FAQs

No. The new law will be implemented over the next several years. HMSA will continue to provide excellent service and will work to implement the new health care law to best serve our members. We are working with federal and state agencies charged to implement the law and will inform you of changes that may impact you.

Since July 2010, consumers with health problems who have been uninsured for six months became eligible for health care coverage through a new high-risk pool. Also, a temporary reinsurance program was created in June 2010 to help employers maintain coverage for their retirees under age 65.

For plan years beginning on or after Sept. 23, 2010, children under age 19 cannot be denied health care coverage for pre-existing conditions. Also, dependents up to age 26 will be able to obtain coverage through their parents’ health plan, if the plan offers dependent coverage. Routine preventive care for non-grandfathered plans (new health plans or plans modified after the law’s enactment) will be covered without cost-sharing, such as copayments or deductibles. And certain annual or lifetime dollar limits on coverage will be eliminated. These requirements will take effect at the beginning of the new plan year, which was Jan. 1, 2011, for many individuals.

Starting in 2014, individuals will be required to purchase a health plan or pay a penalty. They can purchase a health plan regardless of health status. Also, member dues cannot vary because of health status. Both individuals and small businesses will be able to purchase coverage through a state-based exchange; it will cover specified minimum benefits established in the new law. People with incomes up to 400 percent of the federal poverty level who purchase individual coverage through the exchange may qualify for subsidies to help them pay for health care. Subsidies will not be available to those who purchase coverage outside the exchange.

Yes. HMSA supports allowing members access to health care regardless of their health condition. Beginning in 2014, the new law requires individuals to have coverage regardless of their health status. Also beginning in 2014, health plans cannot set member dues based on their health status.

Yes, with few exceptions. Beginning in 2014, U.S. citizens and legal residents will be required to buy health care coverage or pay a penalty. The penalty will be phased in, beginning at the greater of $93.50 per person or 1 percent of a person’s applicable household income that is in excess of the applicable tax filing threshold in 2014. That amount will increase to the greater of $695 per person or 2.5 percent of a person’s applicable household income that is in excess of the applicable tax filing threshold in 2016. For persons under the age of 18, the penalty will be half the stated amount.

Individuals may be exempt from the mandate if they can’t afford health care coverage as defined by the government or if their income does not meet the federal tax-filing threshold. In 2010, the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples.

There are a number of factors that drive health care costs, including increasing use of medical services from an aging population, obesity, chronic illnesses, new treatments, prescription drugs, and expensive new technologies. HMSA will continue to work with doctors, hospitals, employers, and members to contain rising health care costs while improving access to quality health care.

Beginning in 2014, an exchange will help individuals purchase health care coverage by comparing benefits, prices and provider networks. Visit https://www.pcip.gov/ for information on how to apply.

Prior to the exchange in 2014, the federal government created a temporary high-risk pool to provide coverage to certain high-risk individuals who have been uninsured for six months prior and who do not have access to health care coverage. A majority of states already have high-risk pools for their residents.

HMSA offers many different affordable health plan options. Contact HMSA to learn more about a health plan that fits your health care needs and budget.

Beginning in 2014, people with incomes less than 400 percent of the federal poverty level and who purchase coverage on their own may qualify for federal subsidies to help them pay for health care. The Congressional Budget Office estimates that about 20 million American households will be eligible for subsidies.

In addition, eligibility in Medicaid, the federal-state program that provides health care coverage to millions of Americans, will expand to cover families with incomes up to 133 percent of the federal poverty level. Adults under age 65 may qualify for coverage in 2014, if they earn no more than $14,404 for a single adult and $29,326 for a family of four.

HMSA members will receive certain preventive services from participating providers without having to pay deductibles, copayments, or coinsurance. These services include:

• Screenings recommended by the U.S. Preventive Services Task Force.
• Immunizations recommended by the Centers for Disease Control and Prevention.
• Preventive care and screenings provided in guidelines supported by the Health Resources and Services Administration (HRSA) for women, infants, children, and adolescents.

HMSA already provides many of the preventive services required by reform at no cost sharing. We will determine how to provide additional preventive services to members.

In the individual health plan market, policy year means the 12-month period that is designated as the policy year of your health plan coverage. Check your policy for specific information related to your policy year.

If there is no designation of a policy year in the policy document or if no such policy document is available, then the policy year is the deductible or limit year used under the coverage. For example, if deductibles or other limits are not imposed annually, the policy year is defined as the calendar year. Please note that policy year is defined differently for employer-group-sponsored health plans.

No. The law does not affect your choice of doctors or other health care providers. However, please be aware that doctors may leave or change health plan networks.

Treatment decisions will continue to be made between you and your doctor. However, in an effort to improve the overall health care system, the government will increase funding for research into evidence-based outcomes to improve quality of care. As a result, options that are available today may change if some treatments or procedures are found to be less effective than others.

