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Changes Ahead

How the Affordable Care Act could impact business

Last summer, the U.S. Supreme Court upheld the individual shared responsibility component of the Affordable Care Act (ACA). This was a historic decision, but many Americans are still trying to figure out what it means. Under the mandate, virtually every legal U.S. resident will be required to have health coverage, or what the law refers to as minimum essential coverage, beginning in 2014. This coverage will also be required to include specific benefits, or what the law refers to as essential health benefits, also beginning in 2014.


What qualifies as minimum essential coverage?

  • Insurance purchased through an employer.
  • Insurance purchased through the individual market.
  • Enrollment in a government-sponsored program (e.g., Medicare, Medicaid).

The Congressional Budget Office (CBO) estimates that in 2014, 30 million previously uninsured people will have increased access to health coverage1. There is a possibility that your office could

begin to see an increase in insured patients if this estimate comes to fruition.


Another major component of the ACA is the Essential Health Benefits provision. Starting in 2014, part of the minimum essential coverage provision requires the coverage of essential health benefits (EHBs).


What are essential health benefits?

Essential health benefits are categories of medical services which must be covered for any fully insured non-grandfathered health plans in the individual and small group markets. The core package of EHBs must include items and services within at least 10 of the following categories:

  • 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
  • Pediatric services, including oral and vision care
  • Preventive and wellness services and chronic disease management

As the EHBs are required benefits that carriers must cover, you may potentially see an increase in these types of services.


Why is billing different for a grandfathered plan?

The term "grandfathered" refers to group or individual health plans that existed on or before March 23, 2010, when the ACA was signed. The only way to know for sure if a patient is covered under a grandfathered plan is to verify it online through the View Eligibility and Benefits tool on A grandfathered plan is not subject to "certain" provisions of the ACA; for example, the 100 percent preventive care and clinical trial coverage does not apply to grandfathered plans.


Therefore, patient fees for grandfathered plans should be collected at the time services are provided.


1How Has CBO's Estimate of the Net Budgetary Impact of the Affordable Care Act's Health Insurance Coverage Provisions Changed Over Time?(Mar. 20, 2013). Retrieved May 9, 2013, from


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