LMG Insurance Agency, Inc.

office 847.841.3886 | fax 847.841.3848 

Affordable Care Act

Effective January 1, 2014

  • All health plans are guaranteed issue. You can not be declined health insurance coverage.
  • Everyone is required to purchase health insurance or pay a tax penalty.
  • Open enrollment is October 1, 2013 through March 31, 2014.
  • All health plans will contain Essential Health Benefits.
    • Outpatient services
      Emergency services
      Maternity and newborn care
      Mental health/substance abuse treatment
      Prescription drugs
      Rehabilitative services and devices
      Laboratory services
      Preventive services and chronic disease management
      Pediatric services, including oral and vision care
  • You may qualify for help with your insurance premium. Only Qualified Health Plans purchased through the Marketplace are eligible for tax subsidies. You may qualify if you meet the following:

Family Size    Yearly Income

1                        $45,960

2                        $62,040

3                        $78,120

4                        $94,200

5                      $110,280

6                      $126,360


January 1, 2012:  A group of 32 health care systems are piloting as ACOs (Accountable Care Organizations), a concept linking payments to outcomes, which they expect to improve the health of individuals and communities and slow cost growth. ACOs create incentives for health care providers to work together to treat a patient across care settings - including doctor's offices, hospitals, and long-term care facilities. ACOs will begin accepting a flat fee for all care for a small group of Medicare patients in an effort to reduce costs. The flat fee replaces the fee-for-service. The ACOs will be rewarded for lowering growth in health care costs while meeting performance standards on quality of care.

March 1, 2012:  To reduce persistent health disparities, including low-income Americans, racial and ethnic minorities, and other underserved populations, ongoing or new federal health program to collect and report racial, ethnic, and language data.  The Affordable Care Act will help reduce disparities by making improvements in:

  • Preventive Care. Medicare and some private insurance plans will cover recommended like regular check-ups, cancer screenings, and immunizations at no additional cost to eligible people.
  • Coordinated Care. The law calls for new investments in community health teams to manage chronic disease.
  • Diversity and cultural competency. The Affordable Care Act expands initiatives to increase racial and ethnic diversity in the health care professions and strengthens cultural competency training for all health care providers. Health plans will be required to use language services and community outreach in underserved communities.
  • Health care providers for underserved communities. The Affordable Care Act increases funding for community health centers, which provide comprehensive health care for everyone no matter how much they are able to pay.
  • Ending insurance discrimination. Insurance discrimination will be banned, so people who have been sick can't be excluded from coverage or charged higher premiums.
  • Affordable insurance coverage. A new health insurance marketplace will be created in 2014 offering one-stop shopping so individuals can compare prices, benefits, and health plan performance on easy-to-use websites. The new law also provides tax credits to help more Americans pay for insurance.

March 26, 2012:  The Supreme Court is scheduled to hear oral arguments on the Affordable Care Act.

October 1, 2012:  Linking Payment to Quality Outcomes. A hospital "Value-Based Purchasing program (VBP) in Original Medicare offering financial incentives to hospitals to improve the quality of care. Hospital performance is required to be publicly reported, beginning with measures relating to heart attacks, heart failure, pneumonia, surgical care, health-care associated infections, and patients' perception of care. The hospital will also be penalized for patients that are readmitted for a complication that could have been prevented.

October 1, 2012:  Reducing Paperwork and Administrative Costs. Standardized billing and health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information.

December 31, 2012:  The health exchange deadline. The health insurance exchanges are expected to go live in 2014. If the states cannot certify with the administration by the end of this year, the feds will do it themselves.


Affordable Care Act Ensures Women Receive Preventive Services at No Additional Cost

August 1, 2011

Historic new guidelines that will ensure women receive preventive health services at no additional cost were announced today by the U.S. Department of Health and Human Services (HHS). Developed by the independent Institute of Medicine, the new guidelines require new health insurance plans to cover women’s preventive services such as well-woman visits, breastfeeding support, domestic violence screening, and contraception without charging a co-payment, co-insurance or a deductible.

“The Affordable Care Act helps stop health problems before they start,” said HHS Secretary Kathleen Sebelius. “These historic guidelines are based on science and existing literature and will help ensure women get the preventive health benefits they need.”

