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Health Reform 101

with Lisa Zamosky

WebMD helps readers understand their health insurance and the new health care reform law. The Affordable Care Act is bringing sweeping changes to American health care. Lisa Zamosky is here to help you navigate the health care maze and understand how these changes affect you.


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Monday, July 28, 2014

5 Things to Know About Wellness Programs

By Lisa Zamosky

man in workplace

Workplace wellness programs that help you lose weight, get more exercise, stop smoking, and better manage a long-term illness have been growing in popularity for a number of years.

According to the U.S. Labor Department, more than 90% of employers with 200 or more workers have some type of health promotion or disease-prevention program in place.

Wellness programs are one strategy employers use to keep health care costs from rising as a result of long-term conditions, such as diabetes and heart disease, that are sometimes related to lifestyle choices.

Here are five things to know about wellness programs.

1. There’s help for what ails you. More and more employers are offering programs and resources to help you improve your health: exercise areas at work, anti-stress seminars, discounted gym memberships, stop-smoking programs, diabetes counseling, and even free wristbands to track your daily physical activity. If you don’t know what’s available, ask your HR or benefits department.

2. Expect to feel some pressure. Your employer may offer rewards or penalties based on whether you participate in its wellness programs and the progress you make toward your health goals.

More than 4 in 10 companies, for example, reward or penalize employees based on tobacco use, a recent survey by Towers Watson and the National Business Group on Health found. An average of $520 a year is added to the cost of health insurance for those who smoke, according to the survey.

3. You have rights. To prevent discrimination, employers are required by law to offer you another way to earn incentives or avoid penalties.

If there’s a medical reason why completing a certain health habit isn’t possible, you need to be offered an out. For example, if you participate in your employer’s weight reduction program but ultimately don’t meet your goal due to some physical limitations, you may be able to avoid a health insurance surcharge.

So, ask your employer or health plan about reasonable alternatives to the company wellness program.

4. Get technical. Health care apps and wearable fitness devices that track your physical activity and calories burned are now incorporated into many wellness programs. They  can make it easier for you to track your progress and stick with your plan.

Many employers, for example, may subsidize a wearable fitness device, such as a FitBit, that allows you to track how many steps you take in a day and the number of calories burned. You may also be able to share your progress with co-workers through social media, so you can see how others are doing and how your level of activity compares.

5. Ask your insurer. If you’re among the millions of Americans who buy health insurance on their own instead of getting it at work, you should ask your insurance company if it offer wellness programs. Most do.

Coaching for weight management, nutrition, stress management, improving sleep, and quitting smoking are also common, and they can be a big help as you work to improve your health.

Have you participated in a wellness program? Did it help you reach your health goals? Please share your experience in the comments section below.

Posted by: Lisa Zamosky at 10:18 am

Monday, July 14, 2014

Is Your Exam Covered?

By Lisa Zamosky

doctor and patient talking

Last week, the American College of Physicians (ACP) released guidelines saying that the annual pelvic exam is no longer necessary for women who are not pregnant and have no unusual symptoms.

The American College of Obstetricians and Gynecologists (ACOG) disagrees. In a statement, ACOG says: “The College continues to firmly believe in the clinical value of pelvic examinations.”

This isn’t the first time opinions have differed about the value of medical tests we’ve longed assumed were needed. And it likely won’t be the last.

Women need to discuss their particular medical situation with their doctors to determine the best course of action. But if you and your doctor decide a pelvic exam is needed, will the ACP’s new guidelines affect whether or not your insurance plan covers it?

Affordable Care Act and Preventive Care

Pelvic exams are a standard part of well-women visits, which are among a list of 22 types of preventive care outlined in the Affordable Care Act specifically for women. In most cases, these must be covered with no cost to you at the time of your visit.

Well-women visits have been recommended by the U.S. Preventive Services Task Force, a nonpartisan group of medical experts who make recommendations based on rigorous review of existing research.

By law, most health plans must cover preventive services that are recommended by the U.S. Preventive Services Task Force without requiring you to share in the cost.

Although health plans may consider the recommendations of various medical societies, those made by the task force carry the most weight when determining what they will and won’t pay for.

Details of Your Health Plan

Pelvic exams aren’t called out individually in the health reform law. But they are a standard part of the well-women visit, which is.

