ACA FAQ – Obamacare Facts

 Obamacare Facts, Obamacare Calculator and ACA Healthcare Overview

 

The Patient Protection & Affordable Care Act  (ACA) is better known as Obamacare.”  

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Learn and Understand the Obamacare Facts to Make Educated Decisions and the Best Choices for You, Your Family, or Your Business!

This health reform is the largest in the United States in nearly half a century (since Medicare was created in 1965).

The ACA contains a number of drastic measures and program changes that will eventually affect all Americans.  Some are set to take place immediately while others are scheduled to integrate in a few years.  Get to know the Obamacare facts so you can do what is best for you within your budget.

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Seniors, Families, and Individuals are going to be affected right away!  

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Check the page “Free Resources” to learn more about the ACA and how it may impact you.

Check the page “ACA / Obamacare Calculator” to use a FREE tool to help you estimate your costs for a Marketplace policy or even for your state’s exchange.

You can ‘beat the system‘ by clicking on the “Beat the System” page link to see which supplements and services can better meet your needs for less money.

Illustrations (examples) of some cost-effective choices in the private sector for major medical plans, “telemedicine” plans, and inexpensive supplements to cover your deductibles and out-of-pocket expenses are available to most people and can be found on the “Beat the System” page on this site.  Get to know the Obamacare facts!

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Medicare 1965 Image (President Johnson Signs) Cropped               Obama-ACA-Signing

 

Here are some of the questions and topics that Seniors, Business Owners, and Families frequently have. The page “Free Resources” provides links and files to answer these questions.  The ACA is ever changing and many elements of it have yet to be formalized.  Check back here for updates and changes as the Federal 2014 fiscal year begins October 1, 2013.  You may also want to read the Posts & Articles on this site as the information and content may be directly of interest to you.

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Will everyone have to buy health insurance?  What happens if you don’t?

A:   Starting in 2014, most people will be required to have health insurance or pay a penalty if they don’t. Coverage may include employer-provided insurance, coverage someone buys on their own, Medicare, or Medicaid.

Several groups are exempt from the requirement to obtain coverage or pay the penalty, including: people who would have to pay more than 8% of their income for health insurance, people with incomes below the threshold required for filing taxes (in 2012, $9,750 for a single person and $26,000 for a married couple with two children), those who would have qualified for Medicaid except their state did not expand the program, those who qualify for religious exemptions, members of Indian tribes, undocumented immigrants, and people who are incarcerated .

These penalties are phased in over time at $95 in 2014, $325 in 2015, and $695 per adult beginning in 2016 (with annual increases after that) and 1% of income in 2014, 2% in 2015, and 2.5% starting in 2016.The penalty for people who forego insurance is the greater of $695 per year (up to $2,085 for a family) or 2.5% of income starting in 2016.  Income is defined as total income in excess of tax filing thresholds.  The total penalty for the year will not exceed the national average of the annual premium of a bronze level health insurance plan offered through the health insurance marketplaces. The Congressional Budget Office projects that 3.9 million people will pay the penalty in 2016.  Consider the chart below.

Obamacare Tax Penalties

Health insurance plans will provide documents to people they insure that will be used to prove that they have the minimum coverage required by law.

How does the ACA affect Medicare and Medicaid?  Will I have to pay more for either in the future?

A:  The ACA will cut Medicare by $716 Billion (or more) over the first 10 years.  It is estimated the average payment to Medicare service providers will be reduced by 23% or more.  This reduces or eliminates the profit margin for services for most doctors, specialists, and other medical care providers.  As a result, some doctors, specialists, and wellness providers may choose not to accept Medicare any longer or may require Medicare patients to make up the difference through fees or other forms of compensation paid by the Medicare patient.  Many Seniors are selecting telemedicine plans.  {Note:  More information on how Medicare will be affected by the new health reform laws can be found on the “Medicare FAQ & Enrollment” page of this site.}

Will I still have access to my primary care physician (PCP)?  Can I still access specialists and caregivers?

A:  Primary Care Physicians are taking diverse positions in response to ACA.  Some are retiring.  Some are selling their practices.  Some are charging patients a “rights fee” to remain on the patient roster (seen for appointments).  Others are implementing new methods to charge patients for services in an effort to maintain income levels while complying with the ACA’s requirement that 80% of revenue be used for actual healthcare.

Strategists, overseers, and other insiders are divided on how patient access to doctors (primary care physicians and other medical service providers) will play out.  On a recent airing of The McLaughlin Report on PBS, the U.S. News & World Report Editor-in-Chief, Mort Zuckerman, stated his observations and forecasts.  Mr. Zuckerman, a Harvard Law School and Wharton School of Business graduate, believes employers will reduce many full-time positions to part-time positions moving the part-time workforce from 25% currently up to 50% of those earning wages.  This will result in many more Americans having to purchase their healthcare benefits on their own.

