Simple talk about Health Care Reform and How it Affects You

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Answers for your Health Insurance Plan

On March 23, 2010, The Affordable Care Act (ACA) became law. Since then there has been a flurry of discussion, attempts for appeal, an election and a Supreme Court decision. Now, there is no debate that healthcare reform will be implemented and the process is already providing consumers of healthcare additional benefits. This column will provide an overview on ACA and how it will affect you as a consumer in the healthcare marketplace. Since ACA is so extensive, this month’s column will focus on a number of the general highlights starting for people under age 65.

First, it is important to understand that there are plans considered “grandfathered”. These are employee health plans or individual health insurance plans in place prior to 3/23/2010 and have had no real changes to the coverage or, in most cases, percentage of premium paid by an employee for the plan. The second type of plan is called “non-grandfathered plans” and is any creditable medical plans issued after 3/23/2010 or if a plan has had deductible increases or a list of other changes.

Considering non-grandfathered plans: .Already in force are provisions to allow your children up to age 26 (30 if in the military) to remain covered under your healthcare plan. Further, children under age 19 will not have any pre-existing limitations. There will be no deductibles or co-pays for wellness exams and certain types of preventative exams (e.g. mammograms). It is important to understand that exams done to diagnosis or treat illness are not preventative, and deductibles and co-pays would apply. Women do not need an OBGYN referral, and as of your insurance annual renewal after 8/1/2012, contraceptives are now paid at 100%. These plans also have no essential limits; therefore a person receiving a $2.5 million lung transplant would not need to worry about exceeding their maximum coverage.

Some of you received a check from your health insurance company last fall. Individual and small group plans must pay 80% of premiums received in claims and for improved quality for their insureds. This 80%/20% is called the “medical loss ratio” (MLR) and was designed to drive insurance companies to be efficient and not just pass along expenses which are not claims related to you the consumer. The hope is that MLR will help control insurance premium costs.

Starting in October 2013, you can enroll for one of five possible plans to go into effect 1/1/2014. The Bronze plan has a cost share of 60%, Silver 70%, Gold 80%, Platinum 90% and a catastrophic plan which is only available to people up to age 30 or that are exempt. More on these plans in future months.

There has much talk about “health insurance exchanges”. Each state has the option of setting up its own exchange, use the federal government exchange or set up a partnership of the two. Navigators will be hired and trained through the exchanges to assist people enroll in plans, and they are not insurance licensed. It appears insurance agents in Illinois also will be allowed to assist people to enroll in these same plans. Your premium cost and subsidy will be the same working through an insurance agent as it would be working through a navigator.

People with incomes up to 400% of the Federal Poverty level (FPL) (e.g. a family of four is approx $88,200 – this will vary per geographic location) will qualify for a premium tax credit, financial assistance for premiums. People with income from 100% – 250% of FPL will also receive cost sharing subsidies to help them pay out of pocket costs.

ACA makes substantial changes in the whole healthcare system. See the next month’s column for information. If you have specific questions on your current health coverage contact your agent or insurance company.

Written by

Steven A. Buttice is the president of Medical Reimbursement & Management Services, Inc., a firm specializing in issues affecting seniors, including seminars and consultation on Medicare Plans, Long Term Care and other types of insurance, claims issues, and sales/service of insurance products since 1984.

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