Since it took effect in 2010, the health reform law, otherwise known as the Affordable Care Act or ACA, has made important changes to the way health care coverage works for children and families.
It may seem confusing, and it is. The ACA has many moving parts and pieces that make up the Act as a whole. But you can make sense of it with a little help.
Listen in as Robin E. Stockton, M.Ed., comes on to share with you a comprehensive list of key things you should know about this open enrollment option, and what it means for you and your loved ones.
Selected Podcast
Understanding The Affordable Care Act: Obamacare
Featured Speaker:
Robin E. Stockton, M.Ed.
Robin E. Stockton, M.Ed.,is the director of the Center for Family Services, a community partner of Lourdes Health System.Transcription:
Melanie Cole (Host): Since it took effect in 2010, the Healthcare Reform law, otherwise known as the Affordable Care Act, or ACA, has made important changes to the way healthcare coverage works for children and families. It may seem confusing and it is. The ACA has many moving parts and pieces that make up the act as a whole, but you can make sense of it with a little help. My guest today is Robin Stockton. She's the Director of the Center for Family Services, a community partner, and special guest of Lourdes Health System. Welcome to the show, Robin. Let's talk about some of the key features of the Affordable Care Act. What are some of the more important features you like to discuss with people?
Robin Stockton (Guest): Hi, Melanie. Thank you so much for having me and you are right to say that the Affordable Care Act is complicated. Since 2010, the ACA has really worked to strengthen protections for consumers. Before the Affordable Care Act, individuals could be denied health insurance coverage based on pre-existing conditions. It was difficult for consumers to make apples to apples comparisons among plans and premiums and people without employer-sponsored health insurance, or who were ineligible for public programs, such as Medicare, Medicaid, and the Children's Health Insurance Program, generally received no financial help paying for coverage. So, today, the good news is that the health insurance marketplace gives eligible consumers options for comparing and purchasing health care plans and provides consumers with tools to compare options and offers financial assistance in the form of advanced premium tax credits that can help to reduce the cost of health insurance to the majority of enrollees.
Melanie: So, coming up soon, we have open enrollment. Explain what that is.
Robin: So, the 2017 open enrollment period begins on November 1, 2016, and it ends on January 31, 2017. And during that period, millions of Americans will once again be able to shop for high-quality, affordable health care coverage through the marketplace. The marketplace is welcoming new consumers and encouraging those who have previously enrolled to come back, update their information, and select the plan that best meets their needs and budget. All plans in the marketplace that are offered through the exchanges cover essential health benefits and recommended preventative care. So, the way this all works is consumers can get on www.healthcare.gov and see detailed information about each health insurance plan that's offered in their area and can look at estimated yearly out-of-pocket expenses before they apply. The website www.healthcare.gov has tools to help consumers evaluate plans based on factors that are important to them, such as premium cost, deductibles, other out-of-pocket costs, provider networks, prescription drug formularies, customer service, and more. Really important to remember, is that consumer may be eligible for financial assistance to help pay those premium costs and, in some cases, even co-pays and deductibles.
Melanie: Well said. Now, you mentioned preventive visits. So, what does that mean for consumers? What is considered a preventive wellness visit?
Robin: So, actually, all plans offered in the marketplace cover the same set of essential health benefits. So, every plan that any consumer purchases through the marketplace must cover the following services: ambulatory patient services, which is outpatient care you get without being admitted to a hospital; emergency services; hospitalization, like surgery and overnight stays; pregnancy, maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment, which includes counseling and psychotherapy; prescription drug coverage; rehabilitative and habilitative services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills; preventative and wellness services and chronic disease management; laboratory services; and pediatric services, including oral and vision care.
Melanie: So, newer than people had before, things like colonoscopy and mammograms are 100% paid for, yes? So, speak about some of those annual physicals that we can now get without having to worry about big prices.
Robin: Yes, that's exactly right. Some of those preventative services are covered and it's important to note that any costs associated with them are not applied to any of the annual deductibles that a consumer might need to meet through their plan selection. Also, birth control coverage and breastfeeding coverage are one of the essential covered benefits as well.
Melanie: The open enrollment starts soon. What if you're someone who misses that open enrollment?