Mr. Zuckerman went on to state the United States has 87% of its population currently covered with healthcare (medical benefits of some type) at an amount equivalent to 18% of our country’s GDP (Gross Domestic Product). Contrarily, other industrialized countries have up to 98% of their populations covered with medical benefits at a cost of only 12% of their respective GDPs.  Mr. Zuckerman concluded ‘the U.S. has the most expensive healthcare system in the world.’  Given the ACA’s imposed limits on reimbursements to healthcare providers and possible rebates to patients upon reviews of health records  and billing procedures, many doctors, physicians, and specialists are establishing new and nontraditional methods to generate revenues for their practices.  These new methods vary greatly in their scopes and amounts.

Are most doctors (PCP) going to ask for an annual “patient fee” for me to still be his or her patient?

A:  This remains to be seen and will likely evolve as the Affordable Care Act is implemented in stages.  Many are.

What if I can’t afford annual “patient fee” or “rights fee” charges by my PCP?   What are my options?

A:  If affordability becomes an issue to see your current doctor, you may want to select another primary care physician who is NOT charging an annual fee to be on his or her patient roster.  As well, the quickly rising popularity of “telemedicine” plans is making access to Board-certified doctors in the patient’s state much more cost-effective as well as convenient.

If I do pay a rights fee each year to my doctor, can the “right” be transferred as part of my estate?

A:  This remains negotiable and no clear direction has been established.  Ask your doctor if he or she is going to allow you to bequeath your patient roster spot with his or her practice to a family member or other beneficiary.

How many more people in Arizona are going to be allowed into the system?  Will it clog the system?

A:  Forecasts indicate 30-50 million more people will enter the system…about 1,000,000 in Arizona alone.

How long will I have to wait to get an appointment with my doctor or specialist? Weeks?  Months?

A:  Depends on your zip code, number of available PCPs nearby, and patient load at the time you need services among other criteria that may affect your wait time for an appointment.  Many experts predict a typical wait time to get an appointment with a primary care physician or healthcare specialist will be about 2-3 months depending on a number of factors.  Consultants and industry professionals frequently point to comparable healthcare systems in Canada and Europe to predict what may happen once Obamacare is implemented in the United States.  Some constituents in healthcare as well as economic disciplines believe appointments for certain non-emergency surgeries may take years to attain and complete.

Are there any other solutions out there that allow me to talk to a doctor or specialist without an appt.?

A:  Yes.  Many people are choosing “telemedicine” plans for common ailments, medical needs, and illnesses.

What is the Healthcare Marketplace I keep hearing about?   How does it work?

A:  This is the platform for the Dept. of Health & Human Services (HHS) to enroll people in ACA policies.  Health Insurance Marketplaces (also known as Exchanges) are new organizations that will be set up to create more organized and competitive markets for buying health insurance. They will offer a choice of different health plans, certifying plans that participate and providing information to help consumers better understand their options.  This is part of knowing the Obamacare facts.

Beginning in 2014, Marketplaces will serve primarily individuals buying insurance on their own and small businesses with up to 100 employees, though states can choose to include larger employers in the future. States are expected to establish Marketplaces–which can be a government agency or a non-profit organization–with the federal government stepping in if a state does not set them up. States can create multiple Marketplaces, so long as only one serves each geographic area, and can work together to form regional Marketplaces. The federal government will offer technical assistance to help states set up Marketplaces so the Obamacare facts can be understood.

Can I be given medical treatment now for pre-existing conditions that were declined in the past?

A:  Yes.  People with pre-existing conditions can no longer be denied healthcare or medical services by insurers.  Starting in 2014, all health insurers will have to sell coverage to everyone who applies, regardless of their medical history or health status. At that time, insurers will not be allowed to charge more to individuals with pre-existing conditions, nor will they be able exclude coverage of those conditions from the insurance plans they sell.

The law provides new protections for children with pre-existing conditions that will take effect on September 23, 2010. Insurers will not be permitted to deny coverage to children due to their health status, or exclude coverage for pre-existing conditions.

