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The Affordable Care Act and Preventative Health: What services can get and how much are they going to cost you?

April 25th, 2014

The M

Credit: Keoni Cabral via Flickr Under Creative Commons

Things have been a little quiet in the world of the Affordable Care Act, as of late. Mostly this is due to the ending of the legislation’s first open enrollment period, which ran from the start of October 2013 until the end of March 2014. There were plenty of things wrong with this first open enrollment period, and hopefully they’ve ironed out the major bugs in the system for the next one which begins in November 2014.

In the mean time we at ForHealthInsurance.com have taken it upon ourselves to help you get up to speed and ready for the 2015 open enrollment season with a series of articles updating and reminding you about the different aspectes of the ACA and what to look for when enrolling.

This week’s topic is Preventative Care Benefits.

 

What are Preventive Care Benefits?

One of the things that makes the ACA a unique piece of legislation is that it goes beyond simply looking to reform the American health care system. The ACA is attempting to reform the way Americans look at their health.

Americans are sick. The prevalence of preventable, chronic diseases, like diabetes, obesity, and heart disease has never been higher in this country. Seven out of every ten deaths in America can be linked to chronic diseases, according to numbers from the Centers for Disease Control. Just imagine how much those diseases are costing the American health care system, not to mention the economy in the form of lost productivity.

Through that lense it’s no wonder the ACA is making such an attempt to prevent and reverse the damage chronic diseases cause among the American population. The big way the ACA is attempting this is through the inclusion of mandated preventive health services in all health insurance exchange plans.

These are services to help you stay ahead of developing any sort of serious chronic disease. They’re also there to help you give up bad habits, like smoking, that can lead to massive health complications down the road.

 

So what services do you get?

Here below are the lists of preventive health services covered by every health insurance exchange plan sold under the ACA. These service are offered by your health insurance provider with no copays, or coinsurance. This holds true if you haven’t met your yearly deductible amount yet. So essentially as long as you’re paying your monthly premiums these services are free for you to use, though there are some limits on how frequently you can make use of them as described below.

Health insurance exchange plans are required to offer at least 15 different preventive health services to adults between the ages of 18 and 65. For children up to the age of 18 they receive 26 different preventative health service, and women receive 22 until the age of 65.

Here they are listed out according to HealthCare.gov:

 

Adults:

  • Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

  • Alcohol Misuse screening and counseling

  • Aspirin use to prevent cardiovascular disease for men and women of certain ages

  • Blood Pressure screening for all adults

  • Cholesterol screening for adults of certain ages or at higher risk

  • Colorectal Cancer screening for adults over 50

  • Depression screening for adults

  • Diabetes (Type 2) screening for adults with high blood pressure

  • Diet counseling for adults at higher risk for chronic disease

  • HIV screening for everyone ages 15 to 65, and other ages at increased risk

  • Immunization vaccines for adults–doses, recommended ages, and recommended populations vary:

    • Hepatitis A

    • Hepatitis B

    • Herpes Zoster

    • Human Papillomavirus

    • Influenza (Flu Shot)

    • Measles, Mumps, Rubella

    • Meningococcal

    • Pneumococcal

    • Tetanus, Diphtheria, Pertussis

    • Varicella

  • Obesity screening and counseling for all adults

  • Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk

  • Syphilis screening for all adults at higher risk

  • Tobacco Use screening for all adults and cessation interventions for tobacco users

 

Women:

  • Anemia screening on a routine basis for pregnant women

  • Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer

  • Breast Cancer Mammography screenings every 1 to 2 years for women over 40

  • Breast Cancer Chemoprevention counseling for women at higher risk

  • Breastfeeding comprehensive support and counseling from trained providers, and access to breast feeding supplies, for pregnant and nursing women

  • Cervical Cancer screening for sexually active women

  • Chlamydia Infection screening for younger women and other women at higher risk

  • Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply tohealth plans sponsored by certain exempt “religious employers.”

