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Affordable Care Act open enrollment begins soon

By Elena Watts
Sept. 19, 2013 at 4:19 a.m.

Caitlin Janca, a physical therapy assistant, gently guides Ruben Resendez down the corridor  of La Villa Rehabilitation and Healthcare Center while he awaits for his body to mend from the effects of radiation and eventually cancer surgery.

What's covered in the Health Insurance Marketplace

These essential health benefits include at least the following items and services:

Outpatient care

Trips to the emergency room

Treatment in the hospital for inpatient care

Care before and after a baby is born

Mental health and substance use disorder services including behavioral health treatment, counseling and psychotherapy

Prescription drugs

Services and devices to help the injured, disabled or chronically ill recover. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation and more

Lab tests

Preventive services including counseling, screening and vaccines, and care for managing a chronic disease

Pediatric services, which includes dental and vision care for kids

Specific health care benefits may vary by state. Even within the same state, there can be small differences between health insurance plans. Fill out the application and compare plans to see the specific health care benefits each offers.

Source: healthcare.gov

4 categories of Marketplace insurance plans

Marketplace insurance plans are put into 4 categories based on how the consumer and the plan can expect to share the costs of care:

• Bronze

• Silver

• Gold

• Platinum

All marketplace insurance plan categories offer the same set of essential health benefits. The categories do not reflect the quality or amount of care the plans provide.

The category chosen affects how much premiums cost each month and what portion of the bill the consumer pays for things like hospital visits or prescription medications. It also affects total out-of-pocket costs - the total amount spent for the year if one needs lots of care.

Note: The marketplace also offers catastrophic plans to people under 30 years old and to some people with very low incomes.

Source: healthcare.gov

HEALTH CARE Enrollment

Open enrollment begins Oct. 1 and ends March 31. Coverage can begin as soon as Jan. 1.

• Philip Henneke, program coordinator, Gulf Bend Center, 361-575-0611

• Sonia Del Bosque, certified application counselor, Dr. Pattie Dodson Public Health Center, 361-576-2110

• Brenda Lopez, eligibility screening services, DeTar Healthcare System, 361-788-6119

• Marketplace.cms.gov

• HealthCare.gov

• Health Insurance Marketplace Call Center, 800-318-2596

It's not a relief for 66-year-old Ruben Resendez, of Victoria, to stretch out in bed after a long day.

The skin around his left leg, amputated above the knee in 2008, tightens like a sleeve over an arm when the cuff is gathered and held in the hand, he said.

His right knee, which remains slightly bent since arthroscopic surgery, throbs with pain.

If legislation such as the Affordable Care Act had been in place 30 years ago, Resendez could have had access to better health care coverage with lower costs, said Shannan Phillips, media relations chairwoman for the Coastal Bend Association of Health Underwriters.

The question is whether the Affordable Care Act, also known as Obamacare, is the answer.

"It's a start," said G. P. Hardy III, attorney with Hardy McKenzie Law in Victoria. "Congress can take the framework and create a national health care policy that affords good medical care for everyone."

Two work-related accidents made 1980 a pivotal year for Resendez.

Worker's compensation covered the arthroscopic surgery on his right knee after a load of frozen food fell from a lift and pinned him to the wall.

Residual pain kept him from returning to the food distribution company, so he found odd jobs to earn a living.

At his next job, he fell to the ground from a second-story balcony while assisting a roofing contractor.

Without health insurance or other means to pay for a doctor's visit, he did not seek medical attention.

If the legislation had been in place, Resendez would have qualified for subsidies under the bronze level because his health insurance premiums would most likely have surpassed 9.5 percent of his household income.

Deductibles and out-of-pocket expenses for services such as surgeries would have been Resendez's responsibility, but payment plans would have been available.

Texas did not opt into the federally funded Medicaid expansion, which is part of the Affordable Care Act, which will affect lower- to middle-income Texans, Phillips said.

While these Texans did not qualify for Medicaid under the current system, they would have qualified for assistance under the Affordable Care Act.

Many of these area patients frequent the Dr. Pattie Dodson Public Health Center. They earn too much to qualify for Medicaid benefits but too little to purchase health insurance.

Some will likely be eligible for subsidies on the health care exchange and will purchase coverage, Phillips said.

The new law offers four plan options: bronze, silver, gold and platinum.

Each level is required to provide 10 essential benefits.

"Most group plans already offer the benefits," Phillips said. "But they are excluded from most individual plans."

The most important benefit of the new health care act is 100 percent coverage of preventive services, Phillips said. This allows for early detection of disease and reduced chronic illness.

Under the new law, area patients who purchase insurance through the exchange can access services such as lab work and x-rays not covered by the public health center. Specialists will also be more accessible.

In 2014, many individuals might pay the penalty for not having insurance rather than purchase health insurance if it proves less expensive. The annual penalty will be $95 per adult or one percent of the person's annual income, whichever is more, and will be received when an individual files taxes. The annual fee will be $47.50 per uninsured child, and the most a family will be required to pay in 2014 is $285, Phillips said

However, penalties will increase each year.

By 2017, the law will be in full effect, and purchasing health insurance will be more economical than paying the penalties, Phillips said.

South Texas is affected more than other regions of the state because of greater unemployment and lower incomes, she said.

A small percentage of the population will never purchase insurance for a variety of reasons, Phillips said. People may believe they are healthy and do not need insurance, they may not be able to afford it and would continue to use free clinics, or they may be against any government mandate regardless of their need for coverage.

Under the current system, the uninsured typically pay higher rates for the same services than those who pay out of pocket or through private insurance, Medicare and Medicaid, Hardy said. Rates are set by the service providers.

"They (the providers) know the poor cannot pay, they file liens and show a loss on their taxes," Hardy said. "Medical costs have bankrupt many American families."

Few businesses other than those associated with the health care industry have seen 10 percent increases in costs annually and compounded, Hardy said.

"It's going to bankrupt America," he said.

Costs and services should be controlled and standardized by the health care industry, including hospitals, physicians, pharmaceutical companies and insurance companies, Hardy said.

"I do not advocate that health care should be exactly the same for the poorest of us and the wealthiest," Hardy said. "The wealthy should be able to get whatever level of care they are willing to pay for."

He does advocate that the poorest should have access to a reasonable level of care and affordable drugs.

"There will always be those who say, 'Why should my tax dollars pay for their care,'" Hardy said. "People who believe that - there's no reasoning with them. Those people lack both compassion and an understanding of simple economics."

The focus is on insurance now, not cost of care, Phillips added. Costs might be a priority in the future but not anytime soon.

"The basis of the new law is good," Phillips said. "And it would be beneficial if the cost piece changed as well."

An MRI might cost $400 at one hospital and $1,000 across town at another hospital, she said.

In July, the pain in Resendez's legs took second stage to colon cancer. He has been at La Villa Rehabilitation and Healthcare Center since his first cancer surgery, and he recently underwent another surgery. He receives disability benefits, and Medicaid and Medicare cover his health care.

As long as the backlash continues, Congress cannot work on a revival plan, Hardy said.

"There are many ways to achieve our goals, but in order to do so, we must all look beyond our own partisan leanings," Hardy said.

Related stories:

As health care markets open, divisions emerge

How to apply for health insurance

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