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How to Choose a Health Plan Under the Affordable Care Act (ACA-Obamacare)


cant afford that dianosisBy

Bob Aronson

While the Affordable Health Care Act got off to a very rocky start due to massive computer glitches there’s plenty of time for consumers to do research to find the best plan.

The problem faced by most people is trying to make sense of all the legal gobbledegoop.  How do you sort it all out so that you know which health insurance plan to choose?  Well, we think we have some answers for you but it is still going to take some work on your part.

Before we get into any advice here’s the link for information for the Affordable Care Act. It is where you will ultimately determine what kind of coverage you should have and from which company. https://www.healthcare.gov/

The first-ever open enrollment period for individual and family health insurance plans under the Affordable Care Act (ACA) began October 1 and ends March 31, 2014. Open enrollment periods in following years will be shorter than this one-time six-month period.

According to HealthCare.gov the law offers you these rights and protections.

If you have questions you can call 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325).  Judging from the initial experience, however, you can probably expect long wait times and delays.

There are lots of questions so to  help you make your way through the insurance maze.  We relied on several sources for our information among them are:

1)  Consumer reports magazine ( their report is here http://tinyurl.com/odmjmq2

2) The Health Insurance Resource Center http://tinyurl.com/n38asm6   and

3) Forbes Magazine http://tinyurl.com/mrce8lg

4. Politifact http://tinyurl.com/m5pbarx

5. U.S. Dept of labor http://www.dol.gov/ebsa/healthreform/

6. Henry J. Kaiser Family Foundation http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/

7. eHealth https://www.ehealthinsurance.com/affordable-care-act/faqs

8. National Public Radio (NPR) http://www.npr.org/2013/10/11/231101137/faq-what-retirees-and-seniors-need-to-know-about-the-affordable-care-act

Each one of the preceding links is worth reading.  Your health and your financial stability may be on the line so this is absolutely necessary homework.

Health Coverage for Seniors

We’re going to offer information for everyone in this post but I’m going to start with Senior citizens.

The first thing seniors need to know is this. Medicare is not part of the  health insurance exchanges. The exchanges won’t be selling so-called “Medigap” policies that supplement the coverage seniors get through Medicare.

Seniors will still get health coverage through Medicms logocare’s traditional fee-for-service program or Medicare Advantage plans.  Beneficiaries receive more preventive care, including a yearly “wellness” visit, mammograms, colorectal screening, and more savings on prescription drug coverage.  By 2020, the law will close the coverage gap which is also known as the “Donut Hole but  Seniors will still be responsible for 25 percent of their prescription drug costs.

Medigap Coverage

Seniors will still get health coverage through Medicare’s traditional fee-for-service program or Medicare Advantage plans, private health insurance plans that are approved by Medicare. Those who are enrolled in , which covers hospital care, or the Advantage plans will meet the health law’s .

Seniors were pretty much left out of consideration when ACA passed.  They get some benefits like the closing of the donut hole and health screening.  A glaring omission is that while pre-existing conditions cannot be considered for others, they are still a factor for seniors.  Medigap is not bound by that provision of the law.  Medicare is but not the Medigap supplemental policies.   But….and this is a very important But:

The most critical time for Senior Citizens is the six months after you first enroll in Medicare Part B. During that period, you can buy any Medigap policy you want, and the insurer can’t turn you down or charge you more than anyone else your age even if you have pre-existing conditions.

According to Consumer Reports Magazine (CR) you also have the same rights if you have a retiree or union plan that fills in Medicare’s coverage gaps but it ceases operation, or if your Medicare Advantage plan closes up shop or you move out of its coverage area. Read more about the difference between Medigap and Medicare Advantage.

CR goes on to say that Senior Citizens may be stuck with what they have.  “Although it never hurts to shop around. “Medigap plans are generally more permissive about underwriting than health plans sold to younger people,” said Bonnie Burns, a Medicare expert with California Health Advocates, a nonprofit consumer group. “Some are more strict than others.”

Medicare Advantage

Another issue of importance to Seniors is Medicare Advantage.   A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare.

There has been a lot of publicity about cuts to Advantage and a lot of seniors are worried so let’s address that issue.  According to Politifact, an on line, Pulitzer Prize winning organization that checks the accuracy of political stories Advantage is growing in size not getting smaller.  Here’s what they say:

“Today, around 14.4 million seniors and disabled people — that’s 28 percent of all Medicare beneficiaries — are in Medicare Advantage, the most ever.

