Grow Up Folks…Quit Whining…ACA/Obamacare Isn’t Perfect But It Is A Big Improvement On What We Had!

Everyday I wake up and I am excited and thankful that I have health insurance and I am alive to tell my story.  It means I can live each day and look forward to the next, instead of wondering will I survive or how am I going to take care of myself?  You see, I was one of the first people to get health insurance through the Affordable Care Act (ACA), because a little known caveat in the law created a plan for people like me who had a pre-existing illness.

See https://progressiveandproud.wordpress.com/2013/09/30/obamacare-the-health-insurance-that-saved-my-life/.

When I was without traditional insurance, it wasn’t that I couldn’t afford to pay for the premium, it was that no one wanted to insure me.  As soon as I told the truth about my medical problems, it was a flat-out “no”.  I was too big a risk, they might lose money on me.  It was devastating, disgusting, and depressing.  I was overcome with questions like:

  • “Would I wake up in the morning?”
  • “Would I live to see my son grow up?”
  • “Would I see my son marry and have a family?”
  •  “Would I ever be a functioning member of society again or would I be disabled and house bound    forever?”

I suffered in silence. If you asked my family or my close friends, they would tell you, they had no idea I had no insurance and was why I didn’t seek treatment that they perhaps thought I should have.   I was raised to be independent and strong and to have the mind set “when things get tough, the tough get going.” When I realized that I could get insurance, even though I had a pre-existing condition, prior to 2014, I was sure my prayers had been answered and maybe just maybe I could get the medical treatment I needed to get better before my illness got the best of me.   I wish I could say I just applied online and “abracadabra,” got insurance the next day, but it was a process.  Well actually the process wasn’t so bad.  It was set up similar to the healthcare.gov web page,  but everything that could go wrong, did go wrong. In fact, compared to the frustration people are having today, getting signed up, my experience was a nightmare. You can read all about the problems I faced getting signed up in this blog. (https://progressiveandproud.wordpress.com/2013/10/23/sometimes-the-best-things-in-life-arent-easy-dont-give-up-on-the-health-exchanges/)  You know what, it didn’t stop me.   Most people close to me, didn’t know until a few days ago I had any problems in the sign-up process.  It was frustrating at the time, but I was determined to get insurance and I did.  Like I said, I was raised to be tough, independent, and focused on a goal.  I was raised by a single mom as my father died when I was 10 and things were not always easy, but my mom and, in fact, my entire family, lived by the premise “where there is a will, there is a way.”

Tired of cliches? Well so am I, but I am MORE tired of people complaining that:

  • “President Obama ‘lied’ when he said people could change plans and keep their same doctors.”  Who could have ever dreamed there would be the “push back” about this law that there has been?  ACA was supposed to be a plan for people who did not get insurance through their employer, could not afford insurance, and/or had pre-existing conditions that kept them from getting insurance.  This law was not written to circumvent or eradicate the employer’s responsibility to provide benefits.  Somehow though, people are suddenly blaming ACA for not meeting their insurance needs even though they are employed, for their health insurance benefits changing even if the change is ultimately positive for them, and for business decisions by companies where they cancel policies either because they want to save money, reduce their adverse selection, are attempting to up sell policies to their customers or because they wish to replace previous plans with new plans that offer the “ten essential services” required of all plans based on the Affordable Care Act. I guess the employees of these companies should have just been left with the sub-standard policies (also called “junk Insurance” or “mini-insurance”) since the insureds feel so “angry” about losing them. (http://www.latimes.com/business/hiltzik/la-fi-mh-healthplans-20131030,0,5590179.story) It is clear that these folks have never faced a catastrophic illness, accident, or had insurance that cost a lot and covered nothing leave them in the lurch right when the insured needed the policy the most.  Any insurance policy in effect on 3/23/2010 is grandfathered in under the ACA if there are no substantial changes.  But if the customer’s insurance company makes any substantial changes in coverage, terms or pricing, the policy is no longer grandfathered in under the ACA Law and may no longer be offered.  It should also be noted that a grandfathered in policy does not have to contain all ten essential coverage elements required of new policies (https://www.healthcare.gov/what-if-i-have-a-grandfathered-health-plan/.) So when a customer’s insurance company sends them a termination letter, it is only because the insurance company alone made material changes to the policy, not because the ACA law invalidated the customer’s insurance law.  The Press and Pundits are directing their anger and the cause at the incorrect party. The cause lies entirely with the insurance companies, since they had the option to not make any material changes and grandfather in these policies.  Had they done this, these policies would not have had to be cancelled and as the President promised, the customers could have kept their insurance, whether the policies were adequate or not.
  • “People could “choose” to keep their same insurance plan.”  Clearly that was the intent, but nobody could conceive that certain Congressional leaders and insurance companies would do everything possible for political gain and financial gain, while ignoring the needs of everyday Americans in favor of lining their own pockets and campaign coffers, choosing keeping their PUBLIC SERVICE JOB over the “greater good.”  However this is the story of politics today, take care of yourself and your best interests and forget about any sense of community that has always brought out the best in Americans.
  • “The proverbial wool was pulled over the eyes of the American people when they were told that plans through ACA/Obamacare would be cheaper. If you have a plan as a benefit of your job, the cost of that plan is not within the realm of ACA.” That is between the company you work for, the benefit plan offered and the rate they negotiated with the insurance company. “Spending on health care in the United States has grown substantially over the past four decades. In 1965, that spending amounted to $187 billion (in 2005 dollars). It more than tripled in real (inflation-adjusted) terms over 20 years, reaching $666 billion in 1985. Over the next 20 years, spending nearly tripled again, reaching roughly $1.9 trillion in 2005.” See the following link. http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/89xx/doc8948/01-31-healthtestimony.pdf. Remember, as far back as 1992, Democrats wanted a single payer plan, however that was too “Socialist” in the eyes of Republicans when Hilary Clinton chaired the Health Reform Committee after President Clinton was elected. In fact, Universal Health Care was talked about even by the Nixon Administration in a plan that has many similarities to ACA. See the following link. http://www.presidency.ucsb.edu/ws/?pid=3757#axzz2jFxVItXT. In a letter to Congress President Nixon said, “An all-directions reform of our health care system– so that every citizen will be able to get quality health care at a reasonable cost regardless of income and regardless of area of residence–remains an item of highest priority on my unfinished agenda for America in the 1970s.” Read more at the American Presidency Project: Richard Nixon: Special Message to the Congress on Health Care. See the following link. http://www.presidency.ucsb.edu/ws/?pid=3757#ixzz2jFxnZzlv. I include this small summary of the history of Universal Health Care in America just for those people who deny ACA has any roots in Republicanism. In general, the plans offered by ACA are cheaper, however in order to see how much the tax incentive and cost-sharing subsidy will impact your chosen policy under ACA, you have to complete the “enrollment” process.You don’t have to pay for the plan when you complete the enrollment, but you have to get to that point before you will see the tax incentive for the premiums along with the cost- sharing available if you choose the Silver Plan.

Frankly, I am frustrated, fed up and even angry with the senseless complaining that goes on by the media, our elected Congressional leaders, the pundits, and yes even the American people.   For two years, I have woken up every morning thankful for having health insurance.  As the days came closer to the final phase of implementation of ACA/Obamacare my business partner and I worked hard to learn about ACA and it’s regulations to put us in a position of being able to help individuals, families and businesses sign up for ACA, get the best plan to meet their needs at the lowest cost, and educate businesses about how ACA could help their business grow.

Yes it’s true, ACA can help a business grow, based on the tax incentives offered to businesses doing the right thing and either providing health insurance to their employees or providing some part of the premium so their employees can buy insurance in the exchanges.  In fact, we have even seen businesses save enough money on insurance through the ACA and actually add new staff because of the tax credits. See http://thinkprogress.org/health/2013/09/11/2607221/employers-obamacare-wont-stop-hiring/.

Now I wake up every morning and cringe, and wonder:

  • What will be the newest myth about ACA/Obamacare adding to the confusion today?
  • What will be the new online sign-up drama, that the media and the GOP will hype that deceives and leaves people frustrated?
  • Which Congressman will be on television trying to suggest the American people were lied to and manipulated into believing that ACA was going to cure all our medical needs in the United States?

I thought we were the country of “pull yourself up by the bootstraps,” that adversity makes us stronger, and that in America if you believe, and  keep trying you will succeed.   Instead, I suddenly see people complaining that the roll-out of ACA should have been perfect, that businesses are trying to cancel people’s policies because supposedly the regulations are “so tough” under ACA that it is cost prohibitive, and “oh no” birth control prevention services are required to be provided at “no cost”.

Interestingly, any businesses that claim their actions in 2013 were in anticipation of the ACA for 2014 are lying.  They are just doing what they have done as a money saving strategy in previous years.  The President has delayed the requirements for businesses with over 50 employees until 2015.  As such, there is no reason to take any actions in mid to late 2013 or the first half of 2014 which might be related to the ACA implementation as it affects businesses. Also, keep in mind,  abortion is not paid for folks, it is strictly prohibited from being paid for by ACA even though it is paid for within Romneycare.

See http://www.amycontrada.com/Romney_s_FREE_Abortions.html.

You can’t have it both ways.  You can’t say abortion is bad, birth control is bad, but pay for men to have Viagra to make them more virile and in the next breath, punish women for having children out of wedlock or while in poverty.  We need to get a grip and just say, women getting birth control at no cost is better than the other options.  A research study completed a year ago shows  that free birth control would cut abortions between 41-71% in the United States.

http://www.nytimes.com/2012/10/05/us/study-finds-free-contraceptives-cut-abortion-rate.html?_r=0.