If a patient and her doctor feel a pelvic exam is needed, it’s reasonable to expect that it will be covered, says Susan Pisano, a spokeswoman for the health insurance trade group, America’s Health Insurance Plans (AHIP).

“We don’t know of any planned changes in practice,” Pisano says in response to the recent ACP announcement.

But you always need to check the details of your health plan to make sure your exam is covered with no additional cost.

Some things to keep in mind before going for a preventive health care exam:

• Is your health plan grandfathered? Health plans that were in place when the Affordable Care Act took effect on March 23, 2010, and have undergone only minor changes are exempt from covering preventive services at no cost to you.

• Insurers can interpret guidelines differently. Mammograms, for example, are a recommended preventive exam for women over 40 every 1 or 2 years. That means one carrier may pay for the test annually while another will do so only every other year. Be sure to check with your plan.

• Is your exam really preventive? If you make an appointment with your doctor because of a specific medical complaint, the visit isn’t preventive. In that case, you should expect to pay your usual fee for the visit.

What health insurance coverage questions do you have? Leave your questions and comments below.


Posted by: Lisa Zamosky at 3:08 pm

Thursday, June 19, 2014

Medigap: Can I Change Plans?

By Lisa Zamosky

mother and daughter

I recently received a question from a reader with Medicare coverage.

Q: I’m 75 years old with original Medicare and a Medigap plan. My monthly premium recently increased by 40%. I can’t afford it. Can I change Medigap policies?

A: Medigap plans are private insurance policies that work with original Medicare. Medigap covers some or all of the out-of-pocket costs that Medicare alone does not. You’re guaranteed a Medigap policy for the first 6 months of turning 65, but after that, insurers are allowed to consider the state of your health when deciding whether to sell you a plan and at what price. And, as you’ve experienced, the price of Medigap plans can increase over time.

You can certainly inquire about changing your Medigap plan, and you should. All insurers offering these policies have the same standardized packages. The main difference is price, which can vary quite a lot from one insurer to the next. And as you consider your options, keep in mind that although your premium may be high, if you require a lot of medical care, dropping the policy is likely to be even costlier, as you’d be paying on your own for services Medicare alone won’t cover.

Finding the best Medicare supplement and drug benefit plan can be tricky. I suggest you talk with a Medicare counselor for personalized assistance. Contact your State Health Insurance Assistance Programs (SHIP). To find the SHIP near you, visit the Medicare Helpful Contacts or call (800) MEDICARE.

You can also compare plans and their costs side-by-side at the Medicare Plan Finder (go to and look for Medicare Plan Finder under the Resource Locator heading on the home page), or by going to or calling 1-888-296-0117.

Have a question? Leave it in the comments section below.

Posted by: Lisa Zamosky at 2:42 pm

Thursday, June 12, 2014

6 Free Preventive Services for Your Kids

By Lisa Zamosky

child checkup

If you have a health insurance plan under the Affordable Care Act, you have many free preventive services available to you. For parents, there are 26 different preventive services available to your child without extra cost.

Here are six of the most widely used ones. You can find a complete list on

1) Vaccinations: These play an important role in lowering the risk of contracting potentially harmful diseases, such as measles, mumps, and chicken pox. A child may receive up to 14 different vaccines (49 doses, total), per The Centers for Disease Control and Prevention (CDC) recommendations, in the first 6 years.

2) “Well-baby visits”: Babies need to see their doctor six times during their first year. The doctor will do a physical exam and make sure the baby is meeting normal developmental milestones.

3) Autism screenings: Between the ages of 18 and 24 months, during well-baby visits, your child’s doctor will provide screenings for developmental delays and disabilities, including autism spectrum disorder.

4) Obesity screening and counseling: Childhood obesity is on the rise and puts kids at higher risk for developing chronic illnesses such as heart disease and type 2 diabetes. The doctor should regularly check your child’s weight to make sure it is within the healthy range. If overweight, you’ll likely receive counseling and education about how to help your child eat a healthy diet and become more physically active.

5) Vision screening: Children should have their eyes checked by the age of 6, according to the U.S. Department of Health and Human Services. All new health plans must cover, in full, vision screenings for conditions like lazy eye and crossed eyes.

6) Hearing screening: Newborns should have their hearing checked within the first month of life. There may be further tests if your child either doesn’t pass the screening or if the results leave some question about his or her ability to hear.

