Meet some folks like you
The Affordable Care Act is changing many aspects of U.S. healthcare, but we know the most important question on your mind — How will it affect ME? While the law has several ins and outs and quite a few twists and turns, we’ve done our best to highlight the specific changes it will bring for a variety of patients. Find the description that best matches your own life situation and use it as a starting point to learn more!
Courtney, young single woman
Courtney is a healthy 25-year-old woman. Her 26th birthday is fast approaching when she has to go off her parents’ plan. She’s unsure what her health insurance options are. Her job offers health insurance, but she’s worried that her employer will drop coverage. Courtney is trying to pay off her student loans, and wonders if she could save money and find a better deal on the exchange. She knows she will face a penalty if she does not have coverage.
One option for Courtney is to talk with her employer to get more information on the health insurance plan offered through her job. She should make sure to ask whether or not her employer is planning to keep coverage. She should also ask her employer if they offer a workplace wellness program, and if there are any incentives for participating in the program such as reimbursement for the cost of a gym membership, a reward for attending a monthly health education seminar or completing a health risk assessment.
Another option for Courtney is to shop the Wisconsin health insurance exchange, also called a marketplace, at healthcare.gov. She will be able to select from four tiers of plans, with different premium costs. She may also be eligible for a subsidy to help her purchase insurance, depending on her income. Low- to middle-income young adults who purchase insurance through the exchange qualify for different levels of financial assistance. The law offers subsidies to individuals with incomes up to $28,725 in 2013, and also provides tax credits on a sliding scale for individuals with incomes up to $45,960 in 2013.
Courtney’s friends on Facebook and Twitter all seem to be in similar situations. They are hoping someone in their social media network will make sense of the options available to their age group so they can make smart choices as they enroll in a health plan.
Melissa and her baby, Logan
Melissa is a 29-year-old who just gave birth to a son, Logan. Both are healthy and receive health insurance through Melissa’s husband’s employer. He works for a technology company that offers a pretty good insurance plan. Under the ACA, Melissa and Logan will see expanded insurance coverage for several benefits, including maternity and pediatric services. The ACA outlines 10 categories of essential health benefits (EHBs) that must be covered by certain health insurance plans in 2014.*
There are 26 total preventive services for children covered by the new EHB requirement under the ACA. For example, ThedaCare Physicians-Pediatrics uses a “fully immunized by age 2” approach. ThedaCare’s pediatricians want every 2-year-old to be up-to-date on all appropriate vaccinations. Logan’s current health insurance only covers some of the vaccinations needed to be fully immunized. Under the ACA, all of the shots Logan needs are now covered.
The ACA also covers oral and vision care for children, hearing screenings for all newborns, autism screenings, behavioral assessments, and development screenings
For new mom, Melissa, the ACA will provide coverage for breastfeeding counseling and equipment as well as resources for family planning.
*Check with your employer on what type of plan the company will offer in 2014. Employers are not required to provide coverage for essential health benefits if they have a self-insured plan.
Roy, seasonal worker
As a worker in a seasonal job, Roy does not have employer-provided insurance. He relies on unemployment when he is not working. His annual income is enough for him to afford the basic necessities of life for a single, 33-year-old man, and health insurance is not one of them. Roy considers himself healthy. Because he doesn’t have much disposable income, he takes a multi-vitamin, tries to eat healthy foods, and doesn’t waste his money on junk food. When he’s working, he gets plenty of exercise because of the physical labor involved in his job. Plus, he works out fairly regularly in a small weight room in the basement of his parents’ home where he is living temporarily while finishing up his associate’s degree.
He has looked at public assistance programs for his health insurance, but the program he would qualify for, Wisconsin’s BadgerCare Plus Core Plan for childless adults, is changing. He is planning to explore his options in the exchange, or marketplace. If the marketplace determines his income is at or below $11,490 (Federal Poverty level), he will be referred to Wisconsin’s Medicaid program. Roy had hoped to purchase a catastrophic plan to cover an accident or serious illness, and a few basics, on the exchange, but he found out the cut-off age is 30.
Based on preliminary questions he answered at healthcare.gov to help determine his health insurance options, Roy is keeping his fingers crossed he will qualify for a subsidized plan on Wisconsin’s insurance exchange. He thinks he can get a subsidy to help reduce his monthly premium cost. Until then, Roy will keep doing what he can to stay healthy and avoid visiting the doctor.
Josh is a 42-year-old self-employed manufacturer’s rep with Type 2 diabetes. His wife, Sarah, 40, is a stay-at-home mom for their two children, George, 14, and Lilly, 12. Because he is self-employed, Josh purchases individual insurance on his own. To help keep costs down, his family plan has a high deductible, but the premiums are still very expensive. This family of four pays almost $1,200 per month for their health insurance. Josh and Sarah are eager to see if they can find a family policy that’s less expensive on Wisconsin’s health insurance exchange.
