September 29, 2013

Questions and answers about the Affordable Care Act's impact

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Pat Quinn, Kathleen Sebelius
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Health and Human Services Secretary Kathleen Sebelius has played a key role in refining provisions of the Affordable Care Act, including oversight of states’ insurance marketplaces.

The Associated Press

Mitch McConnell
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The clock is running out for Senate Minority Leader Mitch McConnell and other Republicans who are trying to delay the implementation of “Obamacare.”

The Associated Press

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NEW ESSENTIAL BENEFITS

Starting Jan. 1, the following "essential benefits" must be included under all insurance plans that are considered "qualifying health plans" sold on and off the marketplace:

Emergency services

Hospitalizations

Laboratory services

Maternity care

Mental health and substance abuse treatment

Outpatient or ambulatory care

Pediatric care

Prescription drugs

Preventive care

Rehabilitative and habilitative (helping maintain daily functioning) services

Vision and dental care for children

Essential benefits are provided with no "cost sharing" on every insurance plan sold on Obamacare's Online Health Insurance Marketplace.

SOURCE: obamacarefacts.com

IF I GET HEALTH CARE COVERAGE THROUGH MY EMPLOYER, CAN I STILL BUY COVERAGE IN THE MARKETPLACE?

A: If your employer's coverage is not considered "affordable," or if your employer's plan pays less than 60 percent of the cost of covered benefits, you can shop for other coverage and be eligible for a subsidy. Under the Affordable Care Act, "affordable" is defined as 9.5 percent of an employee's household income.

The 9.5 percent test, however, only applies to what it would cost the employee to get coverage only for himself or herself. It does not apply to the cost of coverage that person may want to buy as part of a family plan. If coverage for the employee is less than 9.5 percent of household income, then the employee and family members are ineligible for subsidies.

THE GOVERNMENT HAS DELAYED THE LARGE-BUSINESS MANDATE FOR A YEAR, BUT WHAT WILL THE LAW MEAN FOR OWNERS OF SMALLER BUSINESSES?

A: Under the Affordable Care Act, a small business is defined as having anywhere from two to 50 employees. Those firms are not required to provide their workers with health insurance. In Maine, most companies are considered small or micro-businesses. In fact, 80 percent of Maine businesses have fewer than 10 employees.

Larger businesses with employment levels close to the 50-employee threshold have until 2015 to calculate whether it's worth reducing their workforce or cutting workers' hours to avoid a series of escalating penalties that kick in if just one of their employees ends up receiving government-subsidized health care.

WILL I BE FORCED TO CHANGE DOCTORS OR HEALTH PLANS EVEN IF I DON'T WANT TO, AND WILL MY CHOICES FOR BOTH BE LIMITED?

A: It depends. You can maintain your current providers if you have job-based insurance and can choose any available primary care provider in your insurance plan's network. However, the influx of patients who will be newly insured under the Affordable Care Act could overwhelm the health care system in some areas. That could mean you will see a physician assistant or nurse practitioner, rather than a physician.

In general, the Obama administration says the law offers new rights and protections whether you have coverage or need it, but there are some exceptions. The new rights do not apply to health plans created or bought before March 23, 2010.

In Maine, there are two companies offering products in the marketplace -- Anthem Blue Cross and Blue Shield and Maine Community Health Options. Anthem has proposed a network that includes only 32 of the 38 acute care hospitals in Maine. As a result, some residents in central and western Maine may need to change doctors if they buy an Anthem plan in the marketplace. If consumers want to keep their doctor, they can buy a plan from Maine Community Health Options or from a provider that is not in the marketplace. Outside of the marketplace, Mega Life and Harvard Pilgrim will also offer individual health insurance options.

Although critics have said the Anthem-MaineHealth pact goes against Obama's pledge that consumers would not have to change doctors, the emergence of so-called narrow networks that exclude certain hospitals or providers is a trend emerging in other states as well.

IF I CURRENTLY BUY MY OWN INSURANCE, CAN I KEEP IT OR DO I HAVE TO CHANGE?

A: If you have individual insurance -- a plan you bought yourself rather than what you get through an employer -- you should be able to change to a new plan if you choose. Many popular plans in Maine, such as high-deductible plans that offer only catastrophic coverage, are not allowed under Obamacare, in part, because they do not provide broad coverage for a variety of health issues.

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