The Affordable Care Act is the law of the land and is most likely here to stay.
That was the analysis provided by Andy Figelstahler with Ed Jacobs & Associates in a presentation to the Bradley Sunrise Rotary Club on Thursday.
“It is probably one of the most significant pieces of legislation that will occur during our lifetime,” attorney Matt Coleman said in his introduction of the speaker. “We need to be careful and be compliant, no matter what side of the aisle on which you may sit.”
Figelstahler gave a summarized version of the law.
“It is very complex and very complicated. It affects everybody in some form or fashion,” he said.
He said in 2014, the law defines small businesses as those with under 50 employees.
“In 2016, it bumps it up to 100,” he said.
Figelstahler said for small groups and individuals, the law mandates 10 essential health benefits.
“Eventually, everybody in that segment is going to have to buy a policy that covers those 10 essential health benefits,” he said.
Figelstahler said most policies today cover the majority of those benefits.
He said there are two benefits that have drawn the most attention: maternity and pediatric dental/vision coverage.
“I know I don’t need it as an individual, but I’m going to pay for it to spread that cost over the masses,” Figelstahler said. “That’s been an issue for people on individual plans.”
The pediatric benefit covers children under the age of 19.
“Most people who have families covered will have the dental embedded in their medical plan.”
He said for those over 50 years of age, those essentials are exempted.
Figelstahler said he believes the new requirement under the Affordable Care Act that insurance companies cannot deny coverage based on pre-existing conditions is a “huge benefit.”
“There have been a lot of people around town that have been uninsured that needed coverage and have coverage paid for,” he said.
Another part of the law has all co-payments counting toward the out-of-pocket maximum amount.
“In years past, co-pays just went out into thin air,” Figelstahler said. “Now, if you are buying a compliant health care plan, those office visit co-pays, those prescription co-pays, your emergency room co-pays ... they all accumulate toward the out-of-pocket maximum.”
He said insurance is “really no longer risk based.”
“They can only rate on four factors, and medical condition is not one of them,” he said.
The four factors are age, tobacco use, geographic location and family composition.