Understanding Healthcare

The Affordable Care Act (ACA) became law in 2010 and its provisions continue to be rolled out. If you selected a plan before December 15, 2013, you and your family were covered starting January 1, 2014, maybe for the first time. If you have yet to make a selection, you still have until March 1, 2014 to make your choice; just know that you won’t receive coverage until after that date. Or, if your income qualifies you, your option will be Medicaid–for both you and your family (see “Medicaid” page).

You can choose from among seven “metal” plans, so-called because they are: Platinum, Gold, Silver (with four options) and Bronze; there is also a Catastrophic plan (with a very high deductible).  Each plan is ranked from least expensive to most expensive. Bronze plans cover 60% of the medical bills up to the $6,350 out of pocket maximum, Silver plans cover 70% of medical bills, Gold will cover 80% and Platinum will cover 90%. This is in addition to the monthly premiums that increase as the coverage goes up. However, the ACA has also established subsidies to help you pay for the plan of your choice, based on which plan you select and your monthly income.

So what are the details of each plan? Click on the following link to access a copy of Local 200United’s Healthcare Brochure. There you will find a breakdown of each plan and how much you can expect to pay for each plan, your Medicaid eligibility (if any) and how much of a subsidy you can expect (if any).

Each plan varies by how much your annual deductible will be, your maximum out of pocket expense, surgery cost, co-pays, prescription costs and the like.

The federal health bill left it to states to determine their own benchmark health insurance plan that would be offered in the health benefit exchange—as long as that plan offered benefits across the 10 categories required by the ACA. While plans differ in cost, all have to cover the following services, termed the “Essential Health Benefits.” Requiring coverage in these 10 categories ensures that many services important to your care are available, should you need them. Following are the 10 Essential Health Benefits:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices; habilitative services are defined as services that help you keep, learn, or improve skills and functioning for daily living
  • Laboratory services
  • Preventive care, wellness services and chronic disease management
  • Pediatric services, including oral and vision care

How will health insurance marketplaces help me save money? The theory behind health insurance marketplaces is that presenting the coverage available from each health insurance plan through an easy-to-understand summary of costs and benefits in a centralized location will allow for ease of comparison. This comparison will encourage increased competition between insurance companies, resulting in better benefits and lower costs to attract consumers to their plans. They will be competing for your business.

What if I still cannot afford coverage? Navigators will be able to inform you of any financial assistance available to help reduce your medical costs. If you earn 100%-400% of the Federal Poverty Level, you will qualify for Premium Insurance Tax Credits (also called subsidies), the amount dependent upon the size of your family as well. Your eligibility for financial assistance is determined when you fill out your application during enrollment. After completing your app you should be informed about the amount you would be able to receive immediately. While the PITC is technically a tax credit, you don’t have to wait until you file your taxes to receive it. The PITC is an advanced payment at the beginning of your coverage and is sent directly to your insurance plan to help reduce your monthly premium.

What if I need something that isn’t covered? You have multiple options. You can pay for the non-covered services out of pocket, you can purchase supplemental health insurance through the commercial market to cover gaps, or you can appeal the insurance company’s decision to not cover a service. Find information at www.nystateofhealth.ny.gov. Navigators should also be able to help you with an appeal.

What if I choose not to purchase insurance? Remember, under the Affordable Care Act, it is mandatory that you obtain health insurance (just like auto and home insurances are required, so now is health insurance). You will be required to pay the penalty for each month you are without the appropriate minimal coverage; this is what the law means by “mandate.” In 2014, the total amount of the penalty is $95 per adult and $47.50 per child, with a maximum penalty of $285 per family, or 1% of family income, whichever is greater.

In 2015, the penalty is $325 per adult and $162.50 per child, with a maximum penalty of $975 per family, or 2% of family income, whichever is greater.

In 2016 and beyond, the penalty climbs to $695 per adult and $347.50 per child, with a maximum penalty of $2,085 per family, or 2.5% percent of family income, whichever is greater.

If your income is below 150% of the Federal Poverty Level, you are considered unable to afford health insurance, so you will not pay a penalty if you do not obtain coverage. If you are able to purchase coverage using less than 8% of your annual income, you are deemed able to afford insurance coverage. In some cases, hardship waivers are available if you can afford coverage but have other pressing financial needs.

Things to Think About When Choosing a Health Plan

All plans in the Marketplace offer the same set of essential health benefits.

These are many of the benefits that people need when getting care. They cover things like doctor’s visits, prescriptions, hospitalizations, pregnancy and more.

Plans can offer other benefits, like vision, dental or medical management programs for a specific disease or condition. However, specific benefits may be different in each state. Even within the same state, there can be small differences between plans. As you compare plans, you’ll see what benefits each plan covers. This will be helpful if you have specific healthcare needs.

Balancing monthly premiums with out-of-pocket costs.

As with all health plans, you’ll have to pay a monthly premium. But it’s also important to know how much you have to pay out-of-pocket for services when you get care.

Premiums are usually higher for plans that pay more of your out-of-pocket medical costs when you get care. For example, if you have a Gold plan, you’ll likely pay a higher premium, but may have lower costs when you go to the doctor or use another medical service.

Platinum plans will likely have the highest monthly premiums and lowest out-of-pocket costs. The plan will pay more of the costs if you need a lot of medical care.

In general, when choosing your health plan keep this in mind: The lower the premium, the higher the out-of-pocket costs. The higher the premium, the lower the out-of-pocket costs.

Do you expect a lot of doctor visits or need regular prescriptions?

If you do, you may want a Gold or Platinum plan. They likely have higher premiums, but you could pay lower out-of-pocket costs for each visit, prescription, or other medical service. If you don’t, you may prefer a Bronze or Silver plan. Your monthly premiums will likely be lower, but you’ll likely pay more of the cost when you see a doctor.

You may be able to get lower costs on your health coverage.

If you apply for health insurance coverage through the Marketplace, you’ll find out if you qualify for lower monthly premiums either through tax credits or cost-sharing reductions. Eligibility is based on your household income and size.

If You Already Have Insurance

When it was passed in 2010, several provisions of the ACA immediately went into play. These ensure that you continue to have the following benefits:

  • Requires insurance companies to cover people with pre-existing health conditions
  • Holds insurance companies accountable for rate increases
  • Makes it illegal for health insurance companies to arbitrarily cancel your health insurance just because you get sick
  • Protects your choice of doctors
  • Covers young adults under the age of 26
  • Provides free preventive care
  • Ends lifetime and yearly dollar limits on coverage of essential health benefits
  • Guarantees your right to appeal
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