Advantage plans are required to offer basic health benefits that are at least as rich as original Medicare. But many offer extras, such as rebates on premiums, routine dental care, gym memberships and rides to the doctor, in order to compete for business.

Medicare Advantage members pay premiums just like people who get their benefits through original Medicare.  The private companies turn a profit depending in part on how well they manage costs of care. Sweetening the deal: The government spends more per person — 7 percent more last year for Advantage beneficiaries compared with those in original Medicare, estimated the Medicare Payment Advisory Commission.

The Affordable Care Act aims to gradually bring costs of the two programs in line. At the same time, it seeks to reward private insurers that offer the best care — these are the plans that top the new star rating system.   You might think shrinking payments for Medicare Advantage would mean fewer enrollees, but that hasn’t happened. Since passage of the Affordable Care Act in 2010, enrollment in Medicare Advantage plans has grown by 30 percent.”

The Politifact analysis continues with this:

politifact“After the health law passed in 2010, several government and private analysts predicted Advantage enrollment would decline. More recently, the Congressional Budget Office projected slow growth through 2022, while the CMS Office of the Actuary expects a decline between 2015 and 2018, then an increase.

It’s similarly tough to predict what will happen with costs and benefits, though it’s important to note that Advantage plans can never offer skimpier coverage than original Medicare. Government payments may go down, but they’re only one of the many factors that go into how insurers determine their offerings.

“The payment formula to Medicare Advantage is complex,’’ said Dan Mendelson, CEO of strategic analysis firm Avalere Health. “Honestly, to say that as a result of Obamacare there would be a reduction to Medicare Advantage would be misleading at best, because there are a lot of other things that come into play.’’

“We don’t know what’s going to happen, but that’s true every year,’’ said Joe Baker, president of the Medicare Rights Center, the national nonprofit advocacy group that fields around 12,000 calls a year to its consumer help line.

Still, Baker and others doubt seniors will find a September surprise in their mailboxes.
“If the last few years under the (health law) and this administration is any indication, it’s going to be a pretty smooth year and a pretty even year,’’ Baker said.

Mendelson, too, is dubious of a rate spike.

“In all likelihood, rates are going to be stable, and they’re going to be workable,’’ he said.

Medicaid

Medicaid presented a special difficulty in our effort to offer assistance  to those who need this service.  A U.S. Supreme Court decision left the decision about whether to participate in the Medicaid program under ACA up to the individual states and not all states chose to do so.  While we can offer this link that will help  you gain some understanding of your options, we likely will supplement this blog in a few days with a more detailed report.  http://www.apha.org/advocacy/Health+Reform/ACAbasics/medicaid.htm

Health Care Coverage for Everyone Else

The Exchanges

Plans offered will be in standardized “metal tiers” with various combinations of premiums and cost-sharing.  There are four distinct kinds of plans:

  • Bronze plans will pay 60 percent of the bill and cost the least
  • Silver plans will pay 70 percent.
  • Gold plans will pay 80 percent.
  • Platinum plans will pay 90 percent and cost the most.

Keep in mind that as the percentage of coverage increases so does the premium you pay — but it also means that you will pay less when you get the hospital bill.

Before you consider any plan you should begin by answering these four critical questions so you can make the best possible decision when you finally select a health insurance plan.   The questions are:

1. What does health care cost in your area?

2. How much have you budgeted for health care or, what can you afford?

3. What do you want from your coverage?  Do you have any special medical needs?

4. Does the plan cover the physicians and hospitals you prefer?

As I began my research for this blog I discovered almost immediately that finding the right health insurance coverage is not easy by any means.  It’s going to take some research and diligence on your part if you want the most bang for your buck.

So let us start with the first question.  What does health care cost in your area? Let’s make this as simple as possible.  The really important question is not what they charge but what do you have to pay?  Even that can get complicated because no plan pays a hundred percent and that means you pay something.  If the bill is a thousand dollars and your plan pays ninety percent then your share is one hundred dollars but if the bill is two thousand dollars and you plan still pays ninety percent you pay one hundred eighty dollars.  The ninety percent payment only becomes meaningful when you know the cost of the service or procedure.

Determining what a health care facility will charge you is not easy but we’ll try to help.  The problem is health care costs vary so greatly.   Here are some examples.