To see a complete list of preventive services covered by insurers at no cost to you, visit

Posted by: Lisa Zamosky at 12:50 pm

Monday, June 9, 2014

5 Health Insurance Mistakes to Avoid

By Lisa Zamosky


Shopping for health insurance and selecting the plan that’s likely to best meet your needs is no simple task. But neither is using health insurance once you have it. Insurance terms and health plan rules often lead to confusion, and unfortunately, to costly mistakes.

Here are five common health insurance mistakes to avoid.

1) You assume you’re covered. It’s common for people to assume that once they have insurance, they can simply go for care. But all health plans have limits on the services they offer. Before you make an appointment with your doctor, be sure the care you need is covered by your plan. Also make sure you understand how much of its cost will be paid by insurance. To check your coverage, you can either read your policy or contact your insurer.

2) You don’t check your plan’s medication list. If you take medication, check your health plan’s list of drugs (also called a formulary) to determine if it is covered. If it’s not, ask your doctor if there is a reasonable alternative.

3) You assume your doctor is in-network. Many of the new health plans include far fewer doctors and hospitals than they did before the Affordable Care Act. It’s been difficult in some cases to clearly tell who is and who isn’t participating. Even doctors have been unclear about which plans they’re working with. Check with both your insurer and your health care providers to confirm their in-network status before going for care. Seeing a doctor who is outside your plan’s network can be very costly.

4) You don’t know your insurance terms. Studies have shown that a very small number of people are able to accurately define basic health insurance terms. Not understanding these terms will make it difficult to figure out how much your medical care is likely to cost. Here are four of the most common terms:

  • Co-pays are fixed fees paid at the time of service for a medical visit or prescription drugs, such as $20 each time you see your doctor.
  • Deductible is the amount you’ll have to pay for services your health plan covers before you get any help covering your bills. If your deductible is $2,000, you won’t get any financial help from your plan until you’ve met your $2,000 deductible. Deductibles won’t necessarily apply to all services.
  • Co-insurance is a percentage of the cost of your care you’ll need to pay, generally after meeting your health plan’s deductible. For example, if you’re responsible for 30% co-insurance for a medication that costs $100, you will pay $30 for that drug.

This glossary of health insurance terms provides a comprehensive list of common terms you’re like to come across when using your policy.

5) You pay your bill too soon. After a doctor’s visit, you’ll receive what’s called an explanation of benefits, or EOB. It shows the service you got, how much your doctor charged, and what portion of the bill your insurer paid. If you’ve received a bill from your doctor, hold off on paying that bill until you receive your EOB and can confirm that your insurer paid its portion.

What mistakes have you made when using your benefits? Share your experience in the comments section below.

Posted by: Lisa Zamosky at 11:43 am

Friday, May 30, 2014

Financial Help for Cancer Patients

By Lisa Zamosky

looking at bills

As the media often report, and as patients themselves can attest, the cost of having cancer is extremely high. A recent industry report found that the average brand-name cancer drug in the U.S. costs $10,000 for a month’s supply – and that’s not to mention the cost for doctor visits, tests, hospital stays, etc. In addition, many people are unable to work while being treated for cancer, adding to the financial burden. And though the Affordable Care Act puts limits on the amount of money patients have to spend every year for their medical care, treating cancer can be financially devastating.

Though most are aware of the financial burden of cancer, many are not aware of the resources available for patients in need of financial assistance. Here are a few:

Government programs: Every state has a Breast and Cervical Cancer Early Detection Program that provides care for people who are uninsured, low-income, and in need of treatment. State-specific information can be found at the Centers for Disease Control and Prevention.

Private organizations: Many private community and advocacy groups offer resources and financial help for patients who need assistance paying their insurance premiums, co-pays, and coinsurance. In some cases, you can also get help paying for prescription drugs and therapies, as well as rent, food, child care, and other daily living expenses.

Here are a few sources to explore:

Help with Travel: If you need to travel for treatment, there are organizations that can help you, says Kristen Reineke of, a web-based marketplace for cancer and critical illness insurance.

Two such organizations include:

  • Corporate Angel Network, which arranges free flights for cancer patients using empty seats on corporate jets.
  • Angel Airline Samaritans, which facilitates no-cost or reduced-rate commercial airline tickets for needy cancer patients and their families.

