Key Healthcare

Policies

21.02.2025 I n s t r u c t o r P r e c i o u s C h i s o m U z o e1g h e l u
key healthcare policies
1) Affordable Care Act (ACA)

2) Medicare

3) Medicaid

4) Children's Health Insurance Program (CHIP)

5) Health Insurance Portability and Accountability Act (HIPAA)

6) Mental Health Parity and Addiction Equity Act (MHPAEA)

7) Patient Protection and Affordable Care Enhancement Act

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 Introduction to the ACA
The Affordable Care Act (ACA), also known as Obamacare, is a landmark healthcare reform law
enacted in the United States in 2010.

Its primary goal is to increase the number of Americans with health insurance coverage and improve the
quality and affordability of healthcare.

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 Key Provisions of the ACA
Expansion of Health Insurance Coverage

The ACA mandates that individuals must have health insurance coverage or face a penalty (individual mandate, repealed
in 2019).

It prohibits insurance companies from denying coverage or charging higher premiums based on pre-existing conditions.

Young adults can stay on their parents' insurance plans until age 26.

Health Insurance Marketplaces

The ACA established Health Insurance Marketplaces, also known as exchanges, where individuals and small businesses
can shop for and purchase health insurance plans.

Marketplaces offer a range of plans with different coverage levels and costs, often with subsidies available to lower-
income individuals and families.

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 Medicaid Expansion

The ACA aimed to expand Medicaid coverage to low-income adults with incomes up to 138% of the federal poverty level.

However, the Supreme Court ruled in 2012 that Medicaid expansion was optional for states, leading to a patchwork of expansion across
the country.

Impact on Healthcare Delivery and Access

The ACA has had a significant impact on healthcare delivery and access in the United States.

Millions of previously uninsured individuals gained access to health insurance coverage through Medicaid expansion and the Health
Insurance Marketplaces.

The law has led to improvements in preventive care, chronic disease management, and access to essential health benefits for millions of
Americans.

However, challenges remain, including ongoing efforts to stabilize insurance marketplaces, control healthcare costs, and address
disparities in access to care.

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 Medicare
Medicare is a federal health insurance program in the United States primarily for;

Individuals aged 65 and older.

Some younger people with disabilities.

People with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).

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 Components of Medicare
Medicare Part A: Hospital Insurance
Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home
health care services.
Most people do not pay a premium for Part A if they or their spouse paid Medicare taxes
while working.
Medicare Part B: Medical Insurance
Covers doctor visits, outpatient care, preventive services, and medical supplies.
Requires a monthly premium, which is typically deducted from Social Security benefits.

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 Medicare Part C: Medicare Advantage Plans
Also known as Medicare Advantage (MA) plans.
Offered by private insurance companies approved by Medicare.
Combines Part A, Part B, and usually Part D coverage into one plan.
May include extra benefits like vision, dental, and hearing coverage.
Medicare Part D: Prescription Drug Coverage
Optional prescription drug coverage available through private insurance companies.
Helps cover the cost of prescription drugs.
Requires payment of a monthly premium.

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Eligibility and Coverage

Individuals are typically eligible for Medicare when they turn 65 and:
 Are a U.S. citizen or permanent legal resident for at least five continuous years.
 Receive Social Security or Railroad Retirement Board benefits.

People under 65 with certain disabilities or medical conditions may also qualify for Medicare.

Coverage varies depending on the parts of Medicare individuals enroll in, and additional coverage
options are available through Medicare Advantage and supplemental plans.

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 Medicaid
Medicaid is a joint federal and state program in the United States that provides health coverage to low-
income individuals and families.

It is the largest source of health coverage for low-income populations in the country.

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Purpose and Coverage
Medicaid's primary purpose is to ensure access to healthcare services for low-
income individuals and families who cannot afford health insurance.
Coverage includes a wide range of medical services, such as doctor visits,
hospital stays, preventive care, mental health services, and prescription drugs.
Medicaid also covers long-term care services and supports for eligible
individuals, such as nursing home care and home health services.

