1. Overview of the Patient Protection
and Affordable Care Act (PPACA)
Adapted from a presentation given Saturday, November 6, 2010
to the Illinois Psychological Association
Doug Walter, J.D.,
Counsel for Legislative and Regulatory Affairs, Government Relations, Practice
Organization, American Psychological Association

2. National Health Reform Landmarks
and Developments—2000s
• 2003—The Medicare Modernization Act adds a
prescription drug benefit to Medicare.
• 2006—The Health Insurance Marketplace Modernization
Act (HIMMA) to exempt small business coverage from most
state insurance laws defeated.
• 2009—The Health Insurance Technology for Economic and
Clinical Health Act (HITECH) enacted to encourage a
national electronic health records system.
• 2010—The Patient Protection and Affordable Care Act
(PPACA) enacted to reform the national healthcare system.

3. Patient Protection and Affordable Care
Act (PPACA)—The 20,000 Foot View
Among other things, PPACA provides for:
New delivery systems
Market reforms
New insurer requirements
Tax law changes
Medicare and Medicaid reforms
Children’s and special populations’ reforms
New patient care models
Rural protections
Hospital and nursing home reforms
Prevention initiatives
Health care workforce initiatives
Quality reporting
Health research initiatives
Revenue provisions
And more

4. Many requirements do not fundamentally
alter the health care system
• Rather than providing coverage to all through a single
system, PPACA expands coverage through various targeted
initiatives.
• Instead of requiring integrated care throughout the system,
PPACA tests the concept through demonstration programs.
• Medicare and Medicaid are not transformed; rather, the
programs are expanded with technical issues addressed.
For example:

5. PPACA—From Pledge to Enactment
Image courtesy newsone.com
Feb. 24, 2009: Pres. Obama pledges reform in his 1st address to Congress.
March 5, 2009: The White House holds its first health care summit.
April 21, 2009: Senate Finance Committee begins roundtable discussions to
formulate a reform bill.
July 15, 2009: Senate Health, Education, Labor & Pensions Committee approves
its version of the health bill.
July 31, 2009: House Energy & Commerce is the third House committee, after
Education & Labor and Ways & Means,
to approve its version of health bill.
Oct. 13, 2009: Senate Finance
Committee approves its version.
Nov. 7, 2009: House passes the
Affordable Health Care for America Act
(H.R. 3962).

6. PPACA—From Pledge to Enactment
continued
Dec. 24, 2009: Senate passes the Patient Protection and Affordable Care Act
(H.R. 3590).
March 21, 2010: House passes PPACA and the Health Care and Education
Reconciliation Act.
March 23, 2010: President Obama signs PPACA.
March 25, 2010: The Reconciliation Act passes Senate with PPACA amendments.
The House agrees.
March 30, 2010: President Obama signs The
Reconciliation Act.
Image courtesy culturemap.com

7. APAPO’s Health Care Reform Priorities
1. Integrate mental/behavioral health with other health services.
2. Ensure access to mental/behavioral health prevention and
wellness services.
3. Develop and maintain a diverse psychology workforce.
4. Ensure access to psychologists’ services in benefit plans.
5. Eliminate disparities in mental health status and care.
6. Increase funding for basic and translational psychological and
behavioral research and training.
7. Include strong privacy protections in the development of health
information technology.
8. Enhance involvement of psychologists with consumers, families
and caregivers.

8. Details of PPACA
Three main parts/accomplishments:
• Expands Coverage
 Builds on employer based system through individual mandate and employer
mandate
 Health benefits exchanges
 Expansion of CHIP and Medicaid
 Targeted initiatives
• Provides Market Reforms and Patient
Protections
• Transforms the Underlying Delivery System

9. Details of PPACA: Expands Coverage
Individual mandate: Beginning 2014,
most U.S. citizens and legal residents
are required to have “minimum
essential coverage” or pay a tax
penalty.
Employer mandate: Effective 2014,
employers with 50 or more
employees that do not offer
essential minimum coverage must
pay a fee of $2,000 per employee,
excluding the first 30 employees.

10. Details of PPACA: Expands Coverage
Health Benefits Exchanges
Effective 2014, individuals without employer coverage, those opting out of
their employer coverage, and small employers (with under 100 employees)
may purchase coverage through a Health Benefits Exchange.
Essential benefits:
• preventive services rated A or B by the U.S. Preventive Services Task Force
• recommended immunizations
• preventive care for infants, children and adolescents
• additional preventive care and screenings for women.
Wellstone-Domenici Mental Health Parity and Addiction Equality Act (MHPAEA):
• MHPAEA means that financial requirements and treatment limitations for mental
health and substance use disorder benefits in qualified plans can be no more
restrictive than the requirements and limitations placed on medical/surgical
benefits.