Before health reform, too many Americans didn’t get the preventive health care they need to stay healthy, avoid or delay the onset of disease, lead productive lives, and reduce health care costs. Often because of cost, Americans used preventive services at about half the recommended rate.

Last summer, HHS released new insurance market rules under the Affordable Care Act requiring all new private health plans to cover several evidence-based preventive services like mammograms, colonoscopies, blood pressure checks, and childhood immunizations without charging a copayment, deductible or coinsurance. The Affordable Care Act also made recommended preventive services free for people on Medicare.

Today’s announcement builds on that progress by making sure women have access to a full range of recommended preventive services without cost sharing, including:

  • well-woman visits;
  • screening for gestational diabetes;
  • human papillomavirus (HPV) DNA testing for women 30 years and older;
  • sexually-transmitted infection counseling;
  • human immunodeficiency virus (HIV) screening and counseling;
  • FDA-approved contraception methods and contraceptive counseling;
  • breastfeeding support, supplies, and counseling; and
  • domestic violence screening and counseling.

New health plans will need to include these services without cost sharing for insurance policies with plan years beginning on or after August 1, 2012. The rules governing coverage of preventive services which allow plans to use reasonable medical management to help define the nature of the covered service apply to women’s preventive services. Plans will retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost-sharing for branded drugs if a generic version is available and is just as effective and safe for the patient to use.

The administration also released an amendment to the prevention regulation that allows religious institutions that offer insurance to their employees the choice of whether or not to cover contraception services. This regulation is modeled on the most common accommodation for churches available in the majority of the 28 states that already require insurance companies to cover contraception. HHS welcomes comment on this policy.

Previously, preventive services for women had been recommended one-by-one or as part of guidelines targeted at men as well. As such, the HHS directed the independent Institute of Medicine to, for the first time ever, conduct a scientific review and provide recommendations on specific preventive measures that meet women’s unique health needs and help keep women healthy. HHS’ Health Resources and Services Administration (HRSA) used the IOM report issued July 19, when developing the guidelines that are being issued today. The IOM’s report relied on independent physicians, nurses, scientists, and other experts to make these determinations based on scientific evidence.

Today’s announcement is another part of the Obama Administration’s broader effort to address the health and well-being of our communities through initiatives such as the President’s Childhood Obesity Task Force, the First Lady’s Let’s Move! campaign, the National Quality Strategy, and the National Prevention Strategy.

For more information on the HHS guidelines for expanding women’s preventive services, please visit: http://www.healthcare.gov/news/factsheets/womensprevention08012011a.html. The guidelines can be found at: www.hrsa.gov/womensguidelines/.

Effective January 1,  2011

  • No pre-tax reimbursements from health account for non-prescribed, over-the-counter medication
  • 20% tax for nonqualified HSA withdrawals
  • Reporting the value of employer-sponsored coverage on W-2s
  • Automatic enrollment in new long-term care program with ability for employees to opt out

Preventive Services Covered under the Affordable Care Act

If you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, the following preventive services must be covered without your having to pay a copayment or coinsurance or meet your deductible, when these services are delivered by a network provider.

Covered Preventive Services for Adults

  • Abdominal Aortic Aneurysm:  One-time screening for men of specified ages who have ever smoked
  • Alcohol Misuse screening and counseling
  • Aspirin use for men and women of certain ages
  • Blood pressure screening for all adults
  • Cholesterol screening for adults of certain ages or at higher risk
  • Colorectal Cancer screening for adults over 50
  • Depression screening for adults
  • Type 2 Diabetes screening for adults with high blood pressure
  • Diet counseling for adults at higher risk for chronic disease
  • HIV screening for all adults at higher risk
  • Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:
    • Hepatitis A
    • Hepatitis B
    • Herpes Zoster
    • Human Papillomavirus
    • Influenza
    • Measles, Mumps, Rubella
    • Meningococcal
    • Pneumococcal
    • Tetanus, Diphtheria, Pertussis
    • Varicella
  • Obesity screening and counseling for all adults
  • Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  • Tobacco Use screening for all adults and cessation interventions for tobacco users
  • Syphilis screening for all adults at higher risk

