8 Steps to Prepare for Obamacare
We’re about six weeks away from the opening of the state health insurance marketplaces required by the Affordable Care Act, commonly known as Obamacare.
Oct. 1 is when all those who can’t get affordable health insurance through a workplace — or aren’t eligible for Medicaid or Medicare — can apply to buy health insurance on their own without the possibility of being turned down. The actual health coverage purchased through the marketplaces won’t begin until Jan. 1.
The Oct. 1 deadline is still on, despite some major adjustments and delays. The New York Times recently reported on another postponement:
In another setback for President Obama’s health care initiative, the administration has delayed until 2015 a significant consumer protection in the law that limits how much people may have to spend on their own health care. The limit on out-of-pocket costs, including deductibles and co-payments, was not supposed to exceed $6,350 for an individual and $12,700 for a family. But under a little-noticed ruling, federal officials have granted a one-year grace period to some insurers, allowing them to set higher limits, or no limit at all on some costs, in 2014.
Not postponed is the penalty for failing to have any kind of health insurance next year. The penalty in 2014 will be $95 per adult or 1 percent of adjusted family income, whichever is higher, and will increase to $695 or 2.5 percent of income in 2016.
What can you do to prepare for the opening of the insurance marketplace in your state? Here are a few things to keep in mind:
1. Will this change what you currently do? (Probably not)
The state marketplaces are where people can buy individual coverage and it’s also for businesses that employ fewer than 50 people. Explains PBS’ The Rundown blog:
Currently, the vast majority of Americans with insurance coverage get it through their jobs — and they generally work for companies with more than 50 workers. Large firms already offer coverage similar to what the health law will require insurers to offer individuals and small firms, so little change is expected.
Anyone can apply for individual health insurance through a marketplace, even those who have insurance through work. But if your work-based coverage is considered “affordable” — and it likely will be if your employer is paying part of the cost – you won’t be eligible for a government subsidy to reduce your monthly premium for insurance purchased through the marketplace, explains Carolyn McClanahan on Forbes.
What’s considered affordable? “If premium cost is more than 9.5 percent of your income and you are under 400 percent poverty level, insurance is not considered affordable,” she writes. So, for most of you, it wouldn’t make sense to switch from your work-based plan. But if your employer’s health insurance plan is sufficiently lousy, the marketplace makes sense.
2. Research what the marketplace rates will be in your state
So far 14 states and Washington, D.C., have released what the cost of health plans on their marketplaces will be. If your location is among them, you can find the rates here, on Kaiser Health News. Overall, it’s expected that young, healthy people will have higher premiums than they do now for individual (not work-based) coverage, and older people will have lower premiums. And health insurers will no longer be able to charge a higher premium just because you have a pre-existing condition.
Note (and this is important): If you buy health insurance through a state marketplace, you’ll likely be eligible for a federal subsidy to help with the cost.
3. Research individual policies sold outside the marketplace
In the states that already require more than very minimal coverage from individual insurance policies, your individual policy may cost about the same next year. In other states, the cost of an individual policy purchased outside the state marketplace will likely increase to cover an expansion of the coverage you’ll get. Explains CNNMoney:
Starting next year, nearly all individual plans — both in and out of the exchanges — will be required to cover an array of “essential” services, including medication, maternity and mental health care. Many plans don’t currently offer those benefits.
So, if you currently have an individual policy — some 15 million Americans do – you may or may not want to keep it. Or you may find that your insurance company is eliminating your plan and replacing it with plans that meet the new standards for care.
But keep in mind that unless you buy your individual coverage through a state marketplace, you won’t be eligible for the federal subsidy.
4. Figure in the federal subsidy
A huge part of Obamacare is the help offered to those who can’t afford health insurance premiums. The subsidy is a tax credit that’s applied directly to the premiums. It will be paid to the insurance company, not to you.
Who will be eligible for this help? Plenty of people.
CNNMoney explains, “People with annual income of up to 400 percent of the poverty line — or roughly $45,000 for an individual and about $92,000 for a family of four — will get federal subsidies to help defray the premium costs.” The lower your income, the higher the subsidy. How much will you get? The Kaiser Family Foundation has a calculator.
Compare & Save on CA Health Plans. Get a Fast, Free Quote Online Now!
Anthem.com
5. Get ready to fill out your application to a marketplace
You will need to provide information such as Social Security number and income. As of Oct. 1, information can be submitted through paper forms, over the phone or online. You should get a response within two weeks explaining your next steps.
