Changing Care: Your Guide to the Affordable Care Act

By Karen Nordahl and Linda Laarman

This week, we publish part one in a series on the Affordable Care Act (ACA). Through this series, we seek to explain some of the essential elements of the ACA and their impact. This article highlights current information regarding the new public health insurance marketplace (aka exchanges) for individuals and families. The topic of health insurance exchanges being established for small business will be addressed in a future article.

The health insurance marketplace is scheduled to open for enrollment on Oct. 1. The open enrollment period extends for six months, ending March 31, 2014. Coverage starts as soon as Jan. 1, 2014. The availability of new health insurance options is potentially significant for many individuals, families and businesses in Door County.

What drove creation of health care exchanges?

The principal objective of the health care exchange is to extend health care coverage options to more people, at more affordable prices. It also is hoped that clear and consistent information will enable consumers to better compare and contrast plans, and that increased competition among insurance companies will keep prices in check.

Regardless of employment status, those who don’t work for large employers or otherwise have access to large-group coverage (e.g. through the military or Medicare) have often found it difficult or even impossible to find affordable health insurance.

Availability and affordability have been especially challenging for individuals with preexisting conditions, which, depending on an insurance company’s definitions, may range from seemingly minor and one-time procedures such as a visit to the chiropractor, to chronic conditions such as allergies, to diagnosis of a serious condition such as cancer or heart disease.

In Door County, many individuals are self-employed or work for small businesses that either don’t offer health insurance, or provide limited offerings that are prohibitively expensive. Thus, the exchanges have the potential to open up new opportunities to those who have been previously uninsured or under-insured.

A fundamental concept of an exchange plan is to pool the risks of a large group of people with a variety of health conditions and ages, banning discrimination based on gender or pre-existing conditions (except tobacco use, which may be used as a factor for determining cost). Theoretically, the exchange-related coverage that will extend to individuals should more closely resemble traditional large-group health insurance as opposed to previously available individual insurance policies.

What’s known about the types of plans that will be available in Wisconsin?

Information on the specifics of the plans that will be offered in Wisconsin is unfolding and many unknowns remain. Here are some of the things we do know:

• Essential health benefits in all plans:  All plans in an exchange must offer at least the following 10 benefits, known as “essential health benefits”:  ambulatory patient services; emergency services; hospitalization; pregnancy, childbirth and newborn care; mental health and substance abuse disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric service.

• Federally designed plans in Wisconsin:  Although the state will exercise some controls, the state government chose to have the federal government establish and regulate most aspects of the exchanges. As is permitted by the ACA, some states will have more state involvement.

• Set up by insurance companies and others:  Plans will be offered and operated by private insurance companies and others, such as entities established by hospital systems, that choose to participate in the marketplace and whose plans satisfy “qualified” ACA standards.

• Coverage for different geographies:  Some plans may provide insurance only for health care services obtained in designated Wisconsin counties, and others may offer statewide coverage.

• Names of those potentially offering Wisconsin plans:  In an Aug. 6 press release (available at oci.wi.gov/pressrel/0813qhp.htm) issued by Wisconsin’s Office of the Commissioner of Insurance, the OCI identified 13 companies for which the OCI had reviewed and approved rates and forms for the individual/family marketplace. The OCI didn’t offer any specifics about the plans being offered and also cautioned that further reviews of the companies were pending at the federal level. Some well-known health insurance companies will not participate in 2014, including United Healthcare and Humana.

In a future article, we will detail financial considerations related to the ACA and the health insurance marketplace. Options for families and individuals will be discussed, as well as applicable subsidies and tax requirements.

If you are interested in learning more, you may review the information at HealthCare.gov, where individuals can also register and subscribe to email updates, or call 800.318.2596 for individualized support.

Karen Nordahl has worked in the medical industry for more than 20 years, with a focus on providing educational resources and strategic support to providers and manufacturers on the topics of health policy, economics and reimbursement. Linda Laarman has practiced law for almost 35 years. A key area of practice has been advising employers on employee benefits and compensation matters.