11. Details of PPACA:
Expansion of CHIP and Medicaid
Image courtesy bannerhealth.com
Medicaid:
• Expanded to eligible individuals at or below 133% of the
federal poverty level.
• Mental health services must now be included as basic services,
rather than optional services in benchmark equivalent plans.
CHIP:
• Extended through 2015.
• Beginning in 2015, states will receive an increase in the federal
match rate up to 100%.
• States must maintain current income eligibility levels for children
in Medicaid and CHIP until 2019.
• CHIP-eligible children who are unable to enroll in the program
due to enrollment caps will be eligible for tax credits in state
Exchanges.

12. Targeted Initiatives to Expand Coverage
Details of PPACA: Expands Coverage
• Coverage of dependent children expanded- Age limit for
unmarried children raised to 26 years for all individual and
group health plans (including grandfathered plans).
• Reinsurance program beginning January 1, 2014 will provide
health coverage to retirees over age 55 who are not eligible for
Medicare. The program will reimburse employers for 80% of
retiree claims between $15,000 and $90,000.
• Funding for community health center National Health Service
Corps will be increased over five years beginning in 2011.
• Additional support provided for school-based health centers
and nurse-managed health clinics.

13. Details of PPACA: Market Reforms
and Patient Protections
Coverage
• Requires group and individual health plans to accept all employers and
individuals that apply for coverage and to renew coverage.
• Health plans may not establish eligibility rules based on health status
factors, including medical condition, claims experience, medical history,
and evidence of insurability.
• Health plans may not rescind coverage except in cases of fraud.
• Preexisting condition exclusions applied to children are prohibited
beginning September 23, 2010, and those applied to adults are
prohibited beginning January 1, 2014.
• Coverage waiting periods are limited to 90 days.
Premiums
• Premium rating may vary only by age (limited to a 3 to 1 ratio), rating
area, family composition, and tobacco use (1.5 to 1 ratio) in the
individual and group market and in the Exchange.
• Health plans must report to HHS the proportion of premium dollars
spent on clinical services and quality improvement, and provide a rebate
to enrollees if the amount of the enrollees’ premium spent on clinical
services and quality is less than 85% (large group) 80% (small group and
individual).
• Health plans must justify unusual premium increases. A state may
recommend to HHS that a health plan be excluded from its Exchange
based on unjustifiable premium increases.
Patient Cost-Sharing
• Deductibles for small group market health plans are limited to $2,000
individual/$4,000 family unless contributions are offered that offset
deductible amounts above these limits.
• Out-of-pocket limitations are imposed for individuals enrolled in
qualified health plans whose income is between 100-400% of the FPL.
• Group and individual health plans (including grandfathered plans) may
not place annual or lifetime limits on essential benefits coverage. HHS
determines what limits are acceptable prior to 2014.
Other Patient Protections
• Health plans must implement an effective process for coverage claims
and appeals.
• Health provider nondiscrimination—Prohibits health plans from
discriminating against health professionals from plan participation.
• Grants are provided to states to expand or establish ombudsman or
consumer assistance programs.

14. Details of PPACA: Transforms the
Underlying Delivery System
• Insurance Coverage Changes
• Promoting Primary and Integrated Care
• Prevention and Wellness
• Improving Quality
• Long-term Care
• Workforce

15. Promoting Primary and Integrated Care –
Private Healthcare System
• A new HHS demonstration program will provide grants to
eligible entities to establish community-based
interdisciplinary health teams to support primary care
practices and patient-centered medical homes.
Psychologists may participate in these health teams.
• A new community-based Collaborative Care Network
Program will support consortia of health providers,
including psychologists, to coordinate and integrate health
care services for low-income uninsured and underinsured
populations.
Details of PPACA: Transforms the
Underlying Delivery System

16. Details of PPACA: Transforms the
Underlying Delivery System
Prevention and Wellness—Targeted Initiative
• An HHS Preventive Services Task Force will review scientific
evidence related to effectiveness and cost-effectiveness of clinical
preventive services for the purpose of developing community
healthcare recommendations.
• A prevention and health promotion and education campaign to
raise public awareness of health improvement across life-span.
• A grant program to explore the delivery of evidence-based and
community-based prevention and wellness services to address
chronic disease rates and health disparities, especially in
rural/frontier areas.
• An Institute of Medicine conference on pain in order to increase the
recognition of pain as a significant public health problem.
• New funding for child obesity demonstration projects.

