How do I sign up for “Obamacare”?Unfortunately, there really is no such thing as “obamacare insurance”. The new federal health care laws, otherwise known as “Obamacare”, don’t create any new types of insurance. If you ever hear “obamacare insurance” on the news, they are talking about the redesigned health insurance plans developed by existing insurance companies which are made to comply with the new laws. These new laws require insurance companies to offer certain essential benefits and mandate other kinds of consumer protections like no pre-existing condition exclusions and offering coverage to anyone regardless of health status. In the mainland US, residents can shop for and buy these “redesigned” insurance plans on a website called the “health insurance marketplace” or “exchange”.
We don’t have this type of website in the CNMI. The reasons for this are complex, and if you want to know more about this, contact us (670) 664-3005 or email@example.com.
How do I get health insurance?Currently, the only options to get new health insurance coverage in the CNMI is either through an employer who already has a contract with an insurance company or through Medicaid, or Medicare if you qualify for eligibility. CNMI insurance companies that used to offer “individual coverage”, meaning insurance you don’t get through an employer, are not currently selling new plans (as of 3/14/14). Reasons for this are complex as well, so please contact us for details on this. The Consumer Assistance Program is working with both insurance companies and our insurance regulators to get new insurance plans available as soon as possible.
What is “Obamacare”?Obamacare refers to the Patient Protection and Affordable Care Act (or just ACA) of 2010. It’s a federal law which attempts to address the rising costs of healthcare in the US and make health care more affordable for everyone. To do this, the law focuses on regulating the health insurance industry, providing premium assistance for low-income people, and lowering the cost of care by preventing disease and improving efficiency at hospitals and clinics.
Many people think it creates a new type of public health insurance, but it actually regulates private health insurance.
I’ve heard many different things about “Obamacare” on the news. Who should I believe?The truth often gets caught in political cross-fire, so a landmark policy change like this quickly becomes all about proving that it “worked” or “failed” rather than working harder to reach the goal of making health care more affordable.
National news networks like CNN or Fox news often get caught up in politics as well, rather than giving people unbiased information. Also, national news networks don’t have information on what is going on in the CNMI. The CAP advises everyone to learn about the law and make a decision for themselves.
I don’t have time to do a bunch of research, what’s the truth, is it good or bad?The way this law currently applies to the CNMI is problematic for health insurance companies, but the federal health care reform is too large to say it’s just good or bad. We have the power to change these problems into opportunities and make the law work for us. The good: the CNMI now has a regulatory framework to regulate our health insurance industry. The bad: These new regulations may be too strict and too fast for our health insurance industry to handle, which is having negative effects on health insurance companies.
How does the Affordable Care Act affect me?Unfortunately, there is no simple answer for this. The immediate affect this law has on you is that you have more rights to benefits and protections with any private health insurance coverage than ever before in the CNMI. Currently, any private health insurance company in the CNMI cannot:
• Deny coverage of children because of a pre-existing condition
• Prohibit you from filing an appeal on a coverage denial
• Require you to get prior authorization to use emergency services
• Charge you any cost-sharing or deductible for certain in-network preventive care services
• Deny dependent coverage to your children until their 26th birthday (regardless of residence, marital, or school status)
• Spend less than 80% of premiums collects on medical claims or they must give you back the difference (CNMI residents have been reimbursed over $380,000 so far)
And there are even more new rules for 2014 like guaranteed availability of coverage and requirements to offer a robust set of benefits, but none of these new plans are available in the CNMI.
The long-term effects of the ACA in the CNMI are still uncertain. If the CNMI uses this law as a jumping board and an incentive to improve our health care system, there are opportunities to help CHCC reduce receivables and make care more efficient, improve overall health in the CNMI, and slow the increasing cost of health care.
However, if left unattended, this law could have serious negative consequences on our islands.
I’ve been calling around to health insurance companies, and no one is selling new insurance plans. Why is this?This is the major negative consequence the CNMI is facing as a result of the Affordable Care Act. CNMI health insurance companies have expressed that the new 2014 rules are simply too difficult to abide by without significantly raising premiums and risking the well-being of their businesses. As a result, none of this new 2014-compliant coverage is currently being offered in the CNMI.