One would think that those who felt that abortion was so wrong would be for free birth control since history has shown that taking away access to safe abortions does not eliminate abortions from taking place. See http://www.livescience.com/23726-birth-control-abortion-rate.html.

Whatever happened to common sense? People are having dramatic tantrums because things didn’t turn out perfect, that we have to spend some time on the web site, make a few phone calls, and horror upon horrors be patient. Yet, these same people seem to have no difficulty “camping out” before Black Friday to get the best deal, standing in line to get the new iPhone or video game to hit the market. Let’s act like adults and not just be the “want it, need it, gotta have it now” society.

How to act like an adult in terms of ACA!

  1. Complete your enrollment. In order to see your Silver Plan subsidies you have to do everything EXCEPT pay for your plan.  Know that completion means verifying your income and your identity. (Remember all those undocumented workers the GOP keeps saying are stealing our benefits. You have to be an adult and verify your identity. Then there are the “liars and cheats”, so they verify your income through the IRS, just like in a credit check.  There is one big difference they are only verifying your income, so  your credit will not help you or hurt you purchasing a plan.  You do not find out your subsidies (reducing the premium and cost-sharing to reduce the deductible and co- pay) until you complete the full enrollment. YOU HAVE NOT YET PURCHASED A POLICY, SO DO NOT WORRY ABOUT PAYING FOR THE ENROLLMENT, YOU HAVE NOT COMMITTED TO A PURCHASE YET until you actually make arrangement to pay your monthly premium beginning in January 2014.
  2. Review the plans.  Decide which one is best for you.  Do you choose a television satellite provider for your TV without getting the best deal? Don’t you look to see if your favorite channels are included? Come on  folks, check the offered plans to see if your doctors are on the plan…it’s not rocket science. Every plan has a website that you can go to and explore the specific benefits and identify the doctor, clinics and hospitals approved on that plan.  Guess what, if you find a plan you like and your doctor isn’t listed, call them and ask them to apply to be a provider.  They might just do it. It is beneficial for them to participate in a variety for plans as it increases their business.
  3. When you get a good deal, regardless of the type of purchase, you have to weigh the pro’s and con’s. That is what you have to do with these plans too.  We are talking about an age when people consider the thread count of the sheets they are going to buy, but they can’t take the time to read about the individual plans and find out about the differences between them. Even people on Medicare do this every year during open enrollment in an effort to find the most cost effective plan for them.  Two members of my family changed their Part D enrollment four times in ten years.
  4. Quit the panic mode“OMG someone hacked into the healthcare.gov and they are going to get all my health information.” OK, really, what health information did you give?  Whether you are a smoker…yep…they are really going to be able to demand a ransom for that information.  The call should be for the person who hacked into the system to be arrested and held accountable for the crime.  Hacking is illegal.  Healthcare.gov is not subject to HIPAA (Health Insurance Portability and Accountability Act) since they are not a “Covered Entity”, a “Third Party Payer” or a “Clearinghouse”.  HIPAA admonishes clinics, doctors, and hospitals to name a few to keep your health information confidential.  Any “Covered Entity”, a “Third Party Payer” or a “Clearinghouse”  must give the patient notice of their rights under HIPAA.  These are the only three categories that fall under HIPAA.  You may have heard congress voicing concerns over HIPAA during their current hearings.  These congress people are showing just how little they  understand about security and HIPAA or they are simply fear mongering, because they didn’t want ACA to be the law of the land.
  5. Wake up and smell the roses. You have the big lobbyists, the Tea Party, the Insurance Companies, the Medical Device Industry (https://progressiveandproud.wordpress.com/2013/10/19/the-medical-device-tax-a-burden-or-a-blessing-you-decide/), the Republicans and Big Pharma fighting against this plan. Why? It will hit them in the pocket book. They are not looking out for your interests, they are looking out for their financial interests only.  So, you have to learn how to differentiate between what is rhetoric and what is fact. It is the same as Chicken Little….just because he said the sky was falling didn’t make it true. These folks have a stake in making ACA fail, because guess what, this is the true free market, where you shop for the best plan FOR YOU, within the confines of an exchange and the insurance companies compete for YOUR business instead of making decisions about what YOU need.

The GOP is readying another campaign to bring down ACA.  They are trying to capitalize on any issue they can, because as long as they have insurance, a roof over their head, and food on their table, they don’t give one thought to the average American, who in the past have often had to make health insurance, a luxury in their budget.  Health insurance should not be a luxury. In today’s society it is simply a necessity. Just try going without it when you get ill.  You will figure out very quickly the havoc it can wreak in a person’s life who isn’t “lucky” enough to have coverage.

By: Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO and Lynne Smith, MSSW.

About the AuthorsBarbara is an industrial engineer with an MBA. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services. Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.  Please direct your questions and/or inquiries to askcobuzzi@gmail.com.

Advertisements

Creepy Uncle Sam is baaaaaack? Is He a Koch Brother?

Really? I thought sure Creepy Uncle Sam had been laid to rest, but apparently no such luck. The Republican Anti-Affordable Care Act (ACA) mascot has returned for a Halloween run. Remember him, he is the “Uncle Sam”, that looms over young people who sign up for insurance through the Health Exchanges. (http://thecaucus.blogs.nytimes.com/2013/09/19/creepy-uncle-sam-is-anti-health-care-law-mascot/) In one commercial, a Nurse is heard saying, “Oh, YOU signed up for Obamacare.”  The next scene shows the patient, a young woman, in the doctor’s office with her legs in stirrups, awaiting a gynecological exam, when Creepy Uncle Sam,  who looks remarkably like the stereotypical description of “a dirty old man” suddenly pops up in the examination room and leers at the female patient, speculum in hand.  In the male version of the “Creepy Uncle Sam” commercials, Uncle Sam has medical gloves on and is snapping the gloves.  He seems too interested in a patient’s sex life, and supposedly represents the government being too involved in American’s health care.  The tag reads “Don’t let the Government Control your Health Care.”  Creepy Uncle Sam commercials have drawn much criticism, with some experts even suggesting it minimizes the issue of sexual assault of women.

Just when we thought “Creepy Uncle Sam” was down for the count, he popped back up on our televisions for another round of Anti-ACA ads in the “spirit” of Halloween. (http://www.csmonitor.com/USA/DC-Decoder/Decoder-Wire/2013/1025/Creepy-Uncle-Sam-returns!-Will-Halloween-ad-scare-Millennials-off-Obamacare-video) This ad seeks to suggest that ACA is being shoved down young people’s throats and encourages them to reject the Health Care Exchanges and get their health needs met through other options or at the very least through insurance plans not offered by the exchange. It suggests that young people can find more “cost effective” plans elsewhere.  However, statistics suggest that almost 90% of young people will receive some form of subsidies.( http://finance.fortune.cnn.com/2013/10/21/why-millennials-need-obamacare/) In fact, some young people will be able to purchase health insurance through the Exchanges for about $49.00 a month, which is much less than the average “private” insurance plan available outside the Exchanges. Republicans and Tea Party members seem to leave out the fact that if young people “opt out” of ACA, they will lose the government tax-incentive subsidies.

The “Creepy Uncle Sam” marketing campaign has been relatively popular, but in a “can’t take my eyes off the train wreck” kind of way.  The campaign had about 3.5 millions views on You Tube in September but the “dislikes” far out-weighed the “likes”. ((http://thecaucus.blogs.nytimes.com/2013/09/19/creepy-uncle-sam-is-anti-health-care-law-mascot/) The ad campaign is aimed at young people between the ages of 18 and 30.  It was developed by a marketing company called “Generation Inquiry,” who received a five million dollar contract from “Freedom Partners,” to develop a campaign aimed specifically at young people encouraging them not to participate in ACA.  Freedom Partners is funded by none other than the Koch Brothers. Are you surprised?  Here we go again, with conservative groups, funded by the Koch Brothers and others, this time, trying to take advantage of the website issues associated with signing up for  ACA/Obamacare.  I love the irony of this commercial, keep government out of health care, but “come on down Koch Brothers” and tell us what will be best for our medical needs.  I am pretty sure that “Creepy Uncle Sam” is really the missing lecherous Koch Brother.  I jest, but the sole purpose of this ad campaign is to stop young people from signing up for insurance through the Health Care Exchanges. The success of the Health Exchanges is dependent on people of all ages signing up for the various insurance plans.  Young people, who tend to go to the doctor less often and be in good health are the counter-balance to older enrollees, who may use medical services more often and tend to have more chronic illnesses.  Theoretically, by keeping younger, healthier people from signing up for insurance through the Health Exchanges, Republicans and Tea Party members hope the Affordable Care Act will fail and the costs will be much more than anticipated, so the Republicans can say “told you so” leading up to the 2014 elections and the 2016 presidential elections.

