Health Care Reform: The ACA, Your Practice, and You - Part 2 March 17, 2014 Covered California, Health Care Reform ACA, Affordable Care Act, Andrew Calman, Covered California, Obamacare 0 Continuation of SFMS' Health Care Reform series. Excerpt from "The ACA, Your Practice, and You" article from January/February 2014 issue of San Francisco Medicine. Click here to view Part 1 of this series. The Affordable Care Act specifies a provider subsidy for primary care (but not specialty care) for 2014 and 2015. Unfortunately, implementation of these rates in California has not been finalized. Meanwhile, providers are struggling with Medicaid rates that are among the lowest in the nation. Although SFGH and its affiliated community clinics have received funding to expand primary care and other services, it remains an open question whether enough providers will be available any time soon to care for this increased Medi-Cal population. Individuals and families earning 133%-400% of FPL (up to about $46,000 for an individual or $94,000 for a family of 4) will qualify for subsidized private insurance through Covered California. This encompasses a large number of working-class and middle-class families, from baristas to independent professionals to seasonal construction workers. Individuals and families earning over 400% of FPL can still purchase insurance through Covered California, but without the sliding-scale federal subsidies. In San Francisco, Covered California has contracted with 5 health plans in San Francisco for 2014 and 2015: Kaiser HMO, Anthem Blue Cross EPO, Blue Shield PPO, HealthNet PPO, and Chinese Community Health Care Association (CCHCA) HMO. Other insurers, such as Aetna, Cigna, and United Healthcare, are not currently participating in Covered California. The Healthy San Francisco program will continue to exist, primarily for undocumented immigrants, but most current Healthy San Francisco enrollees will receive coverage through the Medi-Cal expansion or subsidized Covered California private plans instead. Prior to the ACA, those venturing into the individual insurance market too often encountered high premiums and very limited coverage, if they were fortunate enough to obtain insurance at all. Premiums through Covered California should be within reach for most consumers. Individuals and families can choose from Platinum, Gold, Silver, Bronze, and Catastrophic plans; those with lower income can also choose Subsidized Silver, which has lower deductibles and co-payments (see table below). An example of unsubsidized coverage for a hypothetical forty-year-old self-employed physician shows that a Bronze plan can be purchased for as little as $221 per month, regardless of health or income. And, like all Covered California plans, the possibility of medical bankruptcy is virtually eliminated. Even if this physician were to require bone marrow transplantation or coronary bypass, the annual out-of-pocket maximum would still be $6,350, the premiums could not be raised, and the policy could not be canceled due to illness. It is estimated that 28,000 San Franciscans will qualify for subsidies to purchase private insurance through Covered California. The table on the right illustrates the impact of premium subsidies on our hypothetical forty-year-old. If she were a fast-food worker earning $17,000 per year (150% of FPL), she would pay a Subsidized Silver plan monthly premium of between $0 and $76, depending which insurance plan she selected, and would benefit from subsidized co-payments and deductibles and an annual out-of-pocket maximum of $2,250. If she were a receptionist making $29,000 per year (250% of FPL), she would pay between $126 and $212 per month. Two fifty-one-year old adults with two children and a combined income of $60,000 could cover the entire family with a monthly premium of only $2 for a Bronze plan or $267 for a Silver plan. You may want to go to Covered California's website and use the “Shop and Compare” tool to explore these and other examples for yourself. Next Up: Impact on physicians Comments are closed.
