Essential Health Benefits-What Do You Want vs. What Are You Willing To Pay?
The Affordable Care Act requires Americans have access to quality, affordable health insurance. To achieve this goal, the law requires health plans offered in the individual and small group markets, both inside and outside of the Affordable Insurance Exchanges (Exchanges), offer a comprehensive package of items and services, known as “essential health benefits.” Essential health benefits must include items and services within at least the following 10 categories:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, 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
The challenge now facing the Colorado Department of Insurance is what additional, if any, benefits they will require the new policies to contain. Each state is empowered to devise their own list.
Here is a partial run down of additional requirements being consider in other states and of course, each benefit has a very active advacacy group pushing for inclusion:
Acupuncture (now a requirement in California)
Pre-vacation visits to travel clinics (whatever this is, apparently it will be required in Colorado)
Bariatric Surgery (stomach reduction)
Each of these services is, of course, very dear to a segment of the population. The question before the Department of Insurance is “is it reasonable to require all health insurance policy holders to pay higher premiums for these benefits, when they may or may not be “”essential””?
Here is an excellent article written by the Washington Post on this subject.
Child-Only Health Insurance Policy
One of the most impactful regulations of the Affordable Care Act (Obamacare) that has already gone into effect is the requirement that no child under 19 may be turned down for health coverage. For the family with a child with a significant ”pre-existing condition” this is a godsend. For the insurance companies it is a headache.
The reason that this is difficult for the insurance companies, is that although they can “rate-up” the child’s portion of the premium up to 200%, some of these kids have conditions that may cost $100,000′s to treat
Another concern is that parents, knowing the insurance companies must cover their child, will not be willing to purchase and pay for coverage until the child is “literally in the ambulance on the way to the hospital.”
While a parent and child may apply anytime for insurance, to ameliorate this situation somewhat, the feds have allowed the insurance companies to only offer child-only policies during ”open enrollment” periods, except in the case of a “qualifying event.” In Colorado those open enrollment periods are January 1-31 and July 1-31 with coverage starting 30 days after the enrollment period.
Outside these periods, the only other times insurance companies are required to offer child-only coverage is in the case of a qualifying event. A qualifying event is defined in the new Colorado law as within 30 days of birth, adoption, marriage, dissolution of marriage, loss of employer-sponsored coverage, loss of eligibility for Medicaid or Child Health Plan Plus (CHP+), entry of a valid court or administrative order mandating the child have coverage, or involuntary loss of existing coverage other than because of fraud, misrepresentation or failure to pay premium.
A carrier may deny coverage if the child has access to other creditable coverage such as a parent’s plan through an employer.
Most health insurance carriers will offer only one of their plans to child-only applicants. These plans are usually bare-boned and are difficult to apply for, i.e. paper applications, no agent involvement, etc. The only company we work with in Colorado that offers their full array of plans, and no additional barriers in applying, is Rocky Mountain Health Plans.
Of course, we expect this will all change on January 1, 2014 with the full implementation of the Affordable Care Act and the exchanges that go with it.
If you’d like to know more about child-only policies, please call me at 303-541-9533.
- Published in Applications, Child-only, Individual Health Insurance
Why does my Individual Health Insurance Premium go Up Every Year?
Well, to start off, you are a year older each birthday and thus statistically more expensive to cover. Now, the increase for a 25 year old that turns 26 is relatively small. But, for a 55 year old, with growing health care needs that turns 56, the increase can be significantly higher.
So, the older you are, the greater your increase will be each year.
Additionally, there is something called “medical inflation” that is different from your run-of-the mill cost of living increases. Medical inflation takes into account all the expensive new tests, prescriptions, procedures, etc. that come along each year. Your present plan will cover these, but there is a cost involved.
Then of course there are the new federal and state mandates larded on as requirements to health insurance plans. In the past few years the Affordable Care Act has added no co-pays for wellness visits, a provision that no child under 19 can be denied coverage for a pre-existing condition and eliminated any annual and life-time dollar limits to coverage as just a few of the new, expensive add-ons. In Colorado, the recent requirement that all new policies must cover maternity has also significantly increased costs.
These are the basics, but if you need a more detailed explanation go here.
Or you can just call me at 303-541-9533 and we can talk about some ways to trim your premium costs.
- Published in Individual Health Insurance, Premiums
Can’t understand your health insurance? Feds say insurers must give consumers a simple summary
Don’t have the slightest clue what your health insurance covers?
As part of the Affordable Care Act the government intends to take care of that. According to a recent article by the Associated Press “the Obama administration says that’s going to change, starting this year. Officials announced that private health plans will have to provide consumers with a user-friendly summary of what’s covered, along with key cost details such as copays and deductibles.”
“Just six pages long. And no fine print.”
“Officials are calling the summaries a “nutrition label for health care,” trying to capitalize on the name recognition of those information panels found on packaged foods at the supermarket. Consumer groups say the health care version isn’t perfect, but it’s a start.”
“These documents will allow consumers to compare plans on an apples-to-apples basis,” said Medicare chief Marilyn Tavenner, who is also overseeing implementation of President Barack Obama’s health care law. If an insurance plan offers substandard coverage in some respect, they won’t be able to hide it in dozens of pages of text, she added.”
Call me cynical, but judging by past “clarification” efforts by the government on wording to our tax code, federal laws and something called “Plan Descriptions” for present health insurance policies, I am doubtful of anything useful coming out of this venture.
Money Back From Your Health Insurance Company
One of the little discussed provisions in the new Afordable Care Act (Obamacare) that is going to be very popular with the American public is the requirement called Minimum Loss Ratio (MLR). Starting January 1, 2011, health insurance companies must reimburse their clients for excessive premium dollars collected. Health insurance companies are now required to spend 80% (individual policies) or 85% (group policies) of monies collected on patient care, leaving them with only 15-20% for administrative expenses. Anything left over must be returned to clients by August of the following year.
It is my belief that when these checks start rolling in, the American public will feel a lot more positive about the whole Afordable Care Act.
- Published in Federal Law Changes and Mandates, Personal Observation
Age Related Wellness Benefits
Your non-grandfathered health insurance is required to cover wellness benefits at 100%. However, many of these benefits are “age related.” Please find below some of the more commonly used wellness services and the ages, if appropriate, when they begin being covered.
Well-woman visits 18-64
Pap testing 18
HPV Immunization 11-26
HPV DNA testing 30
Osteoporosis Screening 65 (60 if at high risk)
Prenatal visits and testing
STD’s Contraception counseling
Prostate exam 50
Preventative colonoscopy 50 (every 10 years)
Well child visits 0-13 Immunizations 0-18
If you’d like to know more, please give me a call at 303-541-9533
- Published in Individual Health Insurance, Wellness