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Affordable Care & You: December 16, 2013

“To become a healthier society is going to take a lot of work,” says Jim Nathan, President of Lee Memorial Health System.

The learning curve is steep and sometimes bumpy as scores of new people enter the insurance marketplace. Their needs will be met by health professionals- the largest in Southwest Florida is Lee Memorial Health System.

“We’re still educating ourselves- there’s so many unknowns on how all this is going to unfold. What the speed will be, what are the perplexity of the plans; so we keep trying to learn so we can help educate ourselves but also educate patients and families,” says Nathan.

The big picture can be intimidating, so regional navigators are working to demystify the process.

“Individuals can shop the marketplace. Think of the marketplace as online shopping for health insurance,” says Lynne Thorp, health care navigator with the Health Planning Council of Southwest Florida.

Available plans depend on the county where you live. Some have more insurers than others, but each insurer offers multiple plans, based on personal choice and budget.

“It’s really important to know what’s important to you. What your healthcare needs are, what prescription benefits are important to you, what providers are important to you to be in your network,” says Thorp.

You can buy in at various levels. Silver, gold and platinum; they come with different co-pays and coverages. Lee Memorial Health System and its physician group are participating in all the plans.

“There’s no question when people have health insurance the clinical outcomes are better for them. They access health care more appropriately; they don’t wait until it’s too late. But even if you have health insurance if you’re under-insured, what we’re seeing now, people with these large deductible plans are waiting and waiting,” says Nathan.

The Affordable Care Act sets standards that all insurers have to meet, and mandates that all health plans offered to those who buy insurance on their own or in small groups include a set of "essential health benefits”.

“There are ten essential benefits required under every insurance plan. Every plan has to include those 10 essential health benefits in order to be in the marketplace,” says Thorp.

They are:
ambulatory healthcare, which are doctor visits
prescription drugs
emergency care
mental health services
hospitalization
rehabilitation
preventative care
lab services
pediatric care, which includes dental and vision
maternity & newborn care

What is not allowed is also impactful: no lifetime limits, and you can’t be excluded for pre-existing conditions.

“That’s against the law now, you cannot require someone to submit any of their healthcare background,” says Thorp.

It’s covered all the bases; all that’s left is covering the community’s health care needs.