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Affordable Care Act
The Affordable Care Act, referred to by some as Obamacare, is now the law of the land and working for you already. The ACA’s purpose is to increase the quality and affordability of health insurance, lower the number of uninsured citizens (by expanding public and private insurance coverage), and reduce the costs of health care for individuals and the government.
In spite of all the controversy, it’s good news for people with diabetes or those at risk of developing diabetes.
If you already have health insurance either through your employer or purchased on your own and are happy with it – good news - you don’t have to do anything and the cost of your plan may actually come down in price.
Some parts of the law are already in place and people with diabetes are already benefiting from them, while many other protections go into effect in 2014.
The law has a number of provisions that are very beneficial to the consumer which include:
• It establishes certain rights and protections for the consumer
• It establishes certain levels of care
• It provides more free preventive care
• Makes health insurance easier to understand
• It helps to control or reduce health care costs
Rights & Protections
Some rights and protections apply to plans in the Health Insurance Marketplace or other individual insurance, some apply to job-based plans, and some apply to all health coverage.
In the past insurance companies could refuse to cover you or charge you more money for having a pre-existing condition such as diabetes. Starting in 2014, health insurance plans can't refuse to cover you or charge you more just because you have a pre-existing health condition like diabetes.
Once you have insurance, the plan can't refuse to cover treatment for pre-existing conditions and your coverage for pre-existing conditions begins immediately.
This is true even if you have been turned down or refused coverage due to a pre-existing condition in the past.
One exception: Grandfathered individual health insurance plans
The only exception is for grandfathered individual health insurance plans that you’ve purchased yourself. They do not have to cover pre-existing conditions.
But there is more good news - if you have one of these plans you can switch to a Marketplace plan during open enrollment and immediately get coverage for your pre-existing conditions. (more on the marketplaces below)
Coverage for Children and Young Adults
Employee based health plans and new individual plans (available in the marketplace) can no longer deny children coverage because of diabetes or any other pre-existing condition.
In addition, as long as an existing health care policy covers dependents, young adults can stay on their parent’s insurance plan until age 26.
Eliminates Lifetime Dollar Limits on Coverage
Health insurance plans cannot set a dollar limit on the amount the insurance company will spend on “essential health benefits” over the course of the time a person is enrolled in that plan. Essential health benefits must include services in at least the following categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse care, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Preserves Doctor Choice and Emergency Room Access
• You pick your doctor: You can choose any available primary care provider in your insurance plan’s network. You can choose any available network pediatrician as your child’s primary care doctor.
• No referrals needed for OB-GYN services: You will no longer need to get a referral before you can get care from an obstetrician or gynecologist.
• Access to out-of-network emergency room services: Insurance plans can’t require higher copayments or coinsurance if you get emergency care from an out-of-network hospital. They also can’t require you to get prior approval before getting emergency room services from a provider or hospital outside your plan’s network.
Provides Free Preventive Care
Most health plans are required to provide certain health services aimed at preventing disease at no charge. This includes diabetes screenings for adults with high blood pressure; cholesterol screenings; obesity screening and counseling; diabetes screening for pregnant women; and some preventive services for children.
Certain preventive services are also free for people with Medicare, including medical nutrition therapy for people with diabetes and an annual wellness visit
to develop (or update) a personal prevention plan.
Mandates simple language for applications and comparison of plans
You now have the right to get an easy-to-understand summary about all health plans’ benefits and coverage.
Insurance companies and group health plans must provide you with:
• A short, plain-language Summary of Benefits and Coverage (SBC) Sample SBC form (PDF) The SBC includes coverage examples, which allow you to see what the plan would cover in 2 common medical situations: diabetes care and childbirth.
• A Uniform Glossary of terms used in health coverage and medical care Uniform Glossary (PDF)
This information allows you to make “apples-to-apples” comparisons when you’re looking at different plans.
All individual and group health plans must use the same standard form to help you compare plans.
Holds insurance companies accountable for rate increases
The health care law provides 2 new ways to hold insurance companies accountable and help keep your costs down: Rate Review and the 80/20 rule.
