Intro to Insurance

Healthcare Exchange

Insurance helps most people manage their ability to pay for their healthcare. Without it, some care would be too expensive. With it, well, sometimes health care gets complicated. It’s important to know that whatever your health insurance situation, ThedaCare is ready to partner with you for your best health. Here are some basic facts about health insurance in the new world of the Affordable Care Act.

When the law took effect in 2010, it put in place comprehensive health insurance reforms that affect all Americans. In autumn of 2013 and in 2014, significant new components of the law will become active.

Insurance coverage

  • It’s personal. All Americans must carry health insurance or pay a fee effective Jan. 1 2014. That insurance can be provided by your employer, you can purchase it on Wisconsin’s health insurance exchange, or you may qualify for public coverage through Medicare or Medicaid. Some groups of people are exempt from the requirement to carry health insurance, which is also called the individual mandate. Some people qualify for financial assistance to purchase insurance, and some people may be penalized if they do not carry insurance. For example, if you are between the ages of 26 and 45 you face a penalty of $95/person or 1 percent of your household income if you do not purchase health insurance.
  • Beginning in 2015, businesses that employ more than 50 people must provide health insurance to their employees, or pay a fee. Smaller businesses, those with 49 or fewer employees, are not required to provide insurance. To be sure you understand your options, talk with your employer about what is offered where you work. You should always know what your health insurance covers and does not cover, and you should always ask questions about what you don’t understand.
  • ThedaCare has contracts with many local employers. If you work in ThedaCare’s eight-county service area – Calumet, Green Lake, Menominee, Outagamie, Shawano, Winnebago, Waupaca and Waushara counties – there may be a few changes to health insurance coverage for you. Be sure to check with your employer to find out how your insurance might change in the next year.
  • ThedaCare At Work services allow us to partner with local employers to improve workplace health. ThedaCare manages onsite clinics at 51 employer locations. They are staffed by a variety of care professionals from doctors to nurse practitioners to health coaches. We have a great history of long-term partnerships with large local employers, including Appvion and Miller Electric. We work closely with them to keep employees healthy with the goal of reducing costs. In 2012, ThedaCare At Work conducted more than 18,000 periodic health assessments for approximately 100 companies.
  • Around 95% of local health insurance plans, including Network Health Plan, include ThedaCare doctors and hospitals in their plans.
  • You’ve probably heard about the “employer mandate” being postponed. The ACA requires employers to offer health insurance coverage. Originally, that provision of the law was to take effect in 2014. Now, it will take effect in 2015.
  • If you need information about COBRA coverage, or other special insurance situations, visit

Head’s up!

  • The ACA encourages more personal, patient responsibility. You may have to pay attention to decisions about generic medications versus name-brand medications, or talk with your doctor about the most cost effective way to diagnose a sprained ankle, for example. Can you avoid a more expensive visit to the hospital emergency room in favor of a visit to a FastCare or your ThedaCare physician? Asking questions will be important.
  • The new health insurance exchange is an online site where you can review and compare insurance plans. There’s an insurance exchange for individuals and an exchange for small employers (SHOP, or Small Business Health Options Exchange).  Visit Wisconsin’s exchange at
    • Health plans offered on the insurance marketplace (exchange) have met a minimum standard and are authorized by the federal government as a QHP, qualified health plan.
    • Wisconsin’s minimum standard, or benchmark plan, is a plan sold by UnitedHealthcare: Choice Plus Definity HSA Plan
    • Plans are offered at four benefit levels: bronze, silver, gold and platinum. A bronze plan has more affordable premiums, but higher deductibles. A silver plan has more expensive premium costs with better coverage, but lower deductibles. Gold and platinum plans have the most expensive premiums and best coverage, and lowest deductibles.
  • Changes to Medicare:  Changes to Medicare are few. Don’t be surprised if very little changes for you, if you receive Medicare coverage. The few changes you may experience include:
    • Medicare coverage now includes a yearly wellness visit, screenings for diabetes and certain cancers (like mammograms and colonoscopies) at no extra cost to you.
    • If you have Part D prescription drug coverage and fall into the “donut hole” gap in coverage, your out-of-pocket cost will shrink as the hole gradually disappears.
    • Medicare now gives primary care providers incentives for providing quality high care – so you can be certain the already great care you get at ThedaCare will continue.
  • Changes to Medicare Advantage:
    • If you’ve chosen a Medicare Advantage plan instead of traditional Medicare, there are changes you want to know about.
    • There is now a system to rate Medicare Advantage plans. Plans that earn at least three out of five stars receive bonus payments for providing you with quality care. Plans also have to meet new requirements for how they use their bonuses, what they can charge for some services and how much they can spend on administrative services. Your plan may drop coverage for some services like eyeglasses or gym memberships. This is because traditional Medicare previously paid subsidies to the companies that offered Medicare Advantage plans. Those subsidies cost the Medicare program more than traditional Medicare, so they are now reduced.

Medical Assistance:

  • You qualify for Medical Assistance, also called Medicaid or BadgerCare, if you earn approximately $14,000/year for an individual or $29,000/year for a family. To learn more about Wisconsin’s Medical Assistance program, visit


Out of PocketOut-of-Pocket Spending

  • Starting in 2015, the ACA sets maximum limits on how much consumers can be required to pay out-of-pocket annually for their medical care.
  • Some people with high drug costs may find the limits don’t protect them yet, because the government is giving health plans extra time to comply with the rules.
  • Under the law, the maximum amount a consumer with single coverage will pay out-of-pocket in 2015 will be $6,350 while a family could pay up to $12,700 (totals include copayments and deductibles, but not premiums, and apply only to plans that are not grandfathered).
  • If health plans use more than one company to administer their benefits, as many do for major medical and pharmacy benefits, consumers may face no cap on their pharmacy spending at all.
  • An exception to the rule is for plans that use a separate provider to run their behavioral health benefits.

The bottom line for you is that you need to take time to really understand your insurance options, your plan benefits, how they work, and what limits the plan places on your choice of doctors, hospitals and other health care services.

Essential Health Benefits

You’ve heard the phrase “Simple as ABC.” Well, if you’re covered by an individual or small group health plan, understanding your basic coverage under healthcare reform is as simple as EHB — essential health benefits. These are health services the law requires individual and small group insurance plans to cover by 2014.

Your essential health benefits include a package of services within the following 10 categories:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care 

There’s a good chance your existing plan already covers most of these, but pay attention to habilitative services and pediatric oral and vision care as those are largely new. Beginning in 2014, you’ll see Bronze, Silver, Gold and Platinum tiers for EHB packages on Wisconsin’s health insurance exchange. The plans are based on the specific services they cover in each category.

As part of the law, you also no longer have to worry about lifetime and yearly dollar limits on coverage of essential health benefits. This rule applies to large group insurance as well. Though large insurers (and self-funded plans) aren’t required to offer all essential health benefits, they must end coverage limits if they do offer the services.

For more information about essential health benefits, talk with your insurance company.