While adults will not have the same protections as children in the years prior to 2014, some adults may be eligible for a temporary national high-risk pool open to all U.S. citizens and legal residents who have had trouble buying insurance due to a pre-existing condition and have been uninsured for at least six months. This federally subsidized coverage, officially known as the Pre-existing Condition Insurance Plan, will provide temporary coverage until the broader coverage provisions take effect in January 2014. States can operate their own high-risk pool or have the federal government carry out the program. The federal government began accepting applications for enrollment in their high-risk pool on July 1, 2010, with coverage beginning on August 1, 2010. Premiums for this coverage will be based standard premiums for the general population, and therefore will not be higher due to the health problems faced by the high-risk pool beneficiaries. In addition, the amount that premiums can vary based on age will be limited. The high-risk pool insurance must cover 65% of medical costs and the maximum cost sharing is set at the Health Savings Account limits ($5,950 for an individual and $11,900 for a family of four).

What are the plan choices in the Marketplace?   What do they cover?  How expensive are they?

A:  The Obamacare facts are this:  there are four plans.  Platinum, Gold, Silver and Bronze.  Experts predict all will have at least a $2,000 deductible to an individual patient and $4,000 for a family of four.  Once the annual deductible is met, the Platinum plan will pay 90% of costs incurred above the deductible while Gold will pay 80%, Silver 70% and Bronze 60%.  The patient(s) will be responsible for the costs their respective plan(s) do not cover.  For example, if you have a Bronze plan with a $2,000 deductible and you incur medical expenses of about $5,000 in a given year, you will pay the first $2,000 (the deductible) and 40% of the amount over $2,000.  In this case, you would pay 40% of the $3,000 incurred above the deductible, which is $1,200.  As a result, your Bronze plan provided $1,800 of the $5,000 total you paid out during the year while you personally were responsible for $3,200.  If you are a member of a family of four and your deductible is $4,000, you would’ve paid the first $4,000 and then 40% ($400) of the additional $1,000 incurred in the illustration provided.  The Bronze Marketplace plan would’ve paid $600 of the $5,000 total.

Can I grandfather in my current plan (Aetna, Blue Cross, Cigna, United Health, Human, Veteran’s, etc.)?

A:  It depends on whether or not it is now “compliant” with the ACA in that it has earned the designation of  a QHP (Qualified Health Plan).  In order to do so, your major medical or group benefits plan must offer the 10 specific health services set out by law (commonly called the 10 essential benefits) FREE of charge like the Marketplace plans do.  At the same time, your major medical policy or group benefits plan must meet other ACA criteria to be considered a “qualified” health plan.  You will need to confirm with your major medical policy issuer or your workplace group benefits provider to ensure your policy is compliant and you are protected to the levels you believe you are.  Experts and counselors in the medical professions and legal industry encourage people to confirm what they have and to learn what is and isn’t covered while making informed decisions at all times.

10 Essential Benefits

Employer plans that were in place on March 23, 2010, the date the new health reform law was enacted, are referred to as “grandfathered plans” and are subject to some of the new rules but exempt from others. Beginning on September 23, 2010, grandfathered employer plans are required to eliminate any lifetime limits on coverage and restrict any annual limits on coverage, eliminate pre-existing condition exclusions for children, and if the plan provides dependent coverage, extend that coverage to adult children up to age 26.  For Veteran’s, generally speaking, the ACA does not increase out-of-pocket expenses.  At the moment, this is one of the Obamacare facts Veterans like.

Beginning in 2014, grandfathered employer plans will be required to eliminate any annual limits on coverage, eliminate pre-existing condition exclusions for adults, and limit waiting periods for coverage to no more than 90 days. Grandfathered employer plans will not, however, be required to alter their benefits to meet the new minimum benefit standards nor will they have to limit enrollee cost sharing or provide coverage for preventive services with no cost-sharing. In order to maintain its grandfathered status, a plan cannot reduce or eliminate benefits to treat particular conditions, increase employee cost-sharing (including deductibles, co-insurance, and co-payments) above certain thresholds, reduce the employer share of the premium cost, or change insurers. Once a plan loses its grandfathered status, it will have to comply with all the new rules.

Will existing employer health benefits plans be affected by health reform?

A:  Yes.  Employer plans that were in place on March 23, 2010, the date the new health reform law was enacted, are referred to as “grandfathered plans” and are subject to some of the new rules but exempt from others.

Beginning on September 23, 2010, grandfathered employer plans are required to eliminate any lifetime limits on coverage and restrict any annual limits on coverage, eliminate pre-existing condition exclusions for children, and if the plan provides dependent coverage, extend that coverage to adult children up to age 26.  Beginning in 2014, grandfathered employer plans will be required to eliminate any annual limits on coverage, eliminate pre-existing condition exclusions for adults, and limit waiting periods for coverage to no more than 90 days. Grandfathered employer plans will not, however, be required to alter their benefits to meet the new minimum benefit standards nor will they have to limit enrollee cost sharing or provide coverage for preventive services with no cost-sharing.  

