Obamacare: Questions and Confusion

Posted by

What are your questions and concerns about the Affordable Healthcare Act (Obamacare)?

 

The end of open enrollment for ACA (Obamacare) health insurance plans is February 15th.  To make a statement that everyone totally understands these insurance plans, how the tax credits (or subsidies), and the cost sharing work would be absurd.  So, this column will address some of the common misconceptions and problems encountered.

People may buy on the marketplace (also called exchange) or off the exchange.  In either case, you pay a set amount of premium which is not higher (or lower) whether or not you use an agent.  Navigations and the 800# phone number to the marketplace are convenient to answer questions about the process of application and enrollment, but they are prohibited to answer coverage questions.

So, what is actually happening?  People have enrolled in plans not covering their doctors.  Some plans pays 50%, or less, if you go out of the network of doctors contracted with that specific plan.  Your out of pocket costs out of network can be unlimited.   This can be an expense mistake.

Some plans only pay for two doctor’s visits prior to paying your deductible.  Other plans have a limit of 6 visits; some plans may allow unlimited doctor’s visits prior to reaching the deductible.  Other plans do not pay for doctor’s visits until the deductible has been reached.

Drugs are a key component of treatment in today’s world.  Insurance companies have a list of covered drugs that they call formulary drugs.  Prescriptions not covered are called non-formulary.  There is a process to ask a company to cover a non-formulary drug.  As of today, at least one company will probably not allow for any non-formulary drugs to be covered, even with proper request by formulary exception.  It is important to review your prescriptions with any insurance companies considered.  Cheapest is not always best.  Less cost policies may have a smaller formulary list.  Do you think your health may ever change?

Of course, deductibles and out of pockets cost limits are different plan to plan.  Plans can range from catastrophic coverage to platinum coverage (actuarially 90% coverage).  The norm today has become a $6,000+ deductible.  Some plans are available with as little as no deductible.  Maximum out of pocket maximums could be $6,600 to $1,500.  Your company and premium paid will have a direct effect on your plan design.

Sometimes people’s incomes have fluctuate; especially for the self employed or commissioned employee.  People may be receiving a subsidy (tax credit) to help pay premiums.  Due to changes in income, these people may need to pay back a portion or all of any subsidies received.  Watch the news in March and April and see if this becomes an issue.

A larger problem yet may be issues surrounding cost sharing.  Cost sharing where ACA picks up some of the deductible and out of pocket costs for people with incomes higher than 138% of the federal poverty level (FPL), but below 250% of the FPL  (e.g. family of four $32,499 to $58,874).  If people receiving cost sharing have income that changes up or down, the IRS may adjudicate that the people/person owes the cost sharing benefits used back to the ACA.

Mostly, understand that the ACA is vastly inconstant company to company; and company plan to company plan.  This all means you have options.  Options are good, but can be confusing.  Most people should ask for professional assistance from an ACA certified health insurance agent.  As always, feel free to contact our office if you have questions at 309-693-1060.

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.

Comments are closed.