Patient Protection and Affordable Care Act
Choose a Health Plan
As you probably already know, beginning in 2014 the Patient Protection and Affordable Care Act (PPACA), otherwise known as Obamacare or simply the Affordable Care Act, created new health insurance exchanges or marketplaces where people who do not have other sources of insurance can purchase an individual or family policy. This act contains nine titles, which we further explain below.
The 9 Titles of the Patient Protection and Affordable Care Act
Each title addresses an essential component of reform*:
- Quality, affordable health care for all Americans
- The role of public programs
- Improving the quality and efficiency of health care
- Prevention of chronic disease and improving public health
- Health care workforce
- Transparency and program integrity
- Improving access to innovative medical therapies
- Community living assistance services and supports
- Revenue provisions
Because this law requires insurance companies to cover all applicants with new minimum standards, many people are finding that their existing plans are being cancelled because they do not meet these minimum standards of coverage.
Top 10 things to know about the new law*:
- Ends Pre-Existing Condition Exclusions for Children: Health plans can no longer limit or deny benefits to children under 19 due to a pre-existing condition.
- Keeps Young Adults Covered: If you are under 26, you may be eligible to be covered under your parent’s health plan.
- Ends Arbitrary Withdrawals of Insurance Coverage: Insurers can no longer cancel your coverage just because you made an honest mistake.
- Guarantees Your Right to Appeal: You now have the right to ask that your plan reconsider its denial of payment.
- Ends Lifetime Limits on Coverage: Lifetime limits on most benefits are banned for all new health insurance plans.
- Reviews Premium Increases: Insurance companies must now publicly justify any unreasonable rate hikes.
- Helps You Get the Most from Your Premium Dollars: Your premium dollars must be spent primarily on health care – not administrative costs.
- Covers Preventive Care at No Cost to You: You may be eligible for recommended preventive health services. No copayment.
- Protects Your Choice of Doctors: Choose the primary care doctor you want from your plan’s network.
- Removes Insurance Company Barriers to Emergency Services: You can seek emergency care at a hospital outside of your health plan’s network.
*This information taken from http://www.hhs.gov/healthcare/rights/
Checklist to Choose a Health Plan
Shopping for a new health care plan can be a difficult and confusing task. This checklist will hopefully help you navigate this tricky but important decision as to how to choose a health plan that will best suit yours and your family’s needs.
The plans on the exchange are grouped into levels (named after metals) based on their benefit levels and overall price, but the individual plans can vary widely. It is important for you to think about several factors when purchasing a plan on the exchange to help lower your overall costs and increase your access to needed healthcare services.
This easy to fill out checklist/form that has been created, Patient Protection and Affordable Care Act: Choose a Health Plan, identifies key questions that can help you make an informed decision when picking a plan.
Estimating your Health Needs:
□ How many times a year do you visit a doctor? Do you see a primary care doctor, specialists, or both? ___________________________________________________________
□ How many times a year do you visit an urgent care center or emergency room? _________________________________________________________________
□ Have you been hospitalized in the last year? How long is your typical hospital stay?_____________________________________________________________
□ Do you expect to need surgery or another major procedure in the next year? _________________________________________________________________
□ Do you take any prescription medications? Include medications from a pharmacy or that are administered at the doctor’s office. Be sure to think about any medications you may have been prescribed but do not currently take because you cannot afford them. __________________________________________________________________
*If you have a chronic health issue, navigating the formularies (see below under Coverage for Prescription) for medication that help determine your out-of-pocket costs can be difficult and confusing. A patient navigator might be of great assistance in helping you choose the right healthcare plan and understand how the plans and various prescription drug programs work together.
