Learn the basics of ‘Obamacare’

September 17, 2013 

The Affordable Care Act, also known as Obamacare, will begin soon. In this and the next few columns, I hope to answer some questions regarding: the available services; eligibility; enrollment; costs and subsidies.

When I write a column I do try to avoid special terms and acronyms. For this topic, it will be necessary for individuals to learn specific terms so I will also explain the language when possible.

This is a very fluid situation with a great deal of uncertainty and likely changes. As of Oct. 1, enrollment will begin for individual coverage plans. This column will review the plans that are available in the federal marketplace locally.

In York County, and Mecklenburg County, N.C., two health insurance companies will be offering plans. In York County it will be Blue Cross Blue Shield of SC (BCBSSC) and Coventry Health. In Mecklenburg County it will be Blue Cross Blue Shield of N.C. (BCBSNC) and Coventry Health. Companies that provide plans in the federal marketplace are referred to as a Qualified Health Plan Provider (QHP).

All plans in this marketplace must provide the same Essential Health Benefits (EHBs) as set forth by the ACA. The EHBs include: Ambulatory patient services (outpatient care you get without being admitted to a hospital); emergency services; hospitalization; maternity and newborn care (care before and after your baby is born); mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy); prescription drugs; rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills); laboratory services; preventive and wellness services and chronic disease management; pediatric services.

Providers and plans do have differences, including additional benefits, pricing and network availability. Each individual who is considering coverage should review the information carefully.

In addition to providing the EHBs, each QHP is required to offer five types of plans. These plans will be identified as “Platinum” “Gold” “Silver” “Bronze” (the Metal plans) and “Catastrophic.” Catastrophic plans will be offered on a limited basis and the majority of applicants will be applying for one of the other four plans.

The most definitive point that separates each of the “Metal” plans is the co-insurance levels. Coinsurance is your share of the costs of a covered health care service, calculated as a percent (for example, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. The Metal plans are required to have the following coinsurance levels: Platinum Plans 90:10; Gold 80:20; Silver 70:30; Bronze 60:40.

This is the first in a series of columns I will be writing on the health care changes. The next column will be on eligibility and enrollment. I would encourage everyone to visit the government website: healthcare.gov for additional information.

Bob Condron, ChFC, MSFS, can be reached at bcondron@bridgefp.com or 548-8875.

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