The Washington Post did an in-depth analysis of medical pricing in May of 2013 and found what to me is a shocking disparity between hospitals.  For exwashington postample:

Virginia’s highest average rate for a lower limb replacement was at CJW Medical Center in Richmond, more than $117,000, compared with Winchester Medical Center charging $25,600 per procedure. CJW charged more than $38,000 for esophagitis and gastrointestinal conditions, while Carilion Tazewell Community Hospital averaged $8,100 in those cases.”  The entire Washington Post article can be found here http://tinyurl.com/d3xm3g6

We advise you to read the Post report but thought we would include one more relevant piece of information from it.

“In our analysis of the 10 most common medical procedures we found certain patterns by state. Hospitals in six states — California, Florida, Nevada, New Jersey, Pennsylvania and Texas — routinely had higher prices than the rest of the country.

For-profit hospitals tended to bill Medicare at a 29 percent higher rate, on average, than nonprofit or government-owned hospitals.

Is this confusing?  You bet it is because hospitals and insurance companies play games with each other.  The prices and reimbursements they toss around make sense only to them and relate only to situations in which patients are either covered by insurance or Medicare.”

So, as I said earlier,In the end what matters is what you pay, not what the hospitals charge or what either the government or the private insurers pay.

Deciphering Your Hospital Bill

When you get a hospital bill you must know what the codes mean or the bill is meaningless.  You need to be able to do some comparisons between faclities so we found the resources listed and outlined below. I have included information provided by the Centers for Medicare and Medicaid Services (CMS) the government agency that runs Medicare because they keep track of pricing for everyone, not just seniors.  Be aware, though, that even this attempt at clarification can be confusing and that’s because health care is confusing.

Here’s the link to CMS it is very complete http://tinyurl.com/blv4cwg

Here’s another helpful site but….in order to look up a price you will need the CPT code.  http://www.fairhealthconsumer.org/medicalcostlookup/.  Of course you probably don’t know what a CPT code is, right?  Ok — CPT codes (Current Procedural Terminology) are found and used to identify procedures for which you will be charged. A CPT code is a five digit alphanumeric code with no decimal marks. When you receive a bill from your doctor before or after it has been sent to the payer (insurance or Medicare), it will have a list of services. Next to each service will be a 5-digit code. That’s the CPT code.

The American Medical Association (AMA) has every code there is — but you can’t have them all unless you are a physician member who haama logos paid a great deal for them. AMA has the copyright on CPT codes and guards it like it is a nuclear weapons cache.  They will give out one code at a time but they want you to suffer a little so its not easy.  Here’s how to do your AMA CPT code look-up:

  • Step 1: Link to the AMA website
  • Step 2: You’ll find an End-Use License. In essence it tells you that you may look up these codes only for your personal information and that you cannot sell them to anyone else. Further, it tells you that if they think you are using the system too much, they may limit your searches and/or limit the number of CPT codes you look up at one time. There is additional legaleese which you should probably read. You can also print the agreement.
  • Step 3: Click on ACCEPT or DECLINE. If you click on DECLINE, you will not be allowed access to the code lookup.
  • Step 4: The next page is your search page. Choose your state and city. If your city isn’t there, there will be a choice that makes sense. For example, if you live in Tampa, Florida, you’ll find that Tampa isn’t listed (only Miami and Ft. Lauderdale are listed) but there is a designation for “Rest of Florida.”
  • Step 5: If you already have the CPT code and want to see what it means: Simply input the 5-digit CPT code to the field, hit SUBMIT, and you’ll get your result on the next page. Included will be the RVU – see below.
  • Step 6: If you do not have the CPT code, but you know what the procedure or service was, you can do a search to try to figure out the right code. This can get tricky, though.

CMS uses CPT codes, too, but they are called HCPCS codes (why does government always have to change the name of commonly used terms?) and unlike AMA the codes are readily available and free but still take some work to ferret them out.  Here’s a link. http://patients.about.com/od/medicalcodes/a/Look-Up-Hcpcs-Codes.htm

Finally you can try these links for prices of common procedures.

Quality of Care

One of the great mysteries in all of this is that while the government and others have done extensive studies on medical procedure costs in nearly every city and every facility the costs quoted bear no relationship to the quality of care and the outcomes of the procedures. That’s another story completely.  Major medical centers, especially the teaching centers seem to charge a lot more than other facilities.  Many believe that the more something costs the better it is.  That’s not ever true with anything and particularly with health care.  You just can’t judge the quality of care by the price that is charged for it.

