- Health plans for individuals and the small group market (<50 employees) are required to include the Essential Health Benefits (EHB), as determined by the benchmark plan within the appropriate state, providing a minimum of 10 EHB categories. While many of the categories are traditional, some of the added benefits include Rehabilitative and Habilitative services and devices, Preventative and Wellness services, Chronic disease management, and pediatric services including oral and vision care. For all EHBs, there can be no annual or lifetime dollar limit on the benefits.
- There are now maximum dollar limits on deductibles and out of pocket expenses that are mandated.
- Health plans have to guarantee issue and guarantee renewability to all eligible applicants, notwithstanding health history.
- Health plans can no longer exclude care based on a pre-existing condition.
Health plans
will no longer underwrite risk based on traditional criteria, such as health
history, industry, gender, group size, claims history and other personal
info. In the individual and small group
market, the only criteria used for underwriting will be age (3:1 ratio as
opposed to a 7:1 ratio prior to 2014), geography (Where you live), plan design,
and whether or not you smoke. This form
of underwriting is referred to as adjusted community rating.
The list
goes on to include many detailed approaches to care and alterations to how
communication and documentation is executed and maintained. Also, several new taxes will appear on your
health plan invoice as a result of the ACA.
Those too will be paid for by you.
As a result, unless you are a qualified recipient of a premium credit and/or
a cost sharing subsidy, your rates will likely go up.
So, how does
one navigate the new frontier without breaking the household bank? Here are a few suggestions:
- New plans will have higher deductibles for an emergency room visit. The deductible has changed by hundreds of dollars and also subjects the patient to deductible and coinsurance payments for expenses incurred while treating the patient. Therefore, avoid the emergency room, unless it is an actual emergency! There is a disincentive to utilize the emergency room for trivial purposes or for reasons that might be better treated outside of a trauma center. This is actually part of the rationale behind the ACA, as our nation’s health expenditures were spiraling out of control as a result of too many uninsured people visiting the ER for the common cold, etc. While that is not the “Root cause” or the sole reasoning behind the act, it certainly has contributed to the current plan design. Here are a couple of suggestions to keep your expenses in control.
- If you have a minor injury or illness which requires medical attention, consider visiting an urgent care clinic. Costs are typically lower than an ER visit and the personnel are qualified to care for most non-emergency situations such as, fever, earaches, minor injuries and common illnesses.
- Try to visit your primary care physician as an alternative to an ER visit. The co-pay level is much smaller and your primary care physician can be more efficient in your treatment.
- While pharmacy benefits are included as EHBs, strategies to keep control of your drug costs will also yield savings.
- Always ask your doctor about your prescriptive medicines. Is there a generic equivalent, which is manufactured with the same chemical composition as the brand name, although the generic equivalent is likely much less expensive (Sometimes by hundreds of dollars!). If so, he/she can prescribe the generic medicine. Also, ask your doctor if there is a generic alternative medicine, which is not necessarily the same chemical formulation, however, might produce equally effective results for your condition.
- Consider how you buy your prescription drugs. Most plans have a mail order option allowing you to save money and receive a longer term supply.
Consider
wellness as part of your lifestyle.
After all, the healthier you are, the less likely that you will require
chronic care management and experience high health care costs.
One of the
silver linings of the new plans is that all deductible and co-payments are now
applied toward your out of pocket maximum.
Unlike in days past, your deductibles, office visit copays and ER copays
were not allowed to be considered as part of your out of pocket expenses. Now they are, therefore, while you will
possibly see more out of pocket expenses in the new plans, they won’t linger
for quite as long.
The ACA is
anything but affordable for many people and frankly, there are likely better
ways to solve the health care dilemma, for which the debate is far too
long! That said, the more you understand
about how to manage your plan, the better the bite will be.
