(KPLR) – Dr. Sonny Saggar stopped by the studio to continue talking about the Affordable Care Act.
In the second segment of his three part series, he discussed money and Missouri.
What’s the same in every state?
When it comes to your health care options on the Marketplace, some things are the same in every state such as basic coverage.
The U.S. government sets basic guidelines for what are called ‘essential benefits’. Every health plan sold in the Marketplace has to offer them.
They include emergency care, pediatric care, maternity care, lab testing,and more.
There are upper limits on how much you have to spend before your insurance company starts paying toward your care. No plan can charge more based on your health or whether you’re a man or a woman.
Four levels of coverage
To make it easier to compare plans, every Marketplace will rank the types of plans according to the level of benefits they offer, from platinum (the most) to bronze (the least). There’s also a special plan for young adults.
What decisions can Missouri make?
Aside from those basic requirements, states that set up their own Marketplaces have a lot of control over what to include in their health coverage.
Which insurance companies get to sell on their Marketplace and how many
States can choose insurance companies and can set tougher rules for coverage than the federal guidelines require.
Some states, like California, are limiting the number of insurance companies selling on their Marketplace. They hope it will improve the quality of the plans offered. Other states are taking a different approach. For instance, Colorado will allow any insurance company to sell plans.
Treatments that are covered
States running their own Marketplaces can tell companies that they must make the essential benefits more generous than the federal guidelines.
For example, some plans may pay for weight loss surgery, but others may not. Some plans may cover fertility treatments to get pregnant under maternity care, but others may not.
One plan may only cover a few drugs for your condition, like medicine for high blood pressure, while another plan may cover many brands.
What complementary and alternative treatments count as essential benefits
For instance, some states, like California, Maryland, New Mexico, and Washington, are including acupuncture as an essential health benefit. Many other states probably won’t.
How to promote the Marketplace
States are in charge of advertising for their Marketplaces and encouraging people to use them. That matters. If a state is very successful in getting lots of people to buy plans, the costs of insurance in that state could go down for everyone.
State Marketplaces may offer extra coverage for health problems that are more common in that state. For instance, if a state has high levels of diabetes, its Marketplace might include more plans that have special programs to help people with that condition.
Coverage for more people with low incomes
One way health reform was supposed to help more people get medical care was to expand each state’s Medicaid plan. Medicaid is the free or low-cost health program for people with very low incomes.
However, states can decide whether or not to expand Medicaid. If a state doesn’t expand Medicaid, some low-income people won’t be able to afford coverage. To find out whether you qualify for Medicaid, check out the insurance finder on HealthCare.gov.
Things to know about Missouri’s Marketplace
Plans will vary state-to-state. If you’re trying to help an out-of-state relative buy a plan, remember that their options will be different from yours.
We don’t know all the details yet. What exactly will Missouri offer? Presently, nothing. Missouri has so far decided not to participate in any way in the Affordable Care Act.
The Federally-facilitated Marketplace (FFM) will be offering health coverage in Missouri in 2014. The FFM will make assessments of Medicaid/CHIP eligibility and then transfer the applicant’s account to the state agency for a final eligibility determination. Missouri is not expanding Medicaid coverage to low-income adults effective January 1, 2014.
Physician’s point of view
The healthier our citizens are, the more productive they are. It is as simple as that. You can’t contribute much to society if you are crippled with a foot broken years ago and never repaired properly.
You can’t contribute much if you are burdened by depression or an untreated psychosis or lupus or rheumatoid arthritis. We benefit from the productivity of healthy people.
Furthermore, we benefit from their health itself.
If poor people don’t get checked for tuberculosis, the rest of us are at risk. If poor people don’t get treated for addiction, we all suffer from petty theft to secure them a supply of drugs.
If mental illness isn’t diagnosed and treated early, that burden is for all of us to bear. We pay a lot more to care for the mentally ill in prison than early treatment would cost. And it’s cruel as well as expensive.
Medicaid expansion will benefit those of us who don’t need it, who have health insurance, as well as benefitting those who cannot afford insurance.
But most important as a matter of law, caring for the poorest among us, ensuring that they receive the benefits of good healthcare, is a measure of the quality of our society. Do we harden our hearts and turn our backs? Or do we provide quality care to everyone who needs it?
The important thing to note is that the Affordable Care Act is not as much health care reform as it is insurance reform.
St. Louis Urgent Cares presently has 4 locations in St. Louis, and all 4 are active participants in Direct Medical Care: Downtown Urgent Care, Eureka Urgent Care and Creve Coeur Urgent Care, and North City Urgent Care. We are planning even more facilities in the near future.
This is Part 1 of a 3-Part Segment on Healthcare Reform
1. The Basics
2. Money and Missouri
3. Get Ready
1. The Basics: What You Need to Know About Health Care Reform In Case You Didn’t Know
Many changes take effect starting in 2014.
You’re one of the people that health reform may benefit if:
● You make too little to afford health insurance but make too much or can’t otherwise qualify for Medicaid.
● You have young adult children who need insurance coverage.
● You have an existing chronic or serious health condition, including depression or another mental health concern.