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Medicaid Expansion under the ACA
The Affordable Care Act (ACA) included provisions to expand Medicaid eligibility to
include adults with incomes up to 138% of the federal poverty level in states that chose
to participate.
Medicaid expansion aimed to increase access to healthcare coverage for low-income
adults who were previously ineligible for Medicaid but did not qualify for subsidies
through the Health Insurance Marketplaces.
As of [current year], [number] states and the District of Columbia have expanded
Medicaid under the ACA, resulting in millions of previously uninsured individuals
gaining access to coverage.

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 Children's Health Insurance
Program (CHIP)
The Children's Health Insurance Program (CHIP) is a federal-state partnership program in the United
States that provides low-cost or free health coverage to children in families with incomes too high to
qualify for Medicaid but too low to afford private insurance.

CHIP was created in 1997 to expand access to healthcare coverage for uninsured children and pregnant
women.

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Purpose and Coverage for Children from Low-Income Families
CHIP's primary purpose is to ensure that children from low-income families
have access to affordable and comprehensive healthcare coverage.
Coverage under CHIP includes:
 Well-child check-ups and immunizations.
 Doctor visits, hospital care, and emergency services.
 Prescription medications and dental and vision care.
CHIP provides coverage for children up to age 19, regardless of pre-existing
conditions.

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Role in Expanding Access to Healthcare for Children
CHIP plays a critical role in expanding access to healthcare for children who
may otherwise go without necessary medical care due to financial barriers.
By providing affordable health coverage, CHIP helps ensure that children
receive timely preventive care, treatment for acute illnesses and injuries, and
ongoing management of chronic conditions.
CHIP has been instrumental in reducing the uninsured rate among children in
the United States and improving health outcomes for vulnerable populations.

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 Health Insurance Portability and
Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law enacted in 1996 to
safeguard protected health information (PHI) and improve the efficiency and effectiveness of the
healthcare system.

HIPAA includes regulations governing the use, disclosure, and protection of PHI by covered entities,
such as healthcare providers, health plans, and healthcare clearinghouses.

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 Privacy and Security Regulations for Protected
Health Information (PHI)

•HIPAA's Privacy Rule establishes standards for the use and disclosure of PHI, requiring
covered entities to:
• Obtain patient consent for certain uses and disclosures of PHI.
• Provide patients with notice of their privacy rights and how their information will be used.
• Safeguard PHI against unauthorized access, use, and disclosure.

•HIPAA's Security Rule sets forth requirements for protecting the confidentiality,
integrity, and availability of electronic PHI (ePHI), including:
• Implementing administrative, physical, and technical safeguards to secure ePHI.
• Conducting risk assessments and implementing risk management measures to mitigate security
risks.
• Establishing policies and procedures for responding to security incidents and breaches.

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 Impact on Healthcare Organizations and
Patients' Rights

HIPAA has a significant impact on healthcare organizations and patients' rights:

 Healthcare organizations must comply with HIPAA regulations to ensure the
privacy and security of PHI, which requires investment in infrastructure,
technology, and workforce training.
 Patients have greater control over their health information and can request access
to their medical records, request amendments to their records, and file complaints
if they believe their privacy rights have been violated.
 HIPAA violations can result in civil monetary penalties, legal consequences, and
damage to an organization's reputation.
 Overall, HIPAA aims to protect patient privacy, enhance trust in the healthcare
system, and facilitate the secure exchange of health information for treatment,
payment, and healthcare operations.

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 Mental Health Parity and Addiction Equity Act
(MHPAEA)

The Mental Health Parity and Addiction Equity Act (MHPAEA) is a federal law enacted in 2008 to
ensure that health insurance coverage for mental health and substance use disorder (SUD) services is
comparable to coverage for medical and surgical services.

MHPAEA aims to eliminate disparities in coverage between mental health/SUD services and other
medical services.