As of the 2010 Census, 34% of CNMI residents had no health insurance (more than double the US). The CAP’s estimates put this number even higher in 2013. We think this increase in the uninsured is due to several factors, including the struggling economy, increased health insurance costs, and the 2013 law that made it optional for employers to cover CW workers health care costs.
Health insurance costs in the CNMI have probably increased partly because of the increased coverage, benefits and protections mandated by the ACA, but health insurance regulation didn’t really exist in the CNMI before the ACA.
With all of these problems it is causing, wouldn’t the CNMI be better off without the Affordable Care Act?Not necessarily. Because of the ACA:
• CNMI Medicaid spending cap increased by more than $100 million dollars between 2014 and 2019 and the CNMI’s local matching requirement went down from 50% to 45%.
• We have funding to establish programs such as the CAP, the Rate Review Office, and create the infrastructure of a health care data center (to track CNMI health care costs and increase transparency)
• The CNMI has a regulatory framework for health insurance (previously had almost zero regulation on this line of insurance)
Even without the ACA, the CNMI still faces a huge economic burden of disease and CHCC would still be facing millions of dollars in receivables and lack of appropriate reimbursement from the CNMI government.
What is meant by the “economic burden of disease”?
- We have a serious public health crisis in the CNMI:
7 of 10 deaths are attributed to a non-communicable disease (NCD)
45% of children are overweight or obese (33% in US)
90% of off-island medical referral cases are due to NCDs
- Our public health crisis presents a large economic burden:
The CNMI government spends roughly $4.5 million every year for off-island medical referrals due to NCDs.
About 20% of all health care costs in the US are related to obesity (probably similar or higher in the CNMI)
In the CNMI, estimates put the adult diabetes rate anywhere from 11% to well over 25% of the adult population.
On average, a person with type 2 diabetes spends over $85,000 to treat the disease and its complications over his/her lifetime
The more a person needs to go to the hospital, the higher the cost of health insurance becomes.
My lifestyle affects the cost of health care?Absolutely. If you need to go to the hospital but are unable to pay your hospital bill, the hospital will probably need to raise costs for everyone else to pay for it. Even if you have health insurance, when a health insurance must pay out a lot of money for hospital bills, premiums go up. So, preventing disease with a healthy diet and exercise can actually be cheaper for everyone, especially when we work to prevent non-communicable diseases like diabetes, hypertension, and hyperlipidemia.
A lot of money is already being spent on health care in the CNMI, so we need to find ways of spending it more efficiently. Preventing disease is significantly cheaper than treating a disease.
This is an important issue for the CNMI, how can I get involved?• Ask political candidates what their plans are for addressing this issue in the commonwealth.
• Volunteer or Intern for the CAP https://cnmicap.wordpress.com/opportunities/
• Voice your opinions about this issue! We want to hear from you. Submit your comments or questions online at https://cnmicap.wordpress.com/contact-us/
Why are health care costs so expensive and why are they increasing so quickly?Health care costs are rising faster than inflation due to:
• Poor Health
• Research and Technology
• Expensive brand-name drugs
• Excess medical services
Living a healthy lifestyle is an important way that everyone can help to reduce this increase. Improving the way doctors care for people is also an important issue which is another big focus of the ACA.
Affordable Care Act Questions
What is the Affordable Care Act (ACA)?On March 23, 2010, President Obama signed the health care reform bill, or Patient Protection and Affordable Care Act (PPACA), into law. On March 30, 2010, the Health Care and Education Reconciliation Act (HCERA) of 2010 was also signed into law. The two laws are collectively referred to as the Affordable Care Act (ACA). The Affordable Care Act includes a wide variety of provisions designed to promote accountability, affordability, quality, and accessibility in the health care system. The Affordable Care Act also includes significant grant funding for States to work with the Federal government to implement health reform. ACA makes sweeping changes to the U.S. health care system. ACA’s health care reforms are primarily focused on reducing the uninsured population and decreasing health care costs.
The Affordable Care Act puts consumers back in charge of their health care. Under the law, a new “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health.