In order to maintain its grandfathered status, a plan cannot reduce or eliminate benefits to treat particular conditions, increase employee cost-sharing (including deductibles, co-insurance, and co-payments) above certain thresholds, reduce the employer share of the premium cost, or change insurers. Once a plan loses its grandfathered status, it will have to comply with all the new rules.

How much are co-pays going to be affected?  Will it cost me more for prescriptions and med supplies?

A:  There are varying opinions on how secondary medicine such as prescriptions and medical supplies will react to the Affordable Care Act.  Several experts in medicine and pharmacy suggest shopping online for discount pharmaceutical plans and co-pay supplements to address this concern.

What if I opt-out and don’t want healthcare from the Marketplace?  What happens then?

A:  You will either pay a penalty of the GREATER of 1% of your Modified Adjusted Gross Income (MAGI) or $95 in the first year.  The penalty grows each year for those who do not purchase a Marketplace healthcare plan or a QHP (Qualified Health Plan) through another provider (such as through an employer or a major medical policy acquired independently that meets the QHP requirements).

What is an Accountable Care Organization (ACO)?    How does the ACO affect me?

A:  In relation to the Obamacare facts, ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.  

How do dental, vision, chiropractic and other specialty care services get affected by the ACA?

A:  Dental and Vision plans are not required to be part of the “essential” care components of the ACA or Marketplace.  Currently, chiropractic, acupuncture, and massage care are generally NOT considered to be part of the essential health benefits of a Marketplace or major medical plan.  However, there is legislation in place and highly active lobbying among special interest groups representing medical companies, pharmaceutical companies and insurers to include such services as part of the basic essentials of preventative medicine.  It is anticipated that states will have the final say so on which services are or are not included as the required essential benefits to be considered a Qualified Health Plan (QHP).

What amount will Obamacare pay toward assisted living or skilled care if I ever need it?

A:  Lobbying is still going on to determine these aspects of the Affordable Care Act.  Final requirements are expected in late 2013.  Many experts believe this ever-evolving health reform law and its related legislation will continue to be bantered, negotiated and amended through its initial integration as well as its subsequent stages that will affect Americans for the next 10 years and beyond.

Are there any benefits to having a joint or household policy with my spouse or children?

A:  Yes.  You can now keep your children up to the age of 26 on your family policy given certain provisions are met.  The health reform law contains a provision that requires private insurers to continue dependent coverage of children until age 26. Department of Health and Human Services regulations specify that a young adult can qualify for this coverage even if he or she is no longer living with a parent, is not a dependent on a parent’s tax return, or is no longer a student.  Both married and unmarried young adults can qualify for the dependent coverage extension, although that coverage does not extend to a young adult’s spouse or children. For employer plans that were in place prior to March 23, 2010, young adults can only qualify for dependent if they are not eligible for another employer-sponsored insurance plan.  Insurers that do not offer coverage to dependent children will not be required to offer this coverage to young adults.

The extension of dependent coverage to age 26 will go into effect on September 23, 2010, but plans will not be required to comply with the regulations until the first plan year beginning on or after that date.  However, some insurers have said that they will begin to make the extension of dependent coverage available prior to September 2010 for young adults who would otherwise lose coverage.

Regulations also state that young adults who gain dependent coverage under the health reform law cannot be charged more for coverage than similar individuals who did not lose coverage due to the end of their dependent status.  Young adults newly qualifying as dependents under the health reform law must also be offered the same benefits package as similar individuals who were already covered as dependents according to the Obamacare facts.

Currently, some states require that private insurance extend coverage to young adults in their twenties.  These state requirements do not extend to self-funded insurance plans, but the new federal health reform law is designed to apply to these self-funded plans.

What are the tax implications/penalties for noncompliance?  How will the IRS collect a penalty?

A:  Noncompliance will incur a penalty.  Currently, the IRS plans to collect penalties by seizing tax refunds as stated in the Obamacare facts (ACA legislation).

Does Obamacare increase my chances of medical bankruptcy?   Precautions I should take?

A:  This remains to be seen, but medical bankruptcy is the #1 type of personal bankruptcy in the United States.

How does Obamacare impact my children’s and grandchildren’s futures in terms of healthcare?

A:  Opinions vary in the long-term impact of the ACA.  All agree the Obamacare facts indicate its immediate costs will be significant.

Obamacare Tax Increases

Will Obamacare cost me more if I move into assisted living or need skilled nursing help?