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 Requirements for Parity in Mental Health and
Substance Use Disorder Coverage

MHPAEA requires group health plans and insurance issuers offering

mental health and SUD benefits to provide parity in coverage for:
 Financial requirements (e.g., deductibles, copayments, coinsurance).
 Treatment limitations (e.g., number of visits, days of coverage).

Parity must be provided for both quantitative (e.g., visit limits) and
non-quantitative (e.g., prior authorization requirements) treatment
limitations.

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 Impact on Access to Mental Health and Addiction
Treatment Services

MHPAEA has had a significant impact on improving access to mental health and
addiction treatment services:
 Increased coverage: MHPAEA ensures that mental health and SUD benefits are covered to the
same extent as medical and surgical benefits, expanding access to necessary treatments.
 Reduced financial barriers: Parity in financial requirements, such as copayments and
deductibles, reduces out-of-pocket costs for individuals seeking mental health and SUD
services.
 Expanded treatment options: Parity in treatment limitations allows individuals to access the
appropriate level of care based on medical necessity, without arbitrary restrictions.
 Improved health outcomes: Enhanced access to mental health and addiction treatment services
can lead to better health outcomes, reduced substance misuse, and improved quality of life for
individuals and families.

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 Patient Protection and Affordable Care
Enhancement Act

The Patient Protection and Affordable Care Enhancement Act is a proposed legislation aimed at
building upon the Affordable Care Act (ACA) to further expand access to affordable healthcare
coverage and reduce healthcare costs.

It seeks to address existing gaps and challenges in the healthcare system to improve healthcare delivery
and access for individuals and families.

Expanding ACA Subsidies

The legislation proposes expanding subsidies available through the Health Insurance Marketplaces to make
coverage more affordable for individuals and families with lower incomes.

This includes increasing premium subsidies and extending eligibility for subsidies to more individuals.

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Lowering Prescription Drug Costs
The bill aims to address rising prescription drug costs by implementing measures to lower prices and
improve affordability for consumers.
This may include allowing Medicare to negotiate drug prices with pharmaceutical companies and capping
out-of-pocket costs for prescription medications.
Addressing Surprise Medical Bills
The legislation seeks to protect patients from surprise medical bills, which occur when individuals receive
unexpected bills for out-of-network healthcare services.
Proposed measures may include establishing limits on out-of-network charges and requiring greater
transparency in billing practices.

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Potential Impact on Healthcare Delivery and Access
•The Patient Protection and Affordable Care Enhancement Act has the potential to have a
significant impact on healthcare delivery and access:
• Improved affordability: Expanding subsidies and lowering prescription drug costs can make
healthcare coverage and medications more affordable for individuals and families.
• Enhanced consumer protections: Addressing surprise medical bills can protect patients from
unexpected financial burdens and ensure greater transparency in healthcare billing.
• Increased access to care: By making coverage more affordable and reducing financial barriers,
the legislation may lead to increased access to essential healthcare services and preventive care.
• Strengthened healthcare system: By addressing key challenges and gaps in the healthcare
system, the legislation has the potential to strengthen the overall healthcare system and improve
health outcomes for individuals and communities.

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 Conclusion
Importance of Understanding Healthcare Policies

Understanding healthcare policies is crucial for healthcare professionals as it provides insight into the
broader context in which they deliver care.

Healthcare policies shape the healthcare system, influencing access to care, quality of care,
reimbursement, and patient outcomes.

Healthcare professionals need to be informed about healthcare policies to navigate complex

regulatory environments, advocate for patient needs, and ensure ethical and equitable care delivery.

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Importance of Advocating for Healthcare Policies

Advocating for healthcare policies is essential for promoting positive changes in the healthcare
system and addressing systemic issues that impact patient care.

Healthcare professionals are uniquely positioned to advocate for policies that prioritize patient safety,
quality of care, health equity, and access to healthcare services.

By engaging in advocacy efforts, healthcare professionals can influence policy decisions, shape
healthcare legislation, and contribute to improvements in healthcare delivery and outcomes.

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