Sentiments run high regarding the Affordable Care Act, but whether one supports the new law or believes it to be a case of government over-reach, the fact is that the ACA is now the law and as nurses, we are obligated to make sure that patients and their families understand the basic workings of the law. Nurses are in a position of trust and as such we should be able to address patient's questions and concerns regardless of our personal feelings about the ACA.
Open enrollment began on October 1, 2013 and there is still much confusion and disinformation as to what the law does and does not cover. If we are to be a resource for our patients and their families we must educate ourselves so that we don't contribute to the confusion. Paying for medical and drug bills is the most common financial problem Americans report having; even more than missed mortgage payments, job loss and home foreclosure. There are millions of people anxious to get insurance or find less expensive insurance and many patients and their families may look to their nurses for answers to questions about how to enroll, how much it will cost and what will be covered. While we may not become experts in the new law, we can certainly make every effort to become as knowledgeable as possible so that we do not misinform or misdirect those who place their trust in us.
Major changes in the healthcare landscape already took place in March of 2010 when the ACA was signed into law:
- Children are now able to remain on their parent's health care policies until they are age 26.
- Children with pre-existing conditions are now covered.
- There are no lifetime limits on coverage.
- Preventive care is now free for seniors on Medicare and for people with health insurance.
- Prescription drugs are discounted for seniors.
- Insurance companies are required to spend at least 80% of their premium charges on medical care.
After January 2014, no one will be denied health insurance because of a pre-existing condition and all insurance plans will be required to offer the following benefits:
- Emergency services
- Hospitalization
- Prescription drugs
- Laboratory services
- Pediatric services
- Maternity and newborn care
- Preventive and wellness services
- Ambulatory patient services
- Mental health and substance abuse services
- Rehabilitative services and devices
Health insurance exchanges, also known as marketplaces offer several levels of coverage:
- Platinum - Patient pays the highest premium and about 10% of costs
- Gold - Patient pays about 20% of costs
- Silver - Patient pays about 30% of costs
- Bronze - Patient pays the lowest premium, but about 40% of out of pocket expenses through co-pays and deductibles.
ACA Myths and Facts:
Myth: Insurance will be free
Fact: Insurance plans will cost money, however many uninsured will be eligible for Medicaid or receive subsidies to buy insurance from an exchange. Some people will pay the entire amount themselves but will be able to choose from different price ranges and plans.
Myth: There is one government plan that everyone must enroll in.
Insurance will be offered by both for profit and non-profit companies. Medicaid will be expanded to cover those making up to 138% of the poverty level for a family of four ($33,000 annually for a family of four).
Family size:
You may be able to get financial assistance if income is below:
1 family member $46,000
2 family members $62,000
3 family members $78,100
4 family members $94,200
5 family members $110,300
6 family members $126,400
Myth: Health choices will be restricted.
Fact: Health choices for previously uninsured people will be considerably expanded. The ACA allows people to get insurance through Medicaid or buy it on exchanges giving them access to a greater variety of healthcare providers and services.
Myth: Medicare premiums will go up.
Fact: Medicare premiums will not go up under the ACA, however, Medicare recipients will now receive drug discounts and free preventative care.
Myth: Healthcare premiums will go up on individual plans.
Fact: Persons with pre-existing conditions, women and older people are more likely to see their premiums go down. Co-pays and deductibles may also decrease and limits on how much insurance companies will pay for care will be eliminated. Several studies on insurance premiums expect that more people will pay less (than they did prior to the reforms) than those who will pay more and that those premiums will be more stable and transparent due to the regulations on insurance. It is estimated that about half the people who currently buy insurance on their own today will be eligible for subsidies.
Myth: Everyone's premiums will go down under the ACA.
Fact: For a healthy young person who has a low cost, high deductible policy the premiums will likely go up, but the coverage will be better. Those making less than $45,000 annually will probably be eligible for a subsidy.
Myth: People with health insurance now will lose it next year.
Fact: Individual and employer sponsored insurance will probably not change any more than it usually does from year to year. Some people may lose coverage because a few insurers choose not to participate in the exchanges or because some of the low cost, high deductible plans now available don't provide the essential health benefits required by the ACA will be discontinued.
Myth: People who don't buy health insurance will go to jail.
Fact: The penalty for not buying insurance will be $95 per adult, $47.50 per child, and $285 or 1% of household income, (whichever is greater) for families in 2014. In 2015 these penalties will increase to $325 per adult, $162.50 per child, (up to $975 per family) or 2.5% of income for families.
People without insurance can sign up for a plan anytime between October 1, 2013 and March 31, 2014, to be covered in 2014. For those who sign up by December 23, coverage will start on January 1, 2014. People under 30 and those with low incomes who cannot get other types of insurance may choose a catastrophic plan. These catastrophic plans cost less than other plans, but require patients to pay all health costs except preventative services up to a certain amount, (usually thousands of dollars) after which the insurance company usually will cover the 10 basic services (see above). Subsidies may not be applied toward catastrophic plans.
Twenty-two states and the District of Columbia have expanded their Medicaid programs meaning those making up to 138% of poverty level (about $33,000 for a family of four) will be eligible for Medicaid. Those in other states who do not qualify for subsidies are exempt from fines for not having insurance. See websites below for state by state details.
Sixteen states and the District of Columbia are operating their own exchanges, seven have created exchanges in partnership with the federal government and the rest are letting the federal government run the exchange.
In all states, people making up to $45,000 ($94,000 for a family of four) may qualify for
subsidies to help pay for health insurance.
Enrollment dates:
If you buy insurance by -- Insurance begins:
12/15/2013 -- 1/1/2014
1/15/2014 -- 2/1/2014
2/15/2014 -- 3/1/2014
3/15/2014 -- 4/1/2014
3/31/2014 -- 5/1/2014
In subsequent years enrollment will run from Oct 15 thru Dec 7. These waiting periods mean people won't be able to just wait and buy insurance only when they become ill or have an accident.
Persons seeking health insurance or information about the ACA can go to Healthcare.gov where they will find a list of insurance companies and they may begin the application process for insurance. It is also possible to enroll by telephone at 800-318-2596 or in person at a certified enrollment location such as a hospital or community center, which may be desirable alternatives as the government website has been experiencing technical difficulties.
Kaiser Family Foundation: KFF.org/Health-reform and WebMD.com/Health-Insurance provide tools to input one's income and get an estimate of what subsidies might be available and how much one might expect to pay for health insurance on the exchanges based on the state in which you reside.
You can find more information at the following websites:
