Tag: Affordable Care Act

09 Apr 2016

ObamaCare and Things to Watchout For


Obamacare, also known as Affordable Care Act (ACA) has a massive impact on the medical practices. As per CMS, 7.1 million people signed up for affordable insurances through the Health Insurance Marketplace. Till date 26 states have expanded their Medicaid programs under the ACA. From outside, it might seem more profitable for patients versus for healthcare organizations but here’s a look into the Affordable Care Act and the things to watch out for.

The basics.
The Affordable Care Act commonly known as ObamaCare was passed by Congress and then signed into law by the President on March 23, 2010. The act was enacted to have a minimum standard for health insurance policies and the law subsidies to help people with low incomes. The idea being getting as many Americans insured as possible. While ObamaCare dose not create insurance entities of it’s own but it regulates private insurance companies to provide quality medical care at an affordable cost.

There are in total five plan types commissioned under ObamaCare – Bronze, Silver, Gold, Platinum and Catastrophic coverage, based on the percentage of medical coverage a patient is entitled to.

Bronze plan: Health insurance plan pays about 60% on an average and the patients pay about 40%.
Silver plan: Health insurance plan pays about 70% on an average and the patients pay about 30%.
Gold plan: Health insurance plan pays about 80% on an average and the patients pay about 20%.
Platinum plan: Health insurance plan pays about 90% on an average and the patients pay about 10%.
Catastrophic plan: This plan pays less than 60% and is only available to citizens under the age of 30 or have a hardship exemption.

The good.
1. More patients: Millions of uninsured will get access to health insurance through health exchanges.
2. No denials for pre-existing conditions. Under the provision of the ACA, insurances cannot deny claims under pretext of pre-existing conditions.
3. Uninsured patient population can get free or low cost health insurance using their State’s Health Insurance Marketplace.
4. All coverage starting after 2014 must include new preventative services and essential health benefits.

Watch out for.
1. More patients will not necessarily translate to higher reimbursements. Many plans will include Medicaid-type reimbursement models.
2. Increase in insurance premiums due to insurers having to provide covered services.
3. Healthcare organizations may choose to not see patients having ACA plans as the reimbursements may not equate to the time and effort put behind claims submission and follow-ups.
4. May lead to greater premiums on the other commercially available insurances.

ObamaCare is here to stay. There is still a considerable amount of uncertainty surrounding the whole model. Practices are confused about the effect on patient volume, the reimbursement models and associated overhead costs. It would be extremely crucial for healthcare institutions to plan ahead of the curve so that they are equipped and better prepared if things don’t go as per plan.

09 Apr 2016

The “Ex” Condition

theexconditionHow many times have your claims been denied for having a pre-existing condition? How many times have you re-submitted / appealed those claims? Have they ever been paid? How do you proceed?

On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act, commonly called the ACA. The legislation is aimed at increasing the affordability and rate of health insurance coverage for Americans, thus reducing the overall cost of health care. The ACA requires insurance companies to cover all applicants within new minimum standards, and offer the same rates regardless of pre-existing conditions or sex.

The Basics
A “pre-existing” condition or pre-ex condition is a health condition that exists before someone applies for or enrolls in a new health insurance policy. Heart ailments, cancer, asthma, and diabetes are several common pre-ex conditions, but it the insurer who generally defines what constitutes a pre-existing condition. Prior to the Affordable Care Act, in the vast majority of States, insurance companies could deny coverage, charge higher premiums, and/or limit benefits to individuals based on pre-existing conditions.

The Stats
According to a new analysis by the Department of Health and Human Services, 50 to 129 million (19 to 50 percent) of non-elderly Americans have some type of pre-existing health condition. Up to one in five non-elderly Americans with a pre-existing condition–25 million individuals–is uninsured.

How ACA Helps:
1. Insurers can no longer limit lifetime coverage to a fixed dollar amount.
2. Insurers can no longer take away coverage because of a mistake on an application.
3. Insurers can no longer deny coverage to a child because of a pre-existing condition.
4. Thousands of uninsured people with pre-existing conditions have enrolled in the temporary high-risk pool program called the Pre-Existing Condition Insurance Plan, which has saved many lives by covering services like chemotherapy.
5. Starting 2014, no denials for pre-ex conditions.

Like it or not, ACA is here to stay. More and more people will have insurance, leading to more patient volume, less effort to obtain patient collectibles, and higher reimbursements.