Keeping Your Doctor Chart
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“If you like your doctor, you can keep your doctor.” Keeping your doctor under the Senate Democrats’ bill* is as easy as . . . I want to receive care from my Dr.
Am I covered?
GOVERNMENT COVERAGE
EMPLOYER SPONSORED INSURANCE
Defense CHAMPUS/TRICARE OR VA
NO
Has DHHS grandfathered in my small group market coverage?
YES
§ 1251
YES
Veterans’ health system
Is my ESI offered outside the Exchange?
NO
NO
OR
CMS & my Medicaid/CHIP State Managed care plan OR Exchange
Has my State permitted firms with >100 workers to enter the Exchange?
YES
§ 1401
ENROLLMENT STATUS
Can I afford individual market coverage with the help of a state high-risk pool?
Am I currently enrolled and paid up?
NO YES
Can I afford individual market coverage?
Has DHHS grandfathered in my individual market coverage?
I’m unable to receive care. Ombudsman Can I file a grievance with my State Ombudsman?
I’m insured.
§ 1002
Have I provided proof that I’m insured to the IRS? § 1502
FINANCIAL ACCESS Do applicable rules permit my Dr. to accept cash from me?
Can I afford to pay the whole cost in cash?
Can I afford the higher cost-sharing due to the 40% high-cost plans tax and $2,500 FSA cap? §§ 9001, 9005
Can I afford the 3:1 community rating that increases premiums for the non-elderly?
NO
Am I eligible for reduced cost-sharing of sufficient generosity? § 1402
Can I find a different Dr. or a clinic willing to treat me for free?
YES NO
Health plan must meet all federal coverage rules as set forth in this Act.
Health plan must meet DHHS mandatory benefits standards. Benefit Levels: Platinum Gold Silver Bronze
§§ 1001-1253
§ 1302(d)
§ 1501(b)
NO
Is my plan the Govt. Plan or other government plan?
NO
NO
YES
My Dr. is not in my health plan.
CHIP: Children’s Health Insurance Program CHAMPUS: Civilian Health & Medical Program for Uniformed Services CMS: Centers for Medicare and Medicaid Services DHHS: Dept. of Health and Human Services
§ 6301
YES
NO Is coverage of the treatment mandated by a DHHS regulation and/or by my State?
§ 1323
§ 3403
Is the treatment I need covered by my health plan?
PCORI Does my plan deny coverage of the treatment due to PCORI-funded research?
§ 1301
Does my Dr. treat Medicare patients despite the reimbursement rate cuts imposed by this Act and/or proposed by IMAB?
YES
TREATMENT ACCESS
Is my plan a private sector plan that “complies with the regulations developed by the [DHHS] Secretary”?
Does my Dr. participate in my health plan, i.e., accept its reimbursement rates as payment in full? IMAB
Can I afford the premiums and cost-sharing?
YES
Fully insured plan
COVERAGE REGULATIONS
Do I fall into one of the NO categories of persons exempted from the individual mandate? Have I paid the penalty for being uninsured?
I’m uninsured.
DOCTOR ACCESS
NO
§ 1201
NO
YES
NO
NO
OR
INDIVIDUAL MARKET INSURANCE POLICY
YES
§ 1251
I’m unable to receive care from my Dr.
Self-insured plan
YES
§§ 1312(a)(2)(A), 1323
YES
§§ 1301, 1313
YES
Has my employer shifted me into the Govt. Plan?
NO Have I been disenrolled for failing to pay my premiums?
YES
EMPLOYER SPONSORED INSURANCE
YES
Can I afford non-Exchange NO ESI coverage?
INDIVIDUAL MARKET INSURANCE
Is my Dr. willing to treat me for free?
Private plan
§§ 1312, 1511
YES
I’m able to YES receive care from my Dr.
OR
§§ 1311-12, 1321
Can I Have I elected afford an Exchange Exchange YES plan or been NO coverage? auto-enrolled in one?
NO
Has DHHS penalized my State or Exchange, or barred my plan from participation, due to violations of law or regulations?
Govt. Plan § 1323
NO
Are my ESI premiums “unaffordable” (>9.8% MGI)?
§§ 1304, 1312(f)
HEALTH BENEFITS EXCHANGE
YES
§ 1401
YES
§ 1312
Medicare FFS or managed care plan
Am I otherwise eligible for Exchange coverage? Am I eligible for federal Exchange subsidies (MGI=100-400% FPL)?
YES
Is my ESI provided through the Exchange? Does my employer employ ≤ 100 workers?
OR CMS
NO
Does my employer offer me coverage?
COVERAGE OPTIONS
INSURANCE EXCHANGE
PRIVATE COVERAGE
§§ 1001-1304
YES YES Does my plan restrict access to my Dr.?
My Dr. is in my health plan.
NO Am I eligible for this service as determined by an electronic check with or without my “machinereadable [health] identification card”? § 1104
My treatment is not covered.
NO
YES My treatment is covered.
Question Start Current government agency/program ESI: Employer Sponsored Insurance MGI: Modified gross income Positive New government agency/program Added by bill FFS: Fee-for-service PCORI: Patient-Centered Negative New personal responsibility/penalty FPL: Federal poverty level Outcomes Research Inst. FSA: Flexible Spending Arrangement NAIC: Natl. Assn. of Insur. Source: Joint Economic Committee, Republican Staff http://jec.senate.gov/republicans IMAB: Independent Medicare Adv. Board Commissioners * "Patient Protection & Affordable Care Act," intro'd by Sen. Maj. Ldr. Harry Reid (D-NV) 11/18/09
Am I covered?
GOVERNMENT COVERAGE
EMPLOYER SPONSORED INSURANCE
Defense CHAMPUS/TRICARE OR VA
NO
Has DHHS grandfathered in my small group market coverage?
YES
§ 1251
YES
Veterans’ health system
Is my ESI offered outside the Exchange?
NO
NO
OR
CMS & my Medicaid/CHIP State Managed care plan OR Exchange
Has my State permitted firms with >100 workers to enter the Exchange?
YES
§ 1401
ENROLLMENT STATUS
Can I afford individual market coverage with the help of a state high-risk pool?
Am I currently enrolled and paid up?
NO YES
Can I afford individual market coverage?
Has DHHS grandfathered in my individual market coverage?
I’m unable to receive care. Ombudsman Can I file a grievance with my State Ombudsman?
I’m insured.
§ 1002
Have I provided proof that I’m insured to the IRS? § 1502
FINANCIAL ACCESS Do applicable rules permit my Dr. to accept cash from me?
Can I afford to pay the whole cost in cash?
Can I afford the higher cost-sharing due to the 40% high-cost plans tax and $2,500 FSA cap? §§ 9001, 9005
Can I afford the 3:1 community rating that increases premiums for the non-elderly?
NO
Am I eligible for reduced cost-sharing of sufficient generosity? § 1402
Can I find a different Dr. or a clinic willing to treat me for free?
YES NO
Health plan must meet all federal coverage rules as set forth in this Act.
Health plan must meet DHHS mandatory benefits standards. Benefit Levels: Platinum Gold Silver Bronze
§§ 1001-1253
§ 1302(d)
§ 1501(b)
NO
Is my plan the Govt. Plan or other government plan?
NO
NO
YES
My Dr. is not in my health plan.
CHIP: Children’s Health Insurance Program CHAMPUS: Civilian Health & Medical Program for Uniformed Services CMS: Centers for Medicare and Medicaid Services DHHS: Dept. of Health and Human Services
§ 6301
YES
NO Is coverage of the treatment mandated by a DHHS regulation and/or by my State?
§ 1323
§ 3403
Is the treatment I need covered by my health plan?
PCORI Does my plan deny coverage of the treatment due to PCORI-funded research?
§ 1301
Does my Dr. treat Medicare patients despite the reimbursement rate cuts imposed by this Act and/or proposed by IMAB?
YES
TREATMENT ACCESS
Is my plan a private sector plan that “complies with the regulations developed by the [DHHS] Secretary”?
Does my Dr. participate in my health plan, i.e., accept its reimbursement rates as payment in full? IMAB
Can I afford the premiums and cost-sharing?
YES
Fully insured plan
COVERAGE REGULATIONS
Do I fall into one of the NO categories of persons exempted from the individual mandate? Have I paid the penalty for being uninsured?
I’m uninsured.
DOCTOR ACCESS
NO
§ 1201
NO
YES
NO
NO
OR
INDIVIDUAL MARKET INSURANCE POLICY
YES
§ 1251
I’m unable to receive care from my Dr.
Self-insured plan
YES
§§ 1312(a)(2)(A), 1323
YES
§§ 1301, 1313
YES
Has my employer shifted me into the Govt. Plan?
NO Have I been disenrolled for failing to pay my premiums?
YES
EMPLOYER SPONSORED INSURANCE
YES
Can I afford non-Exchange NO ESI coverage?
INDIVIDUAL MARKET INSURANCE
Is my Dr. willing to treat me for free?
Private plan
§§ 1312, 1511
YES
I’m able to YES receive care from my Dr.
OR
§§ 1311-12, 1321
Can I Have I elected afford an Exchange Exchange YES plan or been NO coverage? auto-enrolled in one?
NO
Has DHHS penalized my State or Exchange, or barred my plan from participation, due to violations of law or regulations?
Govt. Plan § 1323
NO
Are my ESI premiums “unaffordable” (>9.8% MGI)?
§§ 1304, 1312(f)
HEALTH BENEFITS EXCHANGE
YES
§ 1401
YES
§ 1312
Medicare FFS or managed care plan
Am I otherwise eligible for Exchange coverage? Am I eligible for federal Exchange subsidies (MGI=100-400% FPL)?
YES
Is my ESI provided through the Exchange? Does my employer employ ≤ 100 workers?
OR CMS
NO
Does my employer offer me coverage?
COVERAGE OPTIONS
INSURANCE EXCHANGE
PRIVATE COVERAGE
§§ 1001-1304
YES YES Does my plan restrict access to my Dr.?
My Dr. is in my health plan.
NO Am I eligible for this service as determined by an electronic check with or without my “machinereadable [health] identification card”? § 1104
My treatment is not covered.
NO
YES My treatment is covered.
Question Start Current government agency/program ESI: Employer Sponsored Insurance MGI: Modified gross income Positive New government agency/program Added by bill FFS: Fee-for-service PCORI: Patient-Centered Negative New personal responsibility/penalty FPL: Federal poverty level Outcomes Research Inst. FSA: Flexible Spending Arrangement NAIC: Natl. Assn. of Insur. Source: Joint Economic Committee, Republican Staff http://jec.senate.gov/republicans IMAB: Independent Medicare Adv. Board Commissioners * "Patient Protection & Affordable Care Act," intro'd by Sen. Maj. Ldr. Harry Reid (D-NV) 11/18/09
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