In addition, the American Cancer Society’s Hope Lodge offers cancer patients and their caregivers a free place to stay when traveling and receiving treatment in another city.

Income replacement: Studies have shown that the majority of cancer patients stop working during their initial treatment and can be out of work for long stretches, causing a loss of income just as medical expenses begin to climb.

Five states — California, New York, New Jersey, Rhode Island, and Hawaii — offer a temporary disability program that allows people to draw on benefits for up to a year to help offset income loss.

In addition, Social Security Disability Insurance and Supplemental Security Income are available to help replace lost income. Go to the Social Security Disability web site for more information.

What resources have you drawn on to help you through cancer treatment? Please share your experience in the comments section.

Posted by: Lisa Zamosky at 2:32 pm

Tuesday, May 27, 2014

Health Insurance after College: 4 Things Grads Need to Know

By Lisa Zamosky


Millions of students are about to graduate college, and as a result will lose their student health insurance policy. Under the Affordable Care Act, everyone is required to have health insurance. That means young adults will face new requirements for having coverage, and a growing fine if they don’t sign up. The good news, however, is that graduates now have more options than they’ve had in the past.

If you’re about to graduate from college (or are the parent of someone who is), here are four things to know about getting a health plan after school ends.

1) Losing student coverage counts as a “qualifying life event.” Open enrollment — the period when you’re allowed to sign up for health insurance — has closed. However, certain qualifying life events allow you to buy an insurance policy outside of open enrollment. Although graduating from college is not a qualifying event on its own, losing a student health plan because of graduation does count as a qualifying event and makes you eligible to enroll.

2) You have multiple insurance options. There are a number of options you can choose from to replace the insurance coverage you’re losing.

If you have a job waiting for you after graduation, you should ask whether your new company offers employee health benefits.

If you are younger than 26 and your parents have health insurance, you can join or stay on their policy. Just keep in mind that many health plans require you to use a network of health care providers within the area where the policy was issued. That means if you don’t live near your parents, this may not be the best option for you.

You can also buy coverage on your own. The Affordable Care Act created new online Marketplaces where you can shop for private health insurance. If you earn less than about $45,000 a year, you may qualify for tax subsidies that help lower your costs. You can also buy a health plan directly from an insurance company or with the help of a broker. However, you can only take advantage of tax subsidies if your plan is purchased through one of the government-run Marketplaces (some brokers can help you do this).

Also, if you earn less than roughly $16,000 a year, you may also be eligible for Medicaid coverage.

3) You may need to take action now. You must sign up for a new health plan within 60 days of the date of your qualifying event. That means if you’ve been covered by your university’s student health plan and it remains in effect until June 30, you’ll have 60 days from that date, or until August 31, to choose and buy a new health plan. If you miss your window of opportunity, you won’t be eligible again for a new plan until 2015.

The one exception is for people who qualify for Medicaid. You can enroll in Medicaid at any time during the year.

4) There’s a tax penalty for being uninsured. If you go uninsured for more than 3 consecutive months in the same calendar year, you may have to pay a penalty on your federal income taxes next year. The penalty is $95 or 1% of your taxable household income, whichever amount is greater.

What are your plans for health insurance after graduation? Please share your comments or thoughts below.

Posted by: Lisa Zamosky at 12:31 pm

Thursday, May 15, 2014

Why Was I Charged for Preventive Care?

By Lisa Zamosky

woman confused at bill

Under the Affordable Care Act, most insurers must cover the full cost of preventive care such as checkups, vaccinations, and screenings. But many people end up surprised when the doctor visit they thought was free suddenly comes with a bill. What gives?

Here are five things to think about to avoid surprise costs at your next doctor’s appointment.

1. Know what’s considered preventive: The Affordable Care Act requires most insurers to cover the full cost of many preventive services with no co-payments or other out-of-pocket costs. (If you have a grandfathered health plan, however, this requirement does not apply.)

Preventive services include vaccinations, annual well-visits, colonoscopies, cancer and other health screenings, which in most cases are available free of charge. You can view a full list of preventive services at

2. Pay attention to the details. The guidelines for preventive services are set by the U.S. Preventive Services Task Force, a panel of health care experts. It’s not enough to look for the services the task force recommends; you also need to be mindful of the specific guidelines of each service.

