Common questions about healthcare reform

Managing the cost

What if I just can’t afford health insurance?

You may be able to find financial help with government subsidies, earmarked for individuals and families with low to moderate incomes. That works out to between $15,282 to $45,960 for singles and $31,322 to $94,200 for a family of four, based on 2013 figures. One form of subsidy will be a monthly tax credit to be put toward the cost of premiums. Another will be a reduction of some out-of-pocket spending, such as the deductible and co-payments for doctor’s visits. If you buy your insurance on a new online “Marketplace” offering plans from a wide range of insurer’s, like Humana, you’ll be able to find out if you quality for a subsidy.

Another option may be Medicaid coverage. Eligibility can be expanded to cover adults under age 65 without children. Starting January 1, 2014, states will have the option to offer Medicaid coverage to all adults over the age of 19 with an income of $15,282 or less (this figure will be adjusted next year). It’s up to each state to decide whether to add this expansion of coverage.

"After The Election: A Consumer's Guide To The Health Law",Kaiser Health News, (accessed 11 Feb. 2013)

I’ve heard that we’re going to pay higher premiums for fewer benefits. True?

Premiums may go up (how much is yet to be seen – rates are affected by many things including medical utilization and increased cost of services). There are changes in benefits that will guarantee certain health services, no matter which insurance plan you’re on. A few examples: Preventive care, including annual check-ups, vaccinations, and routine screenings has been expanded and insurers will cover these at 100% - no out-of-pocket costs when you go to a doctor in your network.

Another change: Beginning in 2014, every insurance plan must include a core package of what’s called Essential Heath Benefits in 10 categories. These benefits include coverage for a hospital stay, lab services (for example, blood tests), maternity care and prescription drugs. Some of these benefits aren’t included in today’s plans.

Young, Jeffrey, "Obamacare Costs To Rise For Some Young People As Benefits Improve," Huff Post Business, (accessed 11 Feb. 2013)

Is there a limit to how much I’ll have to pay for my medical expenses?

Each year limits are set on the maximum amount your insurer expects you to pay before it picks up 100% of covered expenses considered medically necessary. These are called out-of-pocket expenses. They may include the cost of your deductible, copayments, and prescription drugs.In 2014, these limits will be $6,350 for individuals and $12,700 for families. People with lower incomes may pay less; their limits are capped on a sliding scale between one-third to two-thirds of the regular maximum.

“For 2014, Higher Limits for HSA Contributions, Out-of-Pocket Expenses,” Society for Human Resource Management, (accessed 20 June, 2013)

In the past I’ve been denied coverage because I have diabetes. Will I be able to get insurance? Will my premiums cost more?

Yes, you’ll be able to get insurance, and no, your premiums won’t cost more because of it. On January 1, 2014, insurers will no longer deny or limit coverage if you have a health problem or a history of health problems (sometimes called a pre-existing condition). You also can’t be charged a higher premium because of your health status – past or present. Premiums can be based on your age (older adults can’t be charged more than three times what a younger person is charged), geography (insurers can charge more in areas where medical costs are high), family size (an individual versus an individual plus a spouse and/or children) and tobacco use (those using tobacco products can’t be charged more than 1.5 times what a non-tobacco user is charged).

“Health Insurance Market Reforms: Rate Restrictions,” The Henry J. Kaiser Family Foundation , (accessed 25 Feb. 2013).

What if I decide not to buy health insurance?

If you skip it you’ll have a tax penalty. In 2014 the penalty is $95 per adult and $47.50 per child (up to $285 for a family) or 1% of household income, whichever is more. This gradually increases to $695 per adult and $347.50 per child (up to $2,085 per family) or 2.5% of family income in 2016 and beyond.

However, there are a few reasons why the requirement may be waived, such as religious beliefs that bar someone from using health insurance benefits and extreme financial hardship.

"After The Election: A Consumer's Guide To The Health Law," Kaiser Health News, (accessed 25 Feb. 2013)

Is there a way to get free healthcare coverage under the new law?

