Hoover and Associates has completed all training and is an accredited agent by the National Association of Health Underwriters as a representative of Health Insurance Plans under The Affordable Care Act.

WHAT IS HEALTHCARE REFORM (AKA: OMAMACARE) AND WHAT DOES THE AFFORDABLE CARE ACT REQUIRE?

If you are like many people, you may be uncertain about the requirements of the law, now a reality, after years of debates and challenges. The law is officially called the Affordable Care Act (ACA). But many people refer to it as the Healthcare Reform Act or OBAMACARE. We’ll just keep things simple and call it healthcare reform.

What changes has healthcare reform already made?

In 2010, the law started making changes in the ways you’re covered by health insurance. Here are some changes that have already occurred:

  • Young adults up to age 26 can now stay on their parent’s health insurance.
  • Adults who have been without insurance for more than six months and were denied coverage because of a Pre-existing condition may now get coverage.
  • Preventive screenings and services, like annual physical exams and gynecological visits are now free.
  • Health insurance plans include unlimited lifetime benefits.

What is Significant for 2014: Almost everyone will be required to have health insurance.

In 2014, most U.S. citizens must have health insurance or pay a penalty tax, with some exemptions, like financial hardship. Those who choose to go without insurance may face a tax penalty that starts at 1% of income (or $95, whichever is greater) for the 2014 tax year, and go up to 2.5% of income (or $695, whichever is greater) by 2016.

 

You have three options to purchase insurance:

 

1) The Government Run Marketplace

2) Individual Health Insurance Companies – through their Websites

3) An independent Health Insurance Broker, like Hoover and Associates, who can objectively   shop the market and provide information and assistance in choosing the best health insurance option for you and you family’s needs.

YOU DO NOT HAVE TO BUY YOUR INSURANCE THOUGH THE MARKETPLACE

THROUGH WHICHEVER OPTION YOU CHOOSE TO PURCHASE YOUR INSURANCE, THE PREMIUM QUOTED WILL BE NO DIFFERENT. (Pricing is Fixed and PreDetermined by the Carriers )

 

THERE ARE NO ADDED FEES TO GO THROUGH A LICENSED AGENT LIKE HOOVER AND ASSOCIATES.  Purchase through us, and receive continued personal service and claims support

 

WHAT IS A HEALTH INSURANCE MARKETPLACE AND HOW WILL IT WORK?

 In October 2013, all Americans gained access to a Health Insurance Marketplace, where they can shop for and compare different private health insurance plans for 2014 – kind of like a Travelocity® or Expedia® of health plans.

Some states, like Michigan, partnered with the federally-run Marketplace.

  • These Marketplaces don’t offer their own health insurance plans. They offer a variety of options from private health insurance companies.
  • Plans are be available in several levels of coverage: bronze, silver, gold, and platinum.
  • There is also a special “catastrophic plan” option for young adults under 30 and those encountering financial hardship. They have a high deductible, in excess of $5,000 and can’t be used with tax credits. But, these plans may appeal to healthy people who don’t qualify for Medicaid or get health benefits at work as the least expensive option.
  • The Marketplace is also where people can apply for the new Advance Tax credits and subsidies to help pay for their health insurance.

 

REMEMBER, YOU DO NOT HAVE TO BUY YOUR INSURANCE THOUGH THE MARKETPLACE

You have three options to purchase insurance:

 

1) The Government Run Marketplace

2) Individual Health Insurance Companies – through their Websites

3) An independent Health Insurance Broker, like Hoover and Associates, who can objectively   shop the market and provide information and assistance in choosing the best health insurance option for you and you family’s needs.

HOW WILL MEDICARE BE CHANGED?

1. Closing the “donut hole.”

That’s the nickname for the coverage gap that occurs in some Medicare Prescription Drug Plans. Once costs for prescription medicines reach a certain amount, you enter the donut hole. The Affordable Care Act, which went into effect on March 23, 2010, created the “Medicare Prescription Coverage Gap Discount Program” to help fill that gap. It provides manufacturer discounts of 50% on covered brand-name drugs. If you’re a Medicare member, the system keeps track of how much you spend on medications and the discounts are automatic once you reach the coverage gap.

Note: Not all brand-name drugs are covered under these benefits. Only the drug companies that agree with the terms and conditions of the Centers for Medicare and Medicaid Services (CMS) work with Medicare plans.

There are also discounts for those who prefer to buy lower-cost generic prescription medications while in the doughnut hole. Medicare beneficiaries with Plan D coverage get a discount of 21% on generic prescription drugs in 2013, and 28% in 2014 (up from 14% in 2012).

