Understanding Obamacare Affordable Care Act with Dr. Michael Smith and Lisa Zamosky of WebMD

Ever since now-president Barack Obama was campaigning for his first tem of presidency, his plan for healthcare reform has been in the spotlight. Whether you’re a Democrat or Republican, conservative or liberal, wealthy or just making ends meet, it’s safe to say the Affordable Care Act, also known as Obamacare, has left you with tons of questions. And for every answer you get, two more questions pop up, right?

Well luckily, the good doctors and health professionals at WebMD have put together an objective website dedicated to helping people better understand the changes—be them good or bad, wanted or not—and help them navigate the individual state marketplaces that opened on October 1.

This is something that’s really important for all of us to understand, especially women. We have our children to care for, we encourage our husbands to go to the doctor (babies!), we care for elderly parents. Then, last but not least, there’s our own health to maintain (so that everything else in our life doesn’t come to a screeching halt).

[exceptional-citing quoted=”dr.-michael-smith,-medical-director-and-chief-medical-editor-at-webmd” template=”elegant” date=”” ]”We created [the WebMd Healthcare Reform Center] because health insurance is an overwhelming concept to people. And it’s really not that complicated. We ask you a few simple questions, boil it down to what you need to know…step-by-step [to] really [get] you ready to enroll in the new plan.[/exceptional-citing]

I recently had the chance to talk with Dr. Smith and Lisa Zamosky, WebMD’s Health Reform Expert to learn more about parts of the law that will directly affect families and how we can better understand the new law (which takes effect January 1, 2014).

What follows is my complete interview with them to help you make better sense of all things Affordable Care Act.

Understanding the Affordable Care Act

AOM: Concerning the different levels of health insurance once the Affordable Care Act is implemented. Can you talk about how a family can go about determining what option is best for them?

Lisa Zamosky: There are four tiers of health insurance policies that will be available through the marketplaces. They’re referred to as metal levels: bronze, silver, gold and platinum. And the difference between the plans is primarily how much you’ll pay for them and how much they’ll pay towards your medical costs. A platinum plan, which is a plan with the richest set of benefits, will actually cover more of your costs every time you go for medical care but it is also going to be the level of plan that is going to cost you the most on a monthly basis. The less your plan pays towards your medical cost when you go for care the less you’ll pay in a monthly premium. Bronze is the lowest; silver would be the mid-level, gold a little bit up from that and then platinum.

Pregnancy and Maternity Coverage under the Affordable Care Act

AOM: Our blog focuses on families and moms, so for a family that has to purchase their own insurance and is considering starting or expanding their family, how will the Affordable Care Act affect them? I know right now when you purchase insurance you have to wait pay for maternity insurance for nine months before it actually can be used. So will that change?

LZ: Those kinds of waiting periods are done away with. For families that are starting a family the huge difference is that most plans sold today on the private market, meaning you’re buying it on you’re own [and] you’re not getting it from your job, actually don’t include maternity services and you have to pay extra for a rider that covers maternity. That is no longer allowed.

All of the plans, regardless of how much they pay towards your care, are required to cover what are “essential health benefits.” These are 10 categories of care that include, among other things, maternity coverage. So no longer will young families wonder if their pregnancy and newborn is going to be covered. No longer will they be surprised to learn, ‘Oh my gosh. I had a health insurance policy and I just naturally assumed maternity would be covered,’ [only to find out that] its not.  So that’s a big gain.

The other thing is that pediatric services are another one of the 10 essential health benefits that have to be covered. And for children under the age of 19, both dental and vision services must be part of those benefits.

Financial Assistance for the Affordable Care Act

AOM:  Wow, that’s fantastic to hear! What other implications, good or bad, for families do you perceive the Affordable Care Act bringing about?

LZ: The other major thing that people should be aware of is the law provides financial assistance for families making as much as $94,000 a year. That’s most families in this country. So that means you want to check out not only the plans that are available to you—and starting October 1st you can go on to your marketplace and see what’s being sold in your state—but also how much of a tax credit you can be eligible for.  In some cases that can dramatically lower a family’s cost.

Depending upon how much money you make, [families with] lower incomes may even qualify for additional financial assistance that can lower how much they pay each time they go for services. So that’s something important to be aware of and to check out

And some states, not all of them, [but] about half of the states are expanding their Medicaid program. If you’re a family that’s very low income you’ll want to know if your state’s expanding. That’s another potential low-cost or no cost option for getting health insurance.

AOM: Now what if you already purchase your own insurance? Do you have to talk with your company about changes or should you just keep what you already have and not do anything else?

LZ: If you buy your own insurance and have a plan today, that may be the best plan for you. But you should absolutely go on to your state’s market place and take a look at what’s available and compare. Because if you are earning an income that qualifies you for tax credit you can only take advantage of those tax credits if you buy through the marketplace. You can buy health plans outside the marketplace. If you don’t qualify for a tax credit and you’re going to pay the full cost for the health plan, you might as well look everywhere to make sure you’re getting the best deal. But if you qualify for the tax credit, you’re only going to get it if you buy it through the marketplace.

And if you have a plan on the private market today the law does change some things in terms of benefits and availability and financial assistance. Just compare what’s available. As I said, you may decide ‘I like what I have and this works for me.’ And that’s fine. But don’t just make that assumption.

