Keeping Your Doctor Under The Senate Finance Proposal
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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?
PRIVATE COVERAGE
GOVERNMENT COVERAGE
NO
Defense
YES Veterans’ health system OR Medicare FFS or managed care plan
OR
Has DHHS permitted “larger firms” (>50 workers) to enter the Exchange?
YES
Have I been disenrolled for failing to pay my premiums?
NO YES
Can I file a grievance with my State Ombudsman? Title I, subtitle F
Have I provided proof that I’m insured to the IRS?
Can I afford to pay the whole cost in cash?
Can I afford the cost-sharing? Can I afford the higher costsharing due to the 35% high-cost plan tax and $2,000 FSA cap? Title VI
Title I, subtitle C
NO
Self-insured plan
OR
Fully insured plan
INDIVIDUAL MARKET INSURANCE POLICY
YES
NO
Can I find a different Dr. or a clinic willing to treat me for free?
YES
COVERAGE REGULATIONS
YES YES NO
YES
I’m uninsured.
NO
Do I fall into one of the NO categories of persons exempted from the individual mandate? Have I paid the penalty for being uninsured?
Health plan must be acceptable coverage as set forth under the NAIC Model Regulation.
Health plan must meet DHHS mandatory benefits standards. Benefit Levels: Platinum Gold Silver Bronze
Title I, subtitle A
Title I, subtitle C
Title I, subtitle D
TREATMENT ACCESS
Have the rate cuts imposed by America’s Healthy Future Act of 2009 and/or proposed by IMAC caused my Dr. to stop treating Medicare patients?
Is my plan a private sector plan? Is my plan the government CO-OP or other government plan? NO
NO
YES
Is the treatment I need covered by my health plan? PCORI
Does my plan deny coverage of the treatment due to PCORIfunded research? Title III, subtitle F
YES
NO
Is coverage of the treatment mandated by a DHHS regulation and/or by my State?
YES Does my plan restrict access to my Dr.?
Title III, subtitle E
Title I, subtitle A
YES
NO Am I eligible for this service as determined by an electronic check with or without my “machinereadable [health] identification card”? Title III, subtitle G
My Dr. is not in my health plan.
My Dr. is in my health plan. My treatment is not covered.
Am I eligible for an affordability cost-sharing tax credit of sufficient generosity? YES
EMPLOYER SPONSORED INSURANCE
YES
Has my employer shifted me into the government CO-OP?
Does my Dr. participate in my health plan, i.e., accept its reimbursement rates as payment in full? IMAC
FINANCIAL ACCESS Do applicable rules permit my Dr. to accept cash from me?
Can I afford individual market coverage? YES
DOCTOR ACCESS
Title I, subtitle D
NO
Ombudsman
Can I afford NO non-Exchange ESI coverage?
Title I, subtitle A
I’m insured.
NO
Private plan
Title I, subtitle B
Can I Have I elected afford Exchange YES an Exchange plan or been NO coverage? auto-enrolled in one?
NO
Has DHHS grandfathered in my individual market coverage?
YES
Title I, subtitles B, D
I’m unable to receive care.
NO
Title I, subtitle C
Can I afford individual market coverage with the help of a state high-risk pool?
Has my Exchange plan been suspended by DHHS or my State from receiving payments for my coverage due to violations of law or regulations?
OR
Title I, subtitle C
INDIVIDUAL MARKET INSURANCE
Am I currently enrolled and paid up?
I’m unable to receive care from my Dr.
CO-OP Title I, subtitle E
Title I, subtitles B, D
ENROLLMENT STATUS
YES
HEALTH INSURANCE EXCHANGE
YES
Am I eligible for federal Exchange subsidies (MAGI=134-300% FPL)?
Are my ESI premiums “unaffordable” (>13% MAGI)?
Title I, subtitle B
NO
YES
Is my Dr. willing to treat me for free?
NO
YES
Am I otherwise eligible for Exchange coverage?
COVERAGE OPTIONS
Title I, subtitle B
CMS & my Medicaid/CHIP State Managed care plan OR Exchange
I’m able to YES receive care from my Dr.
Has DHHS grandfathered in my small group coverage?
Does my employer offer me coverage?
OR
CMS
NO Is my ESI offered outside the Exchange? Title I, subtitle A NO YES Is my ESI provided through the Exchange? YES Does my employer employ ≤ 50 workers?
CHAMPUS/TRICARE VA
INSURANCE EXCHANGE
EMPLOYER SPONSORED INSURANCE
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
NO
YES My treatment is covered.
MAGI: Modified adjusted gross Question Start Current government agency/program FFS: Fee-for-service income Positive New government agency/program Added by bill FPL: Federal poverty level PCORI: Patient-Centered FSA: Flexible Spending Arrangement Outcomes Research Inst. Negative New personal responsibility/penalty HBAC: Health Benefits Adv. Cmte. NAIC: Natl. Assn. of Insur. Source: Joint Economic Committee, Republican Staff http://jec.senate.gov/republicans IMAC: Independent Medicare Adv. Comm. Commissioners * Finance Cmte. Chairman’s Mark, “America’s Healthy Future Act of 2009,” as released 9/16/09
Am I covered?