No. The law does not provide free government health insurance. Instead, it was designed to help low and moderate-income people who don’t have health insurance obtain it. Some may receive government subsidies, based on family size and income, that reduce the monthly premium. Or you may qualify for Medicaid , which states now have the option of expanding to cover more people by loosening income guidelines.

Changes in benefits

How will the new law affect my children’s benefits?

Important changes have already taken place and there are more to come. Insurers will now offer coverage to children under 19 regardless of any health problem, such as asthma or diabetes. In addition, insurers will no longer have lifetime dollar limits on how much they spend on medical expenses, like doctor’s visits.Annual spending limits are also being phased out, so there’s no cap on how much your insurance company will pay towards your child’s care for the year. Parents now have access to 27 preventive care services for their kids – including regular exams, behavioral check-ups, developmental screenings, and immunizations – that are covered at 100%, which means no copayments or paying towards a deductible. Pediatric dental and vision check-ups must also be a part of the plan.

In January 2014, individual insurance plans must also include a core package of what’s called Essential Health Benefits. These include maternity and newborn care, vision check-ups for kids, prescription drugs, and hospitalization.

Which benefits must insurers offer?

There’s a combination of new benefits plus consumer protections that have been, or will be, put into place by January 2014. Here are some highlights:

Focus on preventive health services

Your insurer picks up the entire cost for well-baby and well-child visits, vaccinations, cancer screenings such as mammograms and colonoscopies. Women also receive well-woman visits, which include a physical exam and other services, such as contraceptive counseling and breastfeeding support.

Coverage can’t be denied

Your application will not be impacted by any current or past health problem, referred to as a “pre-existing condition.”

No limits on reimbursable expenses

There are no annual or lifetime limits on the amount of your healthcare expenses that it covers.

Insurance shopping made simple

Health insurance “Marketplaces” (also called Exchanges) will be created for each state. These virtual mini-malls will make it easy for you to shop and compare plans. Similar in concept to the Nutrition Facts label you see on packaged foods, insurers will describe their benefits in a simple, standardized way.

Choose your own doctors

You’ll be able to choose any primary care physician (PCP) you want from your insurer’s network, a pediatrician for your kids, and women won’t need a referral to choose an in-network OB/GYN.

Emergency

You can get Emergency Room medical care in hospitals outside of your plan’s network without incurring higher out-of-pocket costs in the case of true medical emergencies. This is especially beneficial if you get sick or injured while away from home.

Appeals for denied claims

Consumer Assistance Programs operated by each state can help you appeal decisions made by your insurer. Some states already have them set up; others are in the process of doing so. If payment is still denied, you’ll be able to request a second external review. It’ll be carried out by an independent review organization.

Coverage for more healthcare expenses

A new rule (called the Medical Loss Ratio) requires your insurer to put at least 80% (85% for large groups) of premium dollars collected towards covering your medical costs or improving quality of care. Administrative and other costs are limited to 20%.

I’m pretty healthy. Will there be plans for people like me?

Yes, there’s something called a catastrophic plan option. This type of policy includes a high deductible but still covers preventive services and three primary care visits. Catastrophic plans are permitted for young adults under age 30 and those suffering financial hardships. Because of the high deductible, premiums for catastrophic coverage will be less than for most other plans. This means people who are young and healthy can still have insurance, without paying higher premiums for benefits they may not use.

Choosing doctors

Will I be able to keep my doctor? If I don’t have one, will I be able to choose my own?

Healthcare reform isn’t meant to influence your choice of healthcare providers. You can keep your own doctor, but you’ll want to be sure he or she is in your insurer’s network. Otherwise you’ll end up paying higher out-of-pocket expenses. If you don’t have a doctor it’s up to you to select one -- just be sure to choose from your insurer’s network.

Will there be different plans to choose from?

