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Health Insurance Exchange Question & Answers

2016 January 14
by Sarah Fields

Sharon asks…

Which of these benefits of the new Health Care Reform Law do republicans object to?

This year, children with pre-existing conditions can no longer be denied health insurance coverage. Once the new health insurance exchanges begin in the coming years, pre-existing condition discrimination will become a thing of the past for everyone.
* This year, health care plans will allow young people to remain on their parents’ insurance policy up until their 26th birthday.
* This year, insurance companies will be banned from dropping people from coverage when they get sick, and they will be banned from implementing lifetime caps on coverage. This year, restrictive annual limits on coverage will be banned for certain plans. Under health insurance reform, Americans will be ensured access to the care they need.
* This year, adults who are uninsured because of pre-existing conditions will have access to affordable insurance through a temporary subsidized high-risk pool.
* In the next fiscal year, the bill increases funding for community health centers, so they can treat nearly double the number of patients over the next five years.
* This year, we’ll also establish an independent commission to advise on how best to build the health care workforce and increase the number of nurses, doctors and other professionals to meet our country’s needs. Going forward, we will provide $1.5 billion in funding to support the next generation of doctors, nurses and other primary care practitioners — on top of a $500 million investment from the American Recovery and Reinvestment Act.

Health insurance reform will also curb some of the worst insurance industry practices and strengthen consumer protections:

* This year, this bill creates a new, independent appeals process that ensures consumers in new private plans have access to an effective process to appeal decisions made by their insurer.
* This year, discrimination based on salary will be outlawed. New group health plans will be prohibited from establishing any eligibility rules for health care coverage that discriminate in favor of higher-wage employees.
* Beginning this fiscal year, this bill provides funding to states to help establish offices of health insurance consumer assistance in order to help individuals in the process of filing complaints or appeals against insurance companies.
* Starting January 1, 2011, insurers in the individual and small group market will be required to spend 80 percent of their premium dollars on medical services. Insurers in the large group market will be required to spend 85 percent of their premium dollars on medical services. Any insurers who don’t meet those thresholds will be required to provide rebates to their policyholders.
* Starting in 2011, this bill helps states require insurance companies to submit justification for requested premium increases. Any company with excessive or unjustified premium increases may not be able to participate in the new health insurance exchanges.

Reform immediately begins to lower health care costs for American families and small businesses:

* This year, small businesses that choose to offer coverage will begin to receive tax credits of up to 35 percent of premiums to help make employee coverage more affordable.
* This year, new private plans will be required to provide free preventive care: no co-payments and no deductibles for preventive services. And beginning January 1, 2011, Medicare will do the same.
* This year, this bill will provide help for early retirees by creating a temporary re-insurance program to help offset the costs of expensive premiums for employers and retirees age 55-64.
* This year, this bill starts to close the Medicare Part D ‘donut hole’ by providing a $250 rebate to Medicare beneficiaries who hit the gap in prescription drug coverage. And beginning in 2011, the bill institutes a 50% discount on prescription drugs in the ‘donut hole.’

Sarah Fields answers:

I am particularly pleased with the ban on denying coverage for people with pre-existing conditions.

Millions of people have lost their jobs and their health care insurance. If they can afford to buy a private plan, which many cannot, they will be denied coverage for pre-existing conditions. By the time someone reaches the age of 40, he or she probably has some such conditions, which are considered to be anything for which a patient has been diagnosed with or treated for.

Let’s be realistic: We are all going to pay for this change in our health care plans, but the cost will be small for each of us. It can be devastating for an individual. Most pre-existing conditions can be treated with prescription drugs and do not require surgery or other expensive remedies.

I am not comfortable with the government running our health care, but this is one issue I am very pleased about.

Thomas asks…

What type of health insurance is the best?

I have twin baby boys & I am a single 20 year old mother. Never been married, non smoker. I am also a college student. I am looking for health insurance plans for my family. I need cheap, yet good. I really want to stay away from government help so I would like to keep Medicaid out of it. I also do not know where to start even beginning to look for insurance. Help?

Sarah Fields answers:

Only you can determine what is the best health insurance plan. I say that because you are the one that has to make the decision of what the right balance is between affordability and policy benefits.

For example, if you choose a plan that covers everything i.e. Doctors office visits, prescription drugs, preventative health benefits, maternity coverage as well as low deductibles, low co-pays and optional vision and dental benefits your monthly premiums will be significant. Is the most comprehensive policy coverage the best health insurance? You have to decide if that is the best.

On the other because you are young, healthy and probably use the health care system sparingly you could consider a Health Savings Account plan in conjunction with a high deductible health plan. In exchange for a lower monthly premium, you agree to pay for your health care costs unless there is a major health expenditure. Is this approach the best health insurance policy? You have to decide.

If you’d rather have more comprehensive individual health insurance coverage, with features such as preventive care coverage, consider a PPO or HMO plan with an in-hospital deductible. To keep the cost down you might consider higher co-pays for doctor’s office visits and perhaps not cover prescription drugs. Either of these approaches will result in a lower monthly premium. You then can use the monthly premium savings to pay for the occasional doctor visit or prescription and still come out ahead. Is this approach the best health insurance policy? You have to decide.

You need a trusted adviser to help you through the process of purchasing health insurance so that you understand what you are purchasing. That adviser can answer questions as to what is and is not covered by the policy, explain deductibles and copays and show you the hospitals and doctors that participate in the network. Armed with knowledge of the coverage available and the associated costs you can decide what is the “best” policy. Check with the agent that writes your home or auto insurance he/she can provide you a health insurance proposal that takes into account your budget and health situation.

Some are going to suggest you go to their web site so that they earn a few pennies on a “click through”. Some may suggest going on line to get a quote but you probably already know that there is more to a good health insurance policy than price. Use the Internet to educate yourself but use an agent to purchase the coverage.

Susan asks…

What is a health insurance exchange?

Why should I buy health insurance at such an exchange?
Do apply different laws inside this exchange vs. the normal (outside) market?
Or what would make an insurance offer different products (or different prices for the same product) in this exchange vs. outside this exchange?

Sarah Fields answers:

If the Supreme Court strikes down President Barack Obama’s health care law, employers and insurance companies _ not the government _ will be the main drivers of change over the next decade and maybe even longer.

They’ll borrow some ideas from Obamacare, and push harder to cut costs.

Business can’t and won’t take care of America’s 50 million uninsured, but for the majority with coverage, here’s what experts say to expect:

_ Workers will bear more of their own medical costs as job coverage shifts to plans with higher deductibles, the amount you pay out of pocket each year before insurance kicks in. Traditional workplace insurance will lose ground to high-deductible plans with tax-free accounts for routine medical expenses, to which employers can contribute.

_ Increasingly, smokers will face financial penalties if they don’t at least seriously try to quit. Employees with a weight problem and high cholesterol are next. They may get tagged as health risks and nudged into diet programs.

_ Some companies will keep the health care law’s most popular benefit so far, coverage for adult children until they turn 26. Others will cut it to save money.

_ Workers and family members will be steered to hospitals and doctors that can prove to insurers and employers that they deliver quality care. These networks of medical providers would earn part of their fees for keeping patients as healthy as possible, similar to the “accountable care organizations” in the health care law.

_ Some workers will pick their health plans from a private insurance exchange, another similarity to Obama’s law. They’ll get fixed payments from their employers to choose from four levels of coverage: platinum, gold, silver and bronze. Those who pick rich benefits would pay more. It’s an approach that Rep. Paul Ryan, R-Wis., the GOP budget leader, also wants to try with Medicare.

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