ACA open enrollment – The Basics


Open enrollment for the Affordable Care Act started on November 1, 2015. The first and most important deadline is December 15, 2015. You must enroll or make changes by this date in order for a new policy to take effect by January 1st. Before making a decision, here’s what you need to know about this coming year’s open enrollment:

  • Enrollment for the ACA Marketplace for 2016 runs from November 1, 2015 to January 31, 2016.
  • Consumers can enroll inside or outside of the Marketplace.
  • This ACA open enrollment period applies to new enrollees or those wishing to make changes in last year’s plans or coverage options.
  • Open enrollment is the only time a consumer can enroll in a medical plan (which counts as minimum essential coverage or MEC), switch plans, or apply for assistance with costs, or subsidies.
  • Log onto to access programs by state.
  • If you have Medicare you cannot purchase a new individual policy.

When does coverage start?

A person enrollingMoney and time paid picture dreamstime_m_38644784 November 1, 2015 to December 15, 2015 will see a start in coverage as soon as January 1, 2016.

A person waiting until January 15, 2016 to enroll or change plans will start new coverage on February 1, 2016.

Anyone who enrolls or change plans between January 16, 2016 and January 31, 2016 will have new coverage taking effect on March 1, 2016.

The open enrollment period of the ACA Marketplace will end on January 31, 2016.

If you don’t enroll in a plan the ACA considered minimum essential coverage (MEC) by January 31, 2016, you will not be able to enroll in a health insurance plan for the entire year unless you qualify for a special enrollment period.

A few tips for navigating the ACA marketplace

#1 Subsidies to help with premium costs can only be obtained through the health insurance marketplace.

#2 The law requires individuals to obtain minimum essential coverage, and must carry that coverage through the year to avoid paying a per month fee when not insured. The only way to avoid this fee is to gain an exemption. Any plans offered by the marketplace are considered minimum essential coverage.

#3 If you missed the initial enrollment period, you are unable to sign up again until the next open enrollment, except in the case where you can qualify for a special enrollment. For example, a person who was unable to qualify for Children’s Health Insurance Program (CHIP) or Medicaid may be able to qualify for a special enrollment. Losing employer based insurance or COBRA are also considered qualifying events.

#4 Medicaid and CHIP does not have a limited enrollment period. Consumers can apply at any time.

What’s considered minimum essential coverage?

The ACA considers minimum essential coverage a type of health plan (includes individual policies) bought within the health insurance marketplace, other sources, received from a job, or from Medicare, Medicaid, CHIP, TRICARE (military), and others. The ACA does not consider the following as minimum essential coverage in order to avoid fine:

  •  Vision and dental care only
  • Worker’s compensation
  • Medical service discount plans
  • Specific disease or specific condition coverage only

What about penalty fees?

Entering its third year, Affordable Care Act coverage costs continue to increase. National average premium costs are expected to rise by approximately 7.5% that use the marketplace. Premiums for large insurers are expected to rise 25% to 43% in other states, including Tennessee, Oregon, South Dakota, and Maryland. High deductibles have also soured enthusiasm for many, with deductibles averaging $3,000. However, a Bronze plan comes with a deductible of $5,731 while Silver plans average $3,117. As deductibles decrease, premiums increase. Before coverage even begins these high deductibles cause financial strain that leads to hard decisions and choices for many.

The penalty fee for not having health insurance coverage in 2016 will be charged for every month you are not covered. Fees are calculated in two ways: either as a percentage of household income – 2.5% of household income or the total yearly premium that an average bronze plan would cost. Or a per person fee ($695 per adult and $347.50 for children under 18 years of age) with a maximum fee of $2,085. You’ll pay whichever is higher.
The IRS will hold back penalty fee amounts from future tax refunds, but consumers will not face criminal penalties, levies, or liens against them if the fee is not paid.

Decisions to Make regarding Medicare Open Enrollment

Seniors enrolling in Medicare for the first time or those wanting to make a switch in coverage can do so October 15 through December 7 every year. Why? Because this is the time when prescription and health care plans adjust costs, coverage options, and determine which pharmacies and providers are included in their networks for the coming year.

Therefore, the open enrollment period is the time when seniors or individuals with current Medicare plans can also change their current prescription or health care options and coverage, depending on need.

Comparing coverage plans

Medicare offers a variety of health and prescription coverage plans. Coverage and options differ between states, and sometimes even counties. For example, Medicare plan options can depend on whether you have a Medicare health plan such as a PPO, an HMO, or private fee-for-service plan, and whether you get help from Medicaid, supplemental security income, Medicare savings programs (MSP), or even support through Social Security.

Major components of Medicare include:Medicare and you

 Medicare Part A (Hospital insurance)
 Medicare Part B (Medical insurance)
 Medicare Part C (Medicare Advantage plans)
 Medicare Part D (Prescription drug coverage)

An individual receiving medical care may fall into coverage options offered through any of these parts or a combination of some of them. Billing and coverage questions, forms, and help determining which is which and what is covered when it comes to claims can be overwhelming for many seniors.

What about Medicare advantage plans?

Medicare Advantage plans cover the same and sometimes even more than ‘original’ Medicare, but have different premiums, deductibles, and co-pays based on plan. Medicare advantage plans include:

• HMO/HMOPOS – Health Maintenance Organization/Health Maintenance Organization Point of Service
• PPO – Preferred Provider Organization
• RPPO – Regional Preferred Provider Organization
• PFFS – Private Fee-For-Service
• MSA – Medicare Medical Savings Account
• EGWP – Employer Group Waiver Plan
• SNP – Special-Needs Plans

So what are my options?

Options for Medicare enrollment include:

• Making a change from one prescription plan to another (also includes joining or dropping a prescription plan)
• Switching from an original Medicare to a Medicare Advantage plan or vice versa
• Switching from one Medicare Advantage plan to another

Understanding the differences between options, health care plans, and making choices can be difficult, especially in today’s often convoluted healthcare environment. Individuals opting for Medicare for the first time should know that Medicare is not part of the health insurance marketplace rolled out under the Affordable Care Act, so you will not be dealing with any marketplace during the open enrollment period.

Individuals already enrolled in Medicare and who are satisfied with their services and coverage don’t need to do anything during the open enrollment period. However, changes in prescription policies are common. Review your prescription and other forms of coverage for next year to ensure you’ll be covered.

Consumers should note that if you are covered only under Medicare Part B (medical insurance) and don’t have Medicare Part A (Hospital insurance), you are not considered covered by the healthcare law’s requirements for health insurance.

What if I want to transition from the Marketplace to Medicare?

If you become eligible for Medicare after you have enrolled in the Marketplace, you can cancel your Marketplace coverage and enroll in Medicare during the open enrollment period. You may also take advantage of the initial enrollment period, which means that you can sign up for Medicare during a seven-month period of time that begins three months prior to the month you turn 65 years of age, during the month you  turn 65, and the following three months after you turn 65.

Yes, it can be confusing. Support and resources through the Alliance of Claim Assistance Professionals (ACAP) is available to first-time enrollees or others confused by what to do when assessing options during the open enrollment period to get the best coverage that meets your needs.

Transitioning Challenges Face many with Implementation of ICD-10

ICD 10 coding procedures were effectively initiated on October 1, 2015. For many, it’s about time that the United States medical system joined the rest of the world when it comes to coding practices. With its release, coding professionals can breathe a sigh of relief that the wait is over, but vast differences found between the two versions are causing confusion, frustration, and anxiety for many in healthcare.

During this transition, experts are expecting a greater number of denied claims to be bounced back to health care providers. What does that mean for you? Longer reimbursement time. More red tape. More phone calls and letters. More frustration.

Claims assistance professionals can reduce the number of denials of new claims filed after October 1, 2015 by organizing health insurance paperwork, reviewing claims for accurate coding, and directly deal with insurance companies and medical providers to ensure proper payment.

Why the change? Because after 30 years, medical treatments, knowledge, and technologies have advanced. The new coding procedures will enable doctors and hospitals to share more detailed information that ensures quality of care and plays a huge role in reimbursements for physicians and hospitals.

Over 100,000 new codes in ICD-10 provide challenges not only for billers and coders, but for doctors as well.

Bills with service dates after the October 1 implementation date must have ICD-10 codes or will be rejected or denied. Valid diagnostic codes will also be required in order to gain approval for many medical procedures and costly tests.

Brief history of ICD-10

A number of entities developed what was to become the International Classification of Diseases (ICD) starting in 1950, including the U.S. Public Health Service, the Veterans Administration, and Columbia Presbyterian Medical Center in New York. In 1966, the 8th version was published as the International Classification of Diseases, Adapted. Throughout the 1970s, other versions were published.

The World Health Organization (WHO) has been involved in creation of development of ICD publications since 1946 and helped develop the International Classification of Procedures in Medicine (ICPM) which was published in 1978. WHO was also involved with experimenting with alternative model structures for ICD-10.

