What Providers Need to Know

Health care reform changes

If you’re an HMSA participating provider, health care reform changes your patients’ health plan. Here’s what you need to know.

For health care reform information as a business owner, see the small business (up to 50 employees) or large business (more than 50 employees) section.

What you can expect

You may see more patients starting in 2014. That’s because health care reform requires almost everyone to have health care coverage or risk paying a fine to the Internal Revenue Service (IRS). People who don’t get coverage through their employer or government assistance, such as Medicare or QUEST Integration, will have to buy insurance on their own. And there’s good news for people who were denied coverage in the past because of a serious health condition. They can now get insurance even if they have asthma, cancer, diabetes, or other chronic conditions.

Options to buy coverage

People who don’t have health insurance have two options to buy coverage. They can:

  • Contact health plans like HMSA directly, or
  • Buy a health plan from HMSA or another insurer on healthcare.gov, the federal health insurance marketplace.

Depending on their income, people could get financial help from the government to pay for health insurance on healthcare.gov. Health plans purchased on healthcare.gov aren’t expected to change provider reimbursements.

Expanded funding for providers

Health care reform helps place primary care providers (PCPs) in areas that need more doctors. PCPs can receive scholarships and loan repayments for setting up practices in areas that have doctor shortages. Health care reform also provides more primary care and nurse training programs. And PCPs will get more Medicaid and Medicare payments.

Benefits have changed

Benefits have changed for patients who have health coverage through a small business (up to 100 employees) or on their own through an individual plan. ACA plans include 10 essential health benefits:

  1. Ambulance service
  2. Emergency care
  3. Hospitalization
  4. Laboratory services
  5. Maternity and newborn care
  1. Mental health and substance abuse services
  2. Pediatric oral and vision services
  3. Prescription drugs
  4. Rehabilitation and habilitative services
  5. Services for preventive, wellness, and chronic disease management

Premiums have changed

Health plan premiums have changed for patients who have coverage through a small business (up to 100 employees) or on their own through an individual plan. Premiums for these plans are based on their age and may be adjusted based on their tobacco use. For example, health plans for older patients and patients who smoke may cost more than younger patients and patients who don’t smoke.

Also, the federal government pays for health care reform changes with new fees and taxes imposed on health insurers nationwide, including HMSA. This increases health plan premiums.

When to buy health insurance

People who buy an individual health plan on their own can enroll in an HMSA health plan from November 15, 2014, to February 15, 2015. After that time, they can only enroll during a special enrollment period (SEP) if they lose their health insurance due to a divorce, death of a spouse, or loss of a job.

This information is based on HMSA’s review of the Affordable Care Act (ACA). This overview is intended for educational purposes only and should not be used as tax, legal, or compliance advice.

Frequently Asked Questions

What is health care reform?

  • Health care reform is the Affordable Care Act, which was signed into law by President Barack Obama in 2010
  • It is legislation that aims to:
    • Make health care more accessible for all Americans, including the uninsured
    • Make health care more affordable by eventually lowering costs
    • Improve people’s health by increasing the focus on preventive care

What does health care reform do?

  • It adds preventive benefits to health plans at no additional cost to health plan members
  • It adds benefits such as laboratory tests, pediatric oral and vision services, and prescription drugs to health plans for small businesses
  • It allows dependents up to age 26 to stay on their parents’ health plan
  • It provides health care tax credits for eligible small businesses

What is the federal health insurance marketplace?

  • It’s an online marketplace, healthcare.gov, where individuals can go to buy health coverage
  • Large businesses that have employees who don’t qualify for employee-sponsored health plans can send those employees to healthcare.gov or directly to HMSA, where we’ll help them sign up for an individual health plan

When is the open enrollment period for healthcare.gov?

This year, enrollment through healthcare.gov is from November 1, 2015, to January 31, 2016.

If I'm an employer, do I have to use healthcare.gov?

No. You aren't required to send your employees to healthcare.gov. You can work directly with HMSA. If you choose to go through the marketplace, HMSA will still be here to guide you through the process and answer your questions.

What's the benefit of buying a health plan from HMSA?

HMSA can provide a smooth transition to plans that comply with health care reform to avoid disruption of benefits and services. HMSA will personally help people choose health plans based on their health and financial needs. And we’re always here to answer your questions.

What's the benefit of buying a health plan in the marketplace?

Individuals who don't qualify for employer-sponsored health care coverage may qualify for a subsidy if they purchase a health plan through the marketplace. Small businesses may qualify for a tax credit if they have an equivalent of up to 25 full-time employees with average wages of less than $50,000 a year. You should check with your tax adviser. Also, the marketplace will send employers one consolidated bill for employee health plans.

Do I still need to provide health coverage for my employees?

Yes. Hawaii businesses must still comply with the state’s Prepaid Health Care Act. This law requires employers to provide health insurance for employees who work 20 hours or more a week for four weeks in a row (with some exceptions). Employers must contribute at least half of the employee’s dues for single coverage. The employee contributes the rest, but no more than 1.5 percent of their wages.

Will I have to pay more now to cover my employees?

There are several factors that may impact the cost of health plans. The federal government pays for health care reform with new fees and taxes imposed on health insurers nationwide, including HMSA. This added cost is reflected in your premiums for the upcoming year. ACA compliant small group health plan rates are determined by age. This means health plans for younger individuals may cost less and health plans for older individuals may cost more. Tobacco use and added benefits required by health care reform may impact the cost of health plans.

Have patient out-of-pocket costs change due to health care reform?

HMSA offers a variety of plans with a variety of out-of-pocket costs to meet the needs and wants of all Hawaii consumers.

Are there more preventive benefits added?

Yes. The federal government frequently updates preventive benefits required by the Affordable Care Act.

Do these changes affect my pay-for-quality payments?

No. Changes due to health care reform do not affect your pay-for-quality payments.

What are the benefits that health plans are now required to have?

All ACA compliant small business and individual health plans are required to have the following benefits: prescription drugs, ambulance service, emergency care, hospitalization, laboratory services, maternity and newborn care, mental health and substance abuse services, pediatric oral and vision services, rehabilitation and habilitative services, and services for preventive, wellness, and chronic disease management.

What’s the penalty for not having health coverage? How does the government enforce this?

The penalty for not having insurance is either a flat fee or a percentage of a person’s income, whichever is greater. The penalty increases each year through 2016. The government requires individuals to show proof of coverage when filing tax returns to the IRS. If there is a penalty, it’s deducted from an individual’s tax refund.

Year Penalty
2015 $325 or 2.0 percent of your income
2016 $695 or 2.5 percent of your income

Are my patients who have pre-existing conditions able to get health coverage?

Yes. Health care reform allows more Americans to qualify for health coverage, including individuals who were denied coverage in the past because of a serious health problem.

Where can I go if I have questions?

Call your HMSA representative or call 948-6330 on Oahu or (800) 790-4672 toll-free on the Neighbor Islands.