The provision of the Affordable Care Act that mandates U.S. citizens and legal residents have health insurance went into effect Oct. 1, opening federal and state government-provided marketplaces in which Americans can choose care if not already covered elsewhere.
Insurance providers are now prohibited from denying individuals and families coverage because of pre-existing conditions, and the legislation also requires health-care plans to provide free preventive services, annual checkups, prescriptions and substance use disorder services.
Mike Manes, field consultant for the Louisiana Health Care Education Coalition, said the current health-care program in the U.S. is “broken.”
“The system we have today, until January, is not sustainable financially,” Manes said. “The system we’re moving to is not stable financially.”
Although clear-cut costs for the plans aren’t defined and are dependent upon income — and even factors like tobacco use — most applicants will qualify for lower health care costs of some kind through government subsidies. Coverage can begin as soon as Jan. 1, 2014.
UL political science department head Pearson Cross, Ph.D., however, said the health-care reforms “constitutes one of the great last steps toward a social net of real importance.”
“The Affordable Care Act is the most significant and important expansion of the American welfare state since the creation of Medicare and Medicaid in the 1960s,” said Cross.
According to the Louisiana Department of Health and Hospitals, there were nearly 650,000 people in the state without health insurance in 2012, and The Daily Advertiser reported that 16 percent of Lafayette’s population — that’s 44,285 individuals — are uninsured.
Louisiana opted not to create its own health insurance marketplace, so students ineligible for parent-provided insurance, employer insurance or Medicaid can acquire care through a university-sponsored insurer or the federally run marketplace.
Because of the legislation’s density and complexity, The Vermilion broke down the ACA’s components and detailed how they will affect consumers of the insurance marketplace.
I don’t have insurance. What can I do?
Those 26 years old and younger are eligible to obtain coverage through their parents’ plans. Employees can acquire coverage through an employer-provided insurance plan, if it’s available. Others who qualify will be eligible for coverage through Medicaid. Everyone else can compare plans through the healthcare marketplace that opened Oct. 1.
Who’s eligible for Medicaid?
Although the Affordable Care Act created provisions for states to expand their Medicaid programs for all people making up to 138 percent of the federal poverty level, Louisiana’s Medicaid program will not be expanding. In Louisiana, you’re eligible for Medicaid if:
you receive Supplemental Security Income or receive financial support from the Office of Family Support
you’re disabled or have vision no better than 20/200
you’re a low-income parent of children under 19, are a child under age 19, are pregnant or have no insurance but have breast or cervical cancer
you receive Medicare and are low-income
Doesn’t UL Lafayette provide insurance?
After provisions of the ACA left the university no longer able to provide its sickness-and-accident coverage, it now provides an accident-only policy. In response, UL selected Student Assurances Services, Inc., as its vendor for students who must buy their own plans.
SAS costs $933 per semester and will offer “benefits during the period of coverage” to insured students when they “require treatment by a physician,” Student Health Services told The Vermilion in August. It will cover the allowed amount when insured students are seen by an approved network or “reasonable charges” when seen by a non-approved network.
But if I don’t purchase that insurance, what services does SHS provide?
Tuition includes a $20-per-semester fee that entitles students to an unlimited number of office visits. The fee covers illness assessment, minor injuries and general physicals. It doesn’t, however, cover women’s wellness exams, lab work (including pap smears), X-rays and imaging tests, IV therapy and injections and medications offered through the university’s limited in-house pharmacy.
Now tell me about the healthcare marketplace.
Louisiana chose not to create its own state-run marketplace, but insurance providers Vantage, Blue Cross and Blue Shield of Louisiana, the Louisiana Health Cooperative and Humana will be mostly available across the state.
These insurers’ rates can be compared alongside the federal options, which are offered in four tiers alongside a “catastrophic” plan. The lower tiers have a lower monthly payment but will require higher out-of-pocket costs each time you see a doctor or get prescriptions, and vice versa.
Bronze: 60 percent of health care costs covered
Silver: 70 percent
Gold: 80 percent
Platinum: 90 percent
Catastrophic: lower premiums, but requires the individual to pay all medical costs up to several thousand dollars; protects from worst-case scenarios
How much will it cost?
Monthly premiums vary according to income, family size and even factors like tobacco use, but individuals who earn less than about $46,000 or families that earn less than $94,000 annually may be eligible for tax credits to defer the cost. Under the proposed law, tobacco users can be charged up to 50 percent more in premiums, and subsidies can’t be used to cover that portion of the surcharge.
According to a Sept. 25 report from The Wall Street Journal, “the average premium for a 27-year-old nonsmoker will start at $163 a month for the lowest-cost ‘bronze’ plan; $203 for the ‘silver’ plan, which provides more benefits than bronze; and $240 for the more-comprehensive ‘gold’ plan.”
What will these plans cover?
Even the most basic plan is required to cover ambulatory services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse services, prescription drugs, rehabilitation services, laboratory services, preventive and wellness services and pediatric care.
What about dental and vision services?
These services are considered essential for those under age 18. But the Affordable Care Act does not mandate this coverage for adults, although it will offer stand-alone options in addition to medical coverage.
Are rates now going to be higher for young people?
Before the Affordable Care Act, patients 64 and older could be charged up to seven times as much as a 21-year-old, but now, the elderly can be charged no more than three times as much as the youth. This will increase rates for individuals aged 18-49, yet these individuals are also more likely to qualify for government subsidies.
Children under 21 have slightly lower premiums and families with three or more children under 21 will be charged only for three children, as per proposed regulations by Health and Human Services.
What if I don’t acquire health insurance?
Those without health insurance in 2014 will have to pay full cost for any prescriptions or doctor or emergency room visits, plus a penalty of $95 — or 1 percent of income, whichever is higher. That fee increases annually. By 2016, the penalty will be $695 or 2.5 percent of income — again, whichever is higher. The 2014 fee for uninsured children is $47.50 per child, capping that fee at $285.
When can I sign up?
The marketplace opened Oct. 1 and closes March 31, 2014. It won’t be available again until fall 2014, although “qualifying life events” — like moving to a new state or changes in income or family size — allow for special enrollment periods. If coverage is needed by Jan. 1, you’ll have to sign up by Dec. 15.
Where can I sign up?
Online at healthcare.gov or through the mail. You can attain personal assistance at localhelp.healthcare.gov or the 24-hour, toll-free line at (800) 318-2596. You can also sign up through any federally qualified health center.