Uncomplicating The Healthcare Reform Issue

Healthcare Reform is a complicated issue. This diagram was prepared by the Joint

Economic Committee, and shows just how much consideration had to go into

developing a plan.

Fortunately, they made room for Physicians in the bottom left and Patients in the bottom

right. That they’re not directly connected might be a slight oversight.

 

There are four key provisions of the Patient Protection and Affordable Care Act, typically

referred to as the ACA, that will affect most people: Exchanges, Subsidies, Guaranteed
Insurability, and Individual Coverage Mandates.
 

Exchanges (also referred to as The Marketplace) are a place where people can go to

compare health insurance plans and premiums. In Oregon, it’s called Cover Oregon,
and in Washington, it’s called the Washington Healthplan Finder. As much as possible,
it’s an apples-to-apples comparison. Carriers now have to design their plans based on
Metal Tiers. You may see Platinum, Gold, Silver, and Bronze levels of benefits, although
carriers aren’t required to offer benefits within every tier. And with some minor variation,
a Gold Plan is a Gold Plan no matter which carrier you use. One critical issue now will
be the Provider Network. This will be the easiest way for carriers to affect their rates. So
expect carriers to tighten up their networks, and cut out expensive provider groups.
The primary reason that one would use an Exchange rather than going directly to a
carrier, is the subsidy.

Subsidies are determined by your Modified Adjusted Gross Income (MAGI). If your

MAGI is below 400% of the poverty level, you may qualify for a subsidy. The subsidy
can be used to reduce your premium, or as a tax credit when you file. There are subsidy
calculators available on the websites for all of the Exchanges. There’s also anindependent subsidy calculator created by the Kaiser Family Foundation.

As of January 1st, there is Guaranteed Insurability for everyone. Carriers can no

longer decline coverage to an individual based on previous or current medical issues.
This is critically important for a lot of people. Carriers will have to allow you onto their
plan regardless of your medical conditions. But there are open enrollments (discussed
below) and one must apply by the 15th of the month prior to the effective date. If you
want to have a plan on January 1st, you must apply for that plan (through the Exchange
or directly with the carrier) by December 15th.

In order to help the carriers keep premiums low, Individual Coverage Mandates are

implemented starting in 2014. That means everyone must have health insurance or pay
a penalty. In 2014, that penalty is the greater of $95 or 1% of household income. In
order to discourage people from going without insurance and just paying the penalty,
the ACA only allows individuals to start health insurance at one time during the year.

This year, that’s January through April. In following years, it will be January 1st. If

someone has a major medical issue, they may have to wait for several months until that
issue is covered by health insurance.

There is a lot more to the ACA, and we’re discovering more every day. Some of the

detail may change, but here are some important issues that will not change.

Become more engaged in choosing a plan

Make sure you understand your benefits. A broker can help you, and you won’t have
to pay anything for their services.

Know that provider networks will be shrinking

Verify that providers who are critical to your care are on the plan before you apply.

Consider increasing your deductible

 

Most of the out-of-pocket maximums will be the same now. Health insurance is risk

management. If your biggest risk is bankruptcy, and you can afford to pay the
smaller bills yourself, maybe a higher deductible plan with a lower premium is a
better fit for you.

Become a consumer of your care

Understand the costs. Check out websites like www.healthcarebluebook.com, where

you can see what a procedure should cost in your area. Go directly to the labs to getwork done. I’ve used www.healthcheckusa.com in the past and have been very
happy with them. A quick Google search will show labs in your area. In both Oregon
and Washington, there are free resources to get prescription discounts.



JR Hinds, Health Insurance Broker

http://www.hindsandassociates.net/