For example, although colonoscopies are a recommended preventive test, the guidelines state that it’s only preventive for people 50 and older when recommended by a physician. If you go for a colonoscopy at 40, the test likely won’t be considered preventive, and you’ll be charged.

3. Know your health plan’s rules. Health plans have some flexibility when it comes to interpreting the guidelines.

For example, mammograms are a preventive exam recommended every 1 or 2 years for women over 40. That means your health plan may pay for the test each year for women over 40, or it may only pay for the test once every 2 years. You need to confirm your plan’s coverage guidelines.

4. Provider networks matter. Even if the nature of your visit is preventive, if you go to a doctor outside of your plan’s network, all bets are off. You can be charged for the visit.

5. Medical complaints aren’t preventive. Even if you’ve gone in for a well visit, once you ask the doctor to examine you for the headaches you’ve been having for the past 6 months or to check on your stomach troubles, the visit is no longer preventive and you’ll be charged.

You can avoid unexpected bills by being clear with your doctor’s office about all the reasons for your visit when you make your appointment.

Have you been surprised by a bill for what you thought were preventive services? Please share your experience in the comments section.

Posted by: Lisa Zamosky at 10:32 am

Friday, May 9, 2014

Alternatives to COBRA

By Lisa Zamosky

man leaving job

If you were laid off or left your job and had an ongoing medical condition, the federal law known as COBRA used to be the best option for holding onto health insurance coverage.

That’s changed with the Affordable Care Act. You’re still allowed to keep your work-based health plan through COBRA if you like, but you can also enroll in a new plan, either through one of the government-run health insurance Marketplaces or directly from an insurance company or broker.

Understand the Cost

Your employer is required by law to tell you both about COBRA and your option to buy a health plan sold through the state and federal Marketplaces.

On average, employers cover 83% of an individual employee’s health insurance costs. When you continue coverage with COBRA, you lose that financial help and are left to pay the entire bill (plus an administrative fee) on your own. For many people, the plans available through the Marketplaces are likely to be less expensive because of available tax subsidies that can lower the cost.

Know the Deadlines

If you’re interested in shopping around for other insurance after you lose a job, you have 60 days from the date of your job loss to sign up for a plan. If you’re eligible for Medicaid, however, you’re allowed to enroll at any time during the year.

Your new health plan will start on the first day of the next month.

What questions do you have about enrolling for coverage outside of the open enrollment period? Ask your questions or leave your comments below.

Posted by: Lisa Zamosky at 10:52 am

Thursday, May 1, 2014

Enrollment Gains Don’t Help Obamacare Popularity

By Lisa Zamosky

unhappy crowd

Each month, the Kaiser Family Foundation conducts a survey about attitudes toward the Affordable Care Act.

Even with news about enrollment numbers surpassing initial projections, Americans do not seem impressed. That was the gist of the latest survey, which polled about 1,500 people between April 15 and 21.

While over four in ten correctly identify the number of people who have signed up for insurance, enrollment levels do not register as a success for most Americans,” the report said.

The Public Won’t Budge

The public’s opinion of the law hasn’t changed much since October, when the health insurance Marketplaces first opened. Most people still hold a negative view.

Forty-six percent say they have an unfavorable view of the law, while 38% say they are in favor of it. Opinions follow political affiliation; 70% of Democrats support the law, while 37% of independents and 11% of Republicans are behind it.

Despite the fact that 6 in 10 people say the law isn’t working as planned, the same number of people say Congress should improve it, rather than repeal and replace it.

The survey uncovered some other findings:

  • The most common reason people gave for not buying health insurance was its high cost. Nearly 40% said they couldn’t afford to buy a health plan.
  • Twenty-two percent of those surveyed said they don’t have insurance because of job-related issues. But those reasons also relate to cost. Some people said the job-based insurance they were offered wasn’t worth the cost, or that they couldn’t afford it.
  • Sixty-one percent favor the law’s requirement that insurers cover the full cost of contraceptives.
  • More than half (55%) believe companies should also be required to cover birth control even if it violates the business owners’ personal religious beliefs, an issue that has been challenged by two companies before the Supreme Court.

Fix, or repeal and replace? What’s your feeling about the Affordable Care Act now that we’ve completed the first open enrollment period?

Share your comments in the section below.

Posted by: Lisa Zamosky at 2:20 pm

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