Affordable Care Act Expert Witness

Michael Arrigo expert witness in Federal State and Civil Courts on ACA, HIPAA, Healthcare costs in malpractice and personal injury, False Claims Act cases involving Medicare Advantage and Electronic Health Records.  CONTACT

Affordable Care Act expert witness capabilities should include a thorough understanding of both fee for service medicine and value based care.  Insurance coverage and the shifts in cost for care under the Affordable Care Act should be considered depending on the type of legal matter.

In some cases, medical malpractice litigation leads to an estimate of costs in a life care plan, or other recurring medical costs such as pain management.  A medical professional can prescribe the type of care required in a life care plan, and an expert witness with experience in both Usual Customary and Reasonable costs for care as well as the Affordable Care Act may assist in arriving at an opinion regarding the cost of care over time.

Required Competencies of an Affordable Care Act Expert Witness who Opines Regarding Insurance Coverage or the Cost of Medical Care

Finding an expert witness who opines regarding the benefits available to an injured party, the actuarial value of the plan, the benefits available and the cost of medical care should have a grasp of some important concepts. Cost of care considerations under the ACA may include but not be limited to:

  1. out of pocket maximum (OOPM) costs,
  2. Medicaid Expansion availability and the benefits available in the state where the plaintiff resides, based on individual or household income with respect to the Federal Poverty Level (FPL),
  3. subsidies and premium tax credits in marketplace plans
  4. actuarial considerations and benefits provided by ‘metal’ plans (bronze, silver, platinum) See note below.
  5. plans available in the community where a plaintiff resides on Insurance Exchanges.
  6. health care provider networks available where the plaintiff resides in the community
  7. Americans with Disabilities Act (ADA) considerations as set forth in the Affordable Care Act and medical specialist availability in the community
  8. ‘Dual eligibles’ addressing those who are or may be eligible for both Medicare and State Medicaid

It is important for the expert to provide details on the basis for their assumptions with respect to the ACA and may also be important to contrast the cost versus fee for service medicine.


The Affordable Care Act required that for 2014 forward, individuals and small businesses insurance purchased either via a marketplace Exchange off exchange must meet one of four actuarial value levels: Bronze plans at 60%, Silver plans at 70%, Gold plans at 80% and Platinum plans at 90%.  Actuarial value is a measure of the coverage and benefits a health plan provides in a standardized population.

Section 1557 of the Patient Protection and Affordable Care Act (ACA), requires that an individual is not excluded from participating in, denied benefits because of, or subjected to discrimination as prohibited under Section 504 of the Rehabilitation Act of 1973 (disability), under any health program or activity, any part of which is receiving federal financial assistance, or under any program or activity that is administered by an Executive Agency or any entity established under Title I of the Affordable Care Act or its amendments.

See also:

Knox-Keene Act and California Insurance Regulations