2. Changes in Enrollment Periods.

In the past, people with Medicare enrolled in Medicare Advantage (MA) and Prescription Drug Plans (PDP) from October 15 through December 7 — called the Annual Election Period (AEP) — for the following year’s coverage. Your plan selection became effective on January 1. There were rules in place if you wanted to change your MA plan or prescription drug coverage on or after the first of the year. Now that’s changed and there’s a time called the Annual Disenrollment Period (ADP). Starting in 2013, the ADP is January 1 through February 14 each year. During this time, people who have a Medicare Advantage plan are able to drop their MA coverage and go back to Original Medicare. You will not be able to enroll in a different Medicare Advantage plan, but you can enroll in a stand-alone prescription drug plan.

3. Preventive Care Benefits.

Some of the law’s changes emphasize preventive care to help people of all ages stay healthy. Seniors are eligible for annual wellness checkups, vaccines and flu shots, cancer screenings and more without cost-sharing. Check with your plan to see if qualify.

WHAT IS THE TIMELINE FOR HEATLCARE REFORM?

2010

Adult Kids on Parent’s Plan: Children can now be on a parent’s health plan until their 26th birthday, and maybe even longer in some states. Both married and unmarried children can be included on a parent’s policy. The only exception is that parents covered by a “grandfathered” plan through their job cannot insure an adult child if the child is offered insurance through his or her own job. However, beginning in 2014, the rules change and a child can stay on a parent’s plan up to age 26, even if they are offered insurance by an employer.

No Lifetime Limits: Previously insurers could put a limit on the dollar value of medical costs they would cover over the span of your lifetime. Basically, this meant that if you had a serious, long-term disease, such as cancer, you might be cut off from further health insurance coverage once this pre-determined dollar amount was reached. Insurers may no longer impose these limits on key benefits, such as hospitalization.

Handling Application Mistakes:  Sometimes, people accidentally make a mistake on their insurance application. It’s not hard to overlook something, or unintentionally leave something out. Before, insurers could deny payments on claims and even withdraw a member’s benefits because of these mistakes. This is no longer the case. Now, your insurer can only cancel your policy if you intentionally lie about something important, put incomplete information on your application, or don’t pay your premiums on time.

Insurance For Children: Insurers will not deny insurance to children under 19 with health problems, such as asthma or diabetes.

No-Cost Preventative Care: New policies must cover the cost of preventive care for infants, children and adolescents, including immunizations, annual exams, developmental assessments, hearing and vision screenings, and more. Insurers must also cover the cost of vaccinations and screenings for men and women, including cholesterol, blood pressure, and sexually transmitted diseases. Women receive 8 additional preventive services, at no out-of-pocket cost, such as well-woman check-ups and screenings for cancer, such as mammograms and Pap smears. Many states already have Consumer Assistance Programs (CAP), geared to help consumers with insurance problems. The new law helps strengthen these services by providing grants to states that already have them, and makes it possible for states without CAPs to set them up. These programs can help you.

Appeals process for payment decisions: Many states already have Consumer Assistance Programs (CAP), geared to help consumers with insurance problems. The new law helps strengthen these services by providing grants to states that already have them, and makes it possible for states without CAPs to set them up. These programs can help you file complaints, and provide a standardized review process for appealing health plan decisions. If your plan still denies payment, you can ask for an external review by an independent review organization outside of your insurance company. * An appeal is when you ask your health insurer or plan to reconsider a decision to deny payment or coverage for medical treatment.

Right to Choose Your Own Doctor: This provision, part of a Patient’s Bill of Rights, allows you to choose your own primary care physician for yourself, and pediatrician for your children, from your insurer’s network of healthcare providers. In addition, women can choose their own OB-GYN and schedule appointments without having to get a referral.

Access to Out of Network ERs: In the past, some insurance companies would limit payments for Emergency Room services if you visited an ER outside of your plan’s network. Now, members who need immediate medical care for a true emergency will be charged the same rates, regardless of whether they visit an ER in- or out- of their plan’s network. You also no longer need to wait for approval from your insurer to seek care in an out-of-network Emergency Room. This provision is especially important if you get sick or injured when away from home.

Expanded Medicade Coverage: Under the new law, adults under age 65 who don’t have children and earn a minimum income (according to the state’s salary guidelines) will be eligible. On June 28, 2012, the Supreme Court reached a decision that left it up to each state to decide whether to add this expansion of coverage. States choosing to participate will offer Medicaid coverage to qualifying childless adults by 2014.

2011

Limits on Premium Increases: Starting on September 1, 2011, if insurance companies want to raise the costs of member premiums by more than 10%, they must justify the increase through something called a Rate Review program. Your state or the federal government will review the proposed increase to make sure it is reasonable before it can go into effect.