Rate Review helps protect you from unreasonable rate increases. Insurance companies must now publicly justify any rate increase of 10% or more before raising your premium. This does not apply to grandfathered plans.
The 80/20 Rule requires insurance companies to spend at least 80% of the premiums you pay on your health care instead of administrative, overhead, and marketing costs.
If your insurance company doesn’t meet these requirements, you’ll get a rebate from your premiums.
Creates the Health Insurance Marketplace
The Marketplace is a new way to find health coverage. It can help if you don’t have coverage now or if you want to evaluate other options.
Some states are actively engaged in making the affordable Care Act work for their citizens.
Other states are being obstinate. But regardless of whether your state chooses to participate in the program you can still access the Health Insurance Marketplace. It makes it easier to shop for insurance too - with one Marketplace application, you can learn if you can get lower costs based on your income, compare your coverage options side-by-side, and enroll.
Here is where to find the marketplace for your area.
The Marketplace creates 4 categories of insurance plans
When you compare Marketplace insurance plans, they're put into 4 categories:
All Marketplace insurance plan categories offer the same set of essential health benefits. The categories are not a reflection of the quality or amount of care the plans provide. The category affects how much your premium costs each month and your co-pay for hospital visits or prescription medications. It also affects your total out-of-pocket costs — the total amount you’ll spend for the year if you need lots of care.
In general, when choosing your health plan, keep this in mind: the lower the premium, the higher the out-of-pocket costs when you need care; the higher the premium, the lower the out-of-pocket costs when you need care.
What to consider when choosing your plan
Think about the health care needs of your household when considering which Marketplace insurance plan to buy.
Do you expect a lot of doctor visits or need regular prescriptions?
• If you do, you may want a Gold or Platinum plan.
• If you don't, you may prefer a Bronze or Silver plan. But keep in mind that if you get in a serious accident or have an unexpected health problem, Bronze and Silver plans will require you to pay more of the costs.
You Now Must Have Health Insurance
If you don’t have health insurance you will have to purchase health insurance or pay a fine. But don’t despair, the law makes health insurance more affordable through a health insurance marketplace and most low and moderate income families can receive assistance from the government in paying for their healthcare policies.
If you live in a state that refuses to participate in the exchange program you can still get insurance from the Federal exchanges. You should also be sure to write your governor and state legislature to let them know how the Affordable Care Act helps your family and encourage them to vote to participate in the program. [set up a link in causes].
To avoid the fee in 2014 you need insurance that qualifies as minimum essential coverage. If you're covered by any of the following in 2014, you're considered covered and don't have to pay a penalty (which begin small and increase over a set period of time).
• Any Marketplace plan, or any individual insurance plan you already have
• Any employer plan (including COBRA), with or without “grandfathered” status and retiree health care plans.
• The Children's Health Insurance Program (CHIP)
• TRICARE (for current service members and military retirees, their families, and survivors)
• Veterans health care programs (including the Veterans Health Care Program, VA Civilian Health and Medical Program (CHAMPVA), and Spina Bifida Health Care Benefits Program)
• Peace Corps Volunteer plans
Who doesn't have to pay the fee
Uninsured people won't have to pay a fee if they:
• are uninsured for less than 3 months of the year
• are determined to have very low income and coverage is considered unaffordable
• are not required to file a tax return because their income is too low
• would qualify under the new income limits for Medicaid, but their state has chosen not to expand Medicaid eligibility
• are a member of a federally recognized Indian tribe
• participate in a health care sharing ministry
• are a member of a recognized religious sect with religious objections to health insurance
If you don't qualify for these situations, you can apply for an exemption asking not to pay a fee. You do this in the Marketplace.
The Affordable Care Act is an important first step in bringing down health care costs for families without employer based insurance and many of its provisions will be helpful for people with diabetes and may help reduce the number of people with Type 2 diabetes because of its focus on preventive care.
Open enrollment begins on October 1, 2013 and continues through March 31, 2014.
Updated September 30,2013
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