Yes, the government isn’t selecting an insurer for you; it’s up to you to make the best choice for you and your family. You can buy coverage directly from a health insurance company, like Humana, where you will find several quality plans to choose from. In addition, virtual “marketplaces” are being set up for each state. There you will find more options, as you can shop and compare policies and prices online from a wide range of insurers, including Humana. Or you can work with an insurance agent to find a plan that’s right for you.

Medicare and Medicaid

Will Medicaid and CHIP still be offered?

Yes. In fact, in January 2014 states will have the option to extend Medicaid coverage to include low-income adults without children who are under age 65 and meet the income requirements.

I get my coverage from Medicare. Will there be any changes?

You will still receive your guaranteed Original Medicare benefits. There are additional benefits added to Original Medicare. Check with your plan to see if you’re eligible. Here are some highlights:

No-cost Annual Wellness Visits

Members of the Original Medicare may qualify for a free annual wellness visit. This includes an overall review of your health and a personalized prevention plan that will be reviewed each year.

New Health Screenings

If certain coverage criteria apply, you may get these screenings without a copayment or meeting a deductible: Bone Mass Index, cervical cancer screenings, including Pap smear tests and pelvic exams, prostate cancer screenings, mammograms, colorectal cancer and diabetes screenings, among others.

Closing prescription drug “donut hole”

Those with some Medicare drug plans reach a coverage gap - after you and the drug plan have spent a certain amount on medications each year, the drugs are no longer reimbursed and you pay 100% of the cost. Under the Affordable Care Act, those who reach the gap now receive a 50% discount on brand-name prescriptions. Those taking generic drugs receive a 14% discount. The coverage gap will continue to shrink until it’s eliminated completely in 2020. For more information contact your drug plan or visit Humana’s Medicare page.

Coverage concerns

Do I really need to get health insurance? Is it mandatory?

Yes, for most people it is. Exceptions to the rule include those whose religious beliefs bar them from using health insurance benefits, those with a family income so low that they aren’t required to file a tax return, those who would have to pay more than 8% of their income on insurance (after factoring in any tax credits and employer contributions) and undocumented immigrants. Those who don’t comply will be faced with tax penalties.

“The Requirement to Buy Coverage Under the Affordable Care Act,” The Henry J. Kaiser Family Foundation (accessed 11 Feb. 2013)

When does all of this go into effect?

The Affordable Care Act was signed into law March 23, 2010. Some of its provisions have already been implemented. The rest take effect between now and January 1, 2014.

How will the government know whether or not I have insurance?

Your health insurance company will provide documents to you and the IRS proving that you have adequate coverage, as required by law.

Will there by an open enrollment period for getting coverage?

Yes. Open enrollment begins October 1, 2013. You can buy insurance directly from an insurer, like Humana, buy through an independent insurance agency, or shop online in the virtual “Marketplaces” being set up in each state.

From 2015 on there will be no second phase of open enrollment. It will begin on October 1st of each year and most likely end on or before December 31.

Is there a deadline for when I have to have health insurance?

Yes. January 1, 2014. Mark your calendar in advance to be sure you’re covered!

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This information is only a high-level summary of certain provisions of the health care law. This information does NOT attempt to summarize all provisions of the health care reform law. This information is not and should NOT be used as legal or tax advice; it should not be used as a basis for decisions regarding how the health care reform law will affect you and/or your business. Should you have any questions on how the health care reform law (including the high level summary of certain provisions of health care reform) will affect you and/or your business, you should seek professional advice from attorneys or other advisors.

Insured by Humana Insurance Company, Humana Health Plan, Inc., Humana Health Insurance Company of Florida, Inc., or Humana Health Benefit Plan of Louisiana, Inc. or offered by Humana Medical Plan Inc., Humana Employers Health Plan of Georgia, Inc., or Humana Health Plan of Texas, Inc.

For Arizona residents: Insured by Humana Insurance Company. For Texas residents: Insured by Humana Insurance Company or offered by Humana Health Plan of Texas, Inc.

Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued in force or discontinued. For costs and complete details of the coverage, call or write your Humana insurance agent or broker.