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10 things you need to know about the Affordable Care Act

Doctor With Stethoscope Health Care

As the Affordable Care Act moves quickly to its implementation, there are a number of questions consumers have about how it will really impact their lives.   

While there is still time for most of the law to take effect, there will be substantial changes for consumers, employers, states, insurance companies and doctors.  

Here are a few questions that may help consumers better understand how the Affordable Care Act will truly impact them.  

1. If I get health coverage through my employer, will I have to change plans, or can I keep my own?

Thus far, the majority of employers have opted to continue providing coverage for employees, as well as dependents under the age of 26.   The United States Department of Health and Human Services is currently in the midst of defining the minimum requirements for the various benefit levels that must be adhered to by insurers and the market.  Your employer is not obligated, necessarily, to keep the exact same plan, and the company has the ability to change premiums, deductibles, co-payments and the doctors in your network.   

2. Will I get more incentives from my employer if I lead a healthier lifestyle?

Many employers are choosing to enroll their employees in wellness programs and other initiatives that promote healthier lifestyles.  Under the new law, employers do have the ability to adjust contributions and premiums based upon an individual’s participation in these programs.  Starting next year, you will start to notice more employers who will be measuring employee participation and providing incentives, and maybe even penalties, in certain situations.  

3. Will my insurance company pay for preventative services?  

Starting January 2014, consumers will be eligible for preventative services such as breast cancer screening and cholesterol screening,  without being charged any out-of-pocket costs.  In addition, individuals with preexisting conditions cannot be denied coverage.  

4. If I don’t have insurance will I have to buy it?

Beginning in 2014, consumers will be required to purchase insurance, or they will have to pay a fine that can start at $99 a year, or 1 percent of income.  If the entire family does not purchase coverage, the penalty could be as much as $2,085 per year or 2.5 percent of household income.  Consumers will have to indicate on their tax return whether they have adequate coverage, and this will continually be monitored by their Internal Revenue Service to enforce the penalties.  For those who cannot obtain coverage, they may end up qualifying for Medicaid.  

5. If I can’t buy coverage, am I eligible for Medicaid?  

Beginning in 2014, the Medicaid program can be expanded by funding from the federal government so that an individual who makes less than $14,856 per year, or a family of four who makes $30,556 per year, can be eligible for Medicaid. Every state, however; is not required to abide by that change, according to the Supreme Court ruling –  and it will depend upon the state where you reside whether you will be eligible.   

6. How does the new law impact seniors?

A key component of the Affordable Care Act is that seniors will be able to reduce their responsibility for prescription drug costs in what has typically been known as the donut hole.  Seniors will still be responsible for about 25 percent of their prescription drug costs, but the coverage gap will be closed entirely by the year 2020.   

Seniors will also be able to receive coverage of preventative services, such as screening for colon, prostate and breast cancers, as well as an annual wellness visit.  Those individuals in the Medicare Advantage Plan may end up paying more than before since the federal government has has reduced payment to those insurance plans managing Medicare Advantage options.

7. How will the new law affect my taxes?

Starting in 2013, individuals making more than $200,000 and married couples making more than $250,000, will pay a Medicare Payroll Tax of 2.35 percent.  Also, individuals with a higher income could face a 3.8 percent tax on unearned income, such as dividends and interest.  In 2018, the Cadillac Tax kicks in, at which point there is a 40 percent tax on employer-sponsored benefits  (this does not include dental and vision), which exceed $10,200 per year, and $20,500 for families.  Starting next year there will also be taxes imposed on medical device manufactures, health insurers and a tax on brand name drugs.    

8. Will I be able to keep my doctor?

Many insurance companies are now looking at improving efficiencies of their provider networks by closely monitoring the quality of care being delivered by doctors.  As a result, it is possible that once the law is fully implemented, some of your doctors may no longer be part of an insurers’ network if they don’t meet certain standards of established criteria.  The law also calls for the establishment of accountable care organizations, which is intended to create greater coordination between doctors, hospitals and other practitioners to ensure greater compliance and better outcomes.           

9. Will I have to wait longer to see my doctor under the new law?

While there are no immediate changes anticipated in ones’ ability to see his or her doctor, there is a projected shortage of primary care physicians over the next 10 years that could create challenges for the system, as more people will have insurance and are expected to utilize health care services.  The government is evaluating options to increase the number of physicians for physician training in order to accommodate the anticipated need.    

10. Who will decide what care I will receive?

Under the new law, an independent Payment Advisory Board has been established to make recommendations as how to effectively reduce spending for Medicare, and to try and reduce fraud and abuse in the system.  Some components of the law have already been implemented and, as an example, if a patient is readmitted to a hospital within 30 days of discharge for a diagnosis related to congestive heart failure or pneumonia, the hospital will not be reimbursed for the readmission.  

Dr. Sreedhar Potarazu is an acclaimed ophthalmologist and entrepreneur who has been recognized as an international visionary in the business of medicine and health information technology. He is the founder of VitalSpring Technologies Inc., a privately held enterprise software company focused on providing employers with applications to empower them to become more sophisticated purchasers of health care. Dr. Potarazu is the founder and chairman of WellZone, a social platform for driving consumer engagement in health.

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