MONEY Health Care

Hear Better for Less: How to Save Big on Hearing Aids

New competitors mean more ways to save money. But should you really buy hearing aids at Costco?

Most technology gets cheaper over time — think about what you used to pay for a flat-screen TV or a laptop.

Not so with hearing aids, which can set you back as much as $6,000 a pair and last only three to five years, according to the Better Hearing Institute. What’s more, Medicare doesn’t cover aids, and private insurance typically hasn’t either.

Times are changing. While buying a hearing aid has often meant visiting an audiologist, new competitors are shaking up the industry. With players like Costco and online sellers gunning for more of the action, you can reap significant savings.

“How aids are traditionally sold through audiologists isn’t affordable for a lot of people, so new devices and shopping avenues are gaining traction,” says Frank Lin, an ear, nose, and throat surgeon and assistant professor at Johns Hopkins.

Insurers are starting to change their tune too. UnitedHealthcare, the nation’s largest insurance company, has added discounted and even free aids to its plans. A small number of other plans will pitch in $500 to $1,000 toward the cost.

So it’s time you stopped ignoring missed conversations and garbled movie scenes. First, to rule out other medical conditions, get a checkup from an audiologist or an ear, nose, and throat or primary-care doctor. Then pick from these options.

Over-the-counter devices

What you get. Personal sound amplification products are the drugstore reading glasses of the hearing world. These gadgets, sold online and in electronics stores, are technically meant to help normal hearing people catch every word in places like restaurants.

At one time PSAPs did little more than amplify all sounds, but recent improvements to the technology have made them better at reducing background noise, says David Copithorne, who publishes the industry site HearingMojo.com.

Who it’s best for. Someone with mild hearing loss — meaning you miss a word here and there — could benefit from a PSAP.

“Go for the higher-end version, not the $50 or $100 pair,” says Copithorne.

The Sound World Solutions CS10, which costs $300 and looks like a Bluetooth headset, or the $200 RCA Symphonix, which goes over your ear, may boost sound enough for you to get by at a crowded dinner table, he says.

Drawbacks. Wear a PSAP without an exam, audiologists warn, and you might miss treatable causes of poor hearing, such as wax buildup or an infection.

Another potential pitfall: You try out a PSAP, conclude aids won’t work, and never trade up to the real deal. In case a PSAP is no help, make sure whatever you buy can be returned.

An audiologist’s office

What you get. The most handholding from a pro with the most training — four years of postgraduate study. In addition to testing, audiologists can customize aids for your ear shape and hearing condition and tweak them in follow-up visits, says Bettie Borton, a Montgomery audiologist and the president of the American Academy of Audiology.

You’ll pay $2,500 to $6,000 for a pair of aids depending on the features you want. High-end add-ons include Bluetooth to sync aids with your phone. But since aids aren’t expensive to make, says Lin, a lot of what you’re paying for is service.

Who it’s best for. Anyone with severe hearing loss or different levels of loss in each ear. Stick with an audiologist if you want the most advanced features or in-person help. Find one at audiology.org.

Drawbacks. The price. The costs of the follow-up visits and the aid are typically bundled. Ask for a breakout so that you can negotiate on both, says Nancy Macklin of the Hearing Loss Association of America, a consumer group supported by members, including audiologists.

A trip to Costco

What you get. The big-box retailer stocks discounted hearing aids in 94% of its stores, often from manufacturers affiliated with the ones audiologists use.

Costco’s nine models sell for $1,000 to $3,000, including fitting and follow-up care. The biggest difference from the audiologist’s office is that you’ll probably be seen by a hearing aid specialist, who has a state license and on-the-job training, not a degree.

Who it’s best for. “They’re a good-quality product for someone with mild to moderate loss,” says Copithorne.

Drawbacks. Costco doesn’t carry the right aids for severe loss, concedes Richard Chavez, who runs Costco’s hearing aid business.

Shopping online

What you get. At websites like Americahears.com and Audicus.com, you can pay as little as $800 for a set of aids. First you’ll need to get a hearing exam from a local audiologist or storefront hearing center (expect to pay $50 to $200). Once you submit the results, you can talk to a phone rep about what types of environments you have trouble in and then get a programmed device. Any adjustments are DIY, or you can mail back the aids.

The website Hi HealthInnovations has local audiologists and specialists who will do in-person tests and fittings — go to hihealthinnovations.com to see if there’s one near you. Aids at this site, owned by the parent of insurer UnitedHealthcare, go for $1,600 to $2,000, less if you’re in a UnitedHealthcare plan.

Who it’s best for. If you’re comfortable teaching yourself to adjust and clean your aid — perhaps this is your second set — you’re a candidate. Same goes if you’re near a Hi Health location. Many sites offer free returns without the 5% or so restocking fee you may face elsewhere.

Drawbacks. Limited choice in models. And did we mention do-it-yourself adjustments? True bargains come at a price.

