What You Need to Know About Health Care Reform

BecauseYour

Doctorcares

What You Need to Know About Health ReformüMost people must have health insurance beginning in 2014 or face a tax penalty.

üPeople who cannot get affordable health coverage from their employer can buy it through a federal or state health insurance exchange. starting in 2014, some people can get tax credits to reduce the cost of their premiums, copays, and deductibles.

üsmall businesses also can buy health coverage through an exchange.

üLarge employers (50-plus employees) who don’t offer health coverage to their employees must pay a penalty for each employee who receives a tax credit to buy their health insurance through an exchange.

üHealth insurance companies must provide coverage to anyone, regardless of health status or a preexisting condition. People will not pay more because of their health status or sex.

üThere will be no lifetime or annual dollar limits on health insurance coverage.

üTexas has an option to use federal funding to expand the Medicaid program to cover more low-income adults.

Your Doctor Cares AboutYou and Your HealthDuring the health care debate, doctors worked to make sure nothing would come between you and your doctor. Now that the supreme court has upheld most of the law, that is still our biggest priority.

The goal of health reform was to lower health care costs and cover millions of americans with insurance. Your doctors are working to make sure that doesn’t mean you get lower-quality care or less care.

We know health reform is big and confusing. some parts of the law started in 2010. Other parts are rolling out over the next eight years. Texas physicians have carefully studied the law to help you understand what the changes mean to your health care.

The Big QuestionsQ. Will I still be able to see my current doctor?

a: Generally, yes. However, your doctor may or may not continue to participate in your health plan or in government health plans, such as Medicare or Medicaid. Talk to your doctor.

Q. Will I still be able to get the care I need?

a: There is no simple answer. Much of what is in health reform has never been tried before. We pledge our best to do what we can to make sure our patients get the care they need.

Q. How much will this cost me?

a: again, there’s no simple answer. People who choose not to buy health insurance will be taxed. The law also may shift costs from older, sicker people to younger, healthier ones. How much you pay for health care will depend on the type of health plan you have, amount of the deductible and copay, and whether you qualify for a subsidy, Medicare, or Medicaid.

The good news is preventive services, like vaccines and screening tests, will be fully covered. People on Medicare will find more of their prescription costs covered, too.

Don’t see your question here? Go to MeandMyDoctor.com and ask your question.➚

If You Are Uninsured Q. Is it true that every Texan must now have health insurance? What will happen if I don’t get health insurance?

a. The new law requires most Texans and legal immigrants to have health coverage by 2014.

If you don’t, you will pay a tax penalty. For adults, the penalties are these:ü2014: $95 or 1 percent of income ü2015: $325 or 2 percent of income ü2016: $695 or 2.5 percent of income üafter 2016: The dollar amount increases with

inflation. üFor children, the dollar amount of the penalty is

half the numbers above. üFor a family, the penalty will be no more than

$2,085, which is 2.5 percent of income or three times the penalty for one adult in 2016.

In those states where Medicaid is not expanded, some people who can’t afford to purchase health insurance won’t have to pay the tax penalty.

Q. How does the new law help me now?

a. a new insurance pool, called the Pre-existing condition Insurance Plan (PcIP), allows uninsured people to buy coverage, even if they have a preexisting condition. uninsured Texans — even cancer survivors or those with illnesses like diabetes or high blood pressure — can get the coverage they need. For more information, visit www.pcip.gov.

Here are a few answers to many of the questions Texas patients have asked their doctors.

If You Have Commercial Health InsuranceWhat If I’m on Medicare?Q. Will it be easier for seniors to find a doctor?

a. No. In fact, the new law did nothing to fix a 10-year-old problem in Medicare. That problem is forcing doctors to limit the number of Medicare patients we see or even to quit taking Medicare patients. Your doctors are petitioning congress to fix the problem so we can continue to care for our patients.

Q. Will seniors get preventive services?

a. Medicare now covers the entire cost of checkups and recommended screenings like colonoscopies and mammograms. Medicare patients will not have to pay any copay or deductible.

Q. Does the new law affect the cost of prescriptions?

a. The new law helps seniors on Medicare (Part D) prescription-drug plans by reducing their out-of-pocket costs for prescription drugs. The coverage gap, called “the doughnut hole,” will be gradually reduced until it goes away in 2020.

What If I’m on Medicaid?Q. How can I find a doctor who takes Medicaid?

a. Health reform did little to increase the number of doctors who take Medicaid. state budget cuts in the past two years have forced out even more doctors. Beginning in 2013, higher Medicaid payments to primary care doctors may help more participate in the program. Your doctors are working to find a solution.

Q. Can undocumented immigrants get Medicaid or CHIP?

a. The law has not changed. Medicaid coverage for undocumented immigrants is limited to emergency services. under the children’s Health Insurance Program (cHIP), undocumented immigrant women can enroll in the cHIP Perinatal Program to receive basic prenatal care so they have healthier babies.

Q. How do I know if my children or I qualify for Medicaid?

a. currently, low-income people may qualify for Texas Medicaid if they fit into certain eligibility categories and have low enough incomes. The chart below shows the rules based on the federal poverty level (FPL) for 2012, with income examples for a family of three:

If you think you are eligible and wish to enroll, you can find links to the application information at www.healthcare.gov.

Q. What decision did the Supreme Court leave up to each state to decide regarding Medicaid?

The law told states that if they wanted federal Medicaid money, they had to cover more people under age 65, including, for the first time, childless adults. Families of three earning up to $25,390 or 133 percent of the FPL would qualify. However, the court ruled that states can decide not to expand their Medicaid enrollment but still keep their current level of federal Medicaid funding. With the expansion, about 2 million more Texans would get Medicaid. Without it, most of these Texans will remain uninsured because people with incomes below 100 percent of poverty are not eligible for subsidies to get coverage in the new health care exchanges.

Q. What big changes can I expect?

a. several big changes already are in effect:üThere are no more lifetime dollar limits on what

health insurance plans cover.üadult children younger than 26 can be added to

their parents’ health policies.üIf you get sick, health plans can no longer

retroactively drop your coverage because of honest errors you made in your application.

üHealth plans must spend 80 to 85 percent of their premium dollars on actual patient care versus overhead and profit. Health plans who fail to meet these benchmarks must give rebates to you and/or your employer. In fact, Texas recently received $167 million in rebates for individuals who purchased their own coverage and employers who purchased insurance for their employees.

üHealth plans must provide you simple, plain-language explanations about your coverage and how much you might have to pay.

Beginning in 2014:üHealth plans can no longer exclude adults with

preexisting conditions from coverage nor charge them more based on their health status.

üFederal subsidies (money) will be available to eligible people who purchase a health plan through a state or federal exchange.

Q. Will health insurers cover my children’s vaccinations and my mammogram?

a. Yes. Many preventive services, like vaccinations and cancer screenings, are covered. New private health plans must cover preventive care and screenings recommended by the u.s. Preventive services Task Force at no extra cost to you. This means you won’t have to pay a copay or deductible.

Q. Can health insurance companies raise their premiums under the new law?

a. Yes. The Texas Department of Insurance (TDI) now has more authority to review large rate increases to individuals and employers. But if health care costs go up, premiums will too.

Q. Will the reforms increase my health care premiums?

a. Health insurance premiums were rising prior to the law. No one knows for sure how the new law will affect premiums. However, the law gives states and the federal government authority to scrutinize premium increases. To help make insurance affordable, the federal law requires every state to conduct a special review if a health insurance company wants to raise premiums more than 10 percent. This rate review by TDI will help protect small businesses and individuals who buy their own policies. TDI is supposed to announce whether the increase is acceptable or unreasonable, although it can’t actually do anything to stop it.

The law also prevents health insurers from charging women higher premiums because of their gender or charging small businesses more because of the occupation or number of people employed. But this means the cost of premiums for men (who use fewer health care services) and for people in low-risk occupations may be increased.

Your doctors are very concerned about the affordability of health insurance. We plan to monitor this closely.

Percent of FPLFamily of 3

IncomeAmount

Texas Medicaid Eligibility

Child: 0-1 years 185% $35,316

Child: 1-5 years 133% $25,390

Child: 6-19 years 100% $19,090

Working parent 26% $4,963

Pregnant woman 185% $35,316

Adult with disability 77% $14,699