What is the new Patient’s Bill of Rights?In 2010, a new Patient’s Bill of Rights was created along with the Affordable Care Act. This bill of rights was designed to give new patient protections in dealing with insurance companies. Some of the protections started in 2010, but others will be phased in more slowly and take full effect in 2014. Here are some of the protections covered:
• Annual and lifetime limits to coverage are being phased out.
• Health insurance companies will no longer be able to rescind (take back) your health coverage after you get sick because you made an honest mistake on your insurance application.
• Protect medical emergencies: health plan cannot require preauthorization, cannot put more limits on coverage or charge you more for out-of-network emergency services.
• Requires insurance companies to cover people with pre-existing health conditions
• Helps you understand the coverage you’re getting
• Holds insurance companies accountable for rate increases
• Makes it illegal for health insurance companies to arbitrarily cancel your health insurance just because you get sick
• Protects your choice of doctors
• Extends dependent coverage to children up to age 26
• Provides free preventive care
• Guarantees your right to appealStill, there are exceptions even to these rights. As of late 2012, many existing health plans are “grandfathered”, meaning that they don’t have to follow the new rules as long as they keep an old plan in effect, with the same insured. The new rules only apply to plans issued or renewed on or after September 23, 2010. See the ACA Major Provisions Table to see which provisions apply to your plan.
What is PPACA and what is HCERA?PPACA and the HCERA are two acronyms that are often use by different people or professionals when referencing the Affordable Care Act (ACA). Essentially they mean the same thing, unless they are making detailed legal references to provisions of the acts separately. The PPACA is an acronym that stands for Patient Protection and Affordable Care Act. In health reform, the PPACA was the first law passed on March 23, 2010, followed by the HCERA (Health Care and Education Reconciliation Act) – signed into law on March 30, 2010. The two laws are collectively referred to as the Affordable Care Act (ACA).
What is the PHSA?The PHSA is an acronym for Public Health Service Act which was enacted in 1944. Market reforms that appear in title I of the ACA are actually amendments to title XXVII to the PHSA. The PHSA is important for the CNMI (Commonwealth of the Northern Mariana Islands) because although Section 1304(d) of the ACA, defines “State” to exclude all U.S. Territories, under section 279(d)(14) of the PHSA , the definition of “State” includes all U.S. Territories. Therefore, it is because of the amendments made to the PHSA in the Affordable Care Act that these sections apply to the CNMI.
Is the Affordable Care Act only health insurance regulation?No, the health insurance market reforms are just one of the four inter-related aspects of the ACA. Other facets include: Quality and Cost measures to provide better reimbursement rates for health care providers; Public Health and Prevention Fund expands prevention coverage and created low-cost initiatives such as the Healthy Weight Program, Let’s Move, and tobacco cessation among others; Expansion of Healthcare Safety Net to expand the number and capacity of community health centers and expand other health care services.
What are Market Reforms?The Affordable Care Act market reforms are basically new rules that health insurance companies need to follow. They are federal requirements that apply to private health insurance. The reforms affect insurance offered to groups and individuals, and establish a new standard in the CNMI on access to coverage, premiums, benefits, cost-sharing, and consumer protections.
ACA market reforms that apply to the CNMI include the following that are in effect now for all health insurance plans:
Premium rate review
Health insurance issuers are required to submit justification for unreasonable premium increases to the federal and relevant state governments before they take effect.
Prohibition on lifetime limits and restriction of annual limits
Prohibits health insurance issuers from establishing lifetime limits on the dollar value of benefits and puts forth certain restrictions on annual limits.
Prohibition on rescissions
This means that health insurance issuers can’t retroactively cancel your coverage just because you have high claims.
Coverage of preventive health services with no cost-sharing
Health insurance issuers must cover certain in-network preventive health services without any additional cost to you. These services include diabetes screenings, birth control pills, annual exams and many more. See all of these types of covered services here.
Extension of dependent coverage
If your health insurance company offers dependent coverage, they must offer it to your child until his or her 26th birthday.
Prohibition of discrimination based on salary
This means that group health plans cannot discriminate in favor of high-salary individuals with respect to eligibility and benefits.