There is some statistical evidence to suggest that since the Health Exchanges opened, some people have become frustrated with what they perceive as their inability to sign up for health insurance through the exchanges and have sought coverage through private companies or exchanges. (http://www.reuters.com/article/2013/10/25/us-usa-healthcare-insurers-idUSBRE99O04B20131025) Many times, when these young people contact my partner and I or Navigators they realize they were “duped” and could have qualified for subsidies.  It is important that every young person, in fact anyone who may qualify for ACA give the website “gurus” time to correct the problems.  Perhaps Bill Gates, one of the richest men in the world, said it best in his “picture message.”  (https://scontent-b.xx.fbcdn.net/hphotos-frc3/q71/s720x720/1395325_10200210418781672_442422196_n.jpg)  “Healthcare.gov has Fewer Glitches than GOP, Works More Than John Boehner.” ( This photo, if true, makes a significant statement.  I searched the world wide web for several hours and could not find anything to say this statement and photograph has been photo shopped.  Because we pride ourselves on our fact checking, I used the photo and added this disclaimer.) Let’s give the Obama administration some time to work out the glitches, glitches that could have been resolved if the Republicans and Tea Party members had not thrown enormous temper tantrums about the Affordable Care Act and tried to repeal it over 40 times, and shut down the government when they did not get their way for much of October. Had the Administration been able to focus their attention on tweaking the plan we may not be experiencing the difficulties we are now. It’s important to remember that Medicare didn’t work out the application kinks until about two years after it’s inception;( http://en.wikipedia.org/wiki/Medicare_(United_States)  )There are still several weeks left before January 1, 2014 and with a little patience people will get signed up for the Exchanges and purchase health insurance in an affordable manner.  Tell “Creepy Uncle Sam” and the Koch Brothers  they are not welcome in our homes, our minds, our health insurance, or our wallets.

About the Authors: By: Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO and Lynne Smith, MSSW. Barbara is an industrial engineer with an MBA. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services. Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.  Please direct your questions and/or inquiries to askcobuzzi@gmail.com.

Help, I Am Not Sure How to Sign-Up for the Health Exchanges!! The Process from Start to Finish is Explored Here!

Healthcare.gov is booming since the Federal Health Care Exchange and State Health Care Exchanges opened on October 1st.  There have been so many hits, about eight million unique visitors, that the system has had trouble and crashed repeatedly. People are getting frustrated with the  inability to check out their options and learn how much plans are going to help them. There has been some talk that some of the volume, may be from suspected “hackers.”  However, after investigation, the NY Exchange has concluded that at least for their exchange they do not think hackers have infiltrated their marketplace. (http://www.wgrz.com/news/article/228302/37/Experts-NY-Health-Exchange-Website-Unprepared-For-30M-Visitors) The NY State Exchange has had over 30 million visitors as of October 24th. 

People who are able to access the site and look at the plans are at times incredibly excited, or frighteningly depressed about what they learn or as you are about to find out think they learn.  The Affordable Care Act is not perfect, but it is better than what we had;  a system controlled by the big Health Insurance Companies with premiums for plans spiraling out of control, while denying coverage to anyone and everyone who had a pre-existing illness, unless they or their spouse had insurance through an employer. The Affordable Care Act is changing the “lay of the land” when it comes to health insurance coverage. Anyone who is considering getting health insurance through the health care exchange, or wants to help family or friends will benefit from this step by step discussion of the exchanges.  The reader will learn about the Affordable Health Care system,  the different types of plans available through State and/or Federal Exchanges; helpful hints to insure you get the best price for plans when using the exchange; as well as an overview of the falsehoods being spread to keep people from signing up for The Affordable Care Act.

After President Obama was elected in 2008, he indicated that health care for all Americans was one of the priorities of his presidency. (http://www.nydailynews.com/news/national/high-hopes-political-realities-obama-term-retrospect-article-1.1243468)  By 2009, both the Republicans and the Democrats were involved in discussions about the design of a national health care system.  The Democrats favored a single payer system, while the Republicans were unwilling to consider this “road to socialism.”  After months of discussion, both parties agreed to a plan that was initially suggested by Republicans in the 90’s developed by the Heritage Foundation as an alternative to a single payer system.  Following much compromise and negotiation, the House and Senate, voted for The Affordable Care Act and it was signed into law in March, 2010. Refer to https://progressiveandproud.wordpress.com/2013/10/05/another-acaobamacare-myth-no-negotiation-between-democrats-and-republicans-on-acaobamacare/ for information on the negotiating process in regard to ACA. Let’s review how to sign up for health insurance using the Federal or State Exchanges. While there may be minute differences between the two, the process is similar. It should be noted that even if you think your state may have a program, the sign-up page at http://www.healthcare.gov will connect you with either the federal sign-up for those living in the 26 states that refused to run their own exchange or to the individual State Exchange page in the state in which you reside.  Please make sure you ONLY use http://www.healthcare.gov to initiate the sign-up process for insurance because some companies have set up private exchanges that look similar to the Federal or State Exchanges but do not offer the enrollee any subsides or cost-sharing which may be the difference between a plan being affordable or out of reach.

  1. The first thing a person who wants health care insurance should do is go to http://www.healthcare.gov. (http://b-i.forbesimg.com/robertpearl/files/2013/10/Healthcare.gov_2-e1380635876183.png) The home page will have different choices.  Choose the one that best serves your needs such as individual/family or business.  This is a red alert.  Always start from the http://www.healthcare.gov website even if you think you have a State Exchange. Healthcare.gov will link you to your State Exchange, if available, but people have been fooled by looking up Federal Health Exchange or State Health Exchange in search engines. In order to get around the rules, companies including insurance companies have formed “private exchanges”.  It looks like a real exchange until you get to the costs. It may even have plans that are similarly named to the official ACA plans, but the enrollee will not be offered any subsidies to assist in paying for the plans.  In order to protect yourself and get the best rate ALWAYS begin your process to apply for health insurance at http://www.healthcare.gov.
  2. When you get to the healthcare.gov website click on your state and it will take you to a new screen.  There you will be told whether your state has it’s own exchange or if you will be getting insurance through the Federal Exchange.
  3. The computer will redirect you to your State Exchange home page or continue in the process of signing you up for the Federal Exchange.
  4. The next screen will ask you for your name, email address and zip code.  In some cases, it may ask you what you expect your 2014 income will be.  It may also ask if you are eligible for and have insurance through your employer. If insurance is a benefit offered by your employer, you may not be eligible for the exchange.  Why?  ACA was enacted to insure those who did not have insurance through their job, those who are unable to purchase health insurance due to pre-existing conditions, and those who are unable to afford health insurance.  (http://www.bcwac.org/pdf/Health-Care-Comm-Report-on-ACA-to%20Coalition-11.30.12.pdf)
  5. You may also be asked to identify 3 security questions and their answer.  Please make note of your user name, password, and the 3 questions you chose in addition to their answers. After you have completed this and clicked on “continue” you will see a screen that tells you to go to your email and verify your internet identity by clicking on the link.
  6. Click on the link, contained in the e-mail, and you will go back to the exchange and most likely land on a page with one of the following messages:  You have successfully signed up” and you will be able to proceed with the sign up for insurance, or “The system is very busy”, and then you will be taken to a page that tells you to wait, the exchange is busy, but you will be sent to the next step as soon as possible. http://www.fbnstatic.com/static/managed/img/fb2/news/healthcare_exchange_error.jpg People have reported quite long waits, up to 45 minutes and sometimes the site crashes and you have to put your user name (email) and password in to log in again.  Please do not leave this page, as you will lose your place in line. If you are unable to wait, save your information and simply return at a better time.  The web site is so new, and people are eager to check out the costs for health insurance plans, so the site is very busy and the best time to access the health exchanges seems to be after midnight and before 6:00 AM. Remember you have until Dec. 15, 2013 to sign up and have the insurance start coverage on 1/1/2014 and even longer if you decide after January 1st but before March 15th that you want coverage. If the site is busy, you will also be given a number you can call and a navigator will help you sign up or you can have an application form sent to your address to complete and mail to the place they request. Most of the people I have talked to, indicate they get through to a navigator by phone faster and the navigator is very helpful in completing the application.
  7. At any point between steps 4 and 6 you will be asked if you want to enroll in the plan or see an overview of the plans.  If you choose to review the plans, be aware you will be given an overview of the plans and none of the subsidies or cost -sharing information will be available.  This is causing a problem for many folks because, they do not see any cost sharing or subsidies on these plans, so they panic and immediately assume they do not qualify for subsidies from the federal government and will have to pay the full cost of the premium, deductibles and co-pays.  This is not necessarily true.  People who choose to review their possible plans prior to completing their application will have “artificially” high deductibles, premiums, and out of pocket expenses. You will not be able to see the plans with any subsidies or cost sharing applied until you complete the enrollment process.  (**As a note, this is the point where I am often contacted by email, phone, twitter or facebook because someone is frantic that the premiums are too high and not affordable and the deductibles and out of pocket maximums are often several thousand dollars.) They seem “sure” that they have been lied to and the rates are not what President Obama promised.
  8. Remain calm and check to insure you have completed your enrollment in the program.  You will know if you have completed it because you will get a screen explaining what your subsidy is for the premium and it will tell you, if you are eligible for cost sharing and what types of programs are available for you.  If you choose to view the plans at the start of the application, you will be shown possible subsidies and absolutely no cost-sharing, so the moral of the story is be sure and complete the enrollment process.
  9. The next step will be to fill out an application.  There will be several sections. This is pretty straightforward and simple.  You will be asked to identify the members of your family, and put in their dates of birth and social security numbers.  Be sure to include everyone in your family, you, your spouse and the children for whom you are responsible for obtaining insurance. (Don’t forget children can remain on your policy until they reach the age of 26, regardless of whether they live at home, are in college, or are working.)
  10. Another page will ask you about your income.  There are three different types of income: employment income, small business income, and other income which could include retirement, unearned income from investments etc.  These questions are very specific and if you are married you will have to complete it for both spouses. and if you have children for each of them as well.
  11. Once you enter your income, the program will attempt to verify your income and your identity. This is very similar to the process that occurs when you apply for a credit card, renting a home, or buying car insurance just to name a few. The big three credit companies are used to verify your identity and your last income tax form will be used to verify your income.  Although, in this situation, your credit does not impact your premium or cost sharing alternatives. The computer program is programmed to access your last tax return to compare the income you reported on your last return in comparison to the amount you are projecting you will earn in 2014.    ( find it very interesting that so many Republicans indicate an enrollee does not have to verify income.  For people apply for health insurance through the State or Federal Exchange must verify their income before they will be able to fully complete the application process.  These conservative and/or Republicans seem to assume people will cheat and/or under report their income and I am sure some will, just like some people cheat on their taxes.  However as noted in a previous blog the number of people who cheat on their taxes is much higher than those who cheat on entitlement programs.  If your income is significantly less or more than your most recent tax return, you may be asked to verify your income by submitting documents that support your reported income. You will be given several choices on how to document your income and how to get it to the health care exchange. As a personal note I had to do this.  I know my income will be more in 2014, than in the previous 2 years, so the amount I estimated is more than what is on my previous tax return.  I had to send in documentation to support this.  I sent in a copy of my taxes and a written explanation as to why  I think my income would be significantly more.  You can verify your identity by submitting a copy of your driver’s license or government ID for example. You can send your documents confirming your income by fax, mail, email.  You will have many choices.  You will also have a deadline by which time you must provide these documents.
  12. Whether you choose to send in your income documents immediately via the web or fax or decide to send them to the address provided, you will be given the opportunity to continue with the enrollment process.  You will get a screen that reminds you that if you do not report your income correctly, you may have to return some or all of the subsidy or cost sharing money you received and that your enrollment will not be complete until the supporting documentation is received. (No, this is not just me repeating myself, you will see this statement 2 or 3 times during the process of enrolling in the exchange: at the very beginning, prior to giving any income amounts, after you enter your income if it doesn’t coincide with previous tax years, and finally  again after you have reviewed the plans with the subsidies added in, just before you finish the application process.
  13. The exchange explains the consequences of under reporting your income and reminds you that you have to tell the truth and cites the law in regard to truth in reporting income. You will be asked if you want to continue or wait until after you “recheck your income,”  At this point you can save your data, or you can choose to move forward after acknowledging that the income you have documented does or does not agree with the information on your last tax return, and click on the button validating that the rates they are showing you are based on self-reported income and could change when you send in the verifying documents.
  14. Finally, you will be asked to sign your application electronically. Your signature means that you understand the need to submit supporting documentation, which is simply a statement that says you understand the process, validate you have submitted your correct earnings, and know you need to change your reported income if there are any changes to it in 2014. Failure to notify the exchange about any change in income could result in the IRS subtracting any over payment from your next federal income tax refund. It also reviews the situations in which you can make other changes to your plan during 2014, including but not limited to, the birth of a child, retirement, quitting a job etc, in other words any situation might change your eligibility for the exchange and/or impact your premium subsidy or cost-sharing.
  15. After completion of the application process, even if you have to send supporting documents to verify your income or identity, you will be given the option of reviewing the insurance plans available in your state.  At this point, you will be transferred to a page where you will see the plans available to you, the premium subsidy, and if you are reviewing the Silver Plan, any cost sharing for which you may be eligible.

