What Providers Need to Know
Health care reform changes
If you’re an HMSA participating provider, health care reform will change your patients’ health plan. Here’s what you need to know.
What you can expect
You could see more patients starting in 2014. That’s because health care reform requires almost everyone to have health care coverage or risk paying a fine to the Internal Revenue Service. People who don’t get coverage through their employer or government assistance, such as Medicare or QUEST, will have to buy insurance on their own. And there’s good news for people who were denied coverage in the past because of a serious health condition. They can now get insurance even if they have asthma, cancer, diabetes, or other chronic conditions.
Options to buy coverage
People who don’t have health insurance will have two options to buy coverage. They can:
- Contact health plans like HMSA directly, or
- Buy a health plan from HMSA or another insurer in the Hawai‘i Health Connector, the state’s online health insurance marketplace, starting October 1
Depending on their income, people could get financial help from the government to pay for health insurance in the Connector. Health plans purchased in the Connector are not expected to change provider reimbursements.
Expanded funding for providers
Health care reform is helping place primary care providers (PCPs) in areas that need more doctors. PCPs can receive scholarships and loan repayments for setting up practices in areas that have doctor shortages. Health care reform also provides more primary care and nurse training programs. And PCPs will get more Medicaid and Medicare payments.
Benefits are changing
Benefits will change for patients who have health coverage through a small business (up to 50 employees) or on their own through an individual plan. Starting in 2014, their plans will include 10 essential health benefits:
- Ambulance service
- Emergency care
- Laboratory services
- Maternity and newborn care
- Mental health and substance abuse services
- Pediatric oral and vision services
- Prescription drugs
- Rehabilitation and habilitative services
- Services for preventive, wellness, and chronic disease management
Premiums are changing
Health plan premiums will change for patients who have coverage through a small business (up to 50 employees) or on their own through an individual plan. Starting in 2014, their premiums will be based on their age and may be adjusted based on their tobacco use. For example, health plans for older patients and patients who smoke may cost more than younger patients and patients who don’t smoke.
Also, the federal government will pay for health care reform changes with new fees and taxes imposed on health insurers nationwide, including HMSA. This will increase health plan premiums.
When to buy health insurance
People who buy an individual health plan on their own can enroll in an HMSA health plan from November 15, 2014, to February 15, 2015. After that time, they can only enroll during a special enrollment period (SEP) if they lose their health insurance due to a divorce, death of a spouse, or loss of a job.
This information is based on HMSA’s review of the Affordable Care Act (ACA). This overview is intended for educational purposes only and should not be used as tax, legal, or compliance advice.