The Affordable Care Act – a health care insider tells all

The government’s shut down.  But the Health Care Insurance Exchanges are open and that means all you uninsured theater artists and professionals can sign up for health insurance.

And we’re talking health insurance that you can probably afford and that contains more ample and complete benefits than you have had in the past.  And you may be eligible for government subsidies that will make the cost even cheaper. Medicaid requirements have also been expanded under the Affordable Care Act (ACA) so more people may qualify for Medicaid than ever before.

There really is no reason now for you to go uninsured or to use the most expensive care around—the emergency room—for your routine health care needs.

A little background

When I am not a theater critic I work in the health insurance industry for a major carrier and one of my responsibilities is to communicate about the ACA—also known as Health Care Reform or “Obamacare”—and Lorraine Treanor, the DC Theatre Scene guru, asked me to explain some of the changes and why ACA is a good thing.

Debunking the myths

• The ACA was passed in 2010 and many of the mandates, including no-cost Preventive Services for adults and children, and parents being able to keep their children on their plan until they are age 26 have already gone into effect.  So the October 1 date is not when the entire ACA act becomes law—most notably, on this date the Individual Mandate begins to ramp up for an effective date of January 1, 2014.

The ACA includes a mandate for most individuals to have health insurance or potentially pay a penalty tax for noncompliance. The penalty is the greater of: For 2014, $95 per uninsured person or 1 percent of household income over the filing threshold; for 2015, $325 per uninsured person or 2 percent of household income over the filing threshold; and for 2016 and beyond, $695 per uninsured person or 2.5 percent of household income over the filing threshold.

• Some aspects of the ACA are funded by fees and taxes levied on employers and insurance carriers. These fees and taxes kicked in earlier in 2013 and are already being paid to the feds. The monies to fund ACA have already been appropriated, which makes the government shutdown largely a symbolic (and greatly destructive) gesture.

I repeat – the government shutdown will not dismantle Obamacare. The health insurance Exchanges are open and ready for business.

A couple of important things to know up front

• The health insurance Exchanges opened October 1, which means you can shop now for health insurance and find the best plan for you. The benefit plan you choose will go into effect January 1, 2014.
• Fear not if you were turned down for health insurance before. As of October 1, you cannot be turned down or pay more because of pre-existing conditions. This means you don’t have to lie about your depression or sciatica or pay through the nose because you had a hang-nail in 1998. There is no more medical underwriting for individual and small group health care policies—none. Nada. Gone the way of the dodo.
• Similarly, stop believing that health insurance is only for the Jeff Besos of the world. That’s not true anymore. There are policies on the Exchange that give you coverage for about $150-$200 a month if you are under 30, a nonsmoker and in good health.  That’s latte money. And not much more expensive than the penalty you would pay in 2014 for not having insurance—which is $95 and goes up considerably every year (nearly $700 in 2015) you go uninsured.
• Depending on the carrier, you may have to pay for the first month of coverage when you sign up, even though the coverage goes into effect January 1.

Health Exchange Websites

Go on these sites—depending on where you live—and shop for health care:

• Maryland: www.marylandhbe.com
• DC: https://www.dchealthlink.com/
• Virginia: http://www.healthinsurance.org/virginia/

The benefit plans on the Exchanges are ranked by Metal Levels, which pertains to the “richness” of the benefits offered.  Plans in bronze, silver, gold and platinum metal levels pay a specific percentage of covered benefits, as shown below.

The portion of the covered services not paid for by the plan is your responsibility. This is referred to as “cost sharing,” and these out-of-pocket costs include deductibles, copays and coinsurance.

In general, the higher the percentage of covered services a plan pays, the less you will have to pay in out-of-pocket costs that would be incurred when you receive health care services—but these plans have the highest monthly premiums. Selecting a plan with a lower monthly premium means you must agree to pay for a larger portion of your health care expenses.

The Basics

Expanded Access to Insurance Coverage – It is estimated that the ACA will help extend health insurance coverage to roughly 32 million currently uninsured Americans. This expansion of coverage will be accomplished in many different ways. The biggest changes are coming in 2014 and will:

•  Expand Medicaid coverage for people with incomes below certain established federal poverty guidelines.

Federal Poverty Level is an income level, set at $11,490 for an individual in 2013, updated annually by the U.S. Department of Health and Human Services, indicating that someone is living in poverty.  This income level is used for administrative purposes to calculate eligibility for assistance programs, like those associated with health care reform.

Beginning in 2014, state Medicaid programs—which provide health coverage to low-income Americans—will be expanded to cover all individuals under age 65 with incomes up to 133% of the federal poverty level ($15,282 for an individual or $31,322 for a family of four in 2013). The new law creates a uniform Medicaid eligibility level and income definition across all states and eliminates a prohibition that prevented states from providing Medicaid coverage to adults without dependent children.

• Offer federal subsidies to individuals earning between about $17,000 and $40,000 and families earning between about $34,000 and $80,000 to help make coverage more affordable.

When you go on the Exchanges, you will be guided to a section where there are a series of questions pertaining to whether or not you are eligible for government subsidies.

If you are eligible for government subsidies, you can apply for them during the enrollment process. The subsidies will be applied to the cost of your insurance premium.

Changes to Insurance Benefits – Major 2014 changes on this front include provisions requiring insurers to offer coverage to everyone, regardless of their health status or pre-existing conditions, and limiting insurers from charging more based on health or gender. In addition, all health insurance plans must cover certain “essential” health benefits, such as maternity coverage, dental care and vision care for children and eliminating lifetime caps on coverage.  Essential Health Benefits, required by the ACA, must include:

1. Emergency services
2. Hospitalization
3. Laboratory services
4. Maternity and newborn care
5. Mental health and substance use disorder services (including behavioral health treatment)
6. Prescription drug coverage
7. Rehabilitative and habilitative (helping maintain daily functioning) services and devices
8. Prevention, wellness, and chronic disease management services
9. Pediatric dental & vision coverage
10. Outpatient, or ambulatory, care

These 10 benefits ARE REQUIRED be a part of every health insurance plan on the Exchange. Additionally, the ACA also requires insurance companies to fully cover all preventive care services, such as certain annual health screenings. These services also are exempt from a plan’s deductible.

You’re welcome.

Still more questions?  Check out this article by Ezra Klein and Sarah Kliff in the Washington Post.
Or ask Jayne in the comments below.