Once you get to this point, the application is finished and you are ready to “shop in the exchange”. Don’t forget, that if you have been asked to submit supporting documents you must do so prior to setting up payment arrangements for your plan.  You will not be “officially” enrolled in the Health Exchange until that time.

So what can you expect to see when you review the plans. The first thing you need to know is that beginning in 2014 every health insurance plan will offer ten essential benefits that all enrollees will have in common regardless of what plan they are enrolled in:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization; maternity and newborn care
  4. Mental health and substance use disorder services, including behavioral health treatment
  5. Prescription drugs
  6. Rehabilitative and habilitative services and devices
  7. Laboratory services
  8. Preventive and wellness services
  9. Chronic disease management
  10. Pediatric services, including oral and vision care.

Regardless of which plan you choose, these benefits will be a part of the plan. In addition, even if you have used none of your individual or family deductible you will not have to pay for every medical cost until you reach that deductible.  Some of the preventative services and physicals are provided at no cost to you each and every year, regardless of the plan. In addition, many services will be covered and enrollees will only pay a co-pay for services such as seeing a doctor when sick.

Based on the data currently available, there are four levels of health care plans offered through the State or Federal Exchanges.  They are named Bronze, Silver, Gold, and Platinum, so that regardless of where you live in the United States, you will be able to understand and recognize available plans. http://www.medicoverage.com/images/compare-exchange-plans.jpg. In addition, while the prices may be different, plans in various states, counties, and/or communities that are labeled as Bronze, Silver, Gold or Platinum will be essentially the same regardless of where you live.  The Kentucky State Exchange, for example, offered me sixteen different plans from which to choose.  Please note however, that 12 of the plans were from the same company, but had slight differences between them.  Be sure to review all the plans  carefully and insure they meet your needs.  Plans on the Exchange range from bare bones “Bronze” plans that have high deductibles and co-pays but have the cheapest premiums, to “Platinum” plans which have the most expensive premiums but the lowest deductible and co-pays.  It is also important to note that any Health Insurance Companies can participate in the Health Exchanges as long as they offer at least one Silver Plan and one Gold Plan. Companies may have different provider lists, so be sure to take this into consideration as well.(http://publications.milliman.com/publications/healthreform/pdfs/Employer-healthcare-reform-strategic-impact-study.pdf)  

Before you can understand your options in choosing one of the health insurance policies, on the State or Federal Exchange, you need to understand the two cost saving measures or tax benefits in the ACA. The first tax incentive is perhaps the most widely known and popular subsidy available to enrollees.  Based on the enrollee’s income they may be eligible for pre-tax incentives each year that are payable to the insurance companies to offset the costs of premiums for tax payers. Enrollees have the opportunity to anticipate their 2014 income, and based on that income receive a subsidy, that is sent to the insurance company each month as a partial payment of your premium.  You can also choose to pay the full-cost of the premium each month and reconcile it on your 2015 taxes and receive a refund if you qualified for a subsidy.

The second and more confusing subsidy is a cost sharing subsidy that may help those people who make less than 400% of the poverty rate, which is about $45,000 a year for a single to about $96,000 a year for a family of four. This cost sharing subsidy is only available on the Silver Plans.  While the tax incentive subsidy is available for any level of the plan, the cost sharing subsidy will only be allowed for use on the Silver Plan. The moral of this story is don’t assume the Gold or Platinum Plan is the best plan to choose, because choosing the Silver Plan may allow you to have lower deductibles and co-pays than the Platinum Plan or what is commonly referred to as the “Cadillac” plan.   Let’s review each of the plans:

  • Bronze Plan: The Bronze Plan has the lowest premiums in the exchange, but has the highest out-of-pocket costs and deductibles. There is no cost-sharing subsidy available for this plan. The bronze plan may be a good choice for a young adult who is just going out on their own. People who choose the bronze plan will have 60% of medical costs paid for by insurance, after meeting the deductible.  They will also have certain preventative services provided free each year.
  • Silver Plan: his is considered the “average” plan for most enrollees, because it is the most cost effective choice for reasonably healthy families who use medical services. Before any subsidies are figured into the equation the Silver Plan pays for 70% of the costs of medical services after the deductible is met.  “After the deductible is met” can be rather frightening for any consumer viewing their health insurance benefits.  Deductibles in the current market place can be high and still be “more” than most middle or working class families can afford.  The Silver Plans offered to consumers through the health exchanges, have a $2000.00 deductible and a $6,750.00 out of pocket maximum per year, prior to cost sharing for a single individual.  Once the out of pocket maximum is reached in a calendar year, the insurance company will pay 100% of the enrollees costs including prescription drugs for the remainder of the year.  For families, the deductible  and out of pocket maximum is higher.  This is NOT the whole story when deciding which insurance plan is best for you and your family.  Enrollees are offered another subsidy which is referred to as cost-sharing, if and only if, they earn 400% or less of the poverty level and choose the Silver Plan.  For a single person 400% of the poverty level is approximately $45,000.00 per year or less and for a family is $95,000.00 per year or less.  The purpose of the cost sharing subsidy is to lower the deductible, co-pays, and out of pocket maximums to more affordable rates based on income.  Cost sharing is ONLY available on the silver plan.  Two things are important for consumers to know:
  • First, projecting your 2014 will be important, because if you earn significantly more                than you projected, you will be responsible to pay back that part of the subsidy you                used due to incorrect projections of your income.
  • Second, when you view the plans available to you through the exchange, you will not be          able to see the cost-sharing component until you complete the application, verify your            identity and income, and electronically sign your application.
  • Gold Plan: The Gold Plan is the second most expensive plan and has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.  It has lower deductibles than the Silver or Bronze Plan as well as lower co-pays, and out of pocket maximums per year.  People who do not meet the criteria for subsidies and/or cost-sharing may well find a Gold Plan that will offer them similar benefits to those who qualify for cost-sharing under the Silver Plan.
  • Platinum Plan: The Platinum Plan or “Cadillac Plan” is the plan with the highest premiums offered on the insurance exchange. In this plan 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid for by the enrollee. This plan may be appropriate for those with high incomes and those in poor health. Although coverage is more expensive up front, the 90% coverage of costs will help those who use medical services frequently but do not qualify for cost-sharing on the Silver Plan due to their income.

