Heath Care Reform

With the new health care law, children under the age of 26 can choose to stay under their parent’s New York health insurance as long as they are not offered an employer-based health insurance. This provision enabled 2.5 million young adults to have insurance nationwide. In New York, 150,428 young adults have insurance coverage through this provision as of June 2011.

The new health care law allowed 254,083 Medicare policyholders in New York to receive a $250 rebate check to help with prescription drug costs when they fell into the Medicare gap in 2010. In 2011, 230,115 Medicare plan holders were given a 50% discount on brand-name prescription drugs covered by their plans when they hit the donut hole. An average of $695 per person or a total of $159,916,221 was saved in New York.

Previously uninsured individuals without health coverage because of a pre-existing condition can now apply for a Pre-Existing Condition Insurance Plan. This plan is available to U.S. citizens or legal residents with a pre-existing condition and have been uninsured for at least 6 months. In 2011, 2,632 individuals in New York have benefited from this new law.

When looking at New York health insurance quotes, applicants are assured that at least 80 percent of the price will go directly to health care services and other related improvements. A rebate or premium discount shall be provided if the minimum is not met. Around 4,651,000 private policyholders in New York will get greater value for their premium payments because of this 80/20 rule.

Preventive care services like immunizations, colonoscopies, mammograms, or annual wellness doctor visits must be included in all New York health insurance with no deductibles or co-pays. In 2011, 2,012,136 Medicare subscribers and 3,342,000 individuals with private policies received such services in New York.

Under the new law, insurance companies are no longer allowed to impose an annual dollar limit – a cap on the yearly spending for your benefits, or a lifetime dollar limit – a lifetime cap for spending for your covered benefits. This law frees chronically ill individuals like cancer patients from worrying about getting further treatment because of such limitations. In 2011, 6,432,000 New York residents have benefited from this law.

If insurance companies want to raise their premium rates by ten percent or more, they are required by federal law to publicly announce and justify their actions. To guard against such unreasonable increases, the state of New York received a total of $5.5 million.

All fifty states receive increases in funding for community health centers under the Affordable Care Act. This will help construct new health centers, provide medical services to more patients, improve preventive and primary health care services, and fund infrastructure projects. In New York, 552 community health centers received a total of $104.6 million to fund these improvements.

In 2010, the Affordable Care Act created the Prevention and Public Health Fund. This new fund was created for wellness promotion, disease prevention, and protection against public health emergencies. New York has already received a total of $62 million to support its policies, programs, and communities to help its residents lead healthier lives.

Essential Health Benefits

What Are Essential Health Benefits? Essential Health Benefits are a set of 10  health care benefits established by the federal government under the Affordable Care Act of 2014. The purpose is to ensure that all persons are covered by a set of minimum standards. Specific insurance services may vary by state and all plans must provide dental coverage for children.

1.Ambulatory Patient Services – Medical care provided without admission to a hospital, including doctor’s office visits, clinics and outpatient surgery centers.

2.Emergency Services – Organizations that are responsible to deal with emergencies when they occur. This includes medical care that if not treated could lead to serious conditions or disabilities.

3.Hospitalization – Medical care that patients receive when they are hospitalized.  This includes the care of nurses, doctors and other staff. This also includes medication received , room and board, tests and laboratory work.

4.Maternity – Medical care that a woman receives during pregnancy and post pregnancy. This includes labor, delivery, post delivery and the care for newborn babies.  

5.Mental Health Services and Addiction Treatment – Patient care provided to evaluate, diagnose and treat any mental health conditions or substance abuse disorders.

6.Rehabilitative Services and Devices – Services provided after an injury, accident, disability, or a chronic condition. The purpose is to attempt to help regain the patient’s mental and/or physical skills that were lost (to make the person whole again)

7.Pediatric Services – Medical care that is provided to children and infants, including regular check-ups, recommended vaccines, dental and vision care.

8.Prescription Drugs – Medicine that is prescribed by a doctor, and nurse practitioner, to treat any illness or existing condition.

9.Preventative and Wellness Services and Chronic Disease Treatment – Physicals, Immunizations and cancer screenings to prevent or detect certain medical conditions, and to provide care for chronic conditions.

10.Laboratory Services – Medical tests that are usually ordered by your doctor which include coverage for X-Rays and diagnostic imaging, blood and fluid tests, biopsies, pathology and pregnancy tests

Which Types of Insurance Plans are Not Required to Cover the Essential Health Benefits? The following insurance plan types  are not required to include essential health benefits and most often don’t.