A:  If you’re on Medicare, your costs and expense ratios are set by Medicare.  Private pay clients will likely need to shop for services and compare costs before making a decision to relocate into an assisted living facility or similar type of environment that requires skilled medical care.

If I need emergency services at home or make an emergency room visit, will it cost me more?

A:  The amount you pay will relay heavily on your plan or whether you are on Medicaid or Medicare.  The ACA intends to discourage “over-utilization” of medical services in an effort to curb costs…such as people going to the ER when they do not have true emergency needs.  This approach intends to lower the amount of money it costs any given patient when in the ER.  By the same token, the ACA may shift the costs of ER visits to the more affluent citizens of the U.S. and away from those on Medicaid and in lower income tax brackets.

What are some of the best methods to protect myself and my family against rising healthcare costs?

A:  Educate yourself thoroughly on the ACA and the Marketplace.  Shop actively for quotes from healthcare providers and insurers.  Ask a licensed health insurance specialist for insights, advice, and recommendations. Use the FREE resources on this site and government sites to help you make informed decisions when you go to make important choices for your healthcare needs in 2014 and beyond from both a medical as well as a financial perspective.  Consider contemporary alternative such as telemedicine that save time and money while still providing high quality medical care.

Are the IRS and Dept. of Health & Human Services (DHHS) now tied together?  Do they have my records?

A:  Yes.  They will work cooperatively to enforce the ACA.

What are the major medical plans offered in the Marketplace?

A:  (Platinum, Gold, Silver and Bronze)

Will my major medical benefits at work still be given to me starting in 2014?

A: If it complies with the ACA. However, many employers are raising their deductibles to “catastrophic levels” to shift the increasing costs of healthcare to the employees. If this is the case for you, consider very inexpensive supplements to protect you found on the Beat the System page).

How much will health insurance cost me in the Marketplace?

A: Click on the ACA Cost Calculator page on this site for a practical estimate.

What are the cheaper alternatives?

A:  Click on Beat the System Page to learn about HouseCalls 24/7.  This “telemedicine” service allows you to “talk with a doc” from the comfort of your home, work or car.  HouseCalls 24/7 has plans starting at only $19.95/month with unlimited use.  A family of four can get an unlimited use plan with HouseCalls 24/7 for only $29.95/month.

Why should I pay expensive monthly premiums when there’s still a high deductible in place?

A:  Many people aren’t.  They’re choosing to manage their out-of-pocket costs, time, and resources through innovative and effective supplement plans now available to the public.  Many Americans don’t see the need to pay significant money for co-pays and still have to wait for weeks or months to get an appointment with a doctor or specialist.  Lots of people are choosing to “talk to a doc” 24/7 with HouseCalls 24/7 by video chat, telephone conference, email exchange, or however you prefer.  Prescriptions can be written, too, through HouseCalls 24/7.  

What is the difference between them (the Marketplace plans) I’ve heard about?

A:  See chart below reflecting % AFTER DEDUCTIBLE is paid by Obamacare:

 

Actuarila Chart for Plans

Deducible for Bronze Plan Projected to be $2,000 for Individual and $4,000 for a Family of Four.

 

What states are using the FFM (Federally Facilitated Marketplace) and which aren’t?

A:  See map below of states’ designations for their choice to be part of FFM or independent.

 

State Exchange Model Map

Provided by KidsWellCampaign.org

Follow Up & Insights:

There are also many other inexpensive solutions that will help your family better manage the rising costs of healthcare and give you the services you really need as this sweeping health reform affects all of us and how medicine and healthcare are provided in our country.  Click on the Beat the System page to learn more and get what you truly need.

Note:  From this web site, you can click on a number of different resources, health plans, and supplements that you can customize for your needs.  You can choose your Marketplace policy from this site (opens a new window when you click on link) and then move to additional supplements and services to fill in the “holes” in the ACA.

You can find a number of great solutions from this site including very inexpensive plans for hospital stays, ER visits, prescriptions discounts, co-pay coverage, etc.  Each link you click to review and/or purchase a supplement you or your family needs, will open a new “window” for data input and completion.  You will be able to remain on this site in order to return to it so you can review and make more choices you will need starting Jan. 1, 2014 that are very cost-effective.  Get better benefits for less money when you “Beat the System” known as Obamacare.  Know the Obamacare facts for your own good!

 

2 thoughts on “ACA FAQ – Obamacare Facts

  1. Clarita:

    If you are unemployed or cannot afford Obamacare or perhaps even a basic major medical plan, you should contact your local Medicaid office to see if you qualify for assistance through Medicaid. Many people are and it’s your best bet to find out if you do qualify for health insurance through this State or Federal resource.

    Thanks.

    The Obamacare Facts Team

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