Fewer Limits on Your Coverage
You can have a long-standing health problem (also known as a ‘pre-existing condition’) and still get insurance. No matter how good or bad your health might be, every health plan must let you buy insurance. Plus, having a health problem won’t increase how much you pay for your insurance. This is a big change.
You also don’t have to worry that your health coverage will run out. Insurance companies used to be able to put a yearly or lifetime cap on the amount they would cover. Starting in 2014, your health plan can no longer limit what it spends on your covered benefits each year or in your lifetime. This is another big change. You’ll never “run out” of insurance.
More Affordable Health Plans
Most people are required by law to have health insurance by 2014. But don’t panic – the government has set up new ways to help you. You may be able to buy affordable, even subsidized, insurance through a Marketplace, also called a Health Insurance Exchange or HIE. Every state will have a Marketplace to help you sort out your coverage options and select a plan that best fits your needs. This may help if you don’t have insurance nowor if you have trouble paying for it.
You can begin reviewing your new insurance options right now through your state Marketplace. You can get more information and sign up by phone, in person, or online by visiting www.healthcare.gov. Trained assistants called navigators can answer your particular questions and provide help in signing up. Once you’ve selected a health plan, coverage starts Jan. 1, 2014.
Financial Help to Buy Insurance
In addition to finding a cheaper health plan, you may also qualify for financial help, or subsidies, to help further reduce its cost. You may be able to get a tax credit to lower the cost of your insurance. Whether you qualify for assistance will depend on your income — how much money you think you will make in 2013 — and how many people are in your family. You can find out if you qualify for a tax credit when you apply to buy health insurance through your state’s Marketplace.
Expansion of Medicaid
For others, you might be able to qualify for Medicaid for the first time. In some states, Medicaid is changing its rules because of health reform, and more people will be able to participate. I’ll be covering this in more detail in a later segment because our state has not yet expanded Medicaid.
What’s Already in Effect
Many benefits are already here, but you should check with your health plan about any you’re interested in and haven’t used yet.
● KIDS – Children must be covered by insurance even if they already have a health problem, called a pre-existing condition. If your child develops a chronic condition, such as diabetes or asthma, your insurance still must cover your child.
● ADULT KIDS – You can keep your kids on your existing health insurance longer. As of now, children can stay on your policy until they are 26 years old.
● PREVENTION – You can get some types of care for free. Certain tests and checkups, called preventive services, are now completely paid for by your insurance. These include a well-child visit each year, blood pressure and cancer screenings, and flu shots. This means NO copays and NO deductibles for this preventive care.
● GUARANTEE – You’re better protected by insurance. If you or someone in your family gets sick, your insurance company can no longer cancel your coverage.
● ESSENTIAL HEALTH BENEFITS must be covered by all qualified health insurance plans. These include emergency services, hospitalization, maternity and newborn care, prescriptions, and more.
● PRIMARY CARE PROVIDER CHOICE – You can choose who will be your primary care provider, often referred to as PCP. Your PCP is your lead health care professional — the one you see for screenings and when you’re sick. A PCP can refer you to specialists if you need them.
● APPEALS – You now have an easier way to complain about insurance problems. Each plan must have an appeals process, which are the steps you must go through to ask a health plan to pay for something they said wasn’t covered. Every health plan must tell their members what their appeals process is.
Affordable Primary & Urgent Care Options, without using insurance…
With many employers moving to a high-deductible plan for their employees, there is a grassroots movement called Direct Medical Care or Direct Primary Care, which is similar to concierge medicine for the masses. This means you get “customized” care, but at an accessible and affordable price.
You can find out more at DirectMedicalCareUSA.com, which is the main one in St. Louis. All the St. Louis Urgent Cares facilities actually participate in this program.
- – - –
St. Louis Urgent Cares presently has 4 locations in St. Louis: Downtown Urgent Care, Eureka Urgent Care and Creve Coeur Urgent Care, and North City Urgent Care.
Incidentally, the Ribbon-Cutting Ceremony for North City Urgent Care is tomorrow (Tuesday 22nd October) from 9am to 11am, at 6113 Ridge Avenue, 63133. Be there to join in the celebration if you can make it.
St. Louis Primary Care also operates at each of these locations. All eight practices participate in DirectMedicalCareUSA.com
You can get a cholesterol profile and a flu vaccine for no extra charge at each facility whenever you come in as a patient for any illness or injury.
In the state-run health insurance marketplaces, the government-approved health insurance plans are divided into five tiers: platinum, gold, silver, bronze, and catastrophic. Analysts expect young adults to gravitate towards the bronze and catastrophic plans, which are the lowest-cost options.
Both the bronze and the catastrophic plans cover basic preventative health services including cholesterol tests, immunizations and screenings for depression and alcoholism (a full list is here). Both also cover, to varying degrees, all 10 categories of “essential health services”: hospitalizations, emergency services, ambulatory (outpatient care) services, some maternity and newborn care, pediatric care, vision and dental care for children, mental health and behavioral health treatment, rehabilitative and habilitative services and devices, laboratory services, and chronic care services.
There are some key differences between these two tiers, however. This chart can help you decide which plan may be right for you.