Obamacare and You

Affordable Care Act, Obamacare, Healthcare Costs

Just a few days before the Affordable Care Act, aka “Obamacare” is to be implemented in the quarter before the Jan. 1, 2014 deadline, the news hits us: the budget to fund Obamacare is threatened. Without funding, Americans may not be able to comply with the mandate to have health insurance by the first day of 2014 or risk a tax penalty.

Knowing whether or not Obamacare, mandated in 2010 by President Obama, will be funded only scratches the surface of questions regarding how the new healthcare mandate affects you. Whether you work for a corporation that already supplies a health insurance program or you are a self-employed or contracted employee in need of obtaining health insurance to avoid the tax penalty, it’s time to sort out your options and understand why in many cases you may be paying more for your insurance premiums than ever before.

First, take a moment to read the facts about the Affordable Care Act. You don’t have to understand every point in detail;  a review that should take you less than ten minutes to skim is enough to continue reading this blog post and understand your rights and responsibilities.

Getting the Uninsured Insured

After reading through the government website designed to help Americans understand the   Affordable Care Act, here is my synopsis of what the ACA is, and what it is intended to do.

The ACA’s primary purpose was to create affordable health insurance plans by stimulating competition in the healthcare marketplace in an attempt to increase the health benefits to the 85% of insured people and to get the 15% of uninsured people insured. It is the largest overhaul of the U.S. healthcare system since the 1950’s.

Starting October 1, 2013 through December 31, 2013, all insurance companies must offer competitive premiums for health insurance programs or risk being dropped. Whole companies and individuals will be seeking reasonable pricing during this time in a consumer-driven market. The marketplace will be a place where the consumer can shop for the plan that best meets their needs. Additionally, those living in rural areas, those states most economically depressed, and families with children and seniors who live near or below the poverty line will be the first to benefit from funded healthcare.

All companies with more than 50 employees are required to offer a healthcare insurance plan. Some companies have responded to this ruling by firing employees to get their total enrollment to 50 or less. Other companies have pulled healthcare insurance from part-time employees to save money.  Still other companies have responded to increasing their numbers of contracted workers who are not FTE and therefore do not receive health care benefits. These contracted workers are expected to set aside a portion of their income to purchase a healthcare insurance program in the enrollment period or prove that they have covered insurance from another source such as a spouse or Medicare, or they will receive a tax penalty.

Pre-Existing Conditions Are Welcome

One of the biggest changes in the open enrollment period is in regards to pre-existing conditions. In the past, you could be declined coverage by a health care insurer if you had a  pre-existing condition that it perceived would be costly to treat. Your option was to pay a higher premium, or to reach a limit of care that would leave you vulnerable to large medical bills the average person would be unable to pay.

Under the Affordable Care Act, no one can be turned away from purchasing health care insurance, regardless of medical history. In essence, health insurers have been mandated to accept the healthy as well as the sick, with no discrimination in premium rates. This is very good news for those who have chronic diseases and health challenges that need continual care and monitoring.

You will still be required to complete a comprehensive interview form of your chronic as well as recent health issues, but you will not be denied coverage nor charged a higher rate because of them.

The bad news for some of you is not really bad news, but news that you might find unfair. If you earn a decent but not extravagent income, if you are a healthy individual, even if you have a good job that offers health care benefits, you may find that with the ACA, you will pay more, or your benefits may be decreased by your employer in order for them to save money through the new marketplace. Why is this true? The way third-party payors hope to thrive is attract enough healthy individuals who will pay the same premiums but not need to use their health care benefits to offset the burden of sick individuals who use their healthcare benefits more frequently.

For example, I typically see a doctor once a year for either a check up, or a flu that develops into an upper respiratory infection, such as Bronchitis. If I pay $250 per month for 12 months, but I  see a doctor for a visit that costs $250 in total, my plan would require me to pay the $250 out of pocket because I have a $5000 deductible that must be met first. The health insurance company benefits from me because I am a healthy individual. And while money will be there to cover me if I become more ill, in the year that I am healthy, my dollars are helping to cover other sick individuals. In the year I manage to get a concussion,  I’ll be the one benefiting from the insurance plan after I meet the $5000 deductible [Note: it should be noted I didn’t have coverage when I sustained a concussion this summer, but the cost for this trip to the ER would have still been out of pocket. Had I needed a non-contrast MRI to rule out a slow bleeder, that would have been a different story. ].

