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How Obamacare Works In Colorado Springs

It’s important to understand how Obamacare works in Colorado Springs.

What is Obamacare?

Obamacare is NOT a health insurance policy.  In March, 2010 Congress passed the Affordable Care Act (ACA), now known as “Obamacare”.  The ACA is not an insurance policy.  It is a set of rules designed to control the way health care is provided and paid for in the United States.  It requires (essentially) all US residents to either purchase health insurance or to qualify for a government program such as Medicaid.  If you are required to purchase a policy, the government may subsidize part of your payments, depending on your income.

The insurance plan you end up with (assuming you do not qualify for Medicaid or medicare) has its own rules and requirements.  You will probably have a “Deductible”, a “CoPay”, and “Co-Insurance” that you will be responsible for.

Your Deductible is the amount of money you must pay out-of-pocket for medical services before your insurance will pay ANYTHING.  This means that even though you are insured and even though your provider “accepts” your insurance, you will be required to pay for all visits until your deductible has been met.  There are exceptions to this which will be discussed below.  The insurance company’s contract requires the provider to collect this money from you.

Your Co-Pay is an amount you must pay (regardless of whether or not you’ve met your deductible) prior to seeing your provider.  The amount of your co-pay will generally depend upon what kind of appointment you are having.  Generally a family practice appointment is less than a specialist appointment, which, in turn, is less than an Emergency Room or hospital appointment.

Your Co-Insurance is an amount you must pay (regardless of whether or not you’ve met your deductible) for PROCEDURES (not office visits) which is the difference between what the insurance company believes the visit is worth and what the insurance company actually pays.  Generally co-insurance will be 20-30% of the cost of the visit.

Here’s an example:

You have a health insurance policy with a $2,000 deductible, a 20% co-insurance, and a $25 co-pay for your primary care provider.  You go to your family doctor and your bill is $200, $100 for the office visit and $100 for laboratory work.

If you have a deductible of $2,000 and have not yet met that deductible, you are responsible for the entire $200.  It is the doctor’s responsibility to collect that $200.  If the doctor fails to collect it, he (and you) are guilty of insurance fraud and are subject to severe penalties.

If you have met your deductible, you owe your $25 co-pay (for the office visit) and $20 (20% of $100) for the procedure (laboratory work) for a total of $45.  Your insurance company should pay the balance.  Again, the provider is REQUIRED to collect this money.  Failure to do so is insurance fraud for you and the provider.

Under the ACA, some visits are not subject to your deductible, co-pay, or co-insurance.  These are generally preventative care visits, such as well-woman exams, pap smears, and mammograms.

Other changes that occurred with the passage of the ACA:

  • You can no longer be refused insurance (or charged more for insurance) because of pre-existing conditions (such as hypertension, diabetes, asthma, etc).  These would be medical conditions that you have before applying for insurance.
  • You can’t be penalized because of your gender.  Historically women use medical services more than men.  Insurance companies cannot charge women more than men based on gender.
  • Insurance companies may no longer place a maximum on how much they will pay over your lifetime or in a single year.  Until the ACA was enacted, medical problems were one of the primary causes of personal bankruptcy when your insurance payments had reached their limit.
  • The ACA requires employers with over 50 employees to provider medical insurance for their employees.  This requirement has been delayed until January 2015, but even after that, your employer may choose to pay a penalty rather than purchase insurance for employees.
QwikCareMD Urgent Care, Comfort Care Family Practice and Obamacare:

Urgent care centers in Colorado Springs are popping up in greater numbers here and nationwide, driven by demand for after-hours access to medical care.  The centers reflect a push toward better customer service in health care. A working parent who picks up a sick child at day care doesn’t have to wait for an appointment. A weekend athlete who twists an ankle in a pickup basketball game can go to the neighborhood urgent care center for treatment.

Urgent Care centers in Colorado Springs also fit with the push to reduce health care costs and insure more people. The centers provide an alternative to emergency room care, which generally costs patients twice as much or more. Millions more Americans will obtain health insurance because of the Affordable Care Act, also known as Obamacare, and some of the newly insured can be expected to use that coverage to have colds, the flu and cuts treated at QwikCareMD – Urgent Care.

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Steven Wenrich

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