“AFFORDABLE CARE ACT-NEVADA’S PLAN AND HOW IT WORKS”
BY CHET YARBROUGH
(THE STATE OF NEVADA TURNED THE ACA ENROLLMENT WEB SITE OVER TO THE FEDERAL GOVERNMENT AFTER THIS ARTICLE WAS PUBLISHED)
Mark your calendar. Beginning October 1, 2013, the Federal Government required uninsured residents enroll in one of four health care insurance plans. The following information explains how the Affordable Care Act works, how your premium can be calculated, where to go to get help, and what effect it has on business and the uninsured in Nevada.
Approximately $7,000,000 in grant money has been awarded to private Nevada companies and Nevada government agencies to explain and implement the insurance plan. Much of that $7,000,000 is designed to educate the public on insurance plans offered through the Affordable Care Act passed in 2010. Nevada created an advisory board and insurance exchange website (HealthCare.Gov) to explain the Affordable Care Act to Nevada residents.
Nevada presently has seven potential insurance providers:
- Anthem BlueCross BlueShield
- Health Plan of Nevada
- Sierra Health and Life
As of 9/15/13, Anthem BlueCross BlueShield and Health Plan of Nevada participate in the planned insurance exchange authorized by Governor Sandoval. Aetna indicates on their website that “…Aetna has periodically updated the Aetna Advantage Plans for Individuals, Families and the Self-Employed to include any necessary changes (to comply with the Affordable Care Act). It is important for you to know that your Aetna Advantage Plan will always comply with all of the new federal health care reform legislation.” Without presuming too much, the remaining insurance providers are considering the Affordable Care Act in their business plans.
Preventative care will compel medical service business expansion. Preventative care is included in all four insurance plans mandated by the act. (In retrospect, this feature of the Act may eliminate a consumer’s right to keep their current insurance plan because more health services are required than some existing policies offer.)
Office space for routine check-ups and preventative care will be needed to staff new businesses. Health care facilities are popping up around the valley to meet expected demand. Many entry level positions in the medical field will be needed.
Companies that specialize in health service insurance policies will expand their employment opportunities and facilities to accommodate rising demand. With 600,000 uninsured Nevadans, and an estimated 29 million citizens nationwide, management and administration of health services will be monumental job creators.
As long as the health policy you have is either grandfathered in by the company you work for, or the policy you have meets “Essential Medical Services” of the Affordable Care Act, no fines are mandated for non-compliance with the Act. (Medicare/Medicaid complies with “Essential Medical Services” outlined in the Affordable Care Act.)
NO AHC INSURANCE REQUIRED IF—
- You already have insurance from your employer or you have a private policy that complies with the AHC coverage requirements.
- You have Medicare/Medicaid
With an estimated 600,000 uninsured Nevada residents, the Affordable Care Act offers a number of immediate short-term and long-term employment opportunities. A part of Federal and State grant dollars to private companies is used to hire and train part-time employees to help Nevada residents enroll in Affordable Care’ health insurance plans. The title of the part-time position is “Enrollment Assistant”. Training and education programs will require more classrooms and teachers to train needed enrollment and medical services personnel.
In addition to part-time “Enrollment Assistant” positions, the Affordable Care Act is expected to increase demand for hospital and medical service staff to meet needs of formerly uninsured residents.
Uninsured Nevada residents will become eligible for preventative medical services in 2014. Routine check-up, vaccination, and pre-natal care are mandated by the Affordable Care Act.
Companies like “Urgent Care Extra” have come to town with the capability of supplementing preventative medical services outlined in the Affordable Care Act. Ty Hanks, the Medical Director, of this new company opened its first clinic in December of 2012. Since then, five “Urgent Care Extra” facilities have opened in the Las Vegas Valley. The latest opening is at 4575 Charleston Blvd., near the intersection of Charleston and Decatur. Dr. Hanks said, “Five more clinics are planned in the next six months.”
“Urgent Care Extra” started seven years ago in Gilbert, Arizona. Hanks and his wife, Jacki, opened a new chapter in their lives by moving from Gilbert to Las Vegas. They expanded “Urgent Care Extra” Arizona to build a chapter of “Urgent Care Extra” in Las Vegas. Dr. Hanks observed, “The Affordable Health Care Act is not the primary focus of their business model but they will be able to expand their service with its implementation”.