Under the ACA itself, you are no longer rewarded for being healthy because every applicant will be treated the same. Remember, the benefits are now covering the sick and the healthy at the same rate. Previously, insurance companies could charge more if you were less healthy.  The only interesting caveat to this is that some health insurers may reward those who show positive health behaviors, such as not smoking or exercising regularly, with credits or a coupon they can apply towards their health care costs. While they cannot punish those who don’t demonstrate these healthy behaviors, they aren’t restricted from offering incentives to people to do their part in staying healthy.

Lifetime Limits Are Toast

The most exciting part of the ACA is that lifetime limits have been lifted. If you need medical care for a chronic and lifelong health challenge,  you no longer need to worry that you will be cut off when your bills hit the previous limits that health insurance used to be able to apply. If you never knew about these limits because you are young and healthy, you may know of someone who incurred the medical debt of a parent or loved one. This kind of debt is financially disabling. Additionally, annual limits of care are banned in 2014.

For a list of benefits in Washington State, take a look at the .gov healthcare website for WA state.

 

How Much is the ACA Going To Cost Me?

Your actual cost under the ACA depends on where you live, what kind of insurance program you will participate in (employee based or self-purchase), and what benefits you qualify for if you will be receiving assistance because of your ethnicity, gender, income level,  or disability.For example, if you live in a rural area, the ACA works in your favor to reduce the premium of your health insurance, or to provide insurance through your state.

The major complaint of young people is that they will pay more for health insurance than before purchasing health insurance in the new marketplace. Yes, they will pay more, but they will likely get more robust insurance coverage, which includes maternity care, prescription drug coverage,  and mental health care.  For a good explanation of the mandates on benefits, see CNN’s post on the costs to young adults for Obamacare.

You should note that a lowered premium might also have a higher deductible attached to it. What does that really mean? Well, it could mean that if your high deductible is $5000 per calendar year, and you are relatively healthy and see the doctor twice that year, you will be paying out of pocket for those two visits. If you see a therapist 30 times on a weekly basis at a rate of $100 a visit, you will pay for all of these visits out of pocket. And don’t forget: you’ll still pay your monthly premium. The change is that ACA is federally mandated to keep that out of pocket amount below $6500. In some areas of the country, that amount could have been $12K without the new cap.I predict you will commonly see deductibles set around $5000 in order for insurers to remain competitive. Large companies offering attractive package will sport lower deductibles around between $500 and $3000, and employees will likely be carefully scrutinizing these benefits for their families before accepting employment. They will want to know if their employers are working in the employee’s best interests in the exchange of time and effort for income and benefits.

 

How Will My Providers Be Affected? Will My Provider’s Services Be Covered?

This is a difficult question to answer. The easiest answer is this: we don’t know how providers of healthcare services will be directly affected. Some Providers may drop certain insurance panels, while others may leave one health care system and go to another that your insurance does not cover. You may have noticed this already, with a doctors leaving clinics and re-establishing their family practice elsewhere. As the patient, you get reassigned to another doctor in the same clinic, and your medical record remains with the clinic. Still, I’ll agree with you that the continuity of care can be damaged when the transition to another care provider is repeated over and over.

Additionally, your Provider may sever his or her contract with a health insurance company for decreasing a payout rate. In turn, the health insurance company may respond by refusing out-of-network billing. In other scenarios, I have seen Providers leave the field altogether.

At SDC, I am the only Provider who can accept insurance at our office at this time. Because the ACA is about to take place, I have made the decision to continue with the third party payors Premera and Regence (and their subsidiaries, such as Life Wyse, First Choice Health Network, United Medical Plan, and others) for one additional year past October 1, 2013 in order to provide the best service to the most people that I possibly can.  Last year, I had considered dropping all insurance by October 1, 2013, but with the new changes and the pressing need for qualified therapists with my years of experience and willingness to accept health insurance with the two largest carriers in Washington State, I’ve decided it’s not in my clients’ best interest that I drop all health insurance panels at this time.

We realize that your employer may change your insurance in upcoming months, or you may purchase insurance outside these networks. Please realize that you may no longer be covered at SDC if your insurance is not the ones stated above.  I promise to work closely with you to provide the best and most affordable care I can. Along with my Counseling Associate Allison Bulliman, we are networked with others who do not accept insurance but may work with you through a negotiated scale.

For me, the bottom line is this: the Affordable Care Act may or may not help you specifically, but I’m here to do my part as a Provider in my community in Seattle. If you need mental wellness services now, let’s make that happen! Timing is an essential piece to all good care plans, and we don’t want to make you wait any longer than you need to in order to get started at creating your best and most healthy life!

If you have questions about how to make heads or tails of all the new changes, feel free to give us a call. We’ll be happy to set up a complimentary consultation with you to discuss our services, including how your insurance or your payment options can be made to work for you.