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Saturday, December 20, 2014

Dr. Pegs Prescription

What the Affordable Care Act has to offer UNM students

Oct. 1 was a big day in American health care history, the day the online insurance marketplaces opened up under the Affordable Care Act.

From now until March 31, 2014, you can go online to healthcare.gov and shop for the plan that fits you best. There is a lot of information out there, I know, and I don’t mean to overload you. I thought it might be useful to describe the options with UNM students specifically in mind.

The Affordable Care Act became law in March 2010, and was declared constitutional in 2012. Changes have already happened. For example, insurance companies have to cover preventive services with no copayment. This includes regular checkups, recommended immunizations and screening for some diseases and cancers.

Insurers can no longer cancel your policy if you get sick, or set limits on how much they will pay out over your lifetime. Young adults can stay on a parent’s plan until age 26.

Also, if your insurance company doesn’t spend at least 80% of your premium on health care cost, they have to give you a rebate. This discourages huge executive salaries and overhead excesses. In 2012, 8.5 million individuals got rebate checks.

As of January 2014, more changes will take place. For example, there will be no more denial of insurance based on a pre-existing condition. There will be no more higher premiums just for being a woman (yes, this used to be allowed) or for being unhealthy. There will be no more caps on annual payouts from insurance companies.

All plans will have to cover what are called essential benefits.

These are emergency services, hospitalizations, laboratory services, maternity care, mental health and substance abuse treatment, outpatient care, pediatric care, prescription drugs, preventive care, rehab services and vision and dental care for children.

Here are the basic choices that should apply to most UNM students:

1: If you are under 26, you are financially dependent on your parents and you qualify for coverage under their plan, you need to stick with that.

2: If you are under 26 and your parents have a plan that covers you, you can stay with that, even if you are financially independent or married. You can use their insurance until the end of the month in which you turn 26.

3: If you have insurance with your employer (this includes UNM as an employer for some grad students) or your spouse’s employer, you can keep it if you like it.

4: If you have UNM student insurance and you signed up for a full year of coverage in fall 2013, you are covered until August 2014. This plan provides the full menu of essential health benefits mandated by the ACA. It does have an annual limit of $500,000 payout for the duration of 2013-2014 plan year, however.

5: If you have UNM student insurance and you signed up for fall only, you can choose to sign up for spring/summer with the same plan or you can go to the marketplace. See number 6.

6: If you don’t have insurance, or if you want to change insurance, you can buy it online at healthcare.gov. This is also known as “the marketplace” or “the exchange.” It has been likened to Expedia for health insurance. There are 4 levels of insurance plans there: bronze, silver, gold and platinum, ranked from lowest to highest premium and coverage. At the bronze level you’ll have the lowest premiums, but insurance will cover only 60% of your health care costs. At the platinum level, the premiums are higher but 90% of health care costs are covered.

If your income is low enough—e.g. less than $15,302 per year as an individual—you will probably qualify for Medicaid. This is a state-run but mostly federally funded program that, under the new law, states can choose to expand to cover more adults than in the past. New Mexico has chosen to participate. If you qualify, Medicaid will act as your insurance company. You sign up for this at healthcare.gov as well.

If you choose not to be insured, a poor decision in my medical opinion, you will be required to pay a tax. One reason for this mandate is that if everyone pays into the insurance pool, costs can stay low. The tax starts relatively low, at $95 in 2014 for an uninsured adult, but goes up rapidly until 2016 and beyond, when it will be the higher of $695 or 2.5 percent of family income.

Households with $50,000 in income would owe $1,250 for example. In addition to the tax, of course, you would have to pay 100% for any health care you get.

There are two ways to access the insurance exchange. You can do it online at healthcare.gov, or toll-free by phone at 800-318-2596. And by the way, one of the mandates of the new law is no fine print and no impossible language. The site is quite user friendly.

Check it out.

Dr. Peggy Spencer is a physician at Student Health and Counseling. She is also co-author of the book “50 Ways to Leave Your 40s.” Email your questions directly to her at pspencer@unm.edu. All questions will be considered, and all questioners will remain anonymous.