Health insurance coverage for individuals and families Health care reform is here. If it seems like information is coming at you from all directions, it probably is. But just because it s a hot topic of conversation doesn t mean you understand how it affects you. That s where we come in. We want to ease your anxiety and help you make sense of something that can be pretty complicated. We should know it s what we ve been living and breathing for years. We want to share this important information with you so you can make an informed decision about the kind of care you want and need in your life. We re committed to helping you every step of the way. individuals & families The essentials Many of the remaining health care reform changes will take effect Jan. 1, 2014. If you currently purchase or plan to purchase health insurance for yourself or for your family, you will be affected. Here are the most significant changes, effective Jan. 1, 2014: Most individuals will be required to have health insurance coverage. Individuals will no longer be denied coverage due to preexisting conditions. Benefits will generally be more comprehensive, and total out-of-pocket expenses will be capped at a certain amount. Some individuals will be eligible for tax credits and/or subsidies to help offset the cost of insurance coverage and out-of-pocket health care expenses (called cost sharing ). Your current coverage in most instances will be discontinued. Coverage can be purchased only during open enrollment unless you have a qualifying event. 10/1/2013 3/31/2014: Open enrollment 1/1/2014: New regulations effective We know health care is complicated, and we want to make it as easy as possible to understand while giving you the tools to make the best decision for you or your family. Reform brings with it many changes and new options. Please review the additional details of this guide as well as our glossary of terms to help you make sense of it all. You don t have to go it alone on the road to reform. We re here to help. How the Affordable Care Act affects you
The top 10 The Affordable Care Act brings with it numerous changes, of which there are too many to list. To make it easier on you, we ve pulled out what we think are the top 10 topics that matter most when making health care decisions for 2014. 1. Most individuals will be required to have health insurance coverage. The Affordable Care Act requires most U.S. citizens and legal residents to have basic health coverage beginning Jan. 1, 2014, or to pay a penalty. Exceptions to this requirement include people with certain religious beliefs, members of Native American tribes, undocumented residents, people who are in prison and people whose income is below a certain level. 2. Individuals no longer will be denied coverage due to preexisting conditions. Health insurance companies will be required to provide coverage to anyone who applies for it and cannot base premiums on health status. That means you ll be able to get health insurance coverage, even if you were previously denied. And you can t be charged more if you have significant health issues. 3. Benefits will be more comprehensive. All health plans will be required to cover a comprehensive package of items and services known as essential health benefits. These essential health benefits include services such as outpatient care, prescription drugs, emergency services, mental health and substance abuse care, rehabilitation services and devices, and preventive care, to name a few. 4. Total out-of-pocket expenses will be capped. Out-of-pocket expenses (such as copays and deductibles) will be capped. All health plans must cover a minimum of 60 percent of average health care costs, except catastrophic plans. 5. Some individuals will be eligible for subsidies to help offset the cost of insurance coverage. Many individuals and families will qualify for subsidies to help pay their premiums as well as their out-of-pocket expenses. Eligibility for subsidies is based on income and family size. 6. Coverage can be purchased only during open enrollment unless you have a qualifying event. Open enrollment begins Oct. 1, 2013, and ends March 31, 2014. During this period, you can shop and sign up for health insurance coverage. After March 31, you can purchase health insurance for 2014 only if you have a qualifying event. Examples of qualifying events include marriage, divorce, loss of employment and loss of insurance through your employer. During open enrollment, you will be able to purchase health insurance coverage in many different ways, such as: Directly from an insurance company From a producer who represents multiple insurance companies From private health insurance exchanges, also known as private health care marketplaces, that represent multiple insurance companies online From public health insurance exchanges, also known as public health care marketplaces, that represent multiple insurance companies online and provide tax credits and subsidies to eligible individuals 7. Existing plans will be discontinued. In most instances, existing insurance plans will be discontinued because they do not meet Affordable Care Act requirements.* If you currently have an individual or family insurance plan, your plan will be discontinued and you will be required to purchase one of the many new plans offered by several different insurance carriers. *Discontinuation effective dates will vary by insurance company, so please check with yours to know specifically how and when you will be affected.
8. Catastrophic coverage will be sold only through public exchanges and will be available only to a specific group of people. Catastrophic coverage, as it exists today, is a health plan with a very high deductible that is available to most people. Beginning Jan. 1, 2014, catastrophic health insurance plans will be available to individuals younger than age 30 or those exempt from the individual mandate because no affordable health plan is available to them or because of hardship. For those who are eligible, a catastrophic plan may be purchased only through a public exchange. 9. Portability health insurance plans are going away. All portability contracts will expire on Dec. 31, 2013, and there will be an opportunity to purchase an individual insurance policy during the open enrollment period. Beginning in 2014, there is no requirement for insurance companies to offer portability plans. 10. Pediatric dental coverage is required with medical coverage. Pediatric dental coverage either will be embedded in an insurance company s health plan or it will be available on a stand-alone basis. Embedded means that the dental coverage is integrated with the medical plan benefits. Stand-alone means that the pediatric dental benefits are separate from the medical plan benefits and are purchased separately. When you are shopping for health insurance, be sure to understand whether or not pediatric dental coverage is embedded. Two important nuances in Oregon: Pediatric dental coverage must be offered through Oregon s public health exchange, Cover Oregon, though you are not required to purchase it along with a medical plan if it s not embedded. If you purchase a medical plan outside of Cover Oregon, you are required to purchase pediatric dental coverage if it isn t embedded, regardless of your age. Your health and your health care is very much our concern. This guide is meant to provide an overview of the upcoming changes. We ve covered broad ground, but we know you ll still have questions. Feel free to contact us or one of our producer partners to get the answers you need to make the best decision for your health and your life. Contact your producer or call us toll-free at 800-988-0088, Monday through Friday from 8 a.m. to 8 p.m. or visit us online at www.providencehealthplan.com/reform. We d love to help.
