Health Care Reform
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Health Care Reform
Healthcare Reform Resources

The Affordable Care Act (ACA) brings significant changes to how Americans access and pay for health care. And while these changes will not impact the way you administer dental plans for UnitedHealthcare Dental members, we want to help you understand health reform and let you know that UnitedHealthcare’s plan designs conform to the ACA’s mandates. This information is not specific to dental but rather it offers a brief summary of changes in health care as a whole.

Healthcare Reform Forms Medically Necessary Orthodontia:  click here

Health Insurance Marketplaces

The Health Insurance Marketplaces are intended to help individuals and small groups shop for, select and enroll in high quality, affordable private health plans that fit their needs at competitive prices.

Public Marketplaces

The ACA requires Health Insurance Marketplaces, also called Exchanges, to be established in each state by Jan. 1, 2014. If a state does not establish a Marketplace, the federal government will step in and operate the Marketplace on behalf of the state. Between 2014 through 2016, only individuals and employers in the small group market are eligible to participate in a Marketplace. In 2017, states may permit employers in the large group market to participate. The Marketplace will open for business beginning Oct. 1, 2013, offering coverage beginning Jan. 1, 2014. The Marketplace may be operated by the state or federal government or as a partnership between a state and the federal government. In 2014, small groups will be defined as businesses with up to 100 employees, although until 2016 a state may choose to limit the definition to businesses of up to 50 employees.

The minimum responsibilities of the Marketplaces include the following functions:

• Operate web portal and toll free number

• Determine Eligibility, Enrollment, and exceptions and connect with Medicaid

• Certify Health Plans

• Determine subsidy eligibility and maintain electronic cost calculator

• Determine financial integrity/manage risk adjustment & reinsurance

• Communicate information to the Department of Treasury and employers; use HIPPA data sets if applicable

• Review patterns of rate increases

• Implement health plan rating system and enrollee satisfaction system

• Establish a Navigator program to facilitate enrollment

Private Marketplaces

Private Marketplaces also called Exchanges are being established by a variety of different entities such as consulting firms and cooperatives. Private Marketplaces are available to all business segments and fully insured or self-funded groups of all sizes. Because private Marketplaces are operated by private entities, subsidies are not available to those purchasing health care insurance through a private Marketplace.

Individual Mandate

Beginning in 2014, the health reform law requires most individuals to have health insurance for themselves and their spouses or dependents. The requirement is for each individual to have minimum essential coverage (MEC) or pay a potential penalty for noncompliance. Coverage may be obtained through an employer or individual insurance market, a Health Insurance Marketplace, or a government program such as Medicare or Medicaid. The individual mandate penalty is 1 percent of income for 2014 and is capped for a family at 300 percent of the individual penalty. It increases to 2 percent of income in 2015 and then 3 percent of income in 2016, indexed to inflation in future years. If individuals do not elect coverage offered by their employer and do not have other coverage, in 2014 there will be a tax penalty based on the individual’s income.

Individual Subsidies

Individuals with incomes between 10 percent and 400 percent of the federal poverty level are eligible for sliding scale premium and cost-sharing subsidies (in the form of refundable tax credits) to purchase coverage through the Marketplace. Subsidies are not available for any coverage outside the Marketplace. An employee with access to employer-based coverage is only eligible for a subsidy through the Marketplace if the coverage offered through their employer is “unaffordable” (i.e., required share of the employee’s premium for self-only coverage exceeds 9.5 percent of his or her household income) or if the coverage does not satisfy a “minimum value” requirement (i.e., the plan must pay at least 60 percent or more of the plan’s total allowed benefit costs anticipated for a standard population.)

Removal of Pre-existing Condition Exclusions

For plan/policy years beginning on or after January 2014, the health reform law will remove any restrictions on pre-existing conditions for individuals of all ages. Therefore, coverage may not be denied for pre-existing conditions nor will individuals with pre-existing conditions be charged more. This is an update to the provision from 2010 that did not allow exclusions for children under the age of 19 with a pre-existing condition. This applies to non-grandfathered and grandfathered plans (with the exception of grandfathered individual health plans.)

1 Disproportionate Share Hospitals (DSH) and DSH-eligible Hospitals, Children’s Hospitals, Rural Referral Centers, Sole Community Hospitals,

Free-standing Cancer Centers, and Critical Access Hospitals.

Guaranteed Availability of Coverage (applies to non-grandfathered plans)

Health insurance issuers are to offer coverage to and accept every employer or individual who applies for coverage in the group and individual market, subject to certain exceptions. Exceptions allow issuers to restrict enrollment in coverage to: 1) open and special enrollment periods, 2) employers with eligible individuals who live, work, or reside in the service area of a network plan, and 3) for situations involving limited network capacity and limited financial capacity.

Essential Health Benefits

Beginning in 2014, for non-grandfathered plans, all health insurance in the individual and small group market (offered in or outside the Marketplace) must include all Essential Health Benefits (EHB) specified in the state EHB benchmark plan in their situs state. All annual and lifetime dollar limits will be removed from EHB. These benefits include: 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.

• For plan years beginning on or after September 23, 2010, non-grandfathered health plans are required to cover ER services as in-network without prior authorization; if services are provided out-of-network, the cost-sharing requirement is the same as if services were provide in-network.

• For plan years beginning in 2014, non-grandfathered health plans are also required to cover routine costs of phase I-IV clinical trials.

Out-of-pocket Maximum Changes

Beginning in 2014, all cost sharing, including flat-dollar copayments, toward services that are defined as Essential Health Benefits must accumulate toward the plan’s out of pocket maximum (OOPM). Grandfathered plans are not subject to out of pocket limits.

Essential Community Providers

Qualified Health Plans participating in the Marketplace are required to maintain a network that is sufficient in number and geographic distribution of Essential Community Providers (ECP) to provide timely access to services for low-income and medically underserved individuals. Some examples of ECPs are as follows:

• Federally Qualified Health Centers (FQHCs),

• Ryan White/HIV Service Providers

• Family Planning Providers

• American Indian Health Care Providers

• Mental Health and Substance Abuse Services

• Specified Hospitals

Key Considerations

Widespread coverage expansion may cause an increase in wait times for primary care access.

Newly insured patients with limited familiarity of the health care system may require more education by care providers.

There will be more emphasis needed on preventive care for individuals with no prior source of health care.

There will be a greater reliance on validating patient eligibility at the point of service since there will be some potential for members to move between exchange subsidies, Medicaid, and ineligibility within a single enrollment year.

Benefit plans will provide members with emergency services in and out of the service area.

A small percent of Americans may still be uninsured after the Individual Mandate takes into effect January 1, 2014.


Marketplace Websites

Federal Marketplace:




District of Columbia:








New Mexico:

New York:


Rhode Island: