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Health Care Reform Frequently Asked Questions

There is a great deal of misinformation and misconceptions about the Affordable Care Act, or “Obamacare,” and how it will affect families, businesses, veterans and others accessing healthcare.  Below are just some of the most frequently asked questions.  I hope you find this information helpful and should you have any more questions or require further information, please do not hesitate to contact my Burbank office at (818) 450-2900 or Washington, DC office at (202) 225-4176.

Sincerely,

Congressman Adam Schiff

 

 

What does health insurance cover?

How do I choose a health plan?

I like the health care plan I have. What does this change for me?

What should I look at in choosing a plan?

Will Health Care Reform lead to a government takeover of health care or result in “socialized medicine,”as some claim?

Why are members of Congress “exempt” from having to get their insurance coverage under this new law?

If I already have employer-provided coverage, how does the health care law affect me?

I have been concerned that it seems the premiums in my state seem to be going up rapidly and I’ve heard it’s because of the new health care law. Is that true?  And what can be done about rising premiums?

If I am a senior enrolled in Medicare, how does the health care law affect me?

I am a veteran.  I served my country and I was promised VA health care for the rest of my life.  I am concerned that the health care law will take away the VA health care I have earned. 

I am serving my country and I don’t want to see my family kicked out of TRICARE and I don’t want to lose my military health benefits either now or when I retire.  I am concerned that the Affordable Care Act can change or take away my benefits.

I've been turned down by insurance companies because I have a chronic illness. Will that happen again?

 

 

What does health insurance cover?

Answer: Today, there is a wide range of health insurance policies offering different benefits and access to different doctors, hospitals or other providers. Starting in 2014, all health insurance plans will share some common characteristics. The federal Affordable Care Act now requires that all health plans offered in the individual and small group markets must provide a comprehensive package of items and services, known as Essential Health Benefits. The requirement for insurance plans to offer Essential Health Benefits is just one of many changes coming in 2014.

These benefits fit into the following 10 categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including dental and vision care

 

How do I choose a health plan?

Answer: It can be overwhelming to find the right health plan for you and your family. Before you get started, it is important to understand another big change happening in health insurance. Starting in 2014, all health insurance newly sold to individuals and small businesses must be classified as one of the four levels of coverage – bronze, silver, gold or platinum. In addition, a "catastrophic" plan will be available to those who are under 30 years old or can provide a certification that they are without affordable coverage or are experiencing hardship. This system will make it easier for you to compare plans. You can choose to pay a higher monthly premium for a platinum or gold plan so that when you need medical coverage, you pay less. Or you can choose to pay a lower monthly premium for a silver or bronze plan, but when you need medical coverage, you pay more. It's up to you. If you need help understanding the levels of coverage and making a choice that works for you and your family, Covered California will have help available in person, online or by phone starting later in the year for coverage that begins on January 1, 2014.

 

I like the health care plan I have. What does this change for me?

Answer: If you choose to keep the plan you already have, you will still enjoy many of the benefits of the Affordable Care Act, including the prohibiting of insurance companies from dropping your coverage just because you got sick.  However, if you are covered by a plan that existed before March 23, 2010, your plan may be "grandfathered”, and you may not get some rights and protections that other plans offer. More information on this can be found at HealthCare.gov's "Grandfathered" Health Plan website.

 

What should I look at in choosing a plan?

Answer: You will need to review each plan to determine which plan meets the needs of you and your family based on your individual health care needs. As you shop for a plan, you should consider the following:

  • Premium levels.
  • Out-of-pocket costs, including deductibles, copayments and coinsurance. If you have significant health care needs, you may get better value paying a higher premium if your out-of-pocket costs are lower. In general, the lower the premium, the higher your out-of-pocket costs will be.
  • The number and types of providers within the plan's network. If you have a regular doctor or want to go to a specific hospital, clinic or pharmacy, you should look to see whether they are in the network.
  • What coverage options are available to you outside of a plan's network providers – some plans could require you to pay more or pay the entire costs for services received from out-of-network providers.
  • Whether the plan requires you to meet special criteria for certain services, such as getting prior approval before you can receive certain services and prescription medications or whether you need a referral to obtain certain health care services. You should determine whether a plan does not cover services that you or your family needs.

There will be a number of tools to help you compare plans, including interactive website tools and in-person assistors. The ACA also requires every plan to provide a Summary of Benefits and Coverage (SBC) – an easy-to-understand summary that allows for you to make "apples to apples" comparisons between multiple plans. The SBC also includes two coverage examples that allow you to see the average you will pay under each plan for two common health conditions: diabetes care and childbirth.