Enrollment in the marketplaces closes after March 31, unless you have a major life event like relocation to another state, changes to income, or changes in your family status.
HealthCare.gov recommends you take these steps to prepare for submitting an application in a marketplace.
6. Select your level of coverage
You will have a choice of four levels: platinum, gold, silver and bronze. Platinum will have the highest premium but the lowest out-of-pocket expenses. Bronze will come with the lowest monthly cost but the highest possible out-of-pocket costs.
How to decide which one to pick? HealthCare.gov offers advice about that.
7. Check into Medicaid
Many states have expanded eligibility for Medicaid, a federal/state health insurance program for low-income people. Some states have decided not to participate in the expansion.
What if your state has not and you don’t qualify under the current Medicaid rules? You won’t have to pay the penalty for being uninsured.
8. Kick your pre-existing addiction
Under Obamacare, insurance providers cannot charge more due to pre-existing conditions or gender. But they can charge more if you smoke. Smokers can be charged up to 1.5 times the premiums of those who don’t use tobacco in most states. To quit on the cheap, follow these tips.
Where do you stand on Obamacare and the insurance marketplaces? Voice your opinions on our Facebook page.
Karen Datko contributed to this report.
Read more at http://www.moneytalksnews.com/2013/08/22/8-steps-to-prepare-for-obamacare/#FsmijpYA5gGd8cVJ.99
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MEDICARE – Physician Fee Schedule (CY 2014 Physician Fee Schedule Proposed Rule with Comment Period)
The CY 2013 PFS final rule with comment period was placed on display at the Federal Register on November 1, 2012. The conversion factor dropped from $34.0376 in 2012to $25.0008. Add this to the changes in the RVU values themselves and we could have a real mess on our hands. Physicians are on edge to see what might happen to them with regards to their reimbursement via our beloved government sponsored program: Medicare.
Some of the winners of the new fee schedule include family medicine doctors who , with changes in care coordination payment and some other changes in the rule, stand to see a 7% increase and other primary care providers will see a 3% – 5% increase. However, this will only happen if Congress averts the statutorily required reduction in Medicare’s physician fee schedule. A list of how each specialty is impacted is listed by the AMA here.
In announcing the Final Rule, the Centers for Medicare and Medicaid Services (CMS) said that the final rule with comment period also includes a statutorily required 26.5 percent across-the-board reduction to Medicare payment rates for more than 1 million physicians and non-physician practitioners under the Balanced Budget Act of 1997’s Sustainable Growth Rate (SGR) methodology.
Nothing new to share here, but Congress has overridden the required reduction every year dating back to 2003. The Administration is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect. It is highly likely that the reduction won’t happen in 2013 either. As always, everyone is put on edge and nothing happens. We can only hope that we are not around when something does. The unfortunate problem is that wherever Medicare rates end up, many of the commercial payors who use Medicare as a basis for reimbursement will likely follow suit with cuts, but it is doubtful they would impliment any increases. Most payors are looking for reducing reimbursement rather than making increasing fees that are paid out to their providers.
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Work-life balance: Is life too short to be busy?
By Paul Wilson | JULY 9, 2013
It’s become one of the most pressing questions of our time: Do you set boundaries around your work life? And should you?
http://www.lifehealthpro.com/2013/07/09/work-life-balance-is-life-too-short-to-be-busy
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6 Obamacare Facts You Need to Know
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What the Health Care Reform Delay Means for You
http://www.success.com/articles/2462-what-the-health-care-reform-delay-means-for-you
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05/30/2013
Could Arkansas’ novel approach to Medicaid expansion be a model for others?
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05/29/2013
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The Affordable Care Act (short for “Patient Protection and Affordable Care Act” and commonly referred to as “Obamacare”) is a piece of legislation mired in controversy, complexity and misunderstanding amongst small business owners.
http://premium.docstoc.com/article/157518575/Small-Business-Guide-to-Obamacare
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Millions of Americans affected by doctor shortage
A new study finds that 44 million people reside in areas of the U.S. where estimated demand for primary care access outpaces supply by 5%, while about 7 million Americans live in areas where demand is expected to exceed supply by 10% as coverage expands. Researchers said Texas, Mississippi, Nevada, Idaho and Oklahoma were among the states expected to see sharp increases in physician demand. The study was published in Health Affairs.
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Study: Out-of-network billing is out of control
Just over a year ago, Angel Gonzalez, 36, awoke with searing chest pain at 2 a.m. A friend drove him to the closest emergency room.
