Patient Advocacy: Healthcare on your side
a weekly blog by Martine Brousse,
Healthcare Specialist, Patient Advocate, Certified Mediator
BASIC INSURANCE COVERAGE OPTIONS UNDER ACA
The dedicated website www.healthcare.gov is your best starting point to sign up or get answers.
Many states have set up their own websites and marketplaces. California, for example, is running an efficient and user-friendly site.
There are basically 3 types of insurance coverage and 5 levels offered through the ACA marketplace. Letʻs explore the options, remembering that Medicare and Medicare Advantage plans are not included in the provisions of the ACA, and therefore not accessible through the Marketplace.
A. THREE TYPES OF PLANS
1. PPO (Preferred Provider Organization)
Usually the most versatile plan, it allows its subscribers to access a large network of contracted providers at will. These contracted providers ("in network") accept a reduced fee or allowance as payment in full, and bill you only for whatever amount is dictated by your insurance, based on your plan provisions.
You usually do not require any authorization to see them. There should be few delays in getting an appointment, if any at all. Convenience, choices and limited restrictions are the main attractions of PPO plans.
(Always confirm with the office or your insurance that the provider is indeed "in network". You may still see them if they are not part of the network ("out of network") but at as significant higher cost).
EPOs are "exclusive" mini-networks within a PPO network. Expect a lower patient liability but a harder time finding a provider. EPO providers are PPO providers but few PPO providers are part of the EPO mini-network.
This type of coverage is more restrictive. If you choose an in-house HMO network (ie Kaiser Permanente), you MUST receive all your care there.
If you sign up with a HMO plan through another commercial carrier, you will be assigned a local PCP = Primary Care Physician and IPA (medical group your PCP belongs to). This PCP will be receiving a monthly capitation (payment) to take care of your medical needs. You must ALWAYS go or call there first.
The PCP is responsible for the coordination and supervision of your care, and will refer you to a specialist within the network if and when necessary. These services may be rendered at the same clinic as the PCP, or at an outside office.
The PCP approves and issues all authorizations for you to see any medical provider, receive any service, get any prescription or schedule any appointment. Without an authorization, the HMO will not pay a provider, even within its own network.
Appointments might take longer to get than with a PPO plan, even though some states such as California now impose limits on waiting periods. Because of the lack of choice and smaller networks, you may not like a physician assigned to your care. Switching to another PCP will be relatively easy, finding a new specialist may not.
Always make sure an authorization is on file when going to ANY appointment, even a follow up with an established physician. Understand that the cost of any medical service received outside of the HMO network will be yours.
3. MEDICAID (MediCal in California)
The ACA guidelines significantly expand access to Medicaid for lower-income patients. Certain restrictions, such as car ownership or strict poverty-level income, have been lifted or changed to accommodate a larger population of individuals and families who may not otherwise be able to afford even the cheapest options of PPO or HMO plans.
Depending on your home state, and whether the Medicaid expansion has been approved by its legislature, you may qualify for coverage. You can find out by contacting your state marketplace agency or healthcare.gov. You may also call 1-800-318-2596 24/7 to speak with a trained representative.
B. FIVE LEVELS OF COVERAGE FOR PPO AND HMO PLANS:
In addition to choosing between a HMO and PPO plan (if not enrolling with Medicaid), youwill be asked to decide on a level of coverage between the 5 proposed options: 4 comprehensive (Bronze, Silver, Gold, Platinum) and 1 Catastrophic.
Comprehensive plans cover all medically necessary services, with no limit. Catastrophic plans only cover a set limit (usually just a few thousand $), under specific circumstances.
Basic coverage requirements are the same for all levels, as enforced under the ACA. Guaranteed are: access to emergency services, hospitalization coverage, preventive measures at no cost to patients, Rx coverage, lab services and more. The difference lies in the price of the monthly premiums, and the total share of cost. The more you pay up front in the form of a premium, the less you pay down the line as a deductible, copay percentage, or out-of-pocket amounts.
If you are under 30, if your health is excellent and only anticipate to use your plan in case of an emergency, a catastrophic plan may be for you. If you are older, have few health issues or rarely see a physician, a bronze plan may cover your needs. If you have a condition that requires expensive treatments or frequent visits to doctors, the more expensive premium of a silver or gold plan may offset your total out of pocket liability.
Options, pricing and coverage are detailed on the healthcare.gov website, as well as on the Marketplace sites set up by the participating States. Calculators will indicate any premium assistance or subsidy you may qualify for, based on the size of your household and income, for bronze or Silver plans. Platinum plans are subject to an additional tax.
3 IMPORTANT TIPS:
When choosing a plan, consider other criteria than just the monthly cost, especially if eligible for a premium subsidy. A bronze plan may be the cheapest option, however a silver plan with a subsidy may cost just a fraction more, potentially saving you significant out of pocket costs down the line.
Consider calling any physician you want to keep seeing. Publicized networks are often incorrect, incomplete or misleading. Only the office can confirm whether they will participate in your Marketplace plan.
©  Advimedpro.
©  Martine G. Brousse.
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My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.
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