The World Health Organization adopted ICD-10 in 1994. Since the mid-1990s and heading into the new millennium, a number of issues delayed the transition to ICD-10 in the US.

According to data gathered by the Workgroup for Electronic Data Interchange, delays have also affected readiness to implement the transition from ICD-9 to ICD-10. In March 2015, data was gathered among a small group of health care providers, health plans, and vendors. Less than one fourth of the physicians queried determined that they would be ready to implement ICD-10 by the October 1 compliance date. Approximately twenty-five percent claimed that they would be ready.

Ready or not, claims must be correct in regard to coding and accurate processing measures– if not, those claims will be delayed or denied.

Major differences between ICD-9 and ICD-10

Specificity is the name of the game with the new ICD 10 release. First, the basic and major differences between ICD-9 and ICD can include:

icd9 and ICD 10

In addition, codes for inpatient hospital procedures climbs from 4,000 to 87,000.

For example: a femur fracture using ICD-9 and ICD 10:

ICD-9 (Code 821.11) Open fracture of shaft a femur
(Number of codes for femur fracture? 16)

ICD-10 (S72.351C) Displaced, comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC
(Number of codes for femur fracture? 1,530)

ICD-10 coding define injuries based not on type of injury, but anatomical site. In addition, E and V codes are incorporated into ICD-10, and new code definitions bring the codes into the modern era. Certain disease processes have also been reclassified to new sections or chapters that reflect up-to-date medical knowledge.

Help and solutions for the challenging transition from ICD-9 to ICD-10 are available through the Alliance of Claim Assistance Professionals (ACAP). Whether you’re a patient or a provider, call on the experts to help with your medical claim issues.

Mental Health Parity Still a Distant Wish for Most

Mental health parity remains a constant battle for young and middle aged populations of Americans seeking mental health services for drug and alcohol abuse, eating disorders, rape counseling, and posttraumatic stress disorders (PTSD). The challenges that such individuals face often go against insurance “standards” when it comes to provision of care. Unfortunately, when it comes to mental health and issues, the watchwords of most insurance companies still utilize the acute care standard – “if not suicidal, have to discharge”.

The Paul Wellstone Mental Health and Parity Act signed into law in 2008. The act sought to ensure that insurance companies treated mental health issues and substance abuse disorders on the same level as physical illnesses when a person’s insurance policy offers coverage for both. Since then the Affordable Care Act the mental health parity was extended to provide equal benefits with medical coverage, even for individual health insurance coverage.

Unfortunately, actual changes are not taking hold. Mental and substance abuse problems are still considered only on an acute care basis. Regrettably, such issues are often chronic in nature and necessitate long term management.

An alarming number of individuals between the ages of 20 and 30 are finding it increasingly difficult to obtain care coverage for mental health issues and related behaviors. County health services have begun to develop “transition programs” but in some areas, a four plus month wait or longer is typical. Individuals, including those dealing with PTSD, substance abuse, and eating disorders, are either being denied access to such care facilities or are being discharged from their treatment programs early. When an individual’s treatment courses are cut short, they often return home with ineffective coping skills that lead to relapses and in some cases, death.

60 Minutes recently ran a story related to denial of mental health coverage by insurance companies despite doctor’s prescribed orders for treatments of mental health and addictive behavioral issues. In fact, the exposé noted that many insurance adjusters “aggressively” review not only chronic cases, but long-term mental health care needs. Most health insurance companies often deny coverage for full treatment care plans, cutting off benefits at the halfway point.

In an attempt to enhance mental health treatment opportunities, the Affordable Care Act has shown significant improvements for those seeking care in physician and therapist office settings. Unlimited visits are a definite improvement for those with manageable mental health problems. Unfortunately, for those needing intensive outpatient or inpatient services, the quality of care and the number of in-network providers are limited.

Most reputable mental health treatment centers are out-of-network, placing a significant financial burden on patients and their families. Many of these patients are young adults still in college or high school, which creates a volatile situation within the family dynamic. Young adults often blame parents for their substance abuse; divorce, neglect, emotional distance are just a few reasons. Yet most parents paying for their children’s treatment don’t share this blame.

In today’s healthcare economy, insurance companies are the ones who determine duration of treatment, which makes it extremely difficult not only for patients to receive the care they need, but for patients and family members to struggle through the requirements and demands of filing claims, billing and reimbursement for such services.

Real solutions are only possible with genuine consideration from insurance companies. The Alliance of Claim Assistance Professionals (ACAP) strongly urges our readers to file appeals on all levels, as ACAP experience tells us that meaningful review takes place at the Departments of Insurance levels. Significant change will only come by filing mental health denial appeals to state insurance departments.

