ACA compliant vs. non-compliant

The Affordable Care Act (ACA) was designed to make the public responsible for their own health insurance decisions. The ACA also regulated what all individual policies have to cover. (Remember, employer plans may be different.) All ACA-compliant individual insurance plans must cover the ten essential benefits. They are:

1. Ambulatory patient services (outpatient care like going to your local doctor)
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventative and wellness services and chronic disease management
10. Pediatric services

The level to which these items are covered can be found on your summary of benefits. Knowing how to read your summary of benefits is also a part of the education process the government is hoping will happen.

Non-compliant plans will not include maternity, preventative or mental health service and usually will require either a health exam or health questions on the application. If you are asked any health questions when applying, IT IS NOT COMPLIANT. Non-compliant plans may also exclude certain conditions or not cover any pre-existing conditions.

Starting in 2019, there will no longer be a government penalty for having a non-compliant health insurance plan. The most popular non-compliant options currently in our area are plans from Tennessee Farm Bureau, faith-based sharing plans (such as Medi-Share) and short-term medical plans intended to cover gaps in coverage.

With this easing of the penalty for non-compliant plans, I believe we will see more non-compliant plans pop up. In this case, "Buyer Beware" applies. Be sure you know exactly what you are buying. What does it cover and what doesn't it cover? A good question to ask would still be "Is this plan ACA compliant?" If it is not, ask "Why not?"

I hope this helps and, as always, if you have questions call or email me.

But, the doctor's office said. . .

Occasionally, a client will tell me, "My doctor's office said it would be covered (or would not be covered) by my health insurance." I hate to burst your happiness bubble but a medical office knows about, well, medicine not insurance. I don't try to diagnose medical conditions and they should not try to advise you about what is or is not covered by your insurance policy.



Here's why: Plans differ even when offered by the same insurance company. Someone may have a Cigna plan through their employer who happens to be the State of Tennessee. That plan will differ dramatically from a Cigna plan purchased by an individual or even provided through a different, perhaps smaller employer. Also, plans differ by deductible, co-insurance, maximum out-of-pocket and whether they have out-of-network benefits or not.

Which brings us to the one thing on which the medical office can advise you -- whether they are in- network for your plan. The overwhelming reason people become unhappy with their plan is because their doctors are not in network on their particular plan and this is a BIG ONE. If your doctor is not in-network with your plan, then you will either not be covered at all when you see that doctor and you will have to pay 100% of the charges if your plan does not have out-of-network benefits. If your plan has out-of-network benefits, you will have to pay the out-of-network amount. Your doctor's office SHOULD know which networks they accept from each insurance company. Yes, every insurance company has multiple networks. If you don't know the name of the network you are on, look at your card or call your agent.

Your agent may also be able to help you know whether or not your procedure is covered by looking at the summary of benefits for your plan. (An example of a summary of benefits is shown above.) You should have received a copy of this standardized form when you received information on your plan when you enrolled. It tell you everything you need to know about YOUR plan. If there is still a question, you may need to call your insurance company at the number on the back of your card for clarification.

Help!!! I forgot to pay my health insurance bill!

We are in the brave, new world of federally-controlled heath insurance.  The Affordable Care Act allowed the federal government to set annual open enrollment periods.  During those weeks (usually in the fall of the year), you may enroll in a new health plan or change your current plan.  Outside of those few weeks a year, an individual cannot enroll in health insurance unless they have a qualifying event such as getting married, turning 26 or losing their coverage.  These open enrollment periods apply to ALL health insurance not just insurance purchased on the federal marketplace that people erroneously refer to as "Obamacare."  The only exception are plans provided through employers or government programs such as the VA or Medicare (which has its own enrollment periods).

Now, here is the problem.  If you forget to pay your health insurance bill and that plan is terminated by the insurance company, YOU CANNOT ENROLL IN ANOTHER PLAN until the annual open enrollment.  And, since you did not have coverage for a period of time as required by the federal government, you will be assessed a penalty on your tax return.