Medical loss ratio (MLR)
Under this rule, health insurance companies must spend at least 80% (85% for large group plans) of all premium dollars collected on medical claims every year, leaving only 20% for overhead, administrative costs and profit. If an insurance company does not meet this requirement, it must reimburse the difference to its enrollees. To see which CNMI insurance companies have had to reimburse enrollees, see the medical loss ratio reports here.
Health insurance issuers must provide you with a way to file an appeal or complaint on a coverage denial. You also have the right to file an “external appeal” with an unbiased third party in your insurance company maintains its original denial.
Patient patient’s choice of provider
If a health insurance company requires you to choose a “primary care provider”, they must allow you to choose who you want. This rule also applies to your choice of pediatrician or obstetrician. Additionally, if your insurance covers emergency services, you cannot be required to get prior authorization to use these services, even if it is outside of your coverage network.
Uniform explanation of coverage documents
Health insurance companies must provide an accurate, easy-to-understand summary of benefits and explanation of coverage to you. In other words, your insurance company must provide you with something that looks like this Sample Coverage documents.
Reporting requirements regarding quality of care
This rule requires the Federal government to develop guidelines for health insurance issuers to report information on initiatives and programs that improve health outcomes.The following market reforms become effective for plan years beginning on or after January 1st 2014:
Nondiscrimination based on health status
Health insurance issuers may not impose a pre-existing condition exclusion or discriminate based on your health status.
Guaranteed issue and guaranteed renewability
This means that new plans in 2014 must be offered to everyone, regardless of their health status and this coverage must be renewable.
Requires health insurance issuers to cover a minimum standard of benefits and limits the cost-sharing they can charge for these benefits.
Nondiscrimination regarding clinical trial participation
This rule prohibits insurance issuers from dropping coverage if you choose to participate in a clinical trial and they cannot deny you routine coverage that you would otherwise be receiving during the clinical trial period.
Premium rates for new plans in 2014 can only vary according to age, family size and tobacco use. This means that your premium rates cannot be higher because you have a pre-existing condition.
Waiting period limitation
A health insurance issuer may not make you wait more than 90 days before your coverage becomes effective.
Non-discrimination regarding health care providers
Health insurance issuers may not discriminate against health care providers who follow applicable professional licensing rules and state laws.It is important to note that these market reforms apply differently to specific types of plans. See the ACA Major Provision Table to see which reforms apply to your plan.
To learn the details on these market reforms, see this article from the Congressional Research Service. Or contact the Consumer Assistance Program at 670-664-3005.
Is my plan subject to the market reforms of the ACA?Most likely, your plan must comply with most of the market reforms listed above, but this depends on: the effective date of your plan, and whether your plan is an individual, small-group or large group plan. See the ACA Major Provisions Table
What is a grandfathered plan?While the Affordable Care Act requires all health plans to provide important new benefits to consumers, it allows plans that existed on or before March 23, 2010 to innovate and contain costs by allowing insurers and employers to make routine changes without losing grandfathered status.
Is my plan “grandfathered”?The new rule requires your employer or insurer to provide you notice of its status as a grandfathered plan. If you buy your own insurance, you should ask your insurer if your plan is grandfathered. However, it is unlikely that you have a grandfathered plan, as none in the CNMI have been filed with the Insurance Commissioner.
What are essential health benefits (EHBs)?The ACA requires that non-grandfathered health insurance plans in the individual and small group markets provide coverage for each of the categories below . However, the law does not define the specific services that must be covered, the amount, duration, or scope of services. States were allowed to select a benchmark plan to serve as the standard for plans required to offer essential health benefits . The default plan, Blue Cross Blue Shield Standard Option Plan, was chosen as the benchmark plan for the CNMI with a supplemented pediatric vision benchmark of the FEDVIP . This benchmark plan is also the benchmark for all other U.S. territories except Puerto Rico.
Each state and territory uses their “benchmark plan” to establish the exact benefits in each category. Health Insurance carriers may “substitute” benefits within a category, but the actuarial value must remain the same .
• Ambulatory patient services, such as doctor’s visits and outpatient services
• Emergency services
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision careLarge group plans are required to meet the cost-sharing limits and the benefit levels, but are not required to provide the full scope of benefits in the essential benefits package.
What does actuarial value mean?Actuarial Value is the percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
What does guaranteed-issue mean?Guaranteed-issue refers to the “Guaranteed availability of coverage” provision of the ACA, which says that health insurance carriers must accept every employer and individual in the State that applies for coverage, but are allowed to limit enrollment to annual open and special enrollment periods.
This means that insurance carriers are able to deny coverage to someone who applies for health insurance outside of an open enrollment period.
What does “Guaranteed Renewability” mean?This means that an insurance carrier providing coverage to an individual or group plan shall renew or continue coverage at the option of the person covered as long as the insurance carrier sells that plan.
What are wellness programs?Wellness programs are designed to promote a healthy lifestyle among employees through exercise facilities and classes or seminars. Healthier employees keep absenteeism down, boost workplace morale and can ultimately lower health care costs.
The ACA creates new incentives and builds on existing wellness program policies to promote employer wellness programs and encourage a healthier workforce. Employer-sponsored wellness programs have been gaining popularity in the U.S. and ACA-mandated regulations protect consumers from unfair practices such as rewards given exclusively to those who lose weight.
What is Medical Loss Ratio (MLR)?MLR is the percentage of insurance premium dollars (payments from the consumer) that is spent on reimbursement for clinical services and activities to improve health care quality.
The ACA requires that large group carriers must spend at least 85% of premium dollars on medical claims and individual and small group carriers must spend at least 80% on medical claims.
The ACA for CNMI residents
I’ve been hearing a lot about the ACA on TV and people being charged penalties for not having health insurance. Must I pay a penalty if I don’t have health insurance?No. The residents of the CNMI are treated as having minimum essential coverage simply by being residents of a territory . Therefore, CNMI residents and individuals residing outside the United States do not pay a penalty for not having health insurance.
Will my premiums go up?Unfortunately, health care spending is likely to continue rising faster than general inflation well into the future, resulting in higher premiums. While those with health insurance policies will enjoy greater benefits and protections under the ACA, for most Americans (including residents of territories), premiums will continue to increase from year to year. However, the new regulations are designed to prevent unreasonable and unexpected spikes in premiums and, over time, to slow the growth in health care spending. A rate review process is close to being in place in the CNMI to monitor premium rate increases and ensure the increases are not unreasonable.
Does my insurance have to cover my daughter, even though she is 24 years old and married?If your insurance offers dependent coverage, then yes, your insurance must cover your daughter until she is 26.
A health carrier cannot deny your child coverage up to age 26 regardless of your child’s financial status, residence, marital status or student status . This coverage is extended to children (sons, daughters, stepchildren, adopted children etc.) and does not cover grandchildren unless you are the legal guardian or adoptive parent of your grandchild.
I have diabetes and it has been difficult to get accepted into health care coverage. Will I be able to get covered under the Affordable Care Act?If/When health insurance carriers begin selling plans again in the CNMI it will be much easier for you to get coverage under the Affordable Care Act. Beginning in 2014, health insurance carriers may not impose a preexisting condition exclusion or discriminate based on health status . Additionally, health insurance carriers may not charge you a higher premium because of your health status . The only factors that can affect your premium amount are: family size, age and tobacco use. So, any health information you give to your insurance company cannot be used to deny you coverage or charge a higher premium.
It is important to remember, however, that insurance carriers can restrict open enrollment to certain times of the year. So, be sure you apply for health insurance coverage during an open enrollment period to get covered.
If you think your health insurance is using your health information to deny you coverage or charge a higher premium, contact the consumer assistance program (CAP).
My neighbor received a rebate check from her insurance company last year. Why didn’t I get one?Your neighbor may have received a rebate check because her insurance company didn’t spend enough of the premiums collected on medical claims. This means they were probably charging too much for premiums in the first place.
The ACA requires health insurance carriers to report health plan costs to calculate the carrier’s medical loss ratio (MLR). The ACA requires that large group carriers must spend at least 85% of premium dollars on medical claims and individual and small group carriers must spend at least 80% on medical claims.
Beginning August 2012, health plans must provide rebates to enrollees if their MLR does not meet the minimum standards. So, you probably didn’t get a rebate check because your insurance company reimbursed enough dollars to medical claims.