Not every health insurance provider in the exchange has to offer each tier of the plans outlined by the federal government, however, all participating health insurance companies must offer at least one Silver Plan and one Gold Plan to potential enrollees.  There is one more type of  Health Insurance offered by the State and Federal Exchanges called the  Catastrophic Plan.  This plan is primarily for those people under 30 years of age who are in good health and do not plan or need to use medical services very often.  It protects this group of consumers from very high medical costs should the “unexpected” occur, such as an accident or catastrophic illness.  The Catastrophic Plan includes 3 primary care doctor visits per year as well as free preventive benefits at no additional out of pocket cost. Cost sharing and premium subsidies are not available for the Catastrophic Plans. People 30 and over or those with low incomes, that even with premium subsidies and cost sharing does not make health insurance affordable or who have received a hardship exemption from the fee may also be eligible for Catastrophic Plans. (http://www.advisory.com/Daily-Briefing/2013/06/27/Who-will-be-exempt-from-the-ACA-mandate-The-final-list)   Hardship exemptions include but are not limited to:

  • Prisoners
  • Undocumented immigrants
  • Indian tribal members, living on an Indian reservation will be exempt from the penalties. This exemption is probably due in large part to the fact that Indian Reservations in the United States have an extensive public health system provided by the federal government.
  • Members of some religious organizations or health care sharing ministries also can apply for a religious exemption.
  • Other people or organizations may be granted a hardship exemption including but not limited to:
    • Those who cannot afford coverage, or live in states that have opted out of the Medicaid expansion;
    • People who have no plan options in their state’s health insurance exchange;
    • Individuals who have suffered a hardship or a coverage gap of three or fewer months;
    • Finally, exemptions may also be offered to individuals on a case by case basis.

As you can see, there is much information to take into consideration when you sign up for health insurance through the State or Federal Exchanges.  It is true that the process may be frustrating at times, overwhelming, and even maddening, however the outcome for the vast majority will be well worth the “pain” in getting covered.  How do I know?  In 2010, when the Affordable Care Act became law it included an amendment directing the federal government to set up a plan, the Pre-Existing Condition Insurance Plan (PCIP), through which people with pre-existing conditions could apply for and receive health insurance prior to the Affordable Care Act being available nation-wide in 2014.  I signed up and was approved for PCIP health insurance in 2011. (https://progressiveandproud.wordpress.com/2013/09/30/obamacare-the-health-insurance-that-saved-my-life/)  Premiums were not based on health, gender, or the ability to pay.  It was simply based on age. PCIP served as the “guinea pig” for the roll-out of the Affordable Care Act. If you have read my previous blogs, you would know my application process was not without it’s problems, however once I was approved, the health insurance turned out to be better than 95% of the plans I had ever had, even when I was employed. (https://progressiveandproud.wordpress.com/2013/10/23/sometimes-the-best-things-in-life-arent-easy-dont-give-up-on-the-health-exchanges/) I understand that people are impatient to get insurance. I certainly felt that way, however the end clearly made up for the means.  This was a huge undertaking for the government, to solve a huge problem in the United States. It may take several weeks or several months to work out the “glitches”, but that doesn’t mean we should “throw the baby out with the bath water.”  The administration is taking steps to correct the problems.  Bill Gates, one of the smartest and richest men in the world sent Americans a message on Facebook: https://www.facebook.com/photo.phpfbid=10200210418781672&set=gm.10151722315393861&type=1&theater which is self-explanatory.

Unfortunately, there are those who would rather “throw the baby out with the bathwater” and have consistently and continually since the law was enacted tried to proceed down that path.  Americans have been drowned in “facts” that cast an evil slant on the program. In truth, these aren’t facts at all but rather either a manipulation of information or flat out lies designed to anger or frighten Americans into not supporting this program and not signing up for an insurance plan they may desperately need.  Some of the most common lies and distortions include the following:

  1. A micro-chip will be implanted into people who purchase a plan through the state or federal health exchange that essentially is “the mark of the beast” described in the Book of Revelation in the Bible. This is a flat-out lie.  No one participating in the State of Federal Exchanges will be injected with a chip.  The only injections a person will receive will be no different than those they receive now such as vaccinations, flu shots etc.
  2. There was never any negotiation or compromise between the Republican and Democratic Party in regard to the Affordable Care Act.  President Obama simply “shoved it down the throat” of the American people.  Wrong! (https://progressiveandproud.wordpress.com/wp-admin/post.php?post=313&action=edit)  Affordable health care was a priority of the Obama administration, and in fact, of his campaign to be President in 2008.  Actually, President Obama favored a single payer system which the Republicans would not even consider.  The final plan that passed the Congress and was ultimately signed into law by President Obama was first suggested by the Heritage Foundation, a conservative think tank as an alternative to the single payer system suggested by the committee headed up by Hilary Clinton during the Clinton Administration. (http://online.wsj.com/news/articles/SB10001424052970204618704576641190920152366)
  3. The government and the IRS will have free access to enrollees bank accounts and may use private information to spy on them.  This couldn’t be further from the truth. (https://progressiveandproud.wordpress.com/wp-admin/post.php?post=98&action=edit) Enrollees will be given the opportunity to pay their monthly premium by an automatic withdrawal from their checking account.   This insures that there will be no lapse in health care coverage and is no different than how millions of Americans pay their utility, phone, or cable bills.  The IRS will NOT have any access to a person’s bank account with regard to ACA.

These are just a few of the distortions and absolute lies being told by conservatives in order to make Americans suspicious and afraid of the Affordable Care Act. So much time has been spent debunking these myths and countering the more than 40 repeal efforts by the Republicans that could have been better spent working together in a bi-partisan basis to anticipate any problems that might occur on a program roll-out of this magnitude.  Instead Republicans appear to be gleefully having Congressional Hearings to continue to undercut the Affordable Care Act.  Congressman Issa in a recent Congressional Hearing yielded the floor to a Democrat, who began to counter the implications being presented at the meeting.  Congressman and other Republicans were asking questions of the witnesses that implied that questions about pre-existing illnesses and other health records would be used during the application process.  The Democrat was very vocal in confronting these Republicans about their line of questioning being unnecessary, because age and whether or not the individual applying is a smoker are the only criteria on which costs for the plans are based.  As a consumer, it is extremely important, that you consider the source when given “facts” about the Affordable Care Act.

There are people signing up each and every day under the Federal and State Exchanges. My best advice is to “stay calm and keep going” to quote a popular phrase.  If you can’t seem to get signed up, don’t despair, complete the contact form at the end of this blog and we will be happy to help you or direct you to someone who can.  Good Luck!

 

About the Authors: By: Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO and Lynne Smith, MSSW. Barbara is an industrial engineer with an MBA. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services. Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.  Please direct your questions and/or inquiries to askcobuzzi@gmail.com.

Sometimes the Best Things in Life aren’t Easy! Don’t Give up on the Health Exchanges!

When the Affordable Care Act was passed into law in 2010, there was a little known caveat called the Pre-Existing Condition Insurance Plan(PCIP) connected to the law.  It recognized that there were millions of people in the United States who through no fault of their own did not have access to health insurance due to a chronic illness.  ACA directed the federal government to set up an insurance plan, PCIP, with premiums, based only on age, so that this group of people could purchase insurance enabling them to get the healthcare they needed.

In 2011, the PCIP program was rolled out with very little fanfare or advertisement, but allowed people across the United States who had been denied insurance based on pre-existing illnesses to sign up and pay a monthly premium for insurance. I often tell people that this was the first roll-out of ACA and is very similar to the silver plan offered on the current federal and state exchanges. The primary difference was that there were no tax subsidies or any cost sharing of deductibles and co-pays involved.  Unfortunately, many people did not learn of the available insurance, so while almost a million people signed up for the plan, many others knew nothing about it and have been awaiting 2014 with great anticipation.  In fact, as I have talked about PCIP in the months leading up to the roll-out of the exchanges and since the opening of the federal and state exchanges, many people have accused me of lying about PCIP being the first insurance plan of ACA.

I first applied for PCIP in July, 2011.  I learned about the program, just by luck, when doing some research on the internet on the Affordable Care Act.  I could hardly contain my excitement about being able to purchase health insurance at a reasonable cost.  Based on my age, the premiums would either be $220.00 or $300.00 per month.  The lesser monthly premium meant the enrollee would pay a higher deductible and co-pay.  I chose the more expensive premium that also offered lower deductibles and co-pays. I immediately signed up via the internet and mailed in my “supporting documents.” These documents consisted of a copy of my social security card, my driver’s license and a letter from my doctor indicating I had chronic health issues.  I wish I could say that two weeks later I had health insurance, however like is often true of anything new, there were problems.

It took me four months to get signed up and the problems worked out.  While I got frustrated at times, I never gave up.  The PCIP administration was located in two different places Missouri and Louisiana.  The eligibility workers were in Missouri, but the financial administration was in Louisiana.  The two components did not communicate very well.  I would get letters from one indicating I had failed to provide something, and be told via telephone call that the information had been received. Sometimes I wanted to bang my head against a wall or pull every hair out of my head, but I persevered.  Perhaps the biggest problem came when making arrangements to pay my premium each month.  I elected to have it automatically withdrawn from my checking account each month.  For this, I had to send in a voided check and a check for my first month’s payment.  I did this, not once, but three times.  Each time no one could figure out where it was.  In fact, one time I sent it federal express and they still couldn’t figure out what happened to it.