Nursing Home Medicare Coverage – Skilled vs. Custodial

Obtaining reimbursement from Medicare or third party payor insurance companies has become increasingly complex, especially in today’s healthcare environment following changes in how health care providers and facilities bill for services. Hospitals now discharge patients at a faster rate, often referring them to nursing homes or long-term care and rehabilitation facilities for aftercare services.

Costs for skilled nursing facilities or nursing homes are covered only when skilled nursing rehabilitation or care occurs within 30 days of a three-day long or longer hospitalization and is deemed medically necessary. Medicare Part A does not cover skilled nursing facility care if the patient does not require such services and only requires custodial care.

What’s the difference between skilled rehabilitation and custodial care? Medicare does not cover or reimburse for custodial care when it’s the only kind of care required by a patient or resident. Custodial care is defined as care offered to a patient or resident that does not involve or require skilled nursing services. Help with bathing, dressing, toileting, and other activities of daily living that don’t require specific and licensed medical skills are classified as custodial care.

Skilled nursing care can involve medical treatments and procedures (catheter care, Nebulizer treatments, breathing apparatus, etc.), medication oversight, wound care, physical therapy and other services where a patient or resident requires continued medical care on an inpatient basis. Skilled rehabilitation is deemed medically necessary to provide maintenance or improvement of health to a patient or resident. Skilled rehabilitation services must be supervised or delivered by licensed professional or technical medical personnel in order to achieve a specific medical outcome.

When factoring in reimbursement, be aware that Medicare Part A generally kicks in during the first 20 days, with 100% of the amounts approved. The longer you stay in a skilled nursing facility, the less Medicare eventually pays out. For example, the 2015 figures for reimbursement claims specify that between days 21 and 100, a patient’s coinsurance will pay $157.50 per day for each benefit period. After day 100, the patient is responsible for all costs.

The Affordable Care Act

The Affordable Care Act is Enabling Everyone to Have Medical Insurance
The Affordable Care Act has given many Americans the opportunity to finally be able to afford and obtain health insurance. Through the Affordable Care Act, Americans can now find affordable medical insurance that covers their healthcare needs.

Also known as Obamacare, the Affordable Care Act is based on a lengthy piece of legislation which assigns power to government programs, on an ongoing basis, to continuously improve and reform health care. Reforms impact funding and spending, taxes, insurance company rules, protections, benefits, rights and more.

Most preventive care services are offered without deductibles. For lower income people, subsidies are available through the Health Insurance Exchanges. Through the Medicaid extension provided by many states more people can apply for state funded medical care.

Providing Access for Uninsured Americans with Pre-Existing Conditions
Before the Affordable Care Act was enacted, many Americans were unable to obtain health insurance due to pre-existing conditions they may have had. These Americans only had hope of obtaining insurance if they could find a full time job that offered health benefits, or if they purchased a very expensive policy which offered coverage for a high risk pool, organized by many states. If they lost said job, then their insurance policies would lapse and they would be uninsured. The Affordable Care Act has made it possible for people with pre-existing conditions to finally obtain their own private health insurance. Through this Act, insurance companies are no longer allowed to turn away any customers.

Extending Coverage for Young Adults
With the ACA, young adults have the ability to stay on their parents’ insurance policy until they are 26 years old. This coverage is available without contingencies based on being a student, living with the parent, being financially dependent or being married. This allows young adults to go to college and get married, without the burden of health insurance over their heads. The majority of young adults can also graduate from college and find a job with benefits before they are taken off of their parents’ insurance policy.

Expanding Coverage for Early Retirees
Often, Americans wish to retire before they become eligible for Medicare. Before the Affordable Care Act, these Americans had to either wait to retire until they became eligible for Medicare, or they had to buy private, expensive insurance plans to cover them for a few years. Now, the Affordable Car Act has created a $5 billion program to provide these seniors with financial help and coverage to cover them between their retirement date and the date they become Medicare eligible.

Offering Free Preventative Care
All of the new insurance plans created by the Affordable Care Act must now cover certain preventative services. Preventative services such as, physicals, mammograms, colonoscopies, and many others are free so that patients can stay healthy as they grow older and enjoy their retirement.

The Affordable Care Act has significantly improved the healthcare market in America. It has allowed numerous people to obtain health insurance for an affordable price, and has helped reduce healthcare costs throughout the country. Through the Affordable Care Act, many people have benefited and will continue to benefit from healthcare services for many years.