For security reasons, I don't usually recommend for a person give out their banking information.  However, paying for your HEALTH INSURANCE (and perhaps your car insurance) is a big exception!  You need for that bill to be paid first!  What if you were in an accident or some disaster happened and you were physically unable to pay your bill?  Just when you might need your health insurance the most, it could be terminated for lack of payment and you can't get it back.

So, lesson learned.  Everyone has money problems once in awhile but, with the new ACA law, paying your health insurance premiums is as serious as, well, a heart attack.

.

Day 13: Today's Important Thing to know about Health Care Reform

Today’s thing to know is about grandfathered plans.  By now, most of you should know whether your health insurance coverage through you employer is going to continue into 2014 and what it will cover.  Plans offered by your employer are considered creditable plans but may not cover the ten standardized categories mandated by the Affordable Care Act.  The reason they don’t have to cover those items is because they are grandfathered plans or plans that were in place when the law was enacted in March of 2010.  As long as the plan is not changed, it may remain as it is.  The only thing that can change is the premium.  Now, you may also be a person who has purchased their own private health insurance.  If you haven’t already, you will be receiving from your insurance carrier a letter outlining your options to continue or change your coverage for 2014.  If you need help decide what your best option may be, contact me.

Day 12: Today's Important Thing to know about Health Care Reform

Today’s important thing to know is that health care reform primarily affects health insurance for people over the age of 65.  Yes, in 2014 every American must have creditable coverage or pay a fine or tax but people over the age of 65 are generally covered by traditional Medicare or a Medicare Advantage plan.  Those plans are deemed to be creditable coverage by the Federal government so there is no reason for concern if you are covered by Medicare.  If you are a senior or know a senior, please know that all the confusion surrounding health care reform should not be a concern.  Traditional Medicare and Medicare Advantage plans are alive and well as we head toward their open enrollment period in October as well.

Day 11: Today's Important Thing to know about Health Care Reform

Today’s important thing to know is about premiums on the new ACA-compatible plans.  In previous videos, we have already covered the rich benefits that will be covered by the Affordable Care Act policies.  Some of the benefits, such as maternity and dental for children, have been benefits that were added on at an extra charge if the policyholder needed them and were willing to pay for them.  Now, those benefits are included in everyone’s premium.  Another benefit driving up premiums is the MOOP that we discussed yesterday.  Putting a cap of what you as the policyholder potentially has to pay out of pocket increases what the insurance company will have to pay.  But probably the biggest premium driver is the elimination of the pre-existing condition clause.  More claims costs mean higher premiums for everyone.  Lastly, though younger people will see a sizeable increase in premiums, perhaps as much as 30%, older Americans will be paying the same or less.  Currently health insurance companies can charge as much as five times as much for coverage of a 60 year old as a 20 year old.  The ACA limits the upcharge for age at three times.  Of course, ACA only applies to people under 65.  Don’t think the insurance companies are going to be getting rich anytime soon though.  The Affordable Care Act also capped their overall profits at 20%.  Anything over that must be refunded to their policyholders.  If you have a question you would like for me to answer, send it to me as a comment or via the contact box and I will include it in an upcoming video.

Day 10: Today's Important Thing to know about Health Care Reform

Today’s thing to know is about MOOP which stands for maximum out of pocket.  If you haven’t noticed already, the government has an acronym for everything.  I wanted to talk about MOOPs today because the first thing I heard on the news this morning was that they had been postponed for a year.  Well, the truth is, only the MOOP on a few small group plans has been postponed.  This is an example of how difficult it is to get real information about the Affordable Care Act and, I hope, is the reason you are watching this.  Anyway, back to MOOPs.  MOOPs are a very important part of the new ACA-compatible plans because they limit how much money you spend each year on your deductibles, co-pays and co-insurance.  The individual MOOP for 2014 is $6,350.  The family MOOP is $12,700.  The importance of the MOOPs is huge.  There are many people today who have a deductible higher than next year’s MOOP.  In a perfect world, you would have an emergency fund equal to the MOOP.  Imagine never having to organize a fundraising event for a friend undergoing cancer treatment and about to lose their home.  If you are one of those smart folks with an HSA account, you may already be set to cover your MOOP.  Remember to check back here tomorrow for factual up-to-the-minute information and share this with your friends.