  • Domestic and interpersonal violence screening and counseling for all women

  • Folic Acid supplements for women who may become pregnant

  • Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes

  • Gonorrhea screening for all women at higher risk

  • Hepatitis B screening for pregnant women at their first prenatal visit

  • HIV screening and counseling for sexually active women

  • Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older

  • Osteoporosis screening for women over age 60 depending on risk factors

  • Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk

  • Sexually Transmitted Infections counseling for sexually active women

  • Syphilis screening for all pregnant women or other women at increased risk

  • Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users

  • Urinary tract or other infection screening for pregnant women

  • Well-woman visits to get recommended services for women under 65

 

Children:

  • Autism screening for children at 18 and 24 months

  • Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

  • Blood Pressure screening for children at the following ages: 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years.

  • Cervical Dysplasia screening for sexually active females

  • Depression screening for adolescents

  • Developmental screening for children under age 3

  • Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

  • Fluoride Chemoprevention supplements for children without fluoride in their water source

  • Gonorrhea preventive medication for the eyes of all newborns

  • Hearing screening for all newborns

  • Height, Weight and Body Mass Index measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

  • Hematocrit or Hemoglobin screening for children

  • Hemoglobinopathies or sickle cell screening for newborns

  • HIV screening for adolescents at higher risk

  • **Hypothyroidism screening for newborns

  • Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary:

    • Diphtheria, Tetanus, Pertussis

    • Haemophilus influenza type b

    • Hepatitis A

    • Hepatitis B

    • Human Papillomavirus

    • Inactivated Poliovirus

    • Influenza (Flu Shot)

    • Measles, Mumps, Rubella

    • Meningococcal

    • Pneumococcal

    • Rotavirus

    • Varicella

  • Iron supplements for children ages 6 to 12 months at risk for anemia

  • Lead screening for children at risk of exposure

  • Medical History for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years , 5 to 10 years ,11 to 14 years , 15 to 17 years.

  • Obesity screening and counseling

  • Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.

  • Phenylketonuria (PKU) screening for this genetic disorder in newborns

  • Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk

  • Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years,11 to 14 years, 15 to 17 years.

  • Vision screening for all children.

To learn more about preventative services and the various offerings of the new health insurance exchanges under the Affordable Care Act, visit our Exchange Center and our blog.

How to shop for health insurance: It’s not as easy as it sounds

April 18th, 2014

Health app

Credit: Jason Howie via Flickr under Creative Commons

Many Americans assume that when it comes to shopping for health insurance the process couldn’t be easier, especially with the implementation of the Affordable Care Act (ACA) earlier this year. However with the advent of the  ACA, also known as Obamacare, the already convoluted world of shopping for health insurance, just got a whole lot more complicated.

 

Preparing to buy health insurance

One of the major provision of the ACA was the establishment of health insurance exchanges at the both the state and federal level. These exchanges are online marketplaces where citizens and state residents can shop for government subsidized and approved health insurance policies for sale in their area.

Whether you’re shopping at your state’s exchange or the federal exchange has to do with whether your state chose to build their own exchange or let the federal government do it for them.

One of the big draws of the exchanges is that you can receive a federal health insurance subsidy when shopping there. What that means is that if your annual income is between 100 percent and 400 percent of that current year’s Federal Poverty Level (FPL) then you get a subsidy for you health insurance. As you might imagine that subsidy is bigger the closer you are to 100 percent FPL.

Step 1: Budget

First you want to make sure you know what your health insurance budget is. It’s extremely important to know how much money every month you can afford to spend on health insurance for your and your family.

At this stage you should also figure out how often you plan on seeing a doctor. The reason for this is that the health insurance exchange plans come in four different levels, Bronze, Silver, Gold, and Platinum. Each level of coverage comes with its own monthly premium, copay, and deductible amounts.