Robin: So, open enrollment, as I said before, starts on November 1st and goes through January 31st of next year. If there is a reason why you don't enroll during that open enroll period, if you experience a qualification that would trigger a special enrollment period, you can actually enroll all-year-round. So, those are your typical life change events, such as marriage, divorce, birth, adoption of a child, if you make a permanent move, if there's a change in your immigration status, if there's a change in your tax filing status, if you are recently released from detention or incarceration, or if there is a gain, loss, or denial of health care coverage. One really important thing to note is that if you have a qualifying life-change event that would trigger an enrollment outside of the open enrollment period, you must apply for insurance within 60 days of that life change event.
Melanie: And, how does this keep young adults covered?
Robin: So, the Affordable Care Act has a provision through which young adults who are age 26 or younger can remain on their parents' health insurance policy and/or they can also purchase a plan through the individual marketplace. For adults under the age of 30 who tend to have lower healthcare needs and utilization and are more concerned about the cost of premiums, there are catastrophic plans on the marketplace that are available that are typically lower in premiums, but higher in copays and have more restrictive access, such as one appointment with a primary care physician per year that would be covered.
Melanie: What about Medicare and Medicaid? Are they part of the exchange system now, or no?
Robin: It depends really on what state you live in. For states that elected to expand Medicaid coverage, in some states, in New Jersey, where I work, you can absolutely enroll in Medicaid coverage all year long. There is no open enrollment period for that, and you can enroll right through www.healthcare.gov. In other states, the rules are different.
Melanie: So, Robin, wrap it up for us. Give your best advice when people ask you for all of the information on this very complicated Affordable Care Act, what do you tell them every day about getting into open enrollment, getting on the exchange and finding the plan that suits them best?
Robin: So, I think the most important thing to remember--there are two important things to remember. The first is that this is complicated material for many consumers to understand and to work through. So, in-person assistance is available through all states that have a Federal Insurance Exchange, and if you go on www.healthcare.gov and you look at "Find Local Help" you can find a Federally certified assisters in every community who can sit down one-on-one and answer questions and help consumers to find out what they may be eligible for and walk them through the process of application. So, that's really important to know--that there's help out there for folks who need assistance understanding all of this. And then, the second thing that's really important to know is that it is affordable. More than 70% of consumers can find marketplace plans for less than $75 a month; 77% of consumers can find plans with premiums below $100 after taking into account financial assistance. So, it's super-important to come and shop on the marketplace and see what you may be eligible for, see if you qualify for some financial assistance to offset some of the costs and see what best might meet your utilization needs and your budget.
Melanie: Thank you so much. It is such important information. Thank you, Robin, for being with us today. You're listening to Lourdes Health Talk, and for more information, you can go to www.lourdesnet.org. That's lourdesnet.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Since it took effect in 2010, the Healthcare Reform law, otherwise known as the Affordable Care Act, or ACA, has made important changes to the way healthcare coverage works for children and families. It may seem confusing and it is. The ACA has many moving parts and pieces that make up the act as a whole, but you can make sense of it with a little help. My guest today is Robin Stockton. She's the Director of the Center for Family Services, a community partner, and special guest of Lourdes Health System. Welcome to the show, Robin. Let's talk about some of the key features of the Affordable Care Act. What are some of the more important features you like to discuss with people?
Robin Stockton (Guest): Hi, Melanie. Thank you so much for having me and you are right to say that the Affordable Care Act is complicated. Since 2010, the ACA has really worked to strengthen protections for consumers. Before the Affordable Care Act, individuals could be denied health insurance coverage based on pre-existing conditions. It was difficult for consumers to make apples to apples comparisons among plans and premiums and people without employer-sponsored health insurance, or who were ineligible for public programs, such as Medicare, Medicaid, and the Children's Health Insurance Program, generally received no financial help paying for coverage. So, today, the good news is that the health insurance marketplace gives eligible consumers options for comparing and purchasing health care plans and provides consumers with tools to compare options and offers financial assistance in the form of advanced premium tax credits that can help to reduce the cost of health insurance to the majority of enrollees.
Melanie: So, coming up soon, we have open enrollment. Explain what that is.
Robin: So, the 2017 open enrollment period begins on November 1, 2016, and it ends on January 31, 2017. And during that period, millions of Americans will once again be able to shop for high-quality, affordable health care coverage through the marketplace. The marketplace is welcoming new consumers and encouraging those who have previously enrolled to come back, update their information, and select the plan that best meets their needs and budget. All plans in the marketplace that are offered through the exchanges cover essential health benefits and recommended preventative care. So, the way this all works is consumers can get on www.healthcare.gov and see detailed information about each health insurance plan that's offered in their area and can look at estimated yearly out-of-pocket expenses before they apply. The website www.healthcare.gov has tools to help consumers evaluate plans based on factors that are important to them, such as premium cost, deductibles, other out-of-pocket costs, provider networks, prescription drug formularies, customer service, and more. Really important to remember, is that consumer may be eligible for financial assistance to help pay those premium costs and, in some cases, even co-pays and deductibles.
