INDIVIDUALS & FAMILIES QUESTIONS

A Prices for policies sold in the marketplaces have not been established yet.  The law makes clear that insurers won’t be able to charge more based on your gender or your health status, and there will be limits to how much premiums can vary based on your age. In addition, consumers with income below 400% of the Federal Poverty Level (about $88,000 per year for a family of four) who are buying insurance for themselves or their family will get tax credits that cover a large part of their costs.  A recent report estimated that a family earning twice the federal poverty level would pay less than $3,000 for their coverage for a year – compared to more than $11,000 without health insurance coverage through the marketplace.

A A: On March 4, 2013, the Illinois Department of Health & Family Services (HFS)  published this notice about the increase in fees for primary care physicians. It says, "For dates of service January 1, 2013 through December 31, 2014, the department will apply an increased payment rate to enrolled practitioners for primary care services delivered by a primary care physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. The increased payments will apply to services reimbursed by Medicaid fee-for-service, Voluntary Managed Care Organizations and Integrated Care Program Health Plans."  In order to receive the increased payments, physicians must self attest that they meet certain criteria. Interested primary care providers should read the notice for more information.

A It is true that the Affordable Care Act (ACA) calls for $716 billion in cuts to Medicare. However, none of those cuts will come from or affect the benefits Medicare participants receive.  In fact, the ACA takes steps to improve the medical care that seniors receive via Medicare. First, the majority of the cuts come from getting rid of overpayments to private insurers involved with the Medicare Advantage program. These overpayments were originally authorized in a law signed by George W. Bush (the same law that called for the Medicare Part D Donut hole). Reducing the amount overpaid to these insurance companies will have no impact on the benefits for either Medicare Advantage or traditional Medicare recipients. Also, the ACA will provide seniors with more benefits—not a reduction in benefits. This includes a plan to close the Part D donut hole for prescription drug coverage, as well as more preventative care services offered without a co-pay (such as annual check-ups, prostrate exams, cervical cancer screenings, mammograms and flu shots). As for those seniors enrolled in the Medicare Advantage program, the new Medical Loss Ratio requirements mean that insurance companies have to spend a certain percentage of premium costs on customer’s medical care and improving the quality of care offered. If companies do not spend the required amount on providing care, they must refund the remainder to their customers.

A The recommendation for new preventive health services for women beginning on 8/1/12, including interpersonal and domestic violence screening and counseling, was based on the Institute of Medicine’s (IOM) Report: Clinical Preventive Services for Women: Closing the Gaps. This report defines interpersonal and domestic violence, including intimate partner violence and childhood abuse, as "a pattern of coercive behaviors that may include progressive social isolation, deprivation, intimidation, psychological abuse, childhood physical abuse, childhood sexual abuse, sexual assault, and repeated battering and injury. These behaviors are perpetrated by someone who is or was involved in a familial or intimate relationship with the victim." The report also states that "screening and counseling involve elicitation of information from women and adolescents about current and past violence and abuse in a culturally sensitive and supportive manner to address current health concerns about safety and other current or future health problems." Here is a memo that summarizes this information and provides additional resources.

A You are right - individuals are required to have "minimum essential coverage" (i.e., insurance) beginning January 1, 2014.  Exchanges (whether state-run, federally-run or a state-federal partnership) need to be up and running by then so that individuals have ample opportunity to sign up for affordable coverage options. States need to submit their exchange plans for approval by the federal government no later than January 1, 2013 in order to be ready for the open enrollment period beginning October 1, 2013. The penalty if you don't have minimum essential coverage will be payable for the 2014 tax year; generally taxes are filed a year later – so the first tax will be paid in 2015. Here's a great flowchart from Kaiser Family Foundation explaining who will have to pay the penalty and how much.