For example a Gold plan will be more expensive per month than a Bronze level plan. The difference is that the Gold plan will have a lower deductible and smaller copays than a Bronze plan. Meaning if you’re at the doctor a lot then while you will pay more per month for a Gold plan, you’ll pay less per doctor visit, making it a value.

It’s important to note though that for the most part each level of coverage typically has the same network of doctors and hospitals. Meaning that a Bronze plan buyer and a Platinum plan buyer purchasing their plans from the same company will each be limited to the same in network providers.

Step 2: Watch your networks

One of the big criticisms of the ACA has been the legislation’s impact on the size and availability of health insurance networks. It is a fairly complex subject, but essentially the ACA puts enormous pressure on health insurance companies to keep costs down and prices low.

In response to that pressure insurance companies have drastically reduced the size of their provider networks, and lowered their doctor reimbursement rates to historic lows. Those two factors combined have made it so that the majority of exchange plans have much smaller provider networks.

So when you’re preparing to shop for health insurance it’s vitally important that you take the time to review the exact network size and offerings for each company selling plans in your area.  Often times it’s difficult to tell from the exchange website what the provider network looks like. When that’s the case you should call the exchange and speak with a representative there, or even get in touch with the health insurance company in question.

Step 3: Medicaid

Depending on which state you’re living in, you might qualify for the newly expanded Medicaid program under the ACA. Originally the ACA called for expanding Medicaid eligibility to any individuals with incomes up to 138 percent FPL.

However when the Supreme Court upheld the ACA it struck down the mandated Medicaid expansion provision. So states had the option to expand the program, but they were no longer required to do it. The result is that about half the states expanded Medicaid. Now depending on your location you may qualify for the program.

Step 4: Children’s health insurance

If you have a child and you are looking to purchase a health insurance exchange plan then your child may qualify for coverage through the Children’s Medicaid program known as Child Health Plus. In fact many states require that a child be enrolled in the program if their parents are getting a subsidy at the exchange.

Step 5: Determining your subsidy

As I mentioned earlier in the article if your annual income falls between 100 and 400 percent of the current year’s FPL then you receive a federal health insurance subsidy along with your exchange plan. However when you’re applying for health insurance for the following year during open enrollment, you are asked to estimate your income for the upcoming year. It is from that estimated income amount that the size of your subsidy is determined.

This is good on the one hand because you do not need to wait for a reimbursement, but it can be bad if you suddenly have an income change during the year. For example if you estimate one number and receive a large subsidy because of it, but then your income changes during the year you are liable to pay back the extra part of that subsidy that you received.

The best course of action is to only take about 75 percent of the offered subsidy upfront when purchasing an exchange plan. This will give you some flexibility for unexpected income changes during the year. It should be noted that the opposite is also true. If you start the year with no subsidy then have an income change resulting if your eligibility changing you can get the money back.

Step 7: On your own vs. with a broker

If shopping for health insurance on your own now seems like a daunting task, that’s because it is. But there are plenty of resources to help make your shopping experience go a bit smoother (like this blog).

You might also consider working with a health insurance broker. A broker knows all of your potential health insurance options inside and out. They can hold your hand and guide you through the buying process so that it takes hours instead of weeks.

A broker can also make specific health insurance recommendations to you based on the information you share. Whereas an exchange navigator can only answer your questions without giving recommendations about what plans they think will be best for you. Navigators are actually barred by law from doing this.

You can get all of this for free when working with a health insurance broker. Yes that’s right I said free. Brokers can no longer charge you a fee for working with them, and they get paid from the health insurance company when they find you a plan. Essentially you get expert help finding the health insurance plan that’s right for you, at no cost.

 

Open Enrollment starts in November

I know that’s a lot of chew on all at once. Well the good thing is that the next open enrollment period for the Affordable Care Act does not start until November 2014, specifically November 15, 2014 for health insurance coverage beginning in 2015. Meaning you have plenty of time to digest the information here.