No, not if you purchase an individual health plan on your own. The excise tax on high-cost health plan coverage applies to employer group health plans.

Non-grandfathered health plans must cover emergency care without prior authorization. Copayments and coinsurance for nonparticipating providers generally cannot exceed those for participating providers. However, members may be required to pay the difference between what the out-of-network provider charges and what HMSA is required to pay under federal regulations. HMSA had already allowed emergency services without prior approval.

The new law includes provisions designed to improve women’s health. It will eliminate cost-sharing for certain preventive screenings and ensure direct access to ob-gyns. Additional benefits will be available to women beginning in 2014, including:

• Maternity services on all coverage.
• Eliminating pre-existing coverage exclusions for women who are pregnant, have had a previous Caesarean section, or are the victims of domestic violence.
• Eliminating gender rating that may cause women to pay more than men for coverage at certain ages.

Depending on your income, you may be eligible for Medicaid, the state and federal program for the poor and disabled. According to current poverty guidelines, your income must not exceed 133 percent of the federal poverty level, or $14,404 for individuals and $29,326 for a family of four.

You may be eligible for government subsidies to help pay for coverage from a private health plan that would be sold in the exchange, a new state-based health insurance marketplace slated to open in 2014. Subsidies will be available for individuals and families with incomes between 133 percent and 400 percent of the poverty level ($14,404 to $43,320 for individuals and $29,326 to $88,200 for a family of four).

The new law will make it easier for you to get coverage if you have a medical condition. Starting in the fall of 2010, health plans cannot impose a pre-existing condition exclusion on coverage for children under age 19. In 2014, this will apply to everyone. In the meantime, the law will create a temporary high-risk pool for people who have been rejected by health plans due to a medical condition and who have been uninsured for at least six months.

There may be open enrollment periods in 2014 for people with pre-existing medical conditions to purchase coverage. Waiting periods may apply for people who do not purchase coverage during the open enrollment period.

A new state-based health plan exchange will help consumers shop for, compare, and enroll in health care coverage. People who are not eligible for Medicaid or affordable employer-sponsored health plans may purchase coverage through the exchange beginning in 2014. Those who purchase individual plans on their own and whose incomes are below 400 percent of the federal poverty level may qualify for federal subsidies to help offset the cost of their health coverage in an exchange.

Although the eligibility rules will be finalized over the next few years, you will likely be eligible to purchase health care coverage through the exchange in 2014 if you are:

• Unemployed.
• A sole proprietor.
• An employee of a company with less than 100 employees (or in some states, less than 50 employees in 2014 and 2015).
• Are not eligible for Medicaid or an affordable employer-sponsored health plan. (This is defined as requiring an employee contribution of less than 9.5 percent of family income for a plan that covers at least 60 percent of medical costs on average. This standard also applies to dependents that are eligible to enroll).

For plan years beginning on or after Sept. 23, 2010, dependent children up to age 26 can receive coverage under their parents’ plan if their plan offers dependent coverage. In April 2010, HMSA offered employer groups the option to extend dependent health care coverage up to age 26.

The extension of coverage to adult dependent children does not include coverage for your grandchild or the spouse of your adult dependent.

Grandfathered plans are group health plans that existed before health care reform was enacted in March 23, 2010, and are, in some cases, exempt from certain requirements of the law.

Even with grandfathering, there are provisions of the new law that will be added to your coverage, effective for plan years on or after Sept. 23, 2010. They include:

• Extension of coverage to adult dependent children up to age 26 if the adult dependent is not eligible to enroll in other employer-sponsored coverage. (The law does not require coverage for a child or spouse of dependent children.)
• Elimination of coverage rescissions. Health plans can only cancel your coverage due to fraud, intentional misrepresentation, or failure to pay your dues.
• No lifetime dollar limits on total coverage.
• Requirements that your health plan pay a set amount of dues dollars collected for claims, claims-related expenses, and quality-improvement initiatives.

If your employer does not offer coverage, contact HMSA to find out what health plans may work best for you.

Also, you may be eligible for a state-run high-risk pool that allows you to purchase individual health care coverage if you have been uninsured for six months. Individuals with pre-existing conditions who have been uninsured for more than six months will be eligible to enroll in a high-risk pool and pay regulated dues.

Starting in 2014, health plans must accept all applicants during an annual open enrollment period, including anyone with pre-existing medical conditions. The law limits what health plans can charge older adults and provides government assistance if their incomes are below 400 percent of the federal poverty level.

The law appropriates funds to reimburse employers for offering group health coverage to early retirees, ages 55 through 64, who are not eligible for Medicare. The goal of the program is to help employers maintain their early-retiree coverage until the new exchange becomes operational in 2014. You could benefit from this provision if your previous employer decides to health plan coverage to early retirees. See the small and large group sections for more information on the early-retiree reinsurance provisions.