Melanie: Well said. Now, you mentioned preventive visits. So, what does that mean for consumers? What is considered a preventive wellness visit?
Robin: So, actually, all plans offered in the marketplace cover the same set of essential health benefits. So, every plan that any consumer purchases through the marketplace must cover the following services: ambulatory patient services, which is outpatient care you get without being admitted to a hospital; emergency services; hospitalization, like surgery and overnight stays; pregnancy, maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment, which includes counseling and psychotherapy; prescription drug coverage; rehabilitative and habilitative services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills; preventative and wellness services and chronic disease management; laboratory services; and pediatric services, including oral and vision care.
Melanie: So, newer than people had before, things like colonoscopy and mammograms are 100% paid for, yes? So, speak about some of those annual physicals that we can now get without having to worry about big prices.
Robin: Yes, that's exactly right. Some of those preventative services are covered and it's important to note that any costs associated with them are not applied to any of the annual deductibles that a consumer might need to meet through their plan selection. Also, birth control coverage and breastfeeding coverage are one of the essential covered benefits as well.
Melanie: The open enrollment starts soon. What if you're someone who misses that open enrollment?
Robin: So, open enrollment, as I said before, starts on November 1st and goes through January 31st of next year. If there is a reason why you don't enroll during that open enroll period, if you experience a qualification that would trigger a special enrollment period, you can actually enroll all-year-round. So, those are your typical life change events, such as marriage, divorce, birth, adoption of a child, if you make a permanent move, if there's a change in your immigration status, if there's a change in your tax filing status, if you are recently released from detention or incarceration, or if there is a gain, loss, or denial of health care coverage. One really important thing to note is that if you have a qualifying life-change event that would trigger an enrollment outside of the open enrollment period, you must apply for insurance within 60 days of that life change event.
Melanie: And, how does this keep young adults covered?
Robin: So, the Affordable Care Act has a provision through which young adults who are age 26 or younger can remain on their parents' health insurance policy and/or they can also purchase a plan through the individual marketplace. For adults under the age of 30 who tend to have lower healthcare needs and utilization and are more concerned about the cost of premiums, there are catastrophic plans on the marketplace that are available that are typically lower in premiums, but higher in copays and have more restrictive access, such as one appointment with a primary care physician per year that would be covered.
Melanie: What about Medicare and Medicaid? Are they part of the exchange system now, or no?
Robin: It depends really on what state you live in. For states that elected to expand Medicaid coverage, in some states, in New Jersey, where I work, you can absolutely enroll in Medicaid coverage all year long. There is no open enrollment period for that, and you can enroll right through www.healthcare.gov. In other states, the rules are different.
Melanie: So, Robin, wrap it up for us. Give your best advice when people ask you for all of the information on this very complicated Affordable Care Act, what do you tell them every day about getting into open enrollment, getting on the exchange and finding the plan that suits them best?
Robin: So, I think the most important thing to remember--there are two important things to remember. The first is that this is complicated material for many consumers to understand and to work through. So, in-person assistance is available through all states that have a Federal Insurance Exchange, and if you go on www.healthcare.gov and you look at "Find Local Help" you can find a Federally certified assisters in every community who can sit down one-on-one and answer questions and help consumers to find out what they may be eligible for and walk them through the process of application. So, that's really important to know--that there's help out there for folks who need assistance understanding all of this. And then, the second thing that's really important to know is that it is affordable. More than 70% of consumers can find marketplace plans for less than $75 a month; 77% of consumers can find plans with premiums below $100 after taking into account financial assistance. So, it's super-important to come and shop on the marketplace and see what you may be eligible for, see if you qualify for some financial assistance to offset some of the costs and see what best might meet your utilization needs and your budget.
Melanie: Thank you so much. It is such important information. Thank you, Robin, for being with us today. You're listening to Lourdes Health Talk, and for more information, you can go to www.lourdesnet.org. That's lourdesnet.org. This is Melanie Cole. Thanks so much for listening.
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