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.

Day 5: Today's Important Thing to know about Health Care Reform

One of the important things that the Affordable Care Act legislated was standardized benefits.  All policies sold going forward will have to include these benefits in order for them to be creditable. The standardized benefits are:

               Ambulatory patient services

               Emergency Services
               Maternity & newborn care
               Pediatric services including dental & vision
               Rehabilitative/habilitative services & devices
               Mental health & substance use disorder services, including behavioral health treatment
               Preventive & wellness services & chronic disease management
               Hospitalization
               Prescription Drugs
               Laboratory Services

You will notice that these standardized benefits include maternity, newborn care and pediatric services.  That means EVERYONE gets maternity benefits whether you are a 28 year old man or a 60 year old woman.  Of course, the premiums will also reflect that coverage.  One benefit of standardized benefits is that it makes it extremely easy to compare policies from different insurance carriers.  Now, you know today’s important thing about health care reform – standardized benefits.  Stay tuned for tomorrow’s important thing to know – the federally facilitated marketplace.

Day 4: Today's Important Thing to Know about Health Care Reform

 

Yesterday I mentioned “creditable” health insurance.  Today’s important thing to know is that there is no such thing as “Obamacare.”  The Affordable Care Act is a law that requires health insurance companies to comply with certain requirements in order to offer to you creditable health insurance.  These policies are offered through private insurance companies not the federal government.  The Affordable Care Act is a law not a program like Medicare.  New ACA compliant or creditable policies will offer a standardized set of benefits.  In order to make these benefit rich policies affordable, low income individuals and families will receive a tax subsidy from the federal government.  Tomorrow we will look at what the standardized benefits are.

Day 1: Today's important thing you need to know about health care reform

1.      The Patient Protection and Affordable Care Act, commonly known as Obamacare, was officially signed into law in March of 2010 and upheld by the Supreme Court.  Some parts of the law have already gone into effect like covering children up to the age of 26 and preventative exams provided at 100% on all health insurance.  A major shift occurs with the PPACA.  The primary responsibility of having health insurance shifts to the individual.  So, over the next few days, let’s keep things simple.  Each day I will give you one piece of important you need to know about Health Care Reform.