17. Details of PPACA: Transforms the
Underlying Delivery System
Improving Quality—Medicare Payment Reform
• Medicare value-based incentive payments will be made to hospitals that
meet specified performance standards.
• Hospitals will be subject to a Medicare payment adjustment penalty for
high rates of hospital acquired conditions.
• Medicare physician incentive payments under the quality reporting system
are extended; a penalty is imposed for unsatisfactory reporting (in 2015).
• HHS will establish a value-based payment modifier under the physician fee
schedule based on a quality to cost ratio.
• Long-term care hospitals, inpatient rehabilitation hospitals, and hospices,
starting 2014, will be required to submit data on specified quality measures.
• HHS will develop a plan to implement value-based purchasing for Medicare
payments for skilled nursing facilities, home health agencies and
ambulatory surgical centers.

18. PPACA—Implementation Timeline
By 2010:
• Review of Health Plan Premium
Increases
• Changes in Medicare Provider
Rates
• Medicaid and CHIP Payment
Advisory Commission
• Comparative Effectiveness
Research
• Prevention and Public Health
Fund
• Small Business Tax Credits
• Coordinating Care for Dual
Eligibles
• Medicaid Coverage for Childless
Adults
• Reinsurance Program for
Retiree Coverage
• Pre-existing Condition Insurance
Plan
• New Prevention Council
• Consumer Website
• Adult Dependent Coverage to Age
26
• Consumer Protections in
Insurance (prohibits lifetime
limits, rescinding coverage,
denying children coverage for pre-
existing conditions, restricts
annual limits)
• Insurance Plan Appeals Process
• Coverage of Preventive Benefits
• Health Centers and the National
Health Service Corps
• Health Care Workforce
Commission
• Medicaid Community-based
Services

19. PPACA—Implementation Timeline
By 2011:
• Minimum Medical Loss
Ratio for Insurers
• Medicare Payments for
Primary Care
• Medicare Prevention
Benefits
• Center for Medicare and
Medicaid Innovation
• Medicare Premiums for
Higher-Income
Beneficiaries
• Medicaid Health Homes
• Chronic Disease
Prevention in Medicaid
• Long-term Care CLASS Act
• National Quality Strategy
• Grants to Establish Wellness
Programs
• Teaching Health Centers
• Medical Malpractice Grants
• Funding for Health Insurance
Exchanges
• Graduate Medical Education
• Medicare Independent
Payment Advisory Board
• Medicaid Long-term Care
Services

20. PPACA—Implementation Timeline
By 2012:
• Accountable Care Organizations in Medicare
• Medicare Independence at Home Demonstration
• Medicare Provider Payment Changes
• Fraud and Abuse Prevention
• Medicaid Payment Demonstration Projects
• Health Care Disparities Data Collection

21. PPACA—Implementation Timeline
By 2014:
• Expanded Medicaid
Coverage
• Individual Requirement to
Have Insurance
• Free Choice Vouchers
• Health Insurance Exchanges
• Health Insurance Premium
and Cost Sharing Subsidies
• Guaranteed Availability of
Insurance
• No Annual Limits on
Coverage
• Essential Health Benefits
• Multi-State Health Plans
• Temporary Reinsurance
Program for Health Plans
• Basic Health Plan
• Employer Requirements
• Wellness Programs in
Insurance
• Fees on Health Insurance
Sector
• Medicare Independent
Payment Advisory Board
Report

22. PPACA—What to Expect in the coming months?
Lots of regulations to implement the statute.

23. PPACA—What to expect in the coming months?
With larger Republican Congressional caucus, there
could be calls for repeal or attempts to amend the law.

24. Additional Resources
• APA Practice Central:
http://www.apapracticecentral.org/advocacy/refor
m/patient-protection.aspx
• The Henry J. Kaiser Family Foundation:
http://healthreform.kff.org/
• Official Government Site:
http://www.healthcare.gov/

25. Doug Walter, J.D.
Legislative and Regulatory Counsel
Government Relations
Practice Organization
American Psychological Association
750 First St., N.E.
Washington, DC 20002-4242
(202) 336-5889
(202) 336-5797 (fax)
dwalter@apa.org
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