 

Will Health Care Reform lead to a government takeover of health care or result in “socialized medicine”, as some claim?

Answer: No. The final law preserves our nation’s current employer-based private health insurance system, with public programs such as Medicare and Medicaid continuing to be available as a safety net for older, disabled and low-income Americans. The law relies on private health plans to deliver coverage through new Health Insurance Marketplaces. The “government takeover” concern was largely expressed by those who opposed the public health insurance option that was not included in the final law.

 

Why are members of Congress and their staff “exempt” from having to get their insurance coverage under this new law?

Answer:  They are not. The law requires that Members of Congress and their staff get their health  insurance coverage through the new Health Insurance Marketplaces that are being established in every state by October 1, 2013. In other words, lawmakers and their staff will have the same choices of private coverage that other Americans are being given under the reform law.

Here’s a good Fact Check.

 

If I already have employer-provided coverage, how does the health care law affect me?

Answer: If you have employer-provided coverage, you have already received numerous new protections and benefits under the health care law, including:

  • Your insurer can’t drop you when you get sick. 
  • Your insurer can no longer impose a lifetime limit on your coverage.
  • Your insurer must give you the option of having your young adult children stay on or join your employer-provided plan until they turn 26.
  • If you have a child with a pre-existing condition, your insurer cannot discriminate against that child.
  • Your insurer must spend at least 80% of your premium on health care – not on profits or overhead.  And if they don’t, they have to reimburse you – either with a rebate or with lower premiums.
  • Your insurer has to justify publicly any double-digit premium increases they are seeking.
  • You have free coverage of key preventive services, such as mammograms and colonoscopies (for most people in private plans).

 

Starting January 2014, you will receive additional protections and benefits under the health care law, including:

  • Your insurer cannot discriminate against you if you have or develop a pre-existing condition.
  • If you are a woman, insurers cannot charge you more than men for the same coverage.

 

I have been concerned that the premiums in my state seem to be going up rapidly and I’ve heard it’s because of the new health care law. Is that true?  And what can be done about rising premiums?

Answer: The provisions of the health care law over the last couple of years have not been the main cause of premium increases, which began many years before the ACA was enacted. There are actually key provisions in the Affordable Care Act that have been in effect for two years that can lead to lower rates – including a provision requiring that insurers spend at least 80% of your premium on health care – and not on profits, CEO pay, or overhead. If insurers don’t, they have to reimburse you – either with a rebate or with lower premiums.  In terms of the rates in our state, the insurance premiums in the health insurance marketplace have come in lower than many expected. Should insurance companies nonetheless seek to gouge consumers, our state Insurance Commissioner can audit them to make sure that the new ACA rule on insurers spending at least 80% of premiums on health care is being fully enforced.

 

If I am a senior enrolled in Medicare, how does the health care law affect me?

Answer:  The health care law is strengthening Medicare and providing you with better benefits, including the following:

  • If you fall into the Rx drug ‘donut hole’ coverage gap, you are receiving more than a 50 percent discount on your brand-name Rx drugs.  Already, more than 6.3 million seniors who have fallen into the ‘donut hole’ have saved over $6.1 billion on their Rx drugs.  By 2020, the ‘donut hole’ will be completely closed.
  • You are now receiving free coverage of key preventive services, such as mammograms and colonoscopies.  Before the health care law, some services could have a co-pay as high as $160.
  • You are receiving a free physical – or Annual Wellness Visit – each year.
  • The health care law strengthens Medicare and extends the solvency of the Medicare Trust Fund by 8 years – from 2016 to 2024.

 

I am a veteran.  I served my country and I was promised VA health care for the rest of my life.  I am concerned that the health care law will take away the VA health care I have earned.

Answer: You should not be concerned --  you will remain in the VA health care system.  Nothing changes for you under the Affordable Care Act.


I am serving my country and I don’t want to see my family kicked out of TRICARE and I don’t want to lose my military health benefits either now or when I retire.  I am concerned that the Affordable Care Act can change or take away my benefits.

Answer:  Your family stays in TRICARE.  While you serve, all of your military health benefits continue, and when you retire, you receive all of your military retirement health benefits.  Nothing changes for you under the Affordable Care Act.

 

I've been turned down by insurance companies because I have a chronic illness. Will that happen again?

Answer: No. Starting January 1, 2014, the ACA prohibits insurers from denying you coverage, charging you higher premiums or setting annual or lifetime limits on your benefits because you have a chronic illness or other preexisting condition.  As one of my constituents eloquently put it – “I’m 65.   I am a preexisting condition.”