Was I frustrated?  Absolutely.  Was I ready to give up?  No.  I needed this insurance and I was going to use every option I had to get this insurance.  Now, perhaps for most people that would have involved a few phone calls, however I have been a social worker for 25 years and those who know me “might” say I am very strong willed. I called both the Missouri and Louisiana offices and spoke to workers, supervisors and supervisor’s supervisors.  I documented every call I made and wasn’t afraid to let them know they were going to hear from me every day until I was approved for PCIP.  I remember clearly about three and a half months after applying, I was finally connected to the person who headed up the financial division of PCIP.  I told him the problems I had been having and how badly I needed this insurance.  That day I hit pay dirt.  He made it his mission to find out what happened and promised me I would have insurance within 30 days at the most.

He was true to his word.  He fixed  the problems in three days.  Suddenly I got a call. with an apology. that I was approved for health insurance.  They let me give them a “check” by phone and said my cards would arrive shortly in the mail.  I can not tell you the relief I felt.  You see, I was very ill.  I had spend several weeks during 2010 in the hospital and Nursing Home and it has depleted to a great extent my financial capabilities.  I also knew, that I had ongoing and consistent health problems that needed to be treated and if they were not taken care of would lead to my death.  For me, this insurance was simply a life or death matter.

So, in late 2011, I became a person who had health insurance for the first time in 7 years.  I would have gladly paid for it prior to then, but I couldn’t, due to my health not financial reasons, not one company wanted to offer me insurance.  The process of initially getting that insurance was horrific, however, once I was approved and had the cards in hand, I never had another problem with the insurance.  It paid well, it paid on time, and all my doctors were approved providers.  Even my medications were reasonable and at that time I took a lot of them.  Oh and by the way, just for the purpose of humor, that check I wrote and supposedly they never received was sent back to me about a year later…lol.

I am happy to report that since being approved for PCIP, my health has improved greatly.  If you want to read my story about my slide into chronic illness you can do so here:  https://progressiveandproud.wordpress.com/2013/09/30/obamacare-the-health-insurance-that-saved-my-life/.  Suffice it to say, sometimes the best things in life aren’t easy, but that doesn’t mean they are not worth it.  If you are one of those people having trouble getting signed up through your state or federal exchange for health insurance, don’t give up and don’t give in.  These problems will be solved.  There are many officials like the one who finally helped me out there, who believe in this program and will do whatever it takes to help people get signed up for the exchange.  Remember it took me a few months, but the pay-off has been incredible.  Because of PCIP today, I have more quality of life than I had in the previous ten years.  Stay strong and keep on trying.

About the Authors: By: Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO and Lynne Smith, MSSW. Barbara is an industrial engineer with an MBA. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services. Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.  Please direct your questions and/or inquiries to askcobuzzi@gmail.com.

The Medical Device Tax: A Burden or a Blessing? You decide!

What is the Medical Device Tax?  Why there is such a battle to remove it as a revenue source of The Affordable Care Act (ACA) and/or Obamacare?  The Medical Device Tax has become one of the primary centerpieces of “what is wrong about ACA” for the Republicans.  Republicans advocated for removing this tax because it would be a burden on the American people and on the Medical Device manufacturers.  Looking at the history of revenues for new programs, the financial picture of Medical Device Manufacturers, and the process of determining how to pay for ACA/Obamacare will be reviewed to help the reader determine whether the tax is reasonable or a burden for the taxpayer and medical device manufacturers.

As lawmakers in Congress and the White House were developing the ACA/Obamacare, major healthcare industry players, including but not limited to the pharmaceutical industry, hospital industry, and healthcare insurance industry, were invited to participate in the process and offer suggestions about how the law could best be paid for.  Most of the industries contributed some revenue ideas to help fund the law, negotiated others and finally compromise on a plan and agreements were made on how the ACA/Obamacare would be funded.  However, one health care industry, The Medical Device Industry, appears to have refused to make suggestions, offer possible revenues, or suggested how they could contribute to the process of funding this law. (http://www.politico.com/story/2013/10/medical-device-tax-obamacare-affordable-care-act-government-shutdown-debt-ceiling-talks-98367.html)  Instead they suggested other industry players be the sources of revenue.  The medical device industry never offered any contribution in order to provide health insurance coverage to the 40-50 million uninsured Americans.

What is important to understand is that the Medical device industry is an exceptionally profitable industry.  It includes not only the manufacture of artificial knees and hips, but also CT and MRI equipment made by companies like GE and Seimans.   Recently on the news, it was reported that an artificial hip, just the hardware for it is manufactured for about $350.00 and sold for over $10,000.00. (http://www.motherjones.com/kevin-drum/2013/08/artificial-hip-cost-markup-healthcare) The patient may pay in excess of $20,000.00 for the surgery.  This represents an approximate 900% mark-up on the device alone.

After discussions and negotiations with industry leaders a “forced tax”, of 4.6% was levied, since the Medical Device industry was the only industry player to not offer a contribution to funding the Affordable Care Act. (Resource)  The planned contribution was an estimated $40 billion over 10 years.  This tax was cut in half from 4.6% to 2.3%, and the expected contribution was dropped to $20 billion.  But the industry’s profits have spiked recently, so the revised estimated ACA contribution from this tax is now $30 billion over 10 years due to the industry’s increased profitability. (http://www.politico.com/story/2013/10/medical-device-tax-obamacare-affordable-care-act-government-shutdown-debt-ceiling-talks-98367.html )

On the one hand the medical device industry was complaining about the $30 billion price tag, the industry invested $30 million a year to lobby congress in order to get this tax removed.   They spent in one year of lobbying, the cost to them for the ACA over 10 years.  Think about it, if 2.3% of profits over the next 10 years is $30 billion, that means that the medical device industry’s profits over the next 10 years is $1.3 trillion dollars, or on average, $130 billion a year. (http://www.nytimes.com/2013/10/17/opinion/the-myth-of-the-medical-device-tax.html?src=me&ref=general&_r=0)

If Congress and the President agree to remove the Medical Device Tax, the $30 billion lost to complete the funding of the ACA Law will have to be made up in another area.    What is your opinion?  We would like to know.  Should new programs have a plan to pay for them attached to the law?  Should the Medical Device Industry be given a pass and not have to contribute to the funding of ACA/Obamacare? What are your ideas on funding ACA?  How do you think they will find that $30 billion?  Do you think we should raise taxes on the wealthy?  Do you think we should reduce services and benefits for the poor?  Fill out our poll!  Leave your comments as to what you think should be done with the Medical Device Tax, should it be repealed and if you think it should be repealed, where do you see Congress getting the lost $30 billion?  We will publish the results of our poll on October 25, 2013.

Concessions Requested by Republicans for ACA: Do They Pass The Truth Test?