The famed Cleveland Clinic suggests you ask these questions.cleveland clinic

  • Is the hospital accredited by the Joint Commission?
  • Is the hospital rated highly by state or consumer groups?
  • Does the hospital have experience and success with your condition?
  • Is the hospital one where your doctor has privileges?
  • Is the hospital covered by your health plan?
  • Does the hospital review and continuously improve its own quality of care?

Finding the best quality care can be another daunting task and that’s entirely up to you.  This site may give you some help as you begin your search. http://www.ahrq.gov/legacy/consumer/guidetoq/guidetoq8.htm

OK.  Once you have determined costs in your area and the facility that offers the quality of care that you desire you now have three very important questions to answer before you make a decision on a health insurance policy.

  1. How much have you budgeted for health care or, what can you afford?
  2. What do you want from your coverage?  Do you have any special medical needs?
  3. Are the physicians and hospitals you prefer included in the plan.

I’m not even going to attempt to help you with any of those questions because only you have the answers.  The  information I provided earlier, though, should help.

Consumer Reports says:consumer reports logo

“Before health reform, companies could sell plansthat didn’t cover all types of medical care. For example, some might not cover doctor visits, or prescription drugs, or maternity care.

That was bad for consumers because no one can predict what kind of medical care they might need in the future. The only way to protect yourself financially is to have health insurance that covers every kind of health care.

The new health care law has fixed this problem.

Insurance sold to individuals and small businesses must now cover 10 “essential health benefits.”

  • Emergency services
  • Hospitalization
  • Laboratory tests
  • Maternity and newborn care
  • Mental health and substance-abuse treatment
  • Outpatient care (doctors and other services you receive outside of a hospital)
  • Pediatric services including dental and vision care.
  • Prescription drugs
  • Preventive services (such as immunizations and mammograms) and management of chronic diseases such as diabetes
  • Rehabilitation services

The rules for insurance provided by large employers are a little different but most of them will cover the same set of benefits. To make sure, ask your employer for the Summary of Benefits and Coverage, a standard form that will state exactly what the plan covers and doesn’t cover.

Get health insurance rankings

In general, if you pay a higher premium upfront, you will pay less when you receive medical care, and vice versa.”

I strongly advise readers to click on and read the links at the top of this blog provided by Consumer Reports, the Health Insurance Resource Center,  Forbes Magazine and the others.  They are all credible resources.

If you want to know all the details of the Affordable Care Act and how they are implemented year by year click on this site. http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html

And finally, I’m sure I’ve missed a great deal here and I’m just as sure some of you will have suggestions. They are welcome. Please leave them in the comment section below.


We hope you found this helpful.  Please let us know if you have questions or comments.

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 3,000 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at bob@baronson.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our new music video “Dawn Anita The Gift of Life” on YouTube https://www.youtube.com/watch?v=eYFFJoHJwHs.  This video is free to anyone who wants to use it and no permission is needed. 

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just email me bob@baronson.org and ask for a copy of “Life, Pass it on.“  This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. 

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.

Election 2012 — Senior Citizen Transplants & Healthcare Coverage to Diminish


This is a presidential election year and because of the debate over Medicare, Obamacare and the federal deficit Senior Citizens had better sit up and take notice.  Regardless of who wins big changes are in store that will affect the lives of current and future senior citizens.  While this blog usually confines itself to organ donation/transplantation issues the all-encompassing nature of the healthcare debate caused us to broaden our perspective. From our vantage point this is how the Medicare/Obamacare/deficit debate shakes out.

When it comes to health care in America we have the known (Medicare as it currently stands and the Affordable Care Act or “Obamacare) and we have the unknown (Romney/Ryan – roughly outlined plan)

Here’s what we know we have now and what we can expect.

