of Health Insurance Marketplaces

Health insurance marketplaces, or "exchanges," are a core piece of the ACA. Marketplaces, which can be run on a state level or regionally, will be new organizations that offer a choice of private certified health insurance plans to residents. Marketplaces will be run by either a government agency or a non-profit organization. Marketplaces will serve as "one-stop shopping," where individuals can compare the prices, premiums, and benefits of different health insurance plans and decide which one to purchase. The goal of these marketplaces is to act as a catalyst for competition to reduce health care costs, while also improving quality, access, and efficiency.

The ACA gives states different options for marketplaces implementation, and after much debate, all the states have decided how they will proceed. Sixteen states and the District of Columbia will build and operate their own marketplaces. Seven others will partner with the federal government to build and run the marketplace, while the remaining 26 states opted-out and will receive a federally run exchange. Mississippi is still waiting for clarification; they applied to operate their own marketplace, but did not receive HHS approval.

The first major deadline for the implementation of state marketplaces is October 1, 2014. That is the date when all marketplaces must be ready to begin enrolling citizens and allowing them to comparison shop for health insurance plans. By January 1, 2014, marketplaces must be fully operational.

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