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Shedding Light on Health Insurance Changes

by Paul Francischetti, COO, The Rubino OB/GYN Group

The Affordable Care Act ("ACA"), also known as "Obamacare", has now become the law and has wide ranging implications on health insurance. The Act actually has little to do with the costs of providing health care. The majority of the law addresses the cost of health insurance to consumers and mandates that Americans purchase compliant health insurance policies. While few can argue with the goals of affordable health insurance and its availability, most of the debate on the ACA centers on how it achieves those goals.

This article is meant to address some basic questions about the new law and how it impacts your care with The Rubino OB/GYN Group. The implementation of the ACA will continue to evolve, as will the information in this article.

The widest impact of the ACA is that it requires Americans to purchase or obtain compliant health insurance.   A compliant policy is one that meets the minimum requirements for health insurance coverage as defined by the government. The result of this requirement is that some Americans are losing their coverage since their policies are not compliant with the law. The ACA however, does not require insurance companies to cancel non-compliant policies; those companies that have canceled polices are merely choosing to do so based on the assumption that non-compliant policies are obsolete.  

Americans who choose not to obtain health insurance at all, or to keep a non-compliant policy, are subject to a monetary penalty to be implemented through the tax code and enforced by the IRS.   Thus the choice for the non-insured or under-insured (with non-compliant policies) becomes both economic and related to concerns in avoiding an investigation by the IRS. They must decide which option has the least fiscal impact:

• having no insurance at all
•  maintaining a non-compliant policy and paying the penalty, thus attracting the attention of the IRS
•  obtaining a compliant policy

Recognizing this dilemma, the ACA attempts to address it by setting up Health Insurance Exchanges where the non-insured or under-insured can obtain compliant policies (AKA "Obamacare Policies") that are initially subsided by the federal government through tax credits. These subsidies will be removed over the next few years, under the assumption that premiums for these policies will be driven lower due to a large pool of participants signing up (so far there is little evidence to support such a trend).

In addition, there is hope that by mandating coverage, large numbers of people who don't really need it or want it will sign up for compliant coverage, thus keeping premiums low (another way of subsidizing the premiums). The ACA also expands the availability of Medicaid policies to this group by openingthe eligibility criteria (the ACA funds the Medicaid expansion by reducing Medicare funding for seniors).

In New Jersey, three companies offer compliant policies through the Health Exchange offered by the government:

• Horizon Blue Cross Blue Shield
• Amerihealth
• Health Republic

The Rubino OB/GYN Group participates with these policies; however we still do not participate with Medicaid.

Most Americans whose health insurance is provided by their employer will be able to keep their policies if those policies are modified to be compliant.

Women's Health Issues

Some provisions in the ACA are directed to women's health issues, and therefore, will impact your visits with The Rubino OB/GYN Group. These provisions include: 

• The Act mandates that compliant policies cover preventive care at no out-of- pocket cost to the consumer.  In gynecological terms, this means your basic annual gynecological exam (which consists of a breast and pelvic exam and a Pap smear) will be covered every year if you have a compliant policy (every two years for Medicare patients) with no copay, coinsurance or deductible. If your doctors provide a somewhat more comprehensive annual exam (as is the policy at The Rubino OB/GYN Group) a small portion of the exam may still be subject to out of pocket costs depending on your individual policy; this remains unchanged by the ACA. 

• In regard to pre-existing conditions, under the Act, if you apply for a compliant policy, you cannot be denied coverage for a pre-existing condition. For example, if you do not have insurance and become pregnant, or have a history of heavy menstrual bleeding, you cannot be denied access to a compliant health insurance policy. Also, services provided to you in connection with your pre-existing condition will be covered under a compliant policy, subject to whatever cost sharing provisions your policy has (i.e. copays, coinsurance, and deductibles). 

• A third area involving women's health issues regards contraception. Compliant policies must cover contraceptive services provided by your physician, subject to your policy's cost sharing provisions (i.e., not "free"). It is important to note that the ACA does not mandate coverage for infertility. This is still an area that is subject to the individual parameters of your particular coverage. We encourage patients with fertility issues to closely check the provisions of their policies prior to receiving any services.  

As the ACA is primarily concerned with preventive services, there is little in it that specifically addresses obstetric services, and gynecological services not considered preventive. These services remain subject to copays, coinsurance, and deductibles as defined by your policy. You may find, however, that these cost sharing provisions may result in higher payments than you have been used to prior to the ACA, especially if you purchase a Health Exchange policy.

Increase in Cost Sharing

Increase in cost sharing (how much you pay directly to the doctor versus your insurer) has been a trend in health insurance policies over the past few years and the ACA will no doubt accelerate that trend. Health Exchange policies may have even higher deductibles.

All policies offered through the Health Exchange feature deductibles. This is by design, as higher deductibles keep premiums lower,a result of patients paying more out of their pocket directly to the provider. It is important to be aware that it can become a hidden cost to those who need to use their policies for other than preventive services.

This trend of higher copays, deductibles and coinsurance has both short term and long term implications for your relationships with your doctors.

• In the short term you will notice (and probably already have) that you are receiving more frequent and costlier bills from your doctors than you have in the past.

• In the long term you will begin to see more doctors requiring upfront payments, before services are rendered, to offset the delays and difficulties of collecting fees from consumers that used to be paid directly by health insurers. This may become one of the most significant unintended consequences of the ACA, and is certain to have an impact on your relationship with your doctors over time.

There is certainlymuch more to cover about the ACA and its implications on both your health care and your pocket book.   We encourage you to understand the ramifications of the ACA and how it directly impacts you. As always, the billing staff at The Rubino OB/GYN Group is available to help with specific questions you have regarding your coverage for OB/GYN services and the billing statements you receive from our group.

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