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Know how to navigate the Affordable Care Act to get the best coverage

The Affordable Care Act (ACA) represents a tidal shift in the U.S. healthcare system, bringing with it confusion and legitimate concerns for many Americans. Everyone wants access to safe and affordable healthcare for themselves and their families but, for many, access to quality care has been elusive, and catastrophic medical bills have triggered bankruptcy.

The ACA includes a number of consumer benefits designed to alleviate these issues. It’s important for everyone to understand what these benefits are so that they can take advantage of them. They should also be aware of the individual mandate deadline. On Jan. 1, 2014, individuals will be required to have health insurance or pay a tax penalty -- starting at $95 per individual, $285 per family, or 1 percent of income, whichever is greater, for 2014. The penalty rises to $695 per individual, $2,085 per family, or 2.5 percent of income in 2016.


Do take advantage of free preventive medical screenings

Health insurance companies are now required to provide coverage for a number of preventive medical screenings at no out-of-pocket cost to the plan member. This is important for protecting your health, so contact your insurance company or doctor’s office to confirm if the services you’re receiving are covered with no out-of-pocket cost.

Do consider re-enrolling in your former health plan

Consider re-enrolling in your former health plan if you lost coverage due to exceeding your lifetime dollar limits. Health insurance companies are no longer allowed cap amounts paid out for services deemed “essential” by the Department of Health and Human Services within the lifetime of a plan member.

If you are still eligible for the plan, the health insurance company is required to let you re-enroll. This change applies to all major medical health insurance plans, even Grandfathered plans in effect prior to March 23, 2010.

Do make sure that your children have health insurance coverage

Make sure that your children have health insurance coverage, and if they have been uninsured due to a pre-existing medical condition start exploring options now. Children under the age of 19 can no longer be excluded from group or individual health insurance coverage based on a pre-existing condition.

Also, adult children are allowed to retain health insurance coverage under their parents’ plans until age 26, regardless of whether they live at home, are claimed as dependents, or are currently enrolled in college. This provision includes adult children who are married.

Do look for health plans that include health apps on your mobile devices

This can enable you to interact with your health plan and health care provider at your convenience – wherever you have Wi-Fi access. Health apps provide quick access to important information, such as your medication history, drug look-up, drug savings calculations, plan benefit options, personalized messages from your doctor and biometric trackers. This kind of access furthers the aims of ACA, empowering you to make better, more well-informed choices that can improve your health and curb costs.

Do learn about added protections against rescission

With the ACA, it will be more difficult for health insurance companies to cancel a member’s coverage, except in cases of fraud or intentional misrepresentation on the part of the applicant. Answer all questions on an application for individual health insurance coverage to the best of your ability. If the insurance company tries to cancel your coverage due to misrepresentation, take advantage of the new appeals process which allows you 30 days notice to file an appeal.


Do not assume that your current health plan will automatically cover preventive screenings

Don’t assume that your current health plan will automatically cover preventive screenings for you beginning September 23, 2010. Grandfathered plans (those purchased prior to March 23, 2010) are not required to make these benefits available for free.

Do not assume that all dollar limits are abolished

Insurance companies can still place annual dollar limits on specific types of benefits until annual limits are also phased out for most plans beginning in 2014. Also, do not assume that all services will be automatically covered. Maternity benefits, for example, may still be excluded by some plans.

Do not withdraw your children from Medicaid or SCHIP coverage

Don’t withdraw your children from Medicaid or SCHIP coverage until you’ve compared costs and been approved for new coverage. Also, keep in mind that while this rule applies to all new plans, the only Grandfathered plans for which it applies are Grandfathered employer-sponsored group health plans. You won’t be able to automatically enroll a child with a pre-existing medical condition onto a Grandfathered individual plan. You would have to purchase a new plan instead.

Do not automatically re-enroll your adult children in your own health insurance plan

If your adult children have other coverage options or live out of state, your health insurance plan is not necessarily the best option. For example, out-of-state coverage levels may be decreased or non-existent under your health plan. Also, depending on how much you may be required to contribute toward dependent coverage, your adult children may be able to find more affordable coverage on their own. Also, keep in mind that if you have an individually-purchased plan (rather than a group plan), adult children from 19-25 may still be declined coverage due to pre-existing medical conditions.

Do not assume that the new law will allow you to provide false, incomplete or inaccurate medical history

Assume that the new law will not allow you to provide false, incomplete or inaccurate medical history information in order to get approved for a health insurance plan. While the ACA makes it more difficult for the insurance company to cancel your coverage after the fact, it is not intended to protect persons who intentionally misrepresent themselves on health insurance applications.

Jumping cartoon

The ACA aims to transform the U.S. healthcare system, and has already expanded coverage of young adults, eliminated lifetime limits on what insurance will cover, lowered the cost of drugs for seniors on Medicare, caused 13 million consumers to get premium rebates totaling $1.1 billion, and expanded access to free preventive care for patients of all ages. In 2014, almost all Americans will have access to affordable health insurance that covers essential care.

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Photo Credits: Health Care Costs by Flickr: 401(K) 2012; Check Man, Cross Man and Jump Man © ioannis kounadeas -

Robert Oscar, R.Ph.President and CEO

Robert Oscar, R.Ph., has more than 25 years of experience in healthcare. Throughout much of his career, Oscar has developed and implemented successful programs to effectively manage pharmacy benefit risk including pioneering work in the Medicare...

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