While Republicans are playing a game of chicken with the Democrats,  that may mean America will not be able to pay their bills, they have once again tried to pull the “wool over the eyes” of the American people with two new myths about the Affordable Care Act. These myths are at the center of the debate of keeping the government shut down as well as whether to default on our debt.  The House Republicans refuse to sign a clean Continuing Resolution which would insure our government is reopened and more important we do not default on our debts. As many of you know, most of the time when we write a blog, we go through a long process of verifying the information we put in this blog stating the source so anyone can re-check the facts.  However, in order to get you information in real time, today we are simply going to  tell you the issues the Republicans have indicated are “bad for the public”, worthy of keeping the government closed and possibly defaulting on the country’s debt to “save the American people” from  ACA law and then counter these issues with the truth.  There will be no rhetoric.  The information contained in this blog is just the facts. As author’s of this blog, we recognize changes need to be made to ACA, however these are minor changes and easily fixed by the Congress or administrative modifications, if they just do their job, instead of playing politics with the well-being of the American public.  The Republicans, especially those in the Tea Party, are reporting to the American people that  they are trying to “save them” from the Affordable Care Act.  That is simply untrue, rather they are trying to “save face” and be able to say they won out against big government and out of control spending.  Being correct on the ACA is very important to them, even though, polls indicate the Congressional Republicans approval rating is less than 5%.  The Republican stubborness reminds me of the last election when these same Republicans, supported by FOX news denied that President Obama was elected.  They were sure, that their polls were correct, stating Nate Silver’s 535 predictions were wrong and numbers coming from the voting precincts along with the pundits who declared President Obama the “winner” were just plain wrong.  Of course, in the end the polls cited by the Republicans were wrong and President Obama was re-elected. However, this proved just how out of touch these Republicans are with the reality of how Americans feel in this country.  Now, they are exhibiting the same denial of truth, as moderate Republicans and Speaker Boehner are over-ruled by about 40 members, primarily of the Tea Party  who seem to care very little about the impact shutting our government down and/or defaulting on our debt could have on the American people and the world economy. The two newly reported major myths being spread by the Republicans, in a desperate attempt to have some concessions, surround verifying a person’s income  to “make sure” they are eligible for subsidies and/or cost sharing, as well as forcing ONLY members of Congress to buy insurance from the exchange, effectively exempting their staff from participating. While they are manipulating the data with regard to many issues, what they are saying about the ACA, in this case, is simply categorically untrue.  Let’s begin with the issue of verifying income.  As one of the writer’s of this blog, I can assure you from personal experience that income is verified when applying for coverage through the healthcare.gov website. I have recently finished signing up for a policy through the health care exchange and my income was verified immediately within the process.  In fact, during the sign-up process, I was asked to project what income I thought I would have in 2014,  Now, based on recent information, I have determined my income in 2014 will be greater than it was in 2012.  So, I declared what my best guess is of what my income will be and clicked on enter.  After a small waiting period, I received a message indicating that my stated anticipated income did not match income previously declared on my tax returns.  I was asked to review my information and then asked again if this was my anticipated income for 2014.  I clicked yes, and received a message, that I needed to submit documents to verify my income.  Now, in my case, I could submit a written document by me describing why my income would be increasing.  I was offered many choices on how to verify income, including pay stubs, prior tax returns, etc.  While I was able to continue in the enrollment process and see what subsidies and cost-sharing if any, I was entitled to, based on the income I submitted, I had to electronically agree that the information I was giving was true and correct to the best of my belief and indicate I understood I had to submit documented evidence prior to a certain date to actually get the insurance.  The exchanges do verify income.  This has been a part of the Affordable Care Act from the beginning.  Any information to suggest otherwise is simply false.   Why are the Republicans making this demand about insuring people are truthful about their anticipated income suddenly?  It is part of the same tired strategy and stereotype they have used to demean and embarrass anyone who participate in what they perceive is an entitlement program.  They are trying to make people believe that by nature, Americans will lie about their income and be “given” a handout by the federal government in the form of undeserved subsidies and/or cost sharing. Americans, who would accept a tax incentive or subsidy must be a “shady” kind of person.  Remember. these are also the folks who say millions of people apply for food stamps when they aren’t “truly” needy.  The studies show however that less than three percent of food stamp recipients lie in order to get food stamps. They also ignore the fact, that not only do people have to verify their income at the time of application, but also have to electronically sign a document indicating they know that if their income is proven to be greater in 2014 than stated on their application, they will be liable to return the money on their tax return when they file in April of 2015. Income is verified then at two points, both prior to obtaining insurance and on their 2014 (filed 4/2015) tax return to validate they told the truth on their application. This is simply another untruth promoted by the Republicans to make ACA is a “hot button” issue. The second issue that the Republicans are “taking a stand” on involves whether they and their staff should enroll in the federal exchange.  Initially, they tried saying Congress was exempt from the Affordable Care Act and that wasn’t fair to the average American.  They tried to make it seem as if they had been exempted from a “terrible program”. First of all, Congress and their Staff receive their insurance via the federal employee health insurance group.  Anyone reviving their health insurance from a large employer are not allowed to shop for insurance in the exchanges.  So, by design, Congress and their Staff should not be eligible to get their insurance in the ACA exchanges. While the ACA was in bill form, Senator Grassley (R) submitted an amendment that would require Congress and their staff to be receive their health insurance from the ACA federal exchange like all individuals, families, and smaller businesses in this country.  According to some Republicans he added this amendment as a “poison pill”, thinking that it would cause the bill to not be passed even by its supporters in Congress.  To Senator Grassley’s surprise, the ACA bill passed and became a law, with the Grassley amendment, meaning that all of Congress and their staff would receive their insurance via the ACA exchanges.  So, because of the Grassley Amendment, Congressional Republicans found themselves in the position of having to use the federal health exchange.  However, the executive branch and their staff will continue getting their employer sponsored insurance and rightly so because ACA was passed to insure people with out insurance, those who could not afford insurance, those who had pre-existing illnesses and young adults under the age of 26 would have a cost effective means of  obtaining insurance. Since the inception of the Affordable Care Act, Congress and their staff have known they would  be required to be a part of the exchange beginning in 2014.  In fact, over the past two years, the Government Insurance Health Administration (GIHA) has coordinated the Pre-Existing Condition Insurance Plan (PCIP), that provided insurance to thousands of people, like me, with pre-existing conditions beginning in 2011.  However, the Affordable Care Act is not perfect and there are things that should have been “tweaked” in terms of the law.  One of the tweaks needed involved how members of Congress and their staff, would be able to use their “employer contribution” when purchasing plans.  In the last two years, Republicans in the Congress have flat out refused to fix any issues associated with ACA, instead they appealed the law to the Supreme Court and made over 44 attempts to repeal or defund the law in Congress.  In response to Republicans continuous refusal to “tweak” the bill, President Obama signed an executive order indicating that all federal employees who were staff members or Congressman could use their “employer” contribution to pay for all or part of their insurance through the federal health exchange and still be eligible for subsidies and cost-sharing. In a move that is so hypocritical, it is hard to believe, the Tea Party specifically, and Congressional Republicans have added the Vitter amendment to the Continuing Resolution which will take away the employer contribution to the healthcare plan for all of congress and their staffs.   This represents a income reduction for everyone in Congress as well as their staff.  This does not effect the actual members of Congress to a great degree because due to their salary, they will not be eligible for tax incentives or cost-sharing.  But their staff, is a different story.  Staff members may earn  $40,000 to as high as $175,000 per year.  Taking away the employee benefit which pays for part of their healthcare insurance premium from these employees is simply unfair.  They should not be used as a political pawn just to prove a point by Congressional Republicans.  They are punishing the very people who help them do their job.  Why would they take away the possibility of their own staff members or others who work in the Capital from getting subsidies or cost sharing?  It makes absolutely no sense.  They are not doing the right thing and protecting their employees.  In essence, they are denying them tax cuts or tax incentives that everyone else in the country in the exchanges receive.  The Republicans proclaims that they want more money going to the average American and yet, they want to deny their staffs  the ability to get health insurance for less money so they can say they got a “concession” and declare victory to their constituents.  This is just plain cruel and clearly supports that these Republicans care very little about the people around them or their constituents. A third issue that is being considered in closing a deal to re-open the government and increase the debt limit is to remove the medical device tax.  Again this is being considered as a concession to the Republicans and the Tea Party.  The Medical Device Tax is one source of funding the ACA and removing this tax will require congress to find alternative funding.  The reason there is so much pressure to remove this tax is because the medical device manufactures (ie: GE, Seimons, J&J, etc) have been spending millions of dollars lobbying congress to remove this tax.  So you understand, this is a tax on the artificial hip that costs $350 to manufacture and ultimately costs over $30,000.  The margins in these products are huge and they can well afford this tax. Many of these companies do not pay any income taxes currently (ie: GE) because of tax loopholes.  Removal of this medical device tax will cause us to have to pay for it somewhere else. Watch our blog and we will let you know they want to replace these funds. Once again we have proven that the “concessions”  or major issues associated with ACA are manipulations and/or just plain lies being spread by the Republicans in Congress.  If Republicans and/or Tea Party Republicans were educated about ACA, and they should be because that is their responsibility and their job, they would know one of their “demands” may actually financially harm members of their own staff and the other demand to verify income is already a part of the law.   That is why we have decided to award Republican members of Congress and specifically the Tea Party our first “stupid and you know it” award. Call your Representative and Senators today and tell them to stop these ridiculous demands.  Let them know you are educated about the issues and you want truth as opposed to dishonest rhetoric.They need to re-open the government and not allow the United States to default on it’s debt  for their own political gain. About the Authors: By: Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO and Lynne Smith, MSSW. Barbara is an industrial engineer with an MBA. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services. Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.  Please direct your questions and/or inquiries to askcobuzzi@gmail.com.  

The “Must Know” Terms to Successfully Understand ACA and The Health Care Exchanges

When shopping and/or purchasing  an Individual  or family health insurance policy through the  federal and/or state exchange marketplace there are several terms you must know to best understand your options and insure you get the best policy for the best cost to cover you and/or your family.  The State and Federal Exchange Marketplaces have been up and available to consumers since October 1, 2013.  Healthcare.gov, the primary starting point for Americans seeking affordable health care, opened with a bang, receiving many more hits than expected.  Healthcare.gov saw 8 million unique visitors during the first four days it was open (October 1-4, Tuesday-Friday). (http://www.motherjones.com/mojo/2013/10/it-doesnt-matter-if-no-one-signs-obamacare-week ) This does not include those who went directly to the state run exchanges, for example, California and New York.  Most of those visitors did not purchase insurance when they first visited the website.  There are a variety of reasons for this including but not limited to being a new program, failing to anticipate the number of people who would explore the site immediately after launching it.  Most of the people went on the exchanges to explore, to actually search for the insurance options and some logged on were curious about the exchanges.

Initially upon opening, the website was slow and experienced some glitches, as is often the case on new popular websites upon launch.  I do not think that the designers anticipated the large volume of people that would visit the exchanges all at one time.  As a result, the pent up demand by the long time uninsured, searching for insurance, finally, brought the web site to its knees.  This caused frustration by those excited to price out and find out more about their insurance options which will be effective for them as of January 1, 2014. While many people were frustrated with their inability to access the site, enrollees have until December 15th to sign up for insurance for 2014 beginning on 1/1/2014.  The open enrollment period for 2014 is actually extended for three additional months, from January, 2014 until 3/15/2014.  This will give potential enrollees a little extra time to decide about purchasing health insurance from the exchange.  Enrollment in subsequent years will  last just under three months, from October 1st of the year before the effective date of the insurance year until December 15th before the effective of the insurance year.  So, for the insurance year beginning on of January 1, 2015, we will have an enrollment period of just less than 3 months from 10/1/2014 through 12/15/2014. ‘If someone decides to not enroll in the exchange for 2014, elects to pay the tax penalty, and they get sick or have an accident in the year, they cannot get insurance back dated to the date of the event. This is a common myth that people, who are trying to turn the public against ACA tell people that they don’t need to sign up for insurance, because if something catastrophic happens they can sign up then.   In 2014, if a person happens to have a catastrophic event between January 1st and March 15th, the person will have the opportunity to enroll in ACA with the effective date being about two weeks from the date of their application since the open enrollment period is extended.  However, after March 15, 2013 and in subsequent years, if a person declines to enroll and then gets sick or has an accident, they will not be able to acquire insurance until the next enrollment period, from October-December and their coverage will not start until the following January 1st This could put a large financial burden on the uninsured person and could lead to potential personal bankruptcies.  It is important to remember that more than60% of households who declare bankruptcy say medical bills were one of the leading causes of their bankruptcy. (http://www.sbkass.com/new-york-bankruptcy-news/over-60-of-bankruptcies-caused-by-medical-bills/ ) 20% of the US population between the ages 19 and 64 are expected to suffer some kind of financial hardship due to healthcare costs. (http://madamenoire.com/284014/medical-bills-are-the-number-one-cause-of-bankruptcy-in-americaThis is something to keep in mind when trying to decide whether to purchase your individual insurance or not. the old adage “better safe than sorry” is a good lesson for all to remember in terms of buying health insurance.

