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Healthcare in 2014
2014 has witnessed not only annual updates to health plans but significant changes to the vast segments of the American health insurance market. Learn about the most important provisions of Obamacare (Affordable Care Act) that may affect you as well as recent changes to Medicare insurance in 2014.
How Health Insurance Is Changing
In today’s market, the question is not whether health insurance is changing but how it is changing. Most notably, the Affordable Care Act (also known as Obamacare) has affected a variety of insurance markets including privately purchased insurance, small group insurance, Medicaid, and Medicare. Parallel to these changes in insurance are new models of healthcare delivery such as Accountable Care Organizations, Concierge Healthcare, and pharmacy clinics. Healthcare consumers are changing too. With rising deductibles, there is more incentive for consumers to compare prices for medical services before using them. This is part of a larger movement towards responsible healthcare use known as consumer-driven healthcare.
In the pre-reform health insurance market, individuals often selected health insurance based on the benefits they desired and the level of deductible they could accept. Insurance applicants faced medical underwriting where health status and pre-existing conditions could serve as the basis of an insurance application rejection. In the post-reform individual health insurance market, health plans have been commoditized to a certain degree. All qualified health plans must contain the same 10 Essential Health Benefits. The size of healthcare provider networks are emerging as an important purchase consideration. Health plans are increasing the use of “narrow networks” in order to minimize premium increases associated with broader minimum benefits and enrollee pools that include individuals previously shut out of the individual market. A narrow network is a group of healthcare providers where fewer doctors, hospitals, and other providers serve the enrollees of a health plan. Health plans explore networks to offer a larger scale of patients to healthcare providers in exchange for lower healthcare costs.
Analysts are watching the new individual health insurance market carefully. One of the areas important to analysts is the different segments of enrollees in health plans. The representation of younger (18-34 years-old) enrollees is especially important since this group is more likely to pay premiums without using as much healthcare services as older and less healthy enrollees. Since insurance applicants can no longer be denied insurance due to health status and pre- existing conditions, there is the possibility that the new Obamacare plans will have a higher representation of enrollees that have higher healthcare expenses. Younger and/or healthier enrollees can potentially offset the expenses of this other segment and enable plans to maintain reasonable premium increases. If a proper balance of younger and healthier enrollees is not achieved, there are premium stabilization programs that could be triggered as well as the prospect of larger rates of annual premium increases.
Health insurance can be purchased outside of state marketplaces as well as within the marketplaces. These insurance options are known as off-exchange and on-exchange plans. They both have to meet the Essential Health Benefit requirements of the Affordable Care Act. For individuals eligible for premium and￼cost-sharing subsidies, health insurance must be purchased on-exchange in order to obtain the subsidies. For those ineligible for subsidies, it makes sense to shop both on-exchange and off-exchange plans in order to find the best intersection of value, healthcare providers, and premium affordability.
One of the anticipated changes in the health insurance market did not happen in 2014. While tens of millions receive health insurance through their employer, there are still many employers who do not offer health insurance coverage as an employee benefit. The Affordable Care Act mandated businesses that employ at least 50 full-time equivalent employees are required to provide Obamacare- compliant health benefits for their full-time workers. However, this mandate has been delayed twice, likely due to concerns of its potential effect upon employment. The mandate had specified an annual penalty in the thousands per full-time employee (not including the first 30 full time employees) for companies that failed to provide compliant health insurance coverage.
Medicaid, the government health insurance program for low-income individuals, has also changed under the Affordable Care Act. The law had intended to make states expand Medicaid eligibility to all individuals at or below 138% of the Federal Poverty Level (who were not pregnant or eligible for Medicare). A legal challenge to Medicaid expansion was pursued by 26 states and the challenge won in a landmark Supreme Court ruling. The Medicaid program receives funding from both federal and state governments. Accordingly, some states had concerns of the long-term financial implications of expanding the income eligibility requirements for Medicaid.
Medicare, the government health coverage program for the elderly and the disabled, has also been affected by the Affordable Care Act. The so-called “donut hole” between Medicare Part D’s standard drug coverage period and catastrophic coverage is progressively closed by the Affordable Care Act until cost-sharing for this period matches cost-sharing in Part D’s initial coverage period.
Another area of Medicare affected by the Affordable Care Act is the Medicare Advantage program. Medicare Advantage is a program where Medicare beneficiaries can receive their Part A and Part B benefits through a private health plan. These Medicare Advantage plans typically have a healthcare provider network and also offer additional benefits beyond the standard benefits of Original Medicare Parts A & B. The Affordable Care Act planned to progressively reduce the reimbursement rates to these plans until they matched standard Medicare reimbursement rates. This plan has received considerable debate and the planned reimbursement reductions for 2015 were cancelled.
Small business health plans, another health insurance domain under the legal umbrella of the Affordable Care Act, recently had their maximum deductible amounts eliminated. The Affordable Care Act had dictated that deductibles in small group health plans could not exceed $2,000 for individuals or $4,000 for families. However a significant percentage of small group health plans could not meet the actuarial requirements of the Affordable Care Act while simultaneously complying with the deductible limits. After considering the number of exemptions to the deductible limits granted, Congress decided to repeal the deductible limits for small group health plans.