The Affordable Care Act mandates coverage for everyone, even people with pre-existing conditions. So, Josh no longer has to worry whether or not he can get coverage due to his diabetes. Josh has managed his Type 2 diabetes for the past 20 years. A big part of his treatment includes his partnership with his ThedaCare primary care physician. He also participates in ThedaCare’s Diabetes Self-Management Program. ThedaCare’s doctors are experts in managing diabetes and have the highest rated diabetes care in Wisconsin.
On the Wisconsin health insurance exchange, or marketplace, Josh can compare insurance plans and premiums, and use an online calculator to get an idea of the subsidy he might qualify for. The subsidy is based on a number of factors such as his income, age, age of children and smoking status.
Under the new healthcare law, Josh can now choose a plan on the exchange that includes ThedaCare to ensure he’ll receive the same great care that has helped him successfully control his diabetes.
Miguel, blue collar worker
Miguel is 54 years old and recently strained his knee lifting a heavy crate at the warehouse where he works. The company provides Miguel and his family with health insurance, but since the company is self-insured, his employer does not have to provide coverage for the essential health benefits required by the Affordable Care Act. It does, however, sponsor a workplace wellness program with an onsite nurse from ThedaCare. Miguel is able to get fast treatment advice for his injury. He also gets a referral to ThedaCare Orthopedic Care, which provides him with a plan of care and walks him through rehab exercises to strengthen his knee.
Thanks to his employer’s commitment to employee health, including the onsite clinic, Miguel is soon back on his feet and always connected to his care. He can stop by the clinic with questions, get information on new exercises to try and have peace of mind knowing the onsite nurse is in touch with his ThedaCare Orthopedics Plus team through ThedaCare’s electronic medical record (EMR).
During his follow-up visits to the onsite clinic, he realizes the wellness program also includes support for smoking cessation and healthy eating—two areas where his wife has gently nudged him to make important changes. Miguel knows those changes can also help his family save on health complications and costs down the road. Now, with the support of his company’s wellness program, he feels empowered to take control and make healthy changes.
Paulette is a 66-year-old retired office worker. She was recently diagnosed with breast cancer. Like most people her age, Paulette’s health insurance is provided through Medicare.
The Affordable Care Act strengthens Medicare and helps seniors take charge of their health. With new initiatives to support care coordination, patients can work with their doctor to create a personalized prevention plan. ThedaCare is participating in an Accountable Care Organization (ACO) to ensure our Medicare patients receive high quality, coordinated care.
Under the ACA, Medicare Part B covers some new preventive services including yearly wellness visits, flu shots, bone density, mammograms and prostate screenings. A complete list of preventive services can be found at medicare.gov/coverage/preventive-and-screening-services.html.
Paulette will be happy to learn that the ACA includes benefits to make her Medicare prescription drug coverage (Part D) more affordable. It does this by gradually closing the gap in drug coverage known as the "Donut Hole." Prescription drug out-of-pocket costs should decrease as the donut hole gradually closes over the next six years.
As part of Paulette’s ongoing care, she had her annual screening mammogram at ThedaCare, where her doctor noticed something suspicious on the image. ThedaCare Physicians is ranked #1 in the state when it comes to breast cancer screening. In addition, our breast cancer patients are paired with compassionate cancer care navigators who explain hard-to-grasp details, sit with families during treatment and help make sense of the healthcare maze. Paulette was immediately guided into a comprehensive plan of care, where her ThedaCare breast cancer care navigator sees her through every step of her treatment. Because the cancer was caught at an early stage, her prognosis looks good and she will have many happy years watching her grandbabies grow.
Ed, dairy farmer
Ed is a third-generation dairy farmer. He has spent his entire 56 years on the family farm in a rural area of Wisconsin. Ed and his wife, Nancy, have raised five children ranging in age from 21-31. The two youngest, 21 and 24, are college students and still on the family health insurance plan. The three older children are married, each with children of their own. Nancy works part-time at the coffee shop in town, which provides her with a little spending money and helps her keep a pulse on what’s going on in her community.
Carrying their own health insurance is a financial challenge for Ed and Nancy. They pay $2,000 per month in premiums with a $10,000 deductible. You could call Ed frugal, stubborn, or a little of both. He rarely goes to the doctor because it’s too expensive. Unless there’s a major accident on the farm, which thankfully has not happened, his family never meets their deductible, so everything is paid out of pocket. If a family member comes down with something, they usually power through on their own. It has been stressful at times. Plus, going to the doctor is an ordeal and it takes time. Ed doesn’t like being gone that long and since there’s no one else to do his work, he just has more to do when he gets home.
One positive thing that’s happened for Ed and Nancy is the Rural Health Initiative (RHI), of which ThedaCare is a member. The initiative is designed to improve farmers’ health by taking health care directly to them. A nurse visits their farm where they sit at the kitchen table, have their blood pressure taken and talk about health concerns. Ed heard about the initiative from his neighbor, another farmer who does not carry insurance.
Ed and his neighbor are hoping the new health insurance exchange provides better coverage at a much lower cost. After the morning milking is done, Ed might find a few minutes to sit down and begin researching the best plan option on the new exchange. Plus, all this talk about the new healthcare law has Ed considering getting a flu shot this year.