Day 9: Today's Important Thing to know about Health Care Reform

Today’s thing to know is that the Affordable Care Act made it illegal to deny an individual health insurance based on health conditions.  That means that people with pre-existing health conditions such as diabetes, heart conditions, cancer, etc. cannot be turned down for coverage starting in 2014.  Applications for ACA-compliant health insurance policies will not include any health questions.  In the insurance world, we call this “guaranteed issue” since you cannot be denied coverage.  This provision of the Affordable Care Act will be a great benefit to many people.  Being denied due to pre-existing conditions has prevented many people from purchasing health insurance.  Getting the coverage that they need is definitely a positive.  Now, for the negative.  Covering folks with pre-existing conditions raises the dollars paid out in claims.  This will necessitate increases in insurance premiums to everyone.  Most hard hit will be younger individuals who will have to help share the burden of higher claims costs.  If you are young and make a decent income, you may want to purchase coverage prior to the implementation of ACA-compliant policies to take advantage of lower premiums. 

Day 8: Today's Important Thing to know about Health Care Reform

 

Today’s important thing to know is when will the marketplace open?  Gee, I would like an answer to that one myself.  Open enrollment is supposed to begin October 1 – just six weeks from now.  Unfortunately, there are still many questions about the government’s systems and whether they will be secure and able to handle the amount of traffic they will surely have once they are open.  The insurance companies are so nervous about the actual start date that they have postponed advertising the exchanges at this point.  So, all I can tell you is what the law says and what HHS (Health & Human Services) and CMS (Centers for Medicare & Medicaid Services) are saying.  Federally facilitated exchanges or marketplaces are supposed to open on October 1^st of 2013.  Anyone enrolling October 1 through December 31 will have a policy with an effective date of January 1, 2014.  The exchanges are scheduled to remain open until March 31^st of 2014.  Any policy purchased in January will be effective February 1 and so on.  If you do not enroll during the initial six month enrollment period, you will be locked out until open enrollment next year which will be six weeks starting on October 15^th and running until December 7^th which mirrors Medicare open enrollment.  To stay up to date, check my Facebook page at Holt Health Insurance.  Tomorrow we will talk about how you cannot be turned down for insurance.

Day 7: Today's Important Thing to know about Health Care Reform

Today’s important thing to know is about tax subsidies.  Tax subsidies or credits that will be available from the federal government to low-income individuals and families to help them pay their health insurance premiums.  The Affordable Care Act capped the percentage of income an individual can spend on health insurance at 9.5%.  To be deemed affordable, your health insurance must be no more than 9.5% of your annual income or your modified adjusted gross income from your tax return.  This cap is just for an individual.  Family coverage may, and probably will, cost more than 9.5% of your income.  Individuals and families between 100% and 400% of the federal poverty level (or approximately $45,000 for individuals and $90,000 for a family of four) will receive a federal tax subsidy or tax credit each month paid directly to their insurance company thus lower their insurance premium to the affordable level.  Calculating the tax subsidy is fairly complicated so if you have specific questions, email me via the contact box here.  Tomorrow we will talk about when the marketplace and tax subsidies begin.

Day 6: Today's Important Thing to know about Health Care Reform

Today’s thing to know is how to purchase creditable health insurance.  For people fortunate enough to have health insurance provided through an employer, not much will change except perhaps the premiums.  Most employer plans will be grandfathered for at least some period of time.  Grandfathered plans will not be required to provide the standardized benefits that we discussed yesterday.  If you provide your own health insurance or currently have no health insurance, you can purchase the new health insurance through the federally facilitated marketplace or through a public marketplace.  Tennessee opted out of having its own marketplace.  Through the federally facilitated marketplace you can purchase health insurance and, if you qualify, you can receive tax subsidies from the government to pay a portion of your premiums.  You can access these marketplaces online or via your local, FFM-certified insurance broker, like me.  Tomorrow we will discuss the tax subsidies and how you qualify.