Preparing for Healthcare Reform

Get your ducks in a row while ACA rollout continues
Author: January W. Payne

As key provisions of the Affordable Care Act (ACA) go into effect in 2014, people in the bleeding disorders community with and without health insurance coverage will likely have questions about how they will be affected. Changes include a mandate for small employers to provide insurance and a move to link physician payments to quality of care.

The answer to how ACA affects you varies, depending on your existing coverage and costs. Some may see very little impact on their health insurance. Others may experience changes, especially if they sign up for plans offered under the new Health Insurance Marketplace, an option that will be offered for the first time in 2014. Regardless, there are several things you should keep in mind to stay informed on what’s coming, and how it affects you and your family:

Understand your current coverage. Know whether you are currently covered by a health maintenance organization (HMO), preferred provider organization (PPO) or point-of-service (POS) health insurance plan. The type of plan your employer offers can change, even if your insurance provider remains the same. “You may be offered an HMO rather than a POS plan, for example,” says Marla Feinstein, policy analyst at the National Hemophilia Foundation (NHF). 

Then get a copy of your policy. If you have employer-sponsored coverage, your company’s human resources (HR) department can help you obtain a copy of your insurance policy. “Get a detailed plan summary, not a brochure,” Feinstein says. That same advice goes for an individual plan purchased on your own: Contact your insurer to request a detailed copy of your plan information.

Investigate whether it’s worthwhile to find a new policy. The newly relaunched consumer website, run by the US Department of Health and Human Services (HHS), helps consumers evaluate healthcare options and make educated decisions about coverage. HHS also has a call center available 24 hours a day: 800.318.2596.

HHS’s online support provides only educational resources right now, but during the open enrollment period from October 1, 2013, through March 31, 2014, consumers will be able to create accounts, apply for and compare plans, and evaluate options. Coverage is available starting January 1, 2014. If your state is operating its own marketplace or joining a partnership, will direct you to the appropriate website. The website also includes a chat feature, allowing real-time assistance with certified staff.

Pre-existing conditions no longer disqualify consumers. Starting in 2014, health insurers cannot deny coverage­ to an adult applicant because of a pre-existing medical condition. (The ACA provision preventing denial of health insurance to anyone under age 19 due to pre-existing­ conditions took effect in 2010.) The Pre-existing Condition Insurance Plan (PCIP), a temporary program to cover those who do not qualify for other plans because of pre-existing conditions, has been in place since March 2010 as a stopgap measure.

Before switching insurance plans, contact your HTC. Check with your HTC to make sure the plan you’re considering allows you to continue to visit that HTC and stay in network, Feinstein says.

Confirm coverage of clotting factor before agreeing to a new plan. “Clotting factor is extremely expensive and can cost $300,000 per person a year or more,” says Johanna Gray, MPA, vice president of Washington, DC-based CRD Associates, and an NHF policy advisor. “It’s also important to know how clotting factor is covered: Is it covered under your insurance policy’s medical benefit or the pharmacy benefit? Who are the in-network pharmacy providers? Finding answers to these questions will help you anticipate and manage your out-of-pocket expenses.”

Ask about copayments and deductibles. Consider changing plans if your copay or co-insurance has increased or will significantly change in the future. “If any dollar amount has changed, you might have to re-evaluate your personal finances,” says Feinstein. “If the amount you are paying out of pocket has increased, you might want to weigh the options being offered for other plans.”

Finally, there may be no change to your plan—and that’s OK. It’s always good to review your in­surance coverage to know what you have. But, Feinstein says, “if there is nothing wrong with your current coverage, why would you change it?”

Writer Karen Schwartz contributed to this article.