How Could Health Reform Affect You?
Here are some of the most important changes that could affect you. These changes improve access to care, expand health insurance benefits, and may help lower costs.
Improving Access to Health Care
You can choose your doctors, from among any primary care provider (PCP) or pediatrician who's in your plan's network and accepting new patients. A PCP in the network can refer you to specialists. You may pay more if the specialist is not in the network or if you are not referred by your PCP.
You don't need approval in advance for emergency care, and emergency room visits count as network care. However, this applies only to real medical emergencies. People who use the emergency room when they don't need to may have to pay higher costs.
You don't need a referral for OB-GYN services – you can choose an OB-GYN doctor as your primary care physician (PCP).
Most health insurance plans will cover certain preventive care services with no cost-sharing, including blood pressure and other recommended screenings and immunizations based on your age and gender.
Expanding Health Plan Benefits
Health Insurance Marketplaces (also called "Exchanges") are a new way for people to buy health insurance. There are two types of Marketplaces – the Individual Marketplace and the small business marketplace, called the Small Business Health Options Program (SHOP). The Individual Marketplace is where individuals and families can shop for a plan. The SHOP is where a small business can pick a plan or a range of plans from which its employees can choose. The plans offered in the Marketplaces must meet government requirements for coverage, quality and value.
If you are a new employee, the waiting period for health plan coverage to start can't be longer than 90 days.
Expenses like copayments, coinsurance and deductibles, count toward your out-of-pocket maximum. However, amounts for non-covered health services, balance billing amounts from non-network providers and premium payments do not count toward the out-of-pocket maximum.
Most health insurance includes coverage for essential health benefits, such as doctor visits, hospital care and prescriptions. (This applies to both individual and small business plans.)
Kids can stay longer on a parent's plan – until age 26. In some states, the age limit may be older.
Lowering Health Care Costs
Depending on your plan, yearly network out-of-pocket costs for members of high-deductible plans cannot be higher than $6,650 for an individual and $13,300 for a family in 2018. For members of plans that are not high deductible the individual out-of-pocket cost for 2018 are $7,350 and for families are $14,700.
Expenses like co-payments, co-insurance and deductibles, count toward your out-of-pocket limit. However, amounts for non-covered health services from non-network providers and premium payments do not count toward the out-of-pocket limit.
There are no lifetime or annual dollar limits on essential health benefits. Your plan cannot put an annual or lifetime dollar limit on the essential health benefits covered by the plan.
Important to know
Employers who have had a health plan in place since March 23, 2010, and have made no changes (or very slight changes) since that time, may not have to make some of the changes required under the Affordable Care Act. This is called a "grandfathered" plan. Check with your employer to learn if your health plan is grandfathered and, if so, how health reform changes apply.