  • If you are 65 years old and need an organ transplant Medicare will pay 80% of the cost (your supplemental will pick up the rest) and will pay the full cost of all of your ant- rejection drugs as long as you live.
  • If you are officially disabled, regardless of age, Medicare will offer the same transplant and anti-rejection coverage.
  • If you are under 65 but suffer from Kidney Disease Medicare will cover 80% of the cost of a transplant and will fully cover anti-rejection drugs for 36 months.  Medicare will also cover the cost of dialysis until you get a transplant
  • If you qualify Medicaid, which is mostly federally funded but state run, will cover transplants and the cost of medication but with recent cuts many people will not qualify for transplants.
  • Under “Obamacare” If you are covered by Medicare Part D (that’s prescription coverage) your costs will keep going down until they disappear almost completely in 8 years (2020) that’s when the donut hole closes.
  • 14.3 million Senior citizens in America have already received important preventive benefits under The Affordable Care Act including an annual checkup, without paying any deductibles or co-pays. Also millions of Americans are getting cancer screenings, mammograms, and other preventive services at no charge, but the status quo cannot last.  Even if Medicare/Obamacare survives it will have to change, there will be cuts because the cost of providing care is just too high.  Changes could include a later starting date for Medicare to age 66 or 67; more limited coverage; lowering coverage from 80 to 70%; higher premiums; fewer drugs covered under Part D to name just a few.
  • Still unknown is what change will be made in organ allocation policy.  Under consideration is a measure that would allocate organs by potential long term survivability. That simply means that age will become more of a factor.  Under this practice younger organs would go to younger people because both the organs and the recipient have longer expected life spans.  For example, if an organ came from someone who was 40 years old it might be expected that it would survive another 25 years.  If a potential recipient was 65 and had an expected life span of 75 the available organ might instead go to someone younger, even though the younger person might not be as sick.  A very tough ethical question being asked in light of the on-going organ shortage.

Romney/Ryan are promising to “Change the system for the better.” Unfortunately we don’t know what that is.  What we do know is that both men have committed to repealing the Affordable Care Act.  If they do that, the donut hole will open again, maybe bigger than ever, preventive services will disappear and many senior citizens may be faced with making horrible choices like, eating instead of taking medications.

The GOP ticket is also committed to further spending cuts and if past performance is an indication Medicaid will get cut again, which may mean that there will be few if any Medicaid financed organ transplants.

While neither of the GOP team has said a word about Transplant coverage one certainly gets the feeling that everything to do with health care is on the table.  Here’s the Romney plan according to the Los Angeles Times.

“Romney has said he would waive as much of the 2010 law as he could through his authority as president, and push Congress to repeal the rest. In its place, he would seek a premium-support system like the one Ryan proposed for those becoming eligible for Medicare in 2022 and beyond. Private insurers would compete with Medicare in a new marketplace, or exchange, with each offering coverage roughly equivalent to what Medicare offers. Instead of offering seniors Medicare coverage, the government would provide an insurance subsidy equal to the second-least-expensive offering in the exchange. Seniors who didn’t want that particular coverage could use the subsidy to buy the less expensive insurance and keep the change, or sign up for more expensive coverage and pay the difference out of pocket.”  http://tinyurl.com/8jl5xpb

A new report, (August 24, 2012) from the Center for American Progress finds that the Romney/Ryan proposal to transform Medicare’s guaranteed benefit into a “premium support” structure for future retirees could increase costs by almost $60,000 for seniors reaching the age of 65 in 2023. http://tinyurl.com/9rh2pyo  The Romney/Ryan campaign says this report is inaccurate.

Here’s what bothers me about the Romney/Ryan plan.  It turns nearly everything over to the private sector which, when combined with the Republican penchant for de-regulation, threatens the elderly with minimal coverage for maximum cost for a minimum of people.

Perhaps Romney/Ryan will come up with a more detailed proposal that will offer more certainty, but this sounds too much like a dismantling of Medicare with the result being that seniors will just buy insurance in the private marketplace like everyone else.  Most importantly, though, it appears that Obamacare offers a more certain possibility of organ transplant coverage than does Romney/Ryan which makes no mention of the procedure.  Additionally, if the Affordable Care Act is repealed, pre-existing conditions will return which would automatically rule out anyone who needs a transplant.  And…along those same lines, I can’t think of a single senior citizen who doesn’t have at least one pre-existing condition that would prevent insurance coverage.

On balance, both options leave a lot to be desired for seniors, but repeal of the Affordable Care Act would be a disaster for many of us, especially when faced with the ever increasing cost of drugs, and the senior citizen need for more medications as we age.  Re-opening the donut hole is just not an acceptable option for us.

There is still plenty of time between now and Election Day for Romney/Ryan to clarify their plan and to specifically mention organ and tissue transplant coverage but until they do this blog will play it safe and endorse the present flawed but more understandable Medicare/Obamacare system.

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 2,500 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at bob@baronson.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our video “Thank You From the Bottom of my Donor’s heart” on http://www.organti.org This video was produced to promote organ donation so it is free and no permission is needed for its use.

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just go to http://www.organti.org and click on “Life Pass It On” on the left side of the screen and then just follow the directions. This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. Just write to bob@baronson.org and usually you will get a copy the same day.

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.

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