Though he was living on $18,000 a year as a graduate student, Mr. Gonzalez had good insurance and the hospital, St. Charles in Port Jefferson, N.Y., was in his network. But the surgeon who came in to remove Mr. Gonzalez’s gallbladder that Sunday night was not.
He billed Mr. Gonzalez $30,000, and an assistant billed an additional $30,000. Mr. Gonzalez’s policy covered out-of-network providers, but at a rate it considered appropriate: $2,000. “I was on the hook for more than I made in a year,” Mr. Gonzalez’s gallbladder that Sunday night was not.
A health insurance industry report to be released on Friday highlights the exorbitant fees charged by some doctors to out-of-network patients like Mr. Gonzalez. The report, by America’s Health Insurance Plans, or AHIP, contrasts some of the highest bills charged by non-network providers in 30 states with Medicare rates for the same services. Some of the charges, the insurers assert, are 30, 40 or nearly 100 times greater than Medicare rates.
Insurers hope to spotlight a vexing problem that they say the Affordable Care Act does little to address. “When you’re out of network, it’s a blank check,” said Karen Ignagni, president and chief executive of AHIP. “The consumer is vulnerable to ‘anything goes.’ ”
“Unless we deal with cost, we won’t have affordability,” she added. “And unless we have affordability, we won’t have people participating” under the Affordable Care Act.
Among the fees on the report’s list are a $6,205 outpatient office visit to a doctor in Massachusetts for which Medicare would have paid $152; a $12,000 bill for examining a tissue specimen in New York for which Medicare would have paid $128; and a $48,983 surgeon’s fee for a total hip replacement in New Jersey that Medicare would have reimbursed at $1,543. Many of the highest billers were in New York, Texas, Florida and New Jersey.
Elisabeth R. Benjamin, co-founder of the Health Care for All New York coalition, who is often at odds with the insurance industry, said that “is one area we totally agree on.” She continued, “Out-of-network billing is just out of control.”
Even when out-of-network fees are compared with average commercial insurance reimbursements, which are usually greater than Medicare, she said, “It’s pretty outrageous.”
Doctors say the report is skewed because it focuses on a few dozen cases of overcharging that are not representative of their billing. In response to the insurers’ report, the American Medical Association noted on Thursday that a recent analysis found that doctors’ services account for just 16 percent of health care costs.
“There are outliers in every profession, in every business,” said Dr. Andrew Y. Kleinman, a plastic surgeon who is vice president of the Medical Society of the State of New York.
Dr. Kleinman also noted that insurers had effectively shifted the costs of out-of-network care onto patients by changing reimbursement formulas. Instead of the rates commercial insurers usually pay doctors, insurers increasingly are basing their out-of-network payments on Medicare rates, usually far lower.
A growing number of high-end, flexible health plans offer policies that cover outside providers at, for example, 140 percent of Medicare. “They’re selling you an insurance product you can’t use,” Dr. Kleinman said. “You’re buying an insurance policy where the out-of-network benefit is worthless.”
The industry’s own report suggests that using Medicare rates as a benchmark will lead to patients’ picking up much more of the cost for out-of-network care, whether they carefully select a specialist or, as in the case of Mr. Gonzalez and many others, have no choice in the matter.
Had Mr. Gonzalez been 65 or older, Medicare would have paid only $958 for the surgery. The average commercial price is $12,292, according to Fair Health an independent nonprofit group that tracks information on health care costs.
But Mr. Gonzalez’s health plan, United Healthcare, determined the fee should be $1,273, of which the company paid $838. Mr. Gonzalez filed appeals, which were rejected. He then contacted Community Health Advocates at the Community Service Society of New York for help, and the group’s caseworkers negotiated with the surgeon on his behalf.
After months of wrangling, the surgeon agreed to accept a significantly reduced payment: $340.
Consumer advocates and health insurance executives are calling for greater transparency in health care pricing, including upfront disclosure of prices of medical procedures and services.
“The health care industry can give you an estimate, just like any other industry,” said Carrie H. Colla, an assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice, noting that the Dartmouth-Hitchcock Medical Center has a patient price estimator online.
“It’s just not current practice right now,” Dr. Colla said. “Sometimes a doctor won’t even know. The patient really has to push for it.”
A version of this article appeared in print on February 1, 2013, on page A18 of the New York edition with the headline: Report Faults High Fees for Out-of-Network Care.