Caring for Crohn’s Affordable Care Act Primer Part 2: Insurance Choices & Costs

January 6, 2013 at 7:59 pm 4 comments

In this second installment of the Caring for Crohn’s Affordable Care Act Primer, I explain the provisions of the law designed to increase affordability and accessibility to health insurance.

The Affordable Care Act was designed to give patients and consumers alternatives to individual private insurance plans. Specifically, there are several provisions, some of which were discussed in the previous post, that are designed to increase options for insurance coverage.

Insurance Choices

  • Pre-Existing Condition Insurance Plan: The Affordable Care Act created a Pre-Existing Condition Insurance Plan to ensure coverage for those who were previously denied coverage due to their health conditions. The plan covers a wide range of services including primary and specialty care, hospital care, and prescription drugs. Effective:July 1, 2010
  • Young Adult Coverage: The Affordable Care Act allows parents to keep or add their children onto their health insurance plans until they turn 26. Children who are married, not living at home, attending school, not financially dependent on their parents, or eligible to enroll in their employer’s plan are all eligible under the provision. Effective: health plan years beginning on or after September 23, 2010
  • Affordable Insurance Exchanges: In an attempt to make buying health insurance easier and more affordable, the Affordable Care Act created Insurance Exchanges. These Exchanges will allow individuals and small businesses to compare health plans, get answers to questions, find out what tax credits they are eligible for, and enroll in a health plan that meets their needs. For an individual or family, these Exchanges is a place where you can enroll in private or public health insurance. For small employers, the Exchanges provides you with a better choice of plans and insurers at a lower cost. Effective: 2014
  • Consumer Operated and Oriented Plans: This is a new type of non-profit health insurer created by the Affordable Care Act. Consumer Operated and Oriented Plans (CO-OPs) offer consumer-friendly, affordable options to individuals and small businesses. In a CO-OP, you and other customers/members elect the board of directors, a majority of which must be CO-OP customers themselves. CO-OPs must use profits to lower premiums, improve benefits, or improve the quality of members’ health care. These new plans will be required to meet the same state and federal standards as other insurance plans. Individuals or small business owners may be able to join others in creating a CO-OP and apply for a federal loan to help get it started. You will be able to buy into a CO-OP health plan through the Affordable Insurance Exchanges or outside of the Exchanges. Effective: January 1, 2014

Insurance Costs

  • Value for Your Premium Dollar: The new law requires insurance companies spend consumer’s premium dollars primarily on health care by enforcing an “80/20″ rule. In other words, insurers selling policies to individuals or small groups must spend at least 80 percent of premiums on direct medical care and efforts to improve quality of care. Insurers selling to large groups must spend 85 percent of premiums on care and quality improvement. If an insurer exceeds what they are allowed to spend on things other than care and quality, it must provide a rebate of the portion of premium dollars that exceeded the limit. Effective: January 1, 2011
  • Lifetime and Annual Limits: Previously, insurance companies could set a limit on the total lifetime benefits you received from them. For example, they could impose a total dollar limit on benefits or limits on specific procedures. Once that limit was reached, the insurance plan wouldn’t pay for those services. The Affordable Care Act changes that by eliminating lifetime limits- essential for IBD patients who undergo many expensive procedures and tests yearly.  Like lifetime limits, the law also restricts and phases out annual dollar limits a health plan can place on most benefits. Lifetime Limits Provision Effective: health plan years beginning on or after September 23, 2010. Annual Limits Provision Effective: January 1, 2014
  • Flexible Spending Account Changes: Because of the Affordable Care Act, the costs of over-the-counter medications will be reimbursed under a Flexible Spending Account, Health Savings Account, or Health Reimbursement Account only if the medications are purchased with a doctor’s prescription. This restriction does not apply to the purchase of insulin.
  • Rate Review: Insurance companies must now publicly justify unreasonable rate increases. The new law ensures that any large proposed increases will be evaluated by experts to make sure they are based on reasonable cost assumptions and solid evidence.
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Caring for Crohn’s Affordable Care Act Primer Part 1: Consumer Rights & Protections Caring for Crohn’s Interviews Oak Park Behavioral Medicine

4 Comments Add your own

  • 1. Amy holly  |  June 18, 2013 at 5:38 pm

    So if I’m part time with no insurance how do I go about getting coverage for my crohns with obamacare??

    Reply
    • 2. caringforcrohns  |  June 19, 2013 at 11:17 pm

      Come 2014 you’ll be able to enroll in a public insurance plan through your state health insurance exchange. Unfortunately I’m not sure of your options in the meantime. I’m sorry I couldn’t be of more help!

      Reply
  • 3. Mimi Bold  |  January 9, 2014 at 12:37 pm

    Currently, I am insured under my father plan with Blue-Cross Shield since August of 2013 and I got diagnosed in October of 2013 with Crohns disease. My insurance is denying all of my claims and want me to do appeal. However, I am afraid of the insurance company denying my appeal. So I started researching about the Affordable Care Act and it seems too good to be true? If my insurance company denies my appeal, can I switch over to the state approved insurance company? I also believe Blue Cross is state approved insurance company affiliated with the Affordable Care Act? My question is with the new act, can Blue cross deny my claim even if it is considered as a preexisting condition?

    Reply
    • 4. caringforcrohns  |  January 19, 2014 at 8:12 pm

      Thanks for responding. Unfortunately I don’t know the answers to your specific questions. You should reach out to your states health care exchange or your senators office with any questions specific to ACA.

      I wish you luck and hope you find your answers soon!

      Reply

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