A Many people covered through a mid-sized or big business, won’t see too much change. Small businesses, though, will be able to buy health plans in new state exchanges, often with subsidies.  The hope is that more plans competing — and more people in the new state insurance marketplaces — will restrain costs for small businesses and their workers, making it easier to buy. However, some smaller employers may choose not to provide health insurance for their workers, leaving them to buy into exchanges by themselves.

A Yes. Under the Violence Against Women Act (VAWA), certain non-citizens are eligible for Medicaid (providing they meet income guidelines) and are not subject to the 5 year bar. See #10 in the following Illinois Department of Human Services eligibility chart. If VAWA applicants are eligible now, they should remain eligible under ACA. They typically have to provide a receipt that their application has been filed with US Citizenship and Immigration Services, not that the application has been approved.

A According to the U.S. Census Bureau, 49.9 million people were uninsured in 2010, about 16.3% of the population. The Census Bureau collects its information based on interviews conducted by the government every March as part of the Current Population Survey. According to Kaiser Family Foundation, nine in ten of the uninsured are in low- or moderate-income families, meaning they are below 400% of the federal poverty level. Many of the people without health insurance cannot afford to purchase individual coverage due to the high cost of premiums. Others may be barred from purchasing insurance due to a pre-existing condition. Being low income does not qualify someone for public benefits in Illinois and most other states, so going uninsured is often the only option. The Affordable Care Act will allow many people currently without insurance to obtain health coverage. Starting in 2014, Medicaid will expand to cover all Americans below 138% of the federal poverty level. Those without coverage who are between 138-400% of the federal poverty level will be eligible for tax credits to use towards purchasing insurance in the statewide health insurance exchanges. Historically, young adults make up a disproportionate share of the uninsured. Those aged 19 to 29 make up 29% of the uninsured and have the highest uninsured rate of any age group. Young adults are for the most part neither full-time students nor full-time employees, meaning they likely do not get coverage from their school or employer. Many are unwilling or unable to pay the high premium costs of private insurance. The Affordable Care Act already allows young adults to remain covered by a parent’s private insurance plan until age 26, and when the Medicaid expansion and the Health Benefit Exchanges are put into place, many more will gain new access to coverage. An estimated 11 million of those without health insurance are undocumented immigrants, but the exact number is not known. Neither the health benefits exchanges nor the Medicaid expansions will provide health insurance to undocumented non-citizens.

A If all goes according to the plan in the Affordable Care Act, Illinois will have a health insurance exchange up and running by October 1, 2013. Federal law requires the exchange to establish “Navigators,” who will help guide exchange customers through the insurance-purchasing process. Navigators will also be able to determine if a person using the exchange is eligible for public benefits, such as Medicaid or Medicare. Navigators will assist people in learning about insurance options and any tax credits that a customer may be eligible for, as well as enrolling in a plan. They will also be responsible to refer those who have problems with their plans or other elements of the exchange to the agency that can assist them with that problem. Navigators will be required to provide information in a way that is fair and impartial, in order to help consumers to choose the insurance plan that best fits their needs. In Illinois, approximately 1.5 million people will be eligible to obtain health coverage through the exchange. Navigators are required to serve all facets of that diverse population adequately, including those with low income, single parents, homeless, those with HIV/AIDS or other chronic health conditions, currently or formerly incarcerated people, and immigrants. The Navigator role will be filled by people from a wide array of organizations, such as community and consumer-focused non-profit groups; trade, industry and professional associations; chambers of commerce; unions; partners of the Small Business Administration and licensed insurance agents and brokers.

A Right now, you are not required to have health insurance. But beginning in 2014, most people will have to have it or pay a fine. For individuals, the penalty would start at $95 a year, or up to 1 percent of income, whichever is greater, and rise to $695, or 2.5 percent of income, by 2016. For families the penalty would be $2,085 or 2.5 percent of household income, whichever is greater by 2016 and beyond. The requirement to have coverage, known as the individual mandate, can be waived for several reasons, including financial hardship or religious beliefs. In Illinois, 1.4 million people will be eligible for Medicaid or federal subsidies to buy insurance under the law.