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Health Care Insurance

The Patient Protection and Affordable Care Act (ACA) was enacted by Congress so more Americans could get, afford and keep their health care benefits.  It was intended to put consumers in charge of their own health care.

The ACA preserves accessible and affordable health insurance as both a right and an obligation for most Americans – and requires employers and health insurers to provide certain minimum essential benefits, which include:

  • Preventive Care
  • Emergency Services
  • Hospitalization
  • Maternity and Newborn Care
  • Pediatric Services
  • Mental Health and Substance Use Disorder Services
  • Prescription Drugs
  • Laboratory Services

ACA Key Features:

Coverage:

  • Ends Preexisting Condition Exclusions.  Health plans can no longer limit or deny benefits due to a preexisting condition.
  • Keeps Young Adults Covered.  Young adults under age 26 may be eligible for coverage under their parent’s health plan.
  • Stops Arbitrary Withdrawals of Insurance Coverage.  Companies cannot cancel coverage if the insured person makes a mistake.
  • Guarantees the Right to Appeal.  Consumers have the right to ask for reconsideration of insurance denials.

Costs:

  • Ends Lifetime Limits.  Lifetime limits on most benefits are banned for all new health insurance plans.
  • Reviews Premium Increases.  Insurance companies must now publicly defend any unreasonable rate hikes.
  • Helps You Get the Most Value for Your Money.  Your premium dollars must now be spent primarily on health care – not on administrative costs.

Care:

  • Preventive Care is Covered at No Cost.  You may be eligible for recommended preventive health services without a copayment.
  • Protects Your Choice of Doctors.  You may choose your own primary care doctor from your plan’s network.
  • Removes Barriers to Emergency Services.  You may seek emergency care at a hospital outside of your health plan’s network.

Before 2014, the ACA extended insurance coverage to children of insured individuals up to age 26, and eliminated preexisting condition exclusions up to age 19.  As the law’s provisions increased, the ACA extended its non-discrimination protection to insurance practices (such as preexisting conditions for adults and gender exclusions).  The ACA has:

  • Eliminated cost-sharing for individuals for preventive services.
  • Regulated unreasonable rate increases.
  • Required health insurers to provide rate refunds where their medical loss ratios show them retaining excessive amounts of premiums.
  • Transformed the legal structure for health insurance coverage for persons under age 65.

Even though the ACA made health care benefits more available to more people, this does not mean that all of the employers and health insurers who are supposed to provide extended health benefits have done so or will do so.

There have already been many court cases concerning whether some employers are exempt from the ACA’s mandated women’s contraceptive and family-planning services.  The Supreme Court is expected to hear two of those cases this term.

The ACA also provides that people may not be excluded from participating in health care programs that receive federal funding. Unfortunately, some have accused certain health insurers that receive federal funding of denying coverage to people who suffer from certain preexisting conditions, such as HIV.

The ACA is a long and complex law.  It was hundreds of pages long and has resulted in hundreds of pages more of regulations and guidance from three federal agencies who are involved in carrying out the law.  As the law in this area develops, FDPK lawyers remain committed to ensuring that all eligible individuals receive the benefits for which they are eligible under the new law. Our legal team is available to assess and to tackle new, complex legal issues, such as:

  • Insurance providers failing to pay hospitals and other providers what they are owed for their services.
  • Insurance carriers and administrators terminating or failing to renew providers’ participation agreements for illegitimate or discriminatory reasons.
  • Employees and retired workers seeking their promised health care benefits under ERISA.
  • Insurance carriers and administrators unfairly denying coverage, altering the terms of coverage, or denying reimbursement for medical services to patients and providers.
  • Women seeking coverage for medical services including contraceptive and family-planning services under their employer-provided insurance.
  • Employees seeking reasonable accommodations for their disabilities under the Americans with Disabilities Act.

For more information, review the Affordable Care Act or the White House Blog.

Partner Joel Hurt leads FDPK’s health care insurance legal team.

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Feinstein Doyle Payne & Kravec, LLC

Pittsburgh Office

429 Fourth Avenue, Suite 1300

Pittsburgh, PA 15219

Phone: +1 (412) 281-8400

Toll Free: +1 (888) 355-1735

Fax: +1 (412) 281-1007

New York Office

29 Broadway, 24th Floor

New York, NY 10006-3205

Phone: +1 (212) 952-0014