Answers to frequently asked questions about health care reform.
I have an HMSA health plan. Do I need to do anything now?
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.
When will the new reforms take effect?
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.
Will health plans have to cover everyone regardless of their health status?
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.
Does the law require everyone to purchase a health plan?
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.
How will health reform affect my member dues?
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.
I am currently uninsured. How will I obtain coverage in the future?
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.
What if I can’t afford to purchase coverage?
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.
What kinds of preventive services will be available without cost-sharing under
the new law?
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.
How is a policy year defined?
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.
Will my choice of doctors be eliminated?
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.
Who decides what kind of treatment I can receive?
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.
Will I have to pay extra if I have a high-cost health plan, known as a Cadillac
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.
What are the new provisions for emergency services?
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
What are the new provisions for women’s health?
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.
I want health care coverage, but I can’t afford it. What can I do?
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.
What if I make too much money to qualify for Medicaid, but still can’t
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).
Will I be able to get health care coverage even though I have health problems?
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.
Will there be a waiting period for those with pre-existing conditions?
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.
What is an exchange and who can use it?
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.
How do I know if I am eligible to purchase a health plan through the 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:
- 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).
I am graduating from college this year. Can I receive coverage under my parents’
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.
What is a grandfathered health plan?
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.
What major provisions will apply to grandfathered plans?
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.
I am in the 55 to 64 age range, retired early, and don’t have an employer-sponsored
health plan anymore. What are my options for receiving health care coverage?
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.
What is the law’s early-retiree reinsurance provisions?
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
This information is based on HMSA’s review of the national health care reform legislation.
This overview is intended for educational purposes and should not be used as tax,
legal, or compliance advice. Interpretations of the legislation vary and some reform
regulations differ for particular members enrolled in certain groups. HMSA will
continue to present and update information related to national health care reform
as additional guidance becomes available.