Short Term Medical Insurance

Accident

Critical Illness/Cancer

Hospital Confinement

Association Health Plans

Faith Based Healthcare

Large Group Insurance plans(50 employees or more)

Travel Insurance

Dual Citizenship insurance (As long as you have proof of Identification)

What to Know When Shopping for Health Insurance

Below are some of the most commons concerns when shopping for a New York State health insurance plan.

Are Your Doctors In-Network. – Before purchasing a health insurance plan you should always make sure that your doctor(s) are part of the network. Going to a out-of-network doctor may cost substantially more than if that doctor is in-network. Don’t just ask the doctor’s office if they accept a certain insurance plan before you enroll. You should always confirm  with the insurance company or an agent that your doctors are in-network. Why the concern? Well keep in mind that if an out-of-network provider suggests services, then all of those services provided by that recommended doctor will be considered out of network, even if the facilities and providers are in network

Lower Monthly Premium may Result in Higher Costs- Health insurance follows a simple formula: the lower your monthly premium, the more likely you are to pay higher when you use the insurance. If you’re someone who happens to be in good health and does not foresee any health related issues and doesn’t use medicine on a very regular basis, then perhaps you’re better off opting for a lower costing health insurance plan. However, if you find that your medical expenses and prescription usage is high, then you may save money by purchasing a plan that costs more per month. Be sure to consider your current health condition when shopping for a health insurance plan. Again the less your monthly premium the more likely the higher your actual medical costs.

Health Insurance is a Contract – When purchasing a plan, both parties agree to live up to the contract (usually for a period of one year). If your find that your not happy with your plan, you can’t go back to your insurance company mid-year and ask them to change coverage . You’ll have to wait for your contract to expire. Additionally, if you buy an individual health plan on your state exchange or through healthcare.gov and you allow that plan to lapse or you stop coverage then you don’t qualify to buy a health plan on that exchange for the rest of that calendar  year. As such, be sure to choose the right plan that suits your needs before signing the contract.

Types of Insurance Coverage – EPO,PPO, POS, HMO, HDHP and HSA. The first 4  are acronyms that describe different types of health insurance coverage which provide you with or without the flexibility to see specialists and receive out-of-network and out-of-state care. Also, different plans have different requirements related to the need for referrals. If you’re often seeing specialists out-of-network then you want a plan that offers that flexibility. If you find that you travel often for work or live in multiple states per year ,then perhaps a plan that offers that flexibility is needed. The last two types,  HDHP and HSA’s allow you to set up a tax free savings account specifically for qualified medical costs For a better understanding of these types of coverage please refer to the following article.

Metal Levels – In order to make shopping and comparing health plans easier, a metal system to represent different insurance coverage levels was created These insurance levels are grouped into 4 metals based on actual metal value. Bronze, silver, gold and platinum all represent the metal worth and the level of coverage offered under each metal plan. In theory, a bronze plan will cover 60% of your medical costs and provide you with a maximum out of pocket dollar amount that does not equal the remaining 40% but instead is a threshold set for most bronze plans. Silver is set at 70%, Gold 80% and the most valuable metal platinum is set at 90%. Based on your medical needs you should be able to relatively compare an appropriate metal level. Example, if you find that you have minimal health insurance needs then perhaps a bronze plan would suit those needs. However if you health status require a good deal of  care then perhaps a gold or platinum plan which costs more will actually cost you less in the long run.

Are Essential Health Benefits Covered? – One way of ensuring the plan you purchase or intend to purchase covers the 10 essential health benefits is to buy an on-exchange plan. All exchange plans must cover 10 essential health benefits. This provides you with a guaranteed minimum level of coverage, which is the standard set by the affordable care act. Why would we need a minimum standard level ? Well the cost of medical care is prohibitive without insurance in place and can often lead to financial ruin. Ensuring that a plan includes the minimum essential health benefits provides a safeguard.

Premium, Deductible and Out-Of-Pocket Costs. Each term relates to the cost of using and maintaining your plan.

Premium is the cost of the insurance that you usually pay on a monthly basis  to the insurance company. Premiums are often locked in for a period of one year, meaning the insurance carrier cannot arbitrarily charge you a higher premium within that year.

Deductible is a yearly dollar threshold that you must meet prior to the insurance company paying for medical services. This almost always excludes preventative care.

Out-of-pocket costs are your maximum annual dollar amount that you can spend on health care services and medicines.

Health Insurance Subsidies  A Subsidy is a dollar amount provided by the federal government paid directly to your insurance company based on your current yearly income. This money does not have to be paid back, however if your income does increase there is a strong possibility that your subsidy may change, which would then increase your monthly premium (retroactively).  Conversely if your income decreases within the year, that may reduce your monthly premium at which point you have the right to contact your insurance company and inform them of your income change.