Understanding Health Insurance
Watch a webinar on understanding the new insurance changes and choosing the right insurance for families of children who require frequent medical care.
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Note: this information is provided as a service to Phoenix Children's Hospital patients and their families. Information was obtained from a variety of public sources (see “Resources” below).
Whether you’re already familiar with health care reform or you need an introduction to the basics, we want to help you better understand this complex law and what it means to you and your child’s health care coverage.
What Is Health Care Reform?
Health care reform has been the law of the land since it was signed by President Obama in March 2010. Often referred to as the Affordable Care Act (ACA), it is actually two separate pieces of legislation:
- The Patient Protection and Affordable Care Act (PPACA) and
- The Health Care and Education Reconciliation Act of 2010
Enrollment in a Health Insurance Plan is Mandatory
By law, you must be enrolled in a health insurance plan that meets basic minimum standards. This is sometimes referred to as the “individual mandate.” Simply stated, if you don’t have medical coverage next year, you may be subject to a tax penalty equal to the greater of either:
$95 for an individual, capped at three times that amount or $285 per family;
One percent of your household income above the tax-filing threshold, which is your gross income minus your personal tax exemptions and standard deductions.
All insurance plans will have to cover basic care like:
- Doctor visits
- Maternity care
- Emergency room care
- To see a complete list of benefit categories that all insurance plans will cover, visit www.getcoveredamerica.org/newhealthcare-benefits
- If you have a pre-existing condition, insurance plans can no longer deny you coverage.
- All insurance plans will have to show the costs and what is covered in simple language with no fine print.
- Health insurance exchanges open: If you do not have private insurance or access to coverage through a public plan (such as Medicaid), you can either purchase a plan through the public health insurance marketplace or pay a penalty.
Questions and Answers About Health Care Exchanges
Q: What is an Exchange?
A: These are online health insurance marketplaces to help individuals compare and purchase coverage. People who can’t access coverage someplace else—like through an employer, spouse, or public plan like Medicaid—are those most likely to use these marketplaces.
Q: Who should get coverage under an Exchange?
A: You may soon notice your mailbox filling up with advertisements from insurance companies, competing for your premium dollars and trying to entice you into their marketplace plans. That’s why you’ll need to determine what makes the most sense for your particular situation.
If you have access to coverage through your employer, you may want to continue with that coverage. Employer-sponsored health plans are paid in a large part by the employer. Exchange plans hold you responsible for the entire cost.
If you do not qualify for another plan, then the Exchange plans may be right for you. In some cases, you might even be eligible for a new tax credit or premium subsidy to help defray the cost of coverage purchased through the exchange.
Q: What should I look for in an insurance plan?
A: Insurance companies who participate in the Exchange will provide the details of their coverage online before open enrollment begins. You will see plans labeled bronze, silver, gold and platinum. Each level will have a similar range of benefits.
- Check to see if your primary care provider (general pediatrician, for your child) is an in-network provider for the insurance you are considering.
- See if the plan you are considering restricts out of network physicians. If you travel or have a child attending college out of state, this will limit your choices.
- If your child sees pediatric subspecialists for care, note the plan’s requirements for referrals and the coverage provided by your selected plan.
- Make your decision based on the total value of the plan, considering your family’s specific health care needs and usage pattern. For example, if you have ongoing or chronic health concerns, you may want to consider one of the gold or platinum plans that has a higher monthly premium but covers more of the actual health care costs.
Q: Am I Eligible for a Subsidy?
A: If you qualify for an employer-sponsored health plan that provides sufficient benefits, you probably won’t be eligible for a subsidy if purchasing coverage through the health insurance exchange. If you’re not eligible for coverage under an employer plan and your household income is below a certain level, you may qualify..
Q: Where can I get more information?