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    What do ob/gyns need to know about the new healthcare exchanges?





    Dr. Lockwood, editor in chief, is Dean of the College of Medicine and Vice President for Health Sciences at The Ohio State University, Columbus, Ohio. Contact him at [email protected].


    A new obstetric patient comes to your office recently enrolled in a Bronze tier, high-deductible, high coinsurance federally facilitated health insurance exchange plan. She immediately starts grilling you about your professional charges and your hospital’s technical charges. You soon realize that she is liable for half the costs of having her baby. What is your advice?

    I have already encountered recurrent pregnancy loss patients with high-deductible plans who have refused karyotypes and hysterosalpingograms because they would have to pay out of pocket and the results were unlikely to materially affect their management or prognosis. Welcome to the new world of public health insurance exchanges! Here’s what you need to know about the new public exchanges and how will they will affect your practice.

    Exchange rules 101

    The Affordable Care Act (ACA) includes 2 basic strategies for increasing health insurance coverage of the uninsured: 1) expanding Medicaid coverage to 133%–138% of the federal poverty line (FPL); and 2) providing subsidies to those with incomes between 100% and 400% of the FPL who obtain insurance through a public health insurance exchange “marketplace.” The new exchange plans differ from many current plans in that they mandate 10 categories of benefits (ie, outpatient care, inpatient care, emergency services, obstetrical and newborn care, mental health, rehabilitation, lab tests, prescription drugs, preventative services, and pediatric services) and cover at least 60% of actuarially predicted health costs for that year.1

    President Obama has endured much criticism for backtracking on his campaign promise that everyone could keep their insurance plan, since with the exception of plans that have been “grandfathered” (eg, in place without change since March 23, 2010), only half of current health plans cover all mandated benefits and at least 60% of anticipated costs.1

    Indeed, the 4 tiers of plans offered by public exchanges—Bronze, Silver, Gold and Platinum—are constructed based on their ability to cover 60%, 70%, 80%, and 90% of actuarially projected annual healthcare costs. Enrollees are responsible for the remainder of costs. Different plans offer varying combinations of premiums, deductibles, copays and coinsurance to distribute these costs. Catastrophic coverage-only insurance is also available for adults under 30 years who are exempt from mandates because of low income.

    One of the reasons the exchanges were opposed by the insurance industry is that very few can be denied coverage (ie, guaranteed issue) and because pricing can no longer be set through most traditional underwriting practices (ie, adjusting price based on health risks and expected costs). Thus, health plan pricing can no longer be adjusted for pre-existing medical conditions, gender, type of job, etc., although some adjustment in price is permitted for family size, geography, age, and tobacco use—a process termed “adjusted community rating.”2 Conversely, the ACA mandates a 20% to 30% discount for participation in wellness programs even though the cost-benefit data to support this policy are equivocal at best.3

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...


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