Healthcare Reform and Your Practice

  • Many Washingtonians have healthcare coverage through new individual and small group plans created to comply with the federal healthcare reform (also known as the Affordable Care Act or ACA). Healthcare reform makes federal subsidies available to qualified individuals and families to help them pay for their coverage.

    These changes may have an effect on your patients. It’s important that you and your staff understand the benefits and requirements of these new plans.

    The ACA’s new rules primarily affect people who:

    • Haven’t had coverage in the past
    • Buy their plan without going through an employer
    • Receive their coverage through a small employer

    Washington State’s Exchange is called Washington Healthplanfinder. The Exchange marketplace is one of the key components of federal healthcare reform.

    Extension of Non-Grandfathered Plans 

    On Nov. 14, 2013, President Obama announced a proposal to allow non-grandfathered members in the individual and small group markets to keep their current plans. States could choose to implement the change or not. Washington’s Office of the Insurance Commissioner (OIC) decided to not make these changes, so plan discontinuations proceeded as originally planned.

    Here are some frequently asked questions about Healthcare Reform and Exchanges.

    Frequently Asked Questions

  • Exchanges are places where patients can go to compare and purchase health plans. Patients can shop for plans online, over the phone or even in person. The Exchange is also the place to find out if a patient can qualify for a federal subsidy to help pay for their health plan.

    Many preventive services received in-network are covered with no member cost share.

    Non-grandfathered plans: Preventive Care Services

    Grandfathered plans: Preventive Screenings List

    The new law requires that some preventive services must be covered without copayments or co-insurance to meet deductibles when delivered by a network provider. This applies to all individual and small group plans that are non-grandfathered. For a list of covered preventive services under the law, please visit

    Grandfathered plans are health plans that existed before March 23, 2010 (the day the Affordable Care Act became law). They may be exempt from following certain provisions in the Affordable Care Act.

    Grandfathered plans: Preventive Screenings list

    All individual, small-group, and non-grandfathered plans (those that existed after March 23, 2010) must cover the following 10 essential health benefit categories:

    1. Ambulatory patient services
    2. Emergency services
    3. Hospitalization
    4. Maternity and newborn care
    5. Prescription drugs
    6. Rehabilitative and habilitative services and devices
    7. Laboratory services
    8. Preventive & wellness services & chronic disease management
    9. Pediatric services including oral and vision care, to age 19
    10. Mental health and substance use disorder services, including behavioral health treatment