Since 2012, health insurance companies have rebated over $380,000 to CNMI residents because of this rule.
I know that prevention is important. Does the ACA help me get coverage for preventive screenings?Yes. The affordable care act requires non-grandfathered plans to cover preventive services for free . Some of these preventive services include:
• Type 2 Diabetes Screening for adults with high blood pressure
• Depression screening for children and adults
• Immunizations for children and adults
• Contraception for women
• Well-woman visits
For dozens more preventive services covered with no cost-sharing, visit http://www.healthcare.gov/what-are-my-preventive-care-benefits/
Must dental and vision be covered by my plan?The ACA does not mandate that adult dental and vision coverage be included in your health benefits. However, pediatric (under 19) dental and vision care must be provided in your individual or small group plan’s essential health benefits . Large group plans, such as the CNMI government health plan, are
- not required
to cover all of these benefits for your children.
What if my insurance carrier refuses to reimburse my claim?You have a right to file an appeal with your insurance company’s internal review . Ask your insurance carrier about this process. If your claim is still denied, you may appeal to an external review with the Department of Health and Human Services. Contact the Consumer Assistance Program for help filing an external review.
What does “my right to file an appeal” mean? How do I do this?Under the Affordable Care Act, your insurance carrier “…shall implement an effective appeals process for appeals of coverage determinations and claims .”
This means that if your claim for reimbursement was denied, you have a right to request that the insurance carrier review your claim. At minimum, your insurance carrier must:
• Have an internal claims appeals process
• Provide information to enrollees of this appeals process and provide reference to any consumer assistance office that may help enrolees to file an appeal. In the CNMI, this is the Consumer Assistance Program office.
• Allow an enrollee to review their file, present evidence and testimony as part of the appeals process and receive continued coverage pending the outcome of the appeal
• Provide information on an external review process (an appeal that goes to a state or federal review process after the internal review option has been exhausted)
If your medical claim has been denied reimbursement, first contact your insurance carrier for information on their internal appeals process. If the carrier does not have an internal review process or the process is confusing, contact the CAP office for assistance.
If you have filed an appeal to the insurance carrier’s internal review and your claim was still denied, contact the CAP office for information on how to file an appeal to the external review.
Filing requests to review a claim could help you avoid unfair treatment or abuses to your rights as a consumer.
My health plan doesn’t cover services that I think should be covered. Who can I talk to about this?Contact your insurance carrier and ask for the reason that a service isn’t covered and then contact the Consumer Assistance Program for further assistance.
I have a hard time understanding my health insurance coverage. Will the new health care reform make health insurance simpler?Health insurance policies have been known for small print and jargon-filled language. Under the Affordable Care Act, health insurance carriers must provide a summary of benefits that is not more than four pages in length, that is written in a culturally and linguistically appropriate manner, and contains certain content related to covered benefits, exclusions, cost-sharing and continuation coverage .
This summary of benefits and coverage document will be written in plain language to help consumers better understand the coverage they have and, for the first time, allow them to easily compare different coverage options. This summary of benefits and coverage will include a new, standardized health plan comparison tool for consumers called “coverage examples”, which would illustrate how a health insurance policy or plan would cover care for common benefits scenarios. Your health insurance company should provide you with something that looks like this Sample Coverage documents
So, understanding your health insurance policy should be significantly easier with these provisions of the ACA.
What role does the Consumer Assistance Program (CAP) have in all of this?The CAP is charged with providing health insurance education and assistance to CNMI residents. We can help consumers file complaints or appeals with their insurance company or answer questions they may have about their health insurance, including how to keep it.
Importantly, we also track questions and problems we encounter to help policy makers make decisions. So we are happy to take any kind of question, complaint or comment. Consumer information will always be kept confidential, and insurance companies cannot cancel your coverage just because you complained to the CAP about something.
We never turn away a consumer because “that’s not our job”. If nothing else, we can help refer you to the help you need.
Questions? Thoughts? Concerns? Complaints? Contact us!
Frequently Asked Questions with answers will be updated regularly as more questions from the public are submitted. To send us a question, fill out the form below or email us at firstname.lastname@example.org
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