Screenings and Visits

AOM: Switching gears a little: how will preventative healthcare, as we know it today, change for families under the Affordable Care Act?

Dr. Michael Smith: One of the wonderful things about the Affordable Care Act is now families, and everyone really, have access to preventative care services that they may [not have] had before. There are certain preventative care services that insurance plans now must cover at no additional cost to you. That includes everything from blood pressure and cholesterol screenings to colon cancer and breast cancer screenings. So now you have access to that at no additional cost. So as a healthcare professional that is certainly one of the things that is most exciting to me. And that even includes lot of children’s health preventative service. A lot of people probably don’t even realize that even kids should get blood pressure cholesterol screenings and the Affordable Care Act now pays for those as well, in addition to your wellness exams. So you have access to a lot of healthcare, health services that you may not of before at no additional cost. You can get a complete list of these services at WebMD’s new healthcare reform center that you can find at www.webmd.com/myhealthcare.

AOM: What are some things that people should consider, or prepare themselves for, when they go in for a visit once the new law takes effect?

Dr. Smith:  There’s nothing about the new law that is really going to change your relationship with your doctor or change what to expect in your doctors visit.  But if keeping your current doctor is important to you, you need to take that into consideration when choosing the right health plan. So when you have access to your options after October 1, you want to look for a health plan that your doctor already participates in if you want to keep that doctor. But in the end there’s noting about the Affordable Care Act is going to change your how you work with your doctor.

Pre-Existing Conditions and the Affordable Care Act

AOM: Is there anything people with pre-existing conditions should know specifically when searching for an insurance provider?

LZ: The interesting and useful thing about the law is that is standardizes the plans by making sure that you don’t have to question anymore if this one provides maternity and that one doesn’t. But things like provider networks, which doctors are participating with which health plans, those vary. So you really need to take a close look at that and who’s participating.

If you have a pre-existing health condition and you have a doctor, and people who have a condition usually do want to stick with the doctor that they’ve developed a relationship with, you definitely want to make sure that that doctor is on the panel. And if he or she is not on one, perhaps they’re on another. That may sway your decision. You also need to look at the formularies. What drugs does the insurance company pay for? All of them must cover a minimum of one drug in every class or category, and usually they cover much more than that but it doesn’t meant they cover the specific drug you take. Maybe a drug in the same class but not the one that you take and you and your doctor think you need. You need to take a look closely at those. Other things to look at, maternity, for example.  All  [plans] cover maternity but maybe you want to give birth at home with the help of a doula. That may not be a service that is covered. One plan may cover it, another one may not. So you know maternity services are covered but if certain kinds of services are important to you, look a little bit deeper make sure the plans cover them. Those are the kinds of nuances people need to watch for.

Dr. Smith: And keep in mind that someone with an existing medical condition can no longer  be charged more for that or be denied coverage. But one important thing for people to know is that if you’re a smoker, if you use tobacco you can be charged more for that and potentially up to 50 percent more. So now’s a good day to think about quitting; it will help you save some money come January 1.

Do Your Homework!

AOM: So it sounds like people just really need to do research and not go with the first or the cheapest price that they come in contact with. And you’re resource, you would say, is probably the best place for people to go to get well-rounded information?

Dr.Smith: Yeah, we really do boil it down to what you need to know so that we’re not inundating you with a bunch of information that may not be relevant to you. We ask you a few simple questions, give you the information you need to know, and then step-by-step walk you all the way from knowing what your health insurance options are to actually getting you ready to enroll after October 1. …We even tell you what you can expect to pay for a new plan, if you qualify for a subsidy or tax credit and, if you opt-out of health insurance what you might have to pay as a penalty.

There is some information you need to get together and so WebMD’s Healthcare Reform Center can really give you an idea of what you’re going to need to know when you get ready to sign up for a plan. You can get all that information at www.webmd.com/myhealthcare.

AOM: And everybody has to make a decision about his or her insurance by January 1, 2014, correct?

LZ: Actually the open enrollment period for the first year [is] over the course of six months. So you actually have between October 1 and March 31, 2014 [to enroll]. But if you want your insurance to take effect January 1, which is the first point at which insurance plans under the law can take effect, you need to buy it by mid-December. If you purchase it after that, you’ll be able to still purchase it until March 31, but obviously it’s going to delay the start of your coverage.

Dr. Smith: And keep in mind if you have insurance through your work today you’re very likely going to continue to have insurance through your work. You’ll have an open enrollment, as we all do with our employer, through that process You would not actually go into the exchanges and get your insurance through there now. And that is really intended primarily for people who doe not have insurance or buy it on the private market.

AOM: And the WebMD website, will that help people get in touch with their marketplace for their state?

LZ: Yeah, [the] links [are] there. Each of those state pages [on the WebMD site] keep you up to date on the latest developments in your state. You can also send people to the government’s website, www.healthcare.gov.

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Toni Craig
I came to Akron 10 years ago for school and have been here ever since. My husband Matt, little guy Spencer and fur baby Mason call Green home and love taking advantage of the lakes, parks and fresh farmer's markets right in our backyard! A graduate of The University of Akron with a degree in Mass Communication and English, I've worked in news, radio, publishing and magazine writing, education, and public relations--but writing is my passion. In my free time I enjoy cooking, a good book, yoga, running, cheering on the Zips and experiencing all the great things the Akron area has to offer! Toni blogged for AkronOhioMoms in 2013.
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