Covered Preventive Services for Women, Including Pregnant Women

  • Anemia screening on a routine basis for pregnant women
  • Bacteriuria urinary tract or other infection screening for pregnant women
  • BRCA counseling about genetic testing for women at higher risk
  • Breast Feeding interventions to support and promote breast feeding
  • Cervical Cancer screening for sexually active women
  • Chlamydia Infection screening for younger women and other women at higher risk
  • Folic Acid supplements for women who may become pregnant
  • Gonorrhea screening for all women at higher risk
  • Hepatitis B screening for pregnant women at their first prenatal visit
  • Osteoporosis screening for women over age 60 depending on risk factors
  • Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  • Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
  • Syphilis screening for all pregnant women or other women at increased risk

Covered Preventive Services for Children

  • Alcohol and Drug use assessments for adolescents
  • Autism screening for children at 18 and 24 months
  • Behavioral assessments for children of all ages
  • Cervical Dysplasia screening for sexually active females
  • congenital Hypothyroidism screening for newborns
  • Developmental screening for children under age 3, and surveillance throughout childhood
  • Dyslipidemia screening for children at higher risk of lipid disorders
  • Fluoride Chemoprevention supplements for children without fluoride in the water source
  • Gonorrhea preventive medication for the eyes of all newborns
  • Hearing screening for all newborns
  • Height, Weight and Body Mass Index measurements for children
  • Hematocrit or hemoglobin screening for children
  • Hemoglobinopathies or sickle cell screening for newborns
  • HIV screening for adolescents at higher risk
  • Immunization vaccines for children from birth to age 18 -- doses, recommended ages, and recommended populations vary:
    • Diphtheria, Tetanus, Pertussis
    • Haemophilus influenzae type b
    • Hepatitis A
    • Hepatitis B
    • Human Papillomavirus
    • Inactivated Poliovirus
    • Influenza
    • Measles, Mumps, Rubella
    • Meningococcal
    • Pneumococcal
    • Rotavirus
    • Varicella
  • Iron supplements for children ages 6 to 12 months at risk for anemia
  • Lead screening for children at risk of exposure
  • Medical History for all children throughout development
  • Obesity screening and counseling
  • Oral health risk assessment for young children
  • Phenylketonuria (PKU) screening for this genetic disorder in newborns
  • Sexually transmitted Infection (STI) prevention counseling for adolescents at higher risk
  • Tuberculin testing for children at higher risk of tuberculosis
  • Vision screening for all children

Additional Benefits Effective September 23, 2010

  1. Extending Coverage for Young Adults -- Under the new law, young adults will be allowed to stay on their parent's plan until they turn 26 years old. (In the case of existing group health plans, this right does not apply if the young adult is offered insurance at work.)
  2. Providing Free Preventive Care -- All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Depending on your age and health plan type, you may have easier access to such services as:
    1. Blood pressure, diabetes, and cholesterol tests
    2. Many cancer screenings
    3. Counseling from your health care provider on such topics as quitting smoking, losing weight, eating better, treating depression, and reducing alcohol use
    4.  Routine vaccines for diseases such as measles, polio, or meningitis
    5. Flu and pneumonia shots
    6. Counseling, screening and vaccines for healthy pregnancies
    7. Regular well-baby and well-child visits, from birth to age 21
  3. Prohibiting Insurance Companies from Rescinding Coverage
  4. Appealing Insurance Company Decisions--provides consumers with a way to appeal coverage determinations or claims to their insurance company, and establishes an external review process.
  5. Eliminating Lifetime Limits on Insurance Coverage
  6. Regulating Annual Limits on Insurance Coverage--Insurance Companies' use of annual dollar limits on the amount of insurance coverage a patient may receive will be restricted for new plans in the individual market and all group plans. In 2014, the use of annual dollar limits on essential benefits like hospital stays will be banned for new plans in the individual market and all group plans.
  7. Prohibiting Denying Coverage of Children Based on Pre-Existing Conditions under the age of 19.
  8. Holding Insurance Companies Accountable for Unreasonable Rate Hikes.
  9. Rebuilding the Primary Care Workforce.
  10. Preventing Disease and Illness--A new $15 billion Prevention and Public Health Fund will invest in proven prevention and public health programs that can help keep Americans healthy - from smoking cessation to combating obesity.
  11. Strengthening Community Health Centers--New funding to support the construction of and expansion of services at community health centers, allowing these centers to serve some 20 million new patients across the country.
  12. Payments for Rural Health Care Providers.