How Premium Dollars Are Spent: A new rule, called Medical Loss Ratio, requires health plans to spend 80% (85% for large groups) of premiums on medical services and quality programs designed to help find ways to improve care for members. Only 20% or less can go towards administrative costs (like advertising) and profit for the insurer. Companies that don’t meet this requirement will send rebate checks to members.

Health Spending Account Change: Health saving account (HSA) and flexible spending account (FSA) may no longer be used to purchase over-the-counter drugs unless prescribed by a doctor.

2012

Simplified Benefit Summaries: Insurance companies are required to provide consumers with a clear, concise summary of their plan benefits, allowing them to easily compare plans and/or insurers. The law calls it Summary of Benefits and Coverage (SBC). Standardized language is used across all insurance carriers, making it easy to compare apples to apples when evaluating plans.

2013

Medical Expense Tax Deductions: Some taxpayers who file itemized claims deduct their medical expenses – but they can only do so if their medical expenses are more than 7.5% of their Adjusted Gross Income (AGI). Starting this year, that threshold has been raised to 10.0%.

For example, a person with an adjusted gross income of $100,000 who had $10,500 of medical expenses for the year could claim a $3,000 deduction in 2012, the difference between their medical expenses and $7,500 (7.5% of their AGI). In 2013 that number would be reduced to $500, the difference between their medical expenses and $10,000 (or 10% of AGI).

Those age 65 and over are exempted from this change through 2016.

 

Health Insurance Marketplaces: Virtual online “Marketplaces” must be set up for consumers to shop for policies from a variety of health insurance companies, including Humana. The state-based Marketplaces began open enrollment on October 1, 2013, so that you have time to compare plans, get answers to your questions, and sign up so that your coverage begins by January 1. You’ll also be able to find out if you’re eligible for a government subsidy to help lower the cost.

2014

YOU Must Be Insured: One of the most significant impacts of healthcare reform is called the Individual Mandate. Put simply, starting on January 1, 2014, most everyone – adults and kids alike — must have health insurance or pay a tax penalty. There are some exemptions – for instance, those who are unable to use medical care because of religious beliefs or extreme financial hardship.   There is a phased-in tax penalty for those who remain uninsured. This means that from 2014 on, you will have to pay a fee for each person in your family who doesn’t have coverage. In 2014, the penalty is $95 per adult and $47.50 per child (up to $285 for a family) or 1% of income, whichever is greater. This amount goes up to $695 per adult and $347.50 per child (up to $2,085 per family) or 2.5% of income, whichever is greater, by 2016.

Subsidies Kick In: Subsidies will become available to help middle class families and individuals who buy insurance via the online “marketplace.” Those who are eligible can receive monthly tax credits to help pay their insurance premiums. In some cases, their deductibles and copayments may also be reduced.

Guaranteed Coverage: In 2010 insurers were prohibited from denying insurance coverage to a child with an existing health condition or a history of health problems. In 2014 that rule will be extended to adults. This means that if you have heart trouble, or breast cancer that’s in remission, you can’t be turned down for what was once called a pre-existing condition. Nor can your premiums be higher because of your health status. This rule is called the “Guaranteed Availability of Insurance.” Health insurers must accept every individual who applies for coverage.

No annual spending limits:  In the past, insurers could place annual limits on the dollar value of benefits and limit payment of medical claims for essential health services. Annual spending limits have been phased out on medically necessary care since 2010 – and in 2014 will be prohibited completely.

Limits on Premium Increases: As it stands, there are no federal laws limiting how insurance companies set their rates. Starting in 2014, insurance companies can’t base premiums on how healthy (or unhealthy) you are, the number of claims you’ve filed in the past, or your gender. Premiums can, however, be adjusted based on the following factors:

  • Age – But 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
  • Tobacco use – Those using tobacco products can be charged up to 1.5 times what a non-tobacco user is charged

Guaranteed “essential” Benefits: Under the new law, a core group of benefits, called “Essential Benefits” must be included in every new individual and small-group plan. The benefits currently include coverage for hospitalization, prescription medications, and maternity and newborn care, among others.

Out-of-Pocket Spending Caps: With health insurance plans, you and your insurer share the cost of your medical expenses. Your share is called out-of-pocket expenses, or cost-sharing. This includes deductibles, copayments (a flat fee paid for a doctor’s visit), and coinsurance (the percentage of medical costs your insurer pays after you’ve met your deductible). Starting in 2014, there will be a limit on how much you pay out-of-pocket each year through the combination of deductibles, copayments and coinsurance. If this rule were in effect today, the limit would be $6,250 for individuals and $12,500 for families. This amount will be adjusted each year for inflation.

 

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.