Another reason people did not enroll is because they were just browsing, considering buying health insurance through the exchange while others just wanted to check out the pricing so they can budget for next year or just see what all the controversy is about.  Millions of people in the United States have been unable to purchase insurance because of high prices or because they have had pre-existing conditions which excluded them from underwriting. HHS issued a report on 1/8/2011 that stated “129 million Americans with pre-existing conditions could be denied without new health reform law. Without Affordable Care Act protections, in 2014, 1 in 2 non-elderly Americans could be denied coverage or charged more due to a pre-existing condition” (http://www.hhs.gov/news/press/2011pres/01/20110118a.html)  These people, who number more than 10 million uninsured, when you consider the people using the  federal exchange and the state exchanges, were excited and relieved at the prospect of being able to purchase affordable insurance for both themselves and/or their families.  Many of these people immediately went on the exchanges to get the information they have been waiting for in the past two years.  They had been anticipating the ability to obtain insurance since the ACA bill was signed into law in 2010.  People with pre-existing conditions wanted to see if they qualified for coverage and those who prior to this time could not afford insurance wanted to see if the Affordable Care Act made insurance truly “affordable.”

According to Mother Jones, “Experience shows that getting lots of uninsured people into private health plans and new Medicaid plans is maddeningly difficult and time-consuming.” (http://www.motherjones.com/mojo/2013/10/it-doesnt-matter-if-no-one-signs-obamacare-week ) This is based on the history from implementation of “RomneyCare” in Massachusetts.  The implementation in MA basically followed the same pattern as what we are seeing with the implementation of ACA nationally.  The Massachusetts exchanges opened in October of 2006 and by the time everyone had to be enrolled into an insurance plan, July 1, 2007, the kinks eventually were worked out and everyone got enrolled by the end of the enrollment period ended on 7/1/07.  It is our expectation that the same thing will happen with ACA.  We have a shorter window and many more states to get fully operational since Massachusetts only had to concentrate on their own needs.  Now, Healthcare.gov needs to address the specifics of 49 additional states, some on their own state exchanges and some on the federal exchange.  As matter of fact, HHS (Health and Human Services) took the website down on the weekend of October 11 and 12th for upgrading and maintenance so it would be able to handle the additional traffic. (http://healthcaregov.net/healthcaregov-news/category/healthcaregov/page/3/) Although we are experiencing better access after the upgrades this past weekend, the website still needs some work.  HHS is busily working on addressing all the volume demands

There has been an incredible amount of false information fed to the American people about ACA and many folks seem to have forgotten the primary goal of the Affordable Care Act was to insure that all Americans had access to affordable health care and that pre-existing illnesses would not longer be a reason people were denied insurance. The Democrats initially wanted a system that would serve all people, however this was an issue that upon negotiation and compromise resulted in the Affordable Care Act. This compromise meant that people who have insurance through their employer or Medicare, are not eligible to purchase insurance through the exchange marketplaces.  This also means, these folks are not eligible for subsidies or cost sharing, which has been frustrating for people who work in low paying jobs, with barely adequate insurance. Only those who do not have any insurance and small businesses can purchase their insurance in the exchanges.  The small business exchange will not be ready for exploring and sign-up until November.

Although small businesses under 50 employees will not be penalized if they do not provide insurance for full time employees (30 or more hours a week), these small businesses, with under 50 employees, can offer insurance to their employees through the SHOP Marketplace designed specifically for small businesses with less than 50 employees (https://www.healthcare.gov/what-is-the-shop-marketplace/).  There are small business tax credits worth up to 50% of the premiums paid available to these small businesses when they do offer insurance to their employees.  Some employers have stated that the tax incentives have made it possible for them to hire more employees.

When you go to Healthcare.gov to shop for and purchase your individual/family insurance, you will see a lot of different terms that sometimes get confusing.  Below, are the definitions of many terms that will make understanding the policies that you are considering purchasing easier and guarantee you ultimately get the coverage and the premium you feel most comfortable paying.

  • Tax Credit: Tax Credits are a subsidy provided by the government for lower income individuals and families that offset the cost of the monthly premium.  Even though this is a “credit” on your income taxes, it can be taken up front and directly applied to your monthly premiums.  You select that you want to apply the Tax Credit to your premiums and the government will pay that portion to your insurance company towards your premium and you will owe the balance.  This subsidy can be applied to any level policy (Bronze-Platinum) It is important to remember that if you under estimate your 2014 income, you will be liable for any over payment on your 2015 tax return.
  • Cost Sharing: Cost sharing is also a subsidy, but this subsidy is only available on SILVER POLICIES.  Lower income people applying for Silver Plans will see their Deductibles and Co-Pays reduced by a Cost Sharing subsidy.  So, although the policies have a standard deductible and co-pay, this subsidy reduces the out of pocket costs for the individuals.  For example, instead of the standard $2000 deductible and $45 co-pay found in a Silver policy, based on the purchaser’s income and where they live, their deductible might be lowered to $500 and the co-pay to $25.  It is important to remember that if you under estimate your 2014 income, you will be liable for any over payment on your 2015 tax return.
  • Co-Pay:     There are multiple Co-Pays in the policies, depending on the type of service.  Each one is a different flat, pre-defined amount that the patient pays for that service. The services and Co-Pays without cost sharing subsidies in the Silver policy are exhibited below:
    • Preventative Service                                       $ 0
    • Primary Care Doctor’s Office Visit                     $45
    • Specialist Doctor’s Office Visit                          $65
    • Generic Prescription                                        $19
    • Brand Prescription                                          $50 after $500 Rx deductible
    • Lab Testing                                                    $45
    • X-Ray                                                            $65
    • Maternity                                                       $30% after deductible
    • Out-patient surgery                                         $30% after deductible
    • Hospital Stay                                                  $30% after deductible (up to 5 days)
    • ER Visit                                                          $250 after deductible
    • Urgent Care                                                    $90

It should be noted that prior to completing the application for health insurance through the exchange, you can review the available plans.  These plans will not show any cost sharing subsidies for which you may be eligible.  Do not panic or assume you will not be eligible for cost sharing.  You must go through the entire process of signing up and verifying your income and identity to be shown what cost sharing subsidies for which you may be eligible.  You will also have to sign an attestation statement indicating you have stated your potential income correctly and understand that you will have to pay back any subsidy over-payment.

  • Deductible:   Some services, such as Maternity, out-patient surgery, in-patient hospital stay and ER visits require a Deductible be met by the patient before the insurance starts paying anything.  Note above, that this is not the case for Doctor’s visits, prescriptions, lab tests or radiology services.  All of the co-pays for those services are applied to the deductible.  The Silver plan has a $2000 deductible with no cost sharing applied. Note that Brand name prescriptions have their own separate deductible in the plan.
  • Coinsurance:  Unlike the flat Co-pay which is a single flat amount per service, a Coinsurance is a percentage of the approved fee, usually assessed after the deductible has been met.  As you can see above, the Deductible and the Coinsurance are tied together.  So, Maternity, Out-patient surgery, and inpatient hospital stays are all paid at 70% of the negotiated fee schedule once the patient meets the deductible on the silver plan.  This means that the patient pays the amount of the deductible (in the case of a Silver policy, before any Cost sharing, this is $2000).  Then the patient pays a 30% coinsurance of the fee schedule for these services.
  • Out of Pocket Max: Out of pocket maximums are often confused by those purchasing insurance as a deductible and assume this is an added burden or cost.  But this is actually an added benefit of the plan.  Once the patient has spent the out of pocket max in Co-Pays, Coinsurance and Deductibles, the insurance starts covering everything at 100%.  So, for example, the Silver plan has an Out of Pocket Max of $6,350 for an individual and $12,700 for a family without the application of cost sharing.  This means that once the patient has expended $6,300 out of their own pocket in Co-Pays, Coinsurance and Deductibles, the insurance will start to pay for every service in full (at 100%).  Once a family has paid $12,800 over all the members in the family out of their pocket in Co-Pays, Coinsurance and Deductibles, the insurance will start paying in full, at 100% for all the members in the family.

Hopefully, this has given you a better understanding of the unfamiliar terms in your health insurance policy.  It is important to understand each of these terms and how they affect you.  Remember, all of the figures included in this blog are before any subsidies are determined, because the subsidies are personally customized just for you.

Make sure you follow our blog as the next one published will be a description of the four plans, plus an overview of the step by step process on the exchange to shop for, select and purchase your health insurance policy at: http://wp.me/p3QGSP-1r

Check out our other new blog: Concessions Demanded by Republicans for ACA: Do They Pass The Truth Test?  at http://wp.me/p3QGSP-ap

and Best Use of Tax Dollars: Paying for Government Shutdown or Paying Healthcare Subsidies at http://wp.me/s3QGSP-385

and Do You Choose Life (The Affordable Care Act) or Do You Choose Money? at http://wp.me/p3QGSP-9c

About the Authors: By: Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO and Lynne Smith, MSSW. Barbara is an industrial engineer with an MBA. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services. Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.  Please direct your questions and/or inquiries to askcobuzzi@gmail.com.