The objective of the clinic’s business model is to offer the “in-between” medical service needed by patients that either do not have a primary family physician or need medical help when their primary family physician is not available. Dr. Hanks, a board certified orthopedist, explained, “We want to complement Las Vegas Valley’ physician’ services by developing working relationships in the medical community.” If a patient needs help because of a broken leg at 3:00 p.m. on a Saturday or Sunday afternoon, “Urgent Care Extra” will X-ray the break, identify severity and either cast the injury or refer the patient to an appropriate specialist or primary physician for follow-up. Dr. Hanks said, “Our objective is to be patient centered; with referral to specialists or primary family physician’s (if there is one) after immediate care has been given”.
Dr. Hanks said, “We have 12 part and full-time physicians for the five current ‘Urgent Care Extra’ clinics.” Each facility is staffed by one or two physicians (either on-site or on-call), one or two medical assistants, a medical tech, and one or two front office personnel.
Ms. Hanks said, “We interview ten people for every job opening.” She explained, “Social skill and technical ability are essential qualifications for employment because the clinic’s focus is on patient service.” “Urgent Care Extra” uses IPAD and internet feedback applications to monitor patient perception of clinic services. Ms. Hanks said, “I use patient feedback to improve staff morale and patient relationships.”
The Affordable Health Care Act will significantly increase demand for preventative care. “Urgent Care Extra” is a needed and welcomed service in the Las Vegas Valley.
If you do not have employer-provided, personal, or family medical insurance that meets “Essential Medical Services”’ requirements, the Affordable Care Act requires purchase of health insurance from qualified private insurers or through Silver State Health Insurance Exchange by the end of 2013.
AFFORDABLE HEALTH CARE REQUIRES PURCHASE OF FAMILY HEALTH INSURANCE POLICY IF—-
1)You have no insurance for yourself or family. You have three alternatives:
- Seek insurance from Nevada’s Silver State Insurance Exchange.
- Seek insurance from Nevada Health Co-Op.
- Buy a policy from an insurance company that complies with “Essential Medical Services required by the ACA.
2)You refuse to buy medical insurance. There are consequences:
- Pay a fine to the Federal Government. Beginning January 1, 2014, most un-insured will have to have health insurance or pay a fine. The fine is $95 per adult and $45.50 per child, up to a family maximum of $285 or 1 percent of family income.
- In 2015, fines increase to $325 per adult, $162.50 per child, and a family maximum of $975 or 2 percent of family income.
- In 21016, fines increase to $695 per adult, $347.50 per child, and a family maximum of $2,085 or 2.5 percent of family income.
Call “Silver State Insurance Exchange” at (775) 687-9939 or click www.nevadahealthlink for questions. For enrollment assistance ask for a “Navigator” to help you through the enrollment process. Nevada Health CO-OP (not associated with “Silver State Insurance Exchange) at www.nevadahealthcoop.org (phone number 702-823-COOP) is also making appointments for enrollment in one of the 4 Essential Health Benefit plans required by the Affordable Care Act.
SUMMARY: The Affordable Care Act–signed into law on March 23, 2010. The most significant impact for Nevada begins January 1 of 2014.
Effect on Business’ Group-Health Insurance:
If a business has 50 or more full-time employees or full-time equivalent employees, employers must provide employee health insurance beginning January 1, 2015.
There are no penalties for 50-employee-companies until 2015. Beginning January 1, 2015, a $2,000 annual penalty will be charged for each worker after the first 30.
All businesses with less than 50 full-time employees or full-time equivalent employees are exempt from the Affordable Care Act until 2016; at which time 1 to 100 employee companies will have to offer health insurance.
Small Businesses, fewer than 50 employees, are eligible for tax credits if they provide health insurance to their employees. For details on the tax credit, visit www.irs.gov/uac/Small-Business-Health-Care-Tax-Credit-for-Small-Employers.
By checking www.nevadahealthlink.com small businesses will find what tax credits are available for small businesses.
Businesses should carefully review hours of work. Even if employees do not work 30+ hours a week, which is the definition of a full-time employee, one equivalent employee is created when total part-time hours worked per week are divided by 120 with the nearest whole number being classified an equivalent full-time employee.
If an employer has not significantly changed their group medical coverage plan since March 23, 2010, the plan in place is grandfathered and the Affordable Care Act does not apply.
All non-grandfathered group health insurance plans are to eliminate annual or life time dollar limits.
If premium costs exceed 9.5 percent of an employee’s annual income, the coverage is considered “unaffordable” and the employer must look at “affordability safe harbors” provided in the Affordable Care Act.
Policies must have no lifetime or annual limits. Individuals cannot be removed from the plan.
Preventative health services are to be included. Coverage to be extended to the age of 26 for children of covered employees.
