How Will Pre-Existing Condition Coverage Change with Obamacare?

How Will Pre-Existing Condition Coverage Change with Obamacare?

The Affordable Health Care Act, known as Obamacare, has created a wealth of new mandates, many of which will be beneficial to policy holders. One of the new rules stipulates that no insurance company can refuse to provide coverage if the individual has a pre-existing medical condition.

ObamacareIn the past, insurance carriers could refuse to provide coverage, cancel policies at their discretion, and charge policyholders virtually any amount for their coverage.

Obamacare guarantees that all individuals are eligible for healthcare coverage and can’t be discriminated against, regardless of their health status.

A chronic health problem is no longer a reason for not having coverage.

Relief For Parents

It’s a definite boon for parents of children with a heath condition ranging from autism, blindness and cerebral palsy to asthma, diabetes, cancer and sleep apnea. Children can remain on parental policies until they turn 26, a distinct benefit for those with health issues.

The one exception for pre-existing conditions under Obamacare concerns individuals who have been purchasing private insurance. The good news is that individuals can give up their private insurance policies and purchase coverage through the health insurance Marketplace.

The mandate is also beneficial for adults. The Department of Health and Human Services estimates that 129 million people have something in their medical history that could be construed as a pre-existing condition.

Those participating in the Marketplace can choose from a bronze, silver, gold or platinum policy with varying degrees of financial outlays, all of which will cover pre-existing conditions.

Before Obamacare, insurance companies often imposed caps on the annual and lifetime amounts a policy holder could receive. Obamacare removes those caps. The downside is that the provision has already led to increases in premiums, co-pays and deductibles across the board.

There are no restrictions on the amounts insurance carriers can charge.

Open enrollment in the Marketplace begins Oct. 1, 2013 and coverage for these policies begins Jan. 1, 2014. Enrollment ends on March 31, 2014 and doesn’t open again until Oct. 1, 2014. Many will be eligible for a subsidy from the federal government to help pay for insurance and a tax credit on their income tax return.

Eligibility is determined according to income using a sliding scale.


Medicaid Instead Of The Marketplace

For individuals with an income below a specified level, Medicaid is available.

Obamacare increases the eligibility threshold, providing full coverage for the very poor.

However, many states have refused to participate in the expansion and the Supreme Court has ruled that they may do so without penalties. Participating states will offer better coverage and relaxed eligibility requirements.

Adults and children with a pre-existing condition will benefit from Obamacare. Insurance companies can no longer refuse them coverage or set annual and lifetime limitations on benefits.

At first glance, Obamacare would appear to be a panacea for those with chronic illnesses, but with carriers still free to charge whatever the market will tolerate, many are waiting to see exactly how much that benefit will cost them.

How Will Obamacare Affect those with Private Health Insurance?

How Will Obamacare Affect those with Private Health Insurance?

Many individuals without employer-provided health coverage have taken the initiative and purchased insurance coverage on their own. The Affordable Health Care Act, a.k.a. Obamacare, continues to change the health insurance landscape and could prove beneficial for those who purchase private healthcare insurance.

Obamacare on Private InsuranceOne of Obamacare’s goals was to ease the financial strain for workers forced to buy high-dollar insurance policies when they didn’t have access to employer-provided policies.

People without employer-offered insurance have traditionally paid more for their coverage on the open market.

They’re often faced with numerous restrictions, burdensome requirements and few protections against frivolous cancellations.

The Marketplace For Private Insurance

Those who buy their own insurance will benefit under Obamacare. It created Marketplaces where individuals can purchase their own insurance at rates comparable to workers with coverage through their employment.

Individuals with incomes below specified levels will be eligible to receive government subsidies to help pay for their insurance and they’ll receive tax credits on income tax returns.

A study released by Kaiser Family Foundation indicated that 48 percent of families that buy their own insurance would qualify for subsidies and tax credits. Health and Human Services Secretary, Kathleen Sebelius, estimates as many as 9 in 10 people will qualify for some level of subsidy.

Out-of-Pocket Increases

The downside for the privately insured is that the cost of Marketplace insurance policies will increase in accordance with the market.

Many workers with insurance through their employers are already feeling the sting of increased prices for premiums, co-pays and deductibles. Individuals who purchase private insurance through the Marketplace will also experience the higher prices, but it may still be less than they’re paying now.

The Marketplace opens for business on Oct. 1, 2014. Anyone can visit the website, compare plan prices and purchase their mandatory insurance.

Healthcare plans purchased in the Marketplace won’t take effect until Jan. 1, 2014.

More Marketplace Customers

Many businesses have indicated they plan to drop insurance for employees and pay fines imposed by the federal government. It’s a move that will push many workers with employer-provided health plans into the privately insured sector.

Employees insured through the workplace who are seeking lower pricing may find it in the Marketplace, but it comes with certain conditions.

Employees who give up their work insurance in favor of Marketplace coverage must complete a waiting period before it becomes active.

Obamacare on Private Insurance

Participating Insurance Companies

Many of the self-insured will be perusing plans on the Marketplace with companies with which their unfamiliar.

Some insurance carriers have opted not to offer Marketplace plans in all states or limit their participation to preserve current profit margins.

Obamacare doesn’t place limits on what insurance companies can charge, but some carriers have withdrawn from the Marketplace when state regulators ordered them to dramatically reduce their rates from their proposed levels.

Insurance companies cite Obamacare for continuing price increases. Carriers claim the following mandates are too costly to participate:

  1. Inability to cancel policies at their discretion;
  2. Required coverage for those with pre-existing conditions;
  3. A list of standard required benefits;
  4. Caps on out-of-pocket expenses;
  5. No caps on annual or lifetime benefits.

Obamacare offers those who purchase private health insurance with increased benefits, tax credits, and subsidies to help them pay for coverage. The Marketplace will offer the only option for many individuals to obtain coverage, but only time will tell if available policies are truly affordable.

How to Get the Claim: The Billing Scenario

How to Get the Claim: The Billing Scenario

Building a clean claim is a concerted effort. It begins with the office staff that gathers demographic information and comes to fruition when the funds are deposited in the practice’s account.

Much can happen to a claim on its way to becoming a payment and in this informative article, Nitin Chhoda provides unique insights into the pitfalls that face even perfectly prepared claims and elements that affect payment.

claimWhere’s the Claim?

Aside from coding errors, reimbursement claims can go awry in many ways. The insurance provider may not be known at the clearinghouse or the clearinghouse software may glitch and submit the claim to the wrong provider.

In some instances, the payer may not be using electronic medical record (EMR) software necessitating submission of a paper claim.


Practices that utilize EMR technology receive a report in real time when a claim has been submitted. These receipts provide billers with critical information in the event of a problem. Occasionally, a claim will appear to vanish into the ether.

Clearinghouse reports tell billers when the claim was received, its status and if any problems were identified. If payment isn’t received in a reasonable time or it doesn’t appear on the biller’s daily verification, that data be used to track down the claim and rectify any problems.

Reimbursement Amounts

The whole point of submitting claim is to get paid, but the amount charged can conflict with what the payer is willing to reimburse. When differences occur, billers can easily refer to the contract the clinician has with the payer to define the reimbursable amount.

CPT codes are assigned a relative value that determines reimbursement amounts, derived from the Resource Based Relative Value Scale (RBRVS).  The value assigned is based on the work required, the cost of maintaining a practice and the malpractice/liability for which the practitioner is responsible. A formula is then employed that takes into account geographical locations to calculate the reimbursement rate.


Some contracts are RBRVS based, some aren’t, and the differences in each can be immense. Depending on how the contract is written, procedures may be paid based on RBRVS standards or discounts applied for secondary procedures done at the same time.

Some may be paid at a higher rate determined by prioritization, while others are billed according to expected payment. If the contact doesn’t state which procedure is prioritized, it’s up to the biller.

The Deciding Vote

claim submission

The ultimate decision lies in the hands of the company that provides the patient’s healthcare insurance. Once the clearinghouse completes its search for errors, it forwards the claim to the payer.

When reimbursements are less than expected, billers must refer to contract terms to obtain the maximum payment allowed.

Many hazards await claims, from submission to the wrong payer to glitches in clearinghouse software. EMRs facilitate the process by submitting claims in real time and documenting receipts from the clearinghouse.

Medical billing specialists can help clinicians boost revenues by carefully monitoring claims and referring often to contract details. Practitioners must negotiate their contracts carefully to ensure their services are adequately reimbursed.

What Large (and Small) Businesses Need to Know About Obamacare

What Large (and Small) Businesses Need to Know About Obamacare

While the Affordable Health Care Act (Obamacare) will extend the availability of healthcare services to millions of uninsured Americans, it imposes a variety of mandates on businesses of all sizes that increases the cost of doing business.

Obamacare to BusinessesEmployers are not happy about Obamacare and many fear the effect on their productivity and profit margins.

Businesses with 50 or more employees, and those with workers who put in 30 or more hours per week, are required by Obamacare to provide their workforce with health insurance or face financial penalties of $2,000 per employee.

Many firms are choosing to pay the fine – it’s cheaper than providing insurance.

The outcry by the business community was so great that President Obama delayed the mandate’s effective date until 2015 to give employers time to prepare for the transition. Companies across the nation are looking at strategies to lighten the financial load when Obamacare is fully operational.

Shrinking Business Growth

According to a survey by the Society for Human Resource Management, 41 percent of participating small business owners indicated they would not be hiring new employees due to Obamacare.

Twenty percent said they were reducing their payroll and expansion projects are being placed on hold.

Some businesses will receive tax breaks to help alleviate the financial pain of health insurance premiums they pay for employees. The tax breaks only apply to companies with 25 employees or less and many entrepreneurs fear financial failure with the full implementation of Obamacare.

Reducing Workers and Hours

Obamacare to BusinessesTo elude the fines of Obamacare, many businesses have chosen to:

  • reduce their workforce
  • limit workers to 29 hours per week, and
  • transition to a four-day work week

All three strategies have a negative impact.

Higher unemployment rates and reduced hours will force individuals to utilize social service agencies to survive. According to the Bureau of Labor Statistics, only one full-time job was created for every four part-time jobs in 2012.

A survey conducted by Mercer found that 12 percent of all U.S. employers planned to reduce hours for full-time and part-time employees.

In a Reuters survey, a number of businesses indicated that they would be hiring more temporary employees.

That policy would allow employees to qualify for government subsidies to purchase their own insurance coverage through state operated marketplaces.

The strategy is being used by businesses of all sizes, along with educational institutions.

Companies that do provide insurance for employees are being forced to reduce covered benefits while increasing the cost to workers. Some are choosing to eliminate coverage for spouses and children. Insurance companies have raised their rates in response to the array of mandated services through Obamacare.

Economic Repercussions

The costs incurred by businesses through Obamacare mandates will be passed on to consumers. Companies will have to raise the prices on their goods to make up for a loss in productivity, fines and other costs associated with the healthcare Act.

The impact will be felt at all levels, from food and clothing to housing and the auto industry.

Fear of Obamacare has resulted in significant changes in the business community. To combat the cost of mandatory healthcare, businesses are being forced to lay off workers, cut hours and modify work weeks. The result is a loss in productivity that affects profits and limits the ability to expand and create jobs now and in the future.

Impact of Obamacare on Senior Citizens

Impact of Obamacare on Senior Citizens

According to Health and Human Services Secretary, Kathleen Sebelius, 11,000 seniors are becoming eligible for Medicare each day. As new elements of the Affordable Healthcare Act are introduced, seniors will see changes in their Medicare coverage, out-of-pocket expenses, and even the physicians they see.

Obamacare to Senior CitizensKnown as Obamacare, the Act reduces payments for those with Medicare and who are enrolled in the Medicare Advantage program.

A significant amount of money to fund Obamacare over the next 10 years is being taken from Medicare coffers.

The Congressional Budget Office (CBO) estimates that reimbursement for Medicare-related services will be cut by approximately $716 billion between 2013 and 2022.

Seniors participating in the Medicare Advantage program will see cuts in that as well.

Seniors will face additional cuts through the creation of the Independent Payment Advisory Board (IPAB), which will have control of the Medicare budget in coming years. Insurance companies will be allowed to continue charging seniors and other groups higher rates for their healthcare.

On the plus side for the 49.5 million seniors on Medicare, Obamacare caps the amount seniors will pay for Medicare premiums. It also expands coverage for prescription medications and some preventative care services.

Reducing Payments to Control Costs

Medicare already pays less for services than many commercial carriers and those amounts will be reduced further in the coming years. Facing the prospect of decreasing Medicare revenues, many clinicians are either selling their practice, retiring early, taking employment at hospitals, or refusing to see Medicare patients at all.

A Deficit of Doctors

According to the Association of American Medical Colleges (AAMC), there will be an estimated deficit of 130,000 physicians by 2025. Fewer clinicians mean less access to healthcare for seniors and a longer wait for appointments.

Seniors could be forced to locate a new practitioner, be limited to clinicians within specific networks, and required to travel further distances to receive healthcare.

Medicare Advantage and Excise Taxes

Changes in Medicare Advantage programs could potentially eliminate or drastically reduce vision and hearing coverage. Obamacare raises taxes on medications and medical equipment. Patients will pay an excise tax on medical devices, ranging from wheelchairs and joint replacements to hearing aids.

Funds collected through the tax increase won’t be used for Medicare. The money is earmarked to pay for and sustain Obamacare programs.

The Act assumes that seniors will use the dollars previously used for Medicare Advantage plans to purchase insurance through commercial companies.

IPAB Controls Future Cuts

Obamacare for Senior CitizensFurther measures to control costs in the future will be in the hands of the IPAB. The 15-member board will have the power to cut Medicare spending where it sees fit to reach specific spending goals.

Cuts will automatically take effect unless Congress moves to counteract the changes with a super majority vote of three-fifths by the Senate. IPAB members are appointed and can’t be voted out of office.

The board essentially provides protection for Congress, absolving them of any responsibility for Medicare cuts.

IPAB will be charged with setting reimbursement rates for clinicians and deciding which medications, treatments and procedures will be covered.

IPAB will determine the most effective treatments for specific maladies and the cost for each treatment and procedure.

Most people agree that some type of healthcare reform was needed, but seniors fear Obamacare will limit their access to physicians, medications and treatments at a time when they need them most. One thing is certain. Obamacare will definitely impact the financial health of seniors.

Obamacare – The Problem it is Trying to Solve

Obamacare – The Problem it is Trying to Solve

The goal of the Patient Protection and Affordable Health Care Act was fourfold: to increase access to healthcare, reduce healthcare costs, institute more consumer benefits and protections, and improve efficiency. As different portions of the Act go into effect, it will have a major impact on virtually every individual in the U.S.

ObamacareThe Act has both a human and financial component.

According to the Center for Disease Control (CDC) more than 45 million people had no type of health insurance in 2012.

Individuals at the lower end of the financial spectrum were the most likely to lack coverage.

The Congressional Budget Office estimates the Act will reduce the number of uninsured by 27 million between now and 2023, but will still leave approximately 26 million Americans uninsured and financially unable to purchase coverage.

Increasing Access to Healthcare

Obamacare establishes healthcare exchanges and provides subsidies for low income individuals to help them purchase coverage. Millions of Americans can stop living in fear of becoming ill.

They will no longer be turned down for a preexisting condition and children can remain on parental policies through the age of 26.

The downside is an influx of new patients to practices that are already working to capacity. A poll for the Physicians Foundation showed that 40 percent of medical professionals intend to sell their practice or retire early due to Obamacare, resulting in a shortage of available clinicians and longer wait times to obtain an appointment.

Reducing The Cost of Healthcare

One of the tenants of Obamacare was the control and reduction of skyrocketing healthcare costs. The Act reduces the amounts paid by Medicare to practitioners, but allows hospitals to collect more for the same services.

The inequity is prompting many clinicians to stop accepting Medicare patients, further limiting access to care.

Clinicians are under pressure to reduce the number of tests they order and utilize the least expensive modes of treatment whenever possible. Many healthcare professionals fear the drastic reductions in reimbursements will drive potential physicians into other fields.

Healthcare costs also come in the form of copays, premiums and deductibles. Patients are already seeing an increase in all three, as insurance companies raise prices in response to the services the Act forces them to reimburse for.

With insurance companies placing limitations on reimbursements, pharmaceutical firms are reducing or eliminating medications as unprofitable to produce.

The cost of Obamacare comes in other guises. In 2018, a 40 percent tax will be placed on healthcare plans, dependent upon their value, and collected through tax returns. Fines will be assessed on individuals without insurance.

Employers with more than 50 workers must offer insurance or face financial penalties for each person they employ.

Benefits and Protections

Obamacare provides patients with some perks along with coverage. Insurance companies can’t place an annual limit on benefits, nor can they cancel policies for frivolous reasons, but the Act limits the amount individuals can place in Flexible Spending Accounts (FSAs) and purchases that can be made with the funds.

Improving Delivery and Efficiency

The Act’s components are intended to increase the overall efficiency and delivery of healthcare services. To accomplish that goal, the Act mandated use of an electronic medical records (EMR) system.

The technology is expected to allow clinicians to treat a greater number of patients per day and eliminate paper records.

ObamacareAccountable Care Organizations (ACOs) encourage networks of providers, with financial incentives for clinicians that provide a better level of care.

The focus of healthcare would begin a transition to a system of preventatives measures rather than reacting to treat disease after it occurs.

The Act also creates a panel of individuals to determine and recommend preferred treatment options.

Obamacare has four major goals through the Affordable Healthcare Act. In an effort to solve the glaring problems in the healthcare system, it will change the way clinicians practice their profession and deliver care. Patients will have greater access to clinicians, but only time will tell if Obamacare creates a nation of healthier individuals and more efficient practitioners.