May 17, 2010

Key Facts about New Guidance on the Small Business Health Care Tax Credit

  • Provides detailed information to make it easier for small businesses to determine they are eligible and how large a credit they will receive.
  • Resolves a number of key implementation issues in ways that allow employers to receive the maximum credit available under the law.
  • Clarifies that a business's credit will not be reduced because the business also receives a health care tax credit or subsidy from a state.
  • Allows small businesses to receive the credit not only for regular health insurance but also for add-on dental, vision, and other limited-scope health insurance coverage.



  1. SMALL BUSINESS TAX CREDITS--Offers tax credits to small businesses to make employee coverage more affordable. Tax credits of up to 35 percent of premiums will be available to firms that choose to offer coverage. Effective beginning calendar year 2010. (Beginning in 2014, the small business tax credits will cover 50 percent of premiums.)
  2. NO DISCRIMINATION AGAINST CHILDREN WITH PRE-EXISTING CONDITIONS--Prohibits new health plans in all markets plus grandfathered group health plans from denying coverage to children with pre-existing conditions. Effective 6 months after enactment. (Beginning in 2014, this prohibition would apply to all persons.)
  3. HELP FOR UNINSURED AMERICANS WITH PRE-EXISTING CONDITIONS UNTIL EXCHNAGE IS AVAILABLE (INTERIM HIGH-RISK POOL)--Provides access to affordable insurance for Americans who are uninsured because of a pre-existing condition through a temporary subsidized high-risk pool. Effective in 2010.
  4. ENDS RESCISSIONS--Bans insurance companies from dropping people from coverage when they get sick. Effective 6 months after enactment.
  5. BEGINS TO CLOSE THE MEDICARE PART D DONUT HOLE--Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010. Effective for calendar year 2010. (Beginning in 2011, institutes a 50% discount on prescription drugs in the donut hole; also completely closes the donut hole by 2020.)
  6. FREE PREVENTIVE CARE UNDER MEDICARE--Eliminates co-payments for preventive services and exempts preventive services from deductibles under the Medicare program. Effective beginning January 1, 2011.
  7. EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS' INSURANCE--Requires new health plans and certain grandfathered plans to allow young people up to their 26th birthday to remain on their parents' insurance policy, at the parents' choice. Effective 6 months after enactment.
  8. HELP FOR EARLY RETIREES--Creates a temporary re-insurance program (until the Exchanges are available) to help offset the costs of expensive premiums for employers and retirees for health benefits for retirees age 55-64. Effective in 2010.
  9. BANS LIFETIME LIMITS ON COVERAGE--Prohibits health insurance companies from placing lifetime caps on coverage. Effective 6 months after enactment.
  10. BANS RESTRICTIVE ANNUAL LIMITS ON COVERAGE--Tightly restricts the use of annual limits to ensure access to needed care in all new plans and grandfathered group health plans. These tight restrictions will be defined by HHS. Effective 6 months after enactment. (Beginning in 2014, the use of any annual limits would be prohibited for all new plans and grandfathered group health plans.)
  11. FREE PREVENTIVE CARE UNDER NEW PRIVATE PLANS--Requires new private plans to cover preventive services with no co-payments and with preventive services being exempt from deductibles. Effective 6 months after enactment.
  12. NEW, INDEPENDENT APPEALS PROCESS--Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan. Effective 6 months after enactment.
  13. ENSURES VALUE FOR PREMIUM PAYMENTS--Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders. Effective on January 1, 2011.
  14. COMMUNITY HEALTH CENTERS--Increases funding for community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years. Effective beginning in fiscal year 2011.
  15. INCREASES THE NUMBER OF PRIMARY CARE PRACTITIONERS--Provides new investments to increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, and physician assistants. Effective beginning in fiscal year 2011.
  16. PROHIBITS DISCRIMINATION BASED ON SALARY--Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher way employees. Effective 6 months after enactment.
  17. HEALTH INSURANCE CONSUMER INFORMATION--Provides aid to states in establishing offices of health insurance consumer assistance in order to help individuals with the filing of complaints and appeals. Effective beginning in fiscal year 2010.
  18. HOLDS INSURANCE COMPANIES ACCOUNTABLE FOR UNREASONABLE RATE HIKES--Creates a grant program to support States in requiring health insurance companies to submit justification for all requested premium increases, and insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new Health Insurance Exchanges. Starting in plan year 2011.

Related Links

Employer Coverage Tool