□ Do you have any chronic conditions that could put you at risk of high health costs? __________________________________________________________________
□ Do you qualify for a premium subsidy? You may qualify if your annual household income is below 400% of the federal poverty line- that’s about $46,000 for an individual and $94,000 for a family of four. You can use a premium subsidy for any plan offered on the exchange. __________________________________________________________________
□ Do you qualify for assistance with the share of health costs that are not covered by insurance? You may qualify if your annual household income is between 100% and 250% of the federal poverty line – that’s about $11,500 to $28,700 for an individual and $23,600 to $58,900 for a family of four. In order to receive assistance with your share of health costs, you have to enroll in a silver plan. __________________________________________________________________
Determining the Right Level Plan:
□ Do you qualify for Medicaid in your state? Eligibility varies by state, and you will be notified if you qualify during the first step of applying for an exchange plan. __________________________________________________________________
□ Are you in good health with low current healthcare costs? Do you have savings you could use for unanticipated health costs? If so, a bronze or silver plan may work for you. __________________________________________________________________
□ Are your health care needs and costs moderate? Are you concerned about your ability to pay for unexpected medical costs out of pocket? If so, a silver or gold plan may work for you. __________________________________________________________________
□ Do you have a chronic condition or significant health care costs? Are you concerned that you may not be able to pay for unexpected health costs? If so, a gold or platinum plan may work for you. __________________________________________________________________
Covered Benefits and Costs:
□ Are the services you and your family need covered by the health plan? Although all plans cover certain key benefits, there will be some variation in the services covered by each exchange plan. __________________________________________________________________
□ What is the plan’s deductible? The deductible is the amount you have to pay before a health plan starts to pay for your care. Are there separate deductibles for medical and prescription drug costs? __________________________________________________________________
□ What are you required to pay for physician visits? Is it different for a primary care physician or specialist? What share of hospitalization would be required to pay? __________________________________________________________________
□ Does the plan you are considering limit any services to a number of visits or sessions per year? This may apply to specific types of services, like chiropractic care or physical therapy. __________________________________________________________________
Coverage for Prescription Medication:
□ Are the medications you take regularly covered on the plan’s formulary? A formulary is the list of medicines covered by a health plan. The exchange website will include a link to the formulary so that you can see the list of covered medications. __________________________________________________________________
Formularies typically have several tiers with patients asked to pay more for medicines on higher tiers.
□ Which formulary tiers include your prescriptions? __________________________________________________________________
□ What are the costs you will have to pay for each tier? __________________________________________________________________
□ Will you pay a set amount (a co-pay) or a percent of the medicine’s cost (coinsurance)? __________________________________________________________________
□ Are there any steps you or your doctor will need to take before your drugs will be covered? In some cases, pans only cover a medicine once a patient has gone through step therapy, which means the patient has tried other medicines before taking one the doctor originally prescribed. Insurers also sometimes require that a doctor receive permission from a plan before prescribing a drug through a process known as prior authorization. __________________________________________________________________
□ Is there a separate deductible for prescription medications? If you regularly take prescription(s) but rarely use other health services, you might spend less on health costs if you choose a plan with a lower separate deductible for prescriptions instead of one higher deductible for all costs. __________________________________________________________________
□ Is there a separate out-of-pocket maximum for prescription drugs? If plans tend to require you to pay for a significant percent of the cost of your medicine and you use few other health services, you may pay less overall if you chose a plan with separate out-of-pocket maximum for prescriptions. __________________________________________________________________
□ What are the options if your provider prescribes a medicine that is not on the plan’s formulary? __________________________________________________________________
Access to Providers:
□ Are the physicians you see regularly in the plan’s network? You should check for all physicians you may see. If you see doctors not in the plan’s network, you may be charged more in out-of-pocket costs and that spending may not count toward the limit on your out-of-pocket costs. __________________________________________________________________
□ Is your preferred hospital in the plan’s network? __________________________________________________________________
□ Will the plan require a referral to see a specialist or get other services? __________________________________________________________________
The purpose of this tool is to help clarify some of the factors you may wish to use to understand and compare the various health plans. Each person should make an independent decision about his/her choice of a plan based on individual circumstances and appropriateness of coverage in consultation with trusted advisers. Your individual state’s Exchange should have additional information available.
Author: Karrie Sundbom
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All resources provided by us are for informational purposes only and should be used as a guide or for supplemental information, not to replace the advice of a medical professional. The personal views expressed here do not necessarily encompass the views of the organization, but the information has been vetted as a relevant resource. We encourage you to be your strongest advocate and always contact your healthcare practitioner with any specific questions or concerns.