What s happening in Oregon? Oregon s public health insurance exchange, also referred to as the marketplace, is called Cover Oregon. Beginning in October of this year, you ll be able to shop for health insurance coverage on Cover Oregon s website, where you can choose from many different insurance plans offered by multiple insurance companies. If you are eligible for a tax credit and/or subsidy, you will receive it only if you purchase your insurance coverage through the Cover Oregon website. Providence Health Plan will offer a variety of plans to choose from on the Cover Oregon website, or you may purchase a plan directly from us or through your insurance producer. As part of the Affordable Care Act, you may be eligible for financial assistance to help you pay for your health insurance purchased through Cover Oregon. Depending on your income and number of family members, you may be eligible for subsidies. Here s an example of what this might look like, according to Cover Oregon: If you re an individual earning up to $45,900 a year, or a family of four earning up to $94,200 a year, you ll get a tax credit to help cover the cost of your premiums. You also may be eligible for a costsharing subsidy to help pay for copays, deductibles and other out-of-pocket costs. You can find out if you re eligible for financial assistance by answering a series of questions on the Cover Oregon website available in October. Eligibility will be based on the modified adjusted gross income for your entire household. Exchanges will not necessarily impact those on Medicare, Medicaid, Tricare or other federal plans. You re not in this alone Providence has been caring for Oregonians for 157 years. We ve insured generations for 29 years. Over time, the health insurance landscape has changed significantly, but we ve always kept our focus: We re committed to doing right by you and your health. Your well-being is our priority. We know that where and how you receive care is a personal choice, which is why you have the option to go to a Providence facility or choose a plan with nearly 1 million care options nationwide. We re about more than technology and tools, numbers and claims Providence is about ensuring the greater good and doing right by you, every day. Providence Health Plan offers this information on some of the laws applicable to health care reform so that you can understand the general legal landscape and seek your own counsel. Where possible, we provide tips for how to find additional information from regulators. This guide is offered for general educational purposes only and should not be taken as legal advice.
individuals & families Glossary of terms Coinsurance: Your share of the costs of a covered health care service, calculated as a percentage (for example, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance plan s allowed amount for an office visit is $100 and you ve met your deductible, your coinsurance payment of 20 percent would be $20. Your health insurance plan pays the rest of the allowed amount. Copay: A fixed amount (for example, $15) that you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. Deductible: The amount you owe for health care services that your health insurance plan covers before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won t pay anything until you ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Exchange (or marketplace): A transparent and competitive insurance marketplace in which individuals and small businesses can buy affordable and qualified health benefit plans. The exchange will offer consumers a choice of health plans that meet certain benefits and cost standards. Individual and family plan: A type of health insurance purchased by an individual or family, independent of any employer group or organization. Insurance company or insurance carrier: A company that issues, and assumes the risk of, an insurance policy. Various activities are performed by an insurance carrier, including the underwriting of a policy prior to issue. An insurance carrier not only sells insurance policies but also pays claims that those who are insured make on their policies. Out-of-pocket maximum: The most you pay during a policy period (usually a year) before your health insurance plan begins to pay 100 percent of the allowed amount. This limit does not include your premium, balance-billed charges or health care your health insurance plan doesn t cover. Open enrollment: The period of time set up to allow you to choose from available plans, once a year. For 2014 plans, the open enrollment period in Oregon is Oct. 1, 2013, to March 31, 2014. Plan: An insurance policy that provides or pays the cost of medical care. Portability plans: A type of individual health care plan that s available for qualified individuals whose groupsponsored health insurance has ended. Portability plans, also referred to as conversion plans, provide an option for continued health care coverage, regardless of preexisting conditions. Additional resources: Premium: The total amount paid to the insurance company for health insurance coverage. This is typically a monthly charge. Producer: A state-licensed individual or entity representing one or more insurance companies. A producer solicits and facilitates the sale of insurance contracts or policies and provides services to the policyholder on behalf of the insurer. Producers also may be referred to as agents or brokers. Qualifying event: An event that causes a change in an individual s status that would allow him or her to change insurance plans. Examples of qualifying events include marriage, divorce, loss of employment or loss of insurance through your employer. Subsidy: Cost-sharing assistance to help pay for monthly premiums and/or copays, deductibles and other out-of-pocket costs on plans purchased through Cover Oregon. Income and family size will determine eligibility. Tax credit: A subsidy to help pay the monthly premium on plans purchased through Cover Oregon may be administered as a tax credit. For example, an individual earning up to $45,900 a year or a family of four earning up to $94,200 a year will receive a tax credit to help cover the cost of their premiums. Cover Oregon: www.coveroregon.com Federal government: www.healthcare.gov
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