This Pathfinder addresses the new sources of payment to acute care providers and the particular claims disputes that are likely to arise under the Affordable Care Act.
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The Affordable Care Act adds distinct groups of newly insured persons who will receive coverage under its provisions and thus generate health care claims for the providers of these services.
First, there is an expansion of Medicaid eligibility for those individuals and families with income below specified income limits. There are active challenges to the implementation of this section of the law because it does not provide for subsidization of health care exchanges operated by the federal government.
Second, there is an expansion of insurance to individuals and families who do not have access to health insurance through their employer.
Third, there is an expansion of insurance to certain individuals under the umbrella of the insurance coverage of a parent.
Fourth, there is expanded access to insurance for individuals with preexisting conditions because insurers will no longer be able to exclude coverage nor charge extra for patients with preexisting conditions.
Fifth, there is expanded access to employees of companies with 50 or more full time employees. Implementation of this feature is presently delayed until 1/1/2015.
The Patient Protection and Affordable Care Act was enacted by Public Law 111-148 of 2010, in the 111th Congress. The source bill is H.R. 3590 111 Cong.
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In Nat'l Fed'n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566 (2012), the US Supreme Court heldl that the ACA's imposition of minimum essential health insurance coverage to be invalid under the Commerce Clause but that it was a valid as a "tax" which cleared the way for states to implement insurance clearing houses for individuals to purchase health insurance policies. Nat'l Fed'n of Indep. Bus. v. Sebelius, 132 S. Ct. at 2591 and 2601 (2012).
Additionally, the Court held that the statutory provision allowing HHS to penalize whose States which did not participate in Medicaid expansion exceeded Congress's power under the Spending Clause. Id. at 2608.