The insurance provider is to follow a proscribed format to explain provided insurance coverage that has minimum coverage in accordance with the Affordable Care Act.
Starting in 2014, health insurers will only be able to use age, composition of family, geographic area and tobacco as rating factors for insurance rates. (Same for individual policy)
Pre-existing condition exclusions and concomitant pricing of group policies will be prohibited beginning January 1, 2014. (Same for individual policy.)
Essential Health Benefits are a set of health care services that must be covered with no “annual or lifetime dollar limits.” These benefits may still have other limitations, such as a visit limit. (See essential benefits on Family Insurance side-same for group and private policies.)
Starting in 2014—if insurance companies spend less than 80 percent of their premiums on medical costs–they have to pay a rebate to their enrollees. For health plans that are operating in the large group market, if their medical costs are below 85 percent of the premiums, then they have to pay rebates to their enrollees.
There is wide disagreement on loss of jobs as a result of the Affordable Care Act. Concern is raised about companies that will reduce employees or reduce hours of employees to stay below the 50 employee threshold. Part time employee hours are aggregated and divided by 120 to classify employment numbers. (Essential health benefit requirements are the same for ACA’ group health policies as private policies.)
Effect on Family Health Insurance:
If a Nevada resident does not have Medicare or a personal health insurance policy, beginning January 1, 2014, individual insurance policies become available through NevadaHealthLink.com (aka Silver State Health Insurance Exchange).
Beginning January 1, 2014, health insurance cannot be denied to individuals for current or past health issues. Also, no annual or lifetime dollar limits can be applied to insurance coverage.
If an individual adult makes less than $46,022 and does not receive health insurance from an employer, he/she is likely eligible for private policy premium assistance or Medicaid through the NevadaHealthLink.com.
If a family of four makes less than $93,701 and does not receive health insurance from an employer, they are likely eligible for private policy premium assistance or Medicaid through NevadaHealthLink.com.
Subsidized premiums for eligible individuals and families can be calculated by entering family income in a calculator shown at www.nevadahealthlink.com.
Starting in 2014, health insurers will only be able to use age, composition of family, geographic area and tobacco as rating factors for insurance rates.
Beginning January 1, 2014, most people will have to have health insurance or pay a fine. The fine is $95 per adult and $45.50 per child, up to a family maximum of $285 or 1 percent of family income.
In 2015, fines increase to $325 per adult, $162.50 per child, and a family maximum of $975 or 2 percent of family income.
In 2016, fines increase to $695 per adult, $347.50 per child, and a family maximum of $2,085 or 2.5 percent of family income.
Fines can be waived for several reasons, including financial hardship or religious beliefs.
Use the calculator @ www.nevadahealthlink.com to determine whether your family income is too low to require any payment for an insurance premium. For example, if you enter $16,000 as family income for 2, no premium is charged and no fine for the insurance you sign up for is due.
Tax refunds may be withheld for non-compliance fines.
There are four categories of health plan.
- Bronze-covers 60% of medical costs.
- Silver-covers 70% of medical costs.
- Gold-covers 80% of medical costs
- Platinum-covers 90% of medical costs.
Adults under 30 can opt for lower-cost catastrophic plans. (Same for individual family policies.
Pre-existing condition exclusions and concomitant pricing of group policies will be prohibited beginning January 1, 2014.
ESSENTIAL benefits include:
- Ambulatory patient services;
- Emergency services;
- Maternity and newborn care;
- Mental health and substance use disorder services, including behavioral health treatment;
- Prescription drugs; Rehabilitative and facilitative services and devices;
- Laboratory services; Preventive and wellness services and chronic disease management; and
- Pediatric services, including dental and vision care.
Preventive care services must be provided without any cost-sharing to you long as the service is provided by a network provider.
This means that a network provider cannot charge co-pays, deductibles or co-insurance to you or your family.
- These services include, but are not limited to: Blood pressure, diabetes and cholesterol tests;
- Many cancer screenings, including mammograms and colonoscopies;
- Counseling on such topics as smoking cessation, weight loss, eating healthy, treating depression, and reducing alcohol use;
- Regular well-baby and well-child visits from birth to age 21;
- Routine vaccinations against diseases such as measles, polio and meningitis;
- Counseling, screening and vaccines to ensure healthy pregnancies; and
- Flu and Pneumonia shots.
NBC News reports that the average premium for one person making $25,000/year, after federal tax credit is applied, will be $145/mo. for a “Silver” plan. For a family of four making $50,000/year, after federal tax credit is applied, will be $282/mo. for a “Silver” plan. One person making $46,000/year or more will receive no tax credit.