PRIVATE COVERAGE
GOVERNMENT COVERAGE
NO
Defense
YES Veterans’ health system OR Medicare FFS or managed care plan
OR
Has DHHS permitted “larger firms” (>50 workers) to enter the Exchange?
YES
Have I been disenrolled for failing to pay my premiums?
NO YES
Can I file a grievance with my State Ombudsman? Title I, subtitle F
Have I provided proof that I’m insured to the IRS?
Can I afford to pay the whole cost in cash?
Can I afford the cost-sharing? Can I afford the higher costsharing due to the 35% high-cost plan tax and $2,000 FSA cap? Title VI
Title I, subtitle C
NO
Self-insured plan
OR
Fully insured plan
INDIVIDUAL MARKET INSURANCE POLICY
YES
NO
Can I find a different Dr. or a clinic willing to treat me for free?
YES
COVERAGE REGULATIONS
YES YES NO
YES
I’m uninsured.
NO
Do I fall into one of the NO categories of persons exempted from the individual mandate? Have I paid the penalty for being uninsured?
Health plan must be acceptable coverage as set forth under the NAIC Model Regulation.
Health plan must meet DHHS mandatory benefits standards. Benefit Levels: Platinum Gold Silver Bronze
Title I, subtitle A
Title I, subtitle C
Title I, subtitle D
TREATMENT ACCESS
Have the rate cuts imposed by America’s Healthy Future Act of 2009 and/or proposed by IMAC caused my Dr. to stop treating Medicare patients?
Is my plan a private sector plan? Is my plan the government CO-OP or other government plan? NO
NO
YES
Is the treatment I need covered by my health plan? PCORI
Does my plan deny coverage of the treatment due to PCORIfunded research? Title III, subtitle F
YES
NO
Is coverage of the treatment mandated by a DHHS regulation and/or by my State?
YES Does my plan restrict access to my Dr.?
Title III, subtitle E
Title I, subtitle A
YES
NO Am I eligible for this service as determined by an electronic check with or without my “machinereadable [health] identification card”? Title III, subtitle G
My Dr. is not in my health plan.
My Dr. is in my health plan. My treatment is not covered.
Am I eligible for an affordability cost-sharing tax credit of sufficient generosity? YES
EMPLOYER SPONSORED INSURANCE
YES
Has my employer shifted me into the government CO-OP?
Does my Dr. participate in my health plan, i.e., accept its reimbursement rates as payment in full? IMAC
FINANCIAL ACCESS Do applicable rules permit my Dr. to accept cash from me?
Can I afford individual market coverage? YES
DOCTOR ACCESS
Title I, subtitle D
NO
Ombudsman
Can I afford NO non-Exchange ESI coverage?
Title I, subtitle A
I’m insured.
NO
Private plan
Title I, subtitle B
Can I Have I elected afford Exchange YES an Exchange plan or been NO coverage? auto-enrolled in one?
NO
Has DHHS grandfathered in my individual market coverage?
YES
Title I, subtitles B, D
I’m unable to receive care.
NO
Title I, subtitle C
Can I afford individual market coverage with the help of a state high-risk pool?
Has my Exchange plan been suspended by DHHS or my State from receiving payments for my coverage due to violations of law or regulations?
OR
Title I, subtitle C
INDIVIDUAL MARKET INSURANCE
Am I currently enrolled and paid up?
I’m unable to receive care from my Dr.
CO-OP Title I, subtitle E
Title I, subtitles B, D
ENROLLMENT STATUS
YES
HEALTH INSURANCE EXCHANGE
YES
Am I eligible for federal Exchange subsidies (MAGI=134-300% FPL)?
Are my ESI premiums “unaffordable” (>13% MAGI)?
Title I, subtitle B
NO
YES
Is my Dr. willing to treat me for free?
NO
YES
Am I otherwise eligible for Exchange coverage?
COVERAGE OPTIONS
Title I, subtitle B
CMS & my Medicaid/CHIP State Managed care plan OR Exchange
I’m able to YES receive care from my Dr.
Has DHHS grandfathered in my small group coverage?
Does my employer offer me coverage?
OR
CMS
NO Is my ESI offered outside the Exchange? Title I, subtitle A NO YES Is my ESI provided through the Exchange? YES Does my employer employ ≤ 50 workers?
CHAMPUS/TRICARE VA
INSURANCE EXCHANGE
EMPLOYER SPONSORED INSURANCE
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
NO
YES My treatment is covered.
MAGI: Modified adjusted gross Question Start Current government agency/program FFS: Fee-for-service income Positive New government agency/program Added by bill FPL: Federal poverty level PCORI: Patient-Centered FSA: Flexible Spending Arrangement Outcomes Research Inst. Negative New personal responsibility/penalty HBAC: Health Benefits Adv. Cmte. NAIC: Natl. Assn. of Insur. Source: Joint Economic Committee, Republican Staff http://jec.senate.gov/republicans IMAC: Independent Medicare Adv. Comm. Commissioners * Finance Cmte. Chairman’s Mark, “America’s Healthy Future Act of 2009,” as released 9/16/09
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