TIME Medicare

The Return of Mediscare

In Arkansas, Democrats dust off an old tactic in order to retain control of the U.S. Senate

Tom Cotton is your basic republican red-state fantasy candidate. He is 36 years old, a former Army captain who served in both Iraq and Afghanistan, and a graduate of Harvard University and Harvard Law. He is a member of the House running for the U.S. Senate from Arkansas. His opponent is an unflashy Democratic moderate, Mark Pryor, who spent the first months of the campaign barraged by an estimated $2 million in Obamascare ads provided by Americans for Prosperity, the Koch brothers’ super PAC. Not surprisingly, Cotton has been leading–and is one of the reasons the Republicans may retake the Senate in 2014. Or maybe not: the polls suddenly turned around in March, and Pryor is now narrowly ahead. What happened?

Meet Linda … who joins Harry and Louise, and dozens of other average Americans–some real, some conjured–in the long, sordid history of political ads designed to scare the bejeezus out of other average Americans over health care. Linda appears to be real. She’s from Little Rock. She’s been married to the same lucky fellow for 37 years, and they have two “great” kids. We know this because a black-and-white family photo is shown prominently at the beginning of the ad. Then we see Linda, who seems to be in her 50s, with tightly curled gray hair and glasses, sitting in her breakfast nook gazing at her Apple computer. Retirement is just around the corner, she says. “That’s why I was so concerned when I read”–and here she seems to be reading off her computer–”that Tom Cotton voted to turn Medicare into a voucher system” that would allow insurance companies to “increase rates, cut benefits and cost seniors thousands more each year.”

It’s a brilliant ad, classic Mediscare. The fact that Linda seems to be reading the horrific news about Cotton off her computer lends a subtle authority to the information. Is it accurate? Well, yes and no. Cotton and 218 of his colleagues in the House did indeed vote for the Paul Ryan budget, which would slash costs by moving to a privatized “premium support”–or voucher–system of health care delivery for senior citizens. Is that a bad idea? Probably not. In fact, a more generous version already exists in the form of Medicare Advantage, the private-sector Medicare alternative that seems to be going great guns in the Obamacare era: an estimated 30% of seniors have signed up, an increase of 38% in recent years. The brute force of competition (plus some federal subsidies that both parties want to diminish) has allowed increased benefits like gym memberships and free medication. The fact that many of these plans are based within systems where doctors are paid salaries makes it potentially more cost-effective than classic fee-for-service Medicare. It would be very valuable to have a serious conversation about this. Pryor is a fiscal conservative. He’s said that all programs (including Medicare, presumably) should be on the table. He could be part of the solution, rather than hiding behind traditional Democratic battlements.

Democrats will say, Oh, come on. It’s about time we started playing hardball again. The Republicans strolled into a tornado by voting–symbolically, since it never had a chance of passage–for the Ryan budget. The Koch brothers have spent gazillions putting sketchy Obamascare ads on the air, including one starring Jerry, an Arkansas truck driver who “lost” his health coverage because of Obamacare, although maybe he didn’t, because the Arkansas insurance commissioner put a two-year delay on that ruling and now Jerry is “confused” by all these newfangled government machinations. This was one of the less toxic Koch ads–and “Jerry” has been smoked by “Linda” in the court of public opinion.

Of course, next month there could be a killer Obamascare ad starring “Arnie,” an Arkansas druggist whose health care premiums have skyrocketed. And later we may get to know “Marge,” who survived breast cancer because Obamacare saved her health insurance. We could go back and forth, Obamascare vs. Mediscare, all the way until November. It’s happened before. It’s worked before. But is it what you really want this election to be about? Isn’t it precisely the sort of campaign that turns people off politics? Don’t we have more important things to talk about? “I think the Republicans will still win the House and Senate,” says Steve Schmidt, a GOP consultant. “But when you have no real governing agenda, it becomes very easy to get caught up in entitlement issues.”

That is true for Democrats as well. They are proud of their demographics, especially the favor bestowed on them by younger voters. But younger voters may decide they don’t like paying for an unreformed Medicare system as we baby boomers live on and on and on. Those who live by the anecdote can die by the anecdote.

MONEY Ask the Expert

If You’re on Medicare, Do You Also Need Medigap?

If you're considering getting supplement insurance, or Medigap, sign up within six months of enrolling in Medicare.

My father just went on Medicare. Should he buy Medigap insurance? Which policy is best? — Joe, Houston.

If your dad isn’t insured by a former employer, he should buy supplement insurance, or Medigap, which pays for some costs not covered by Medicare.

And, says Bonnie Burns, a policy specialist with California Health Advocates, he should sign up within six months of enrolling in Medicare, when he can’t be rejected for health reasons (some states let you qualify later on for a similar six-month window if your employer plan is canceled).

Since switching policies later may involve a physical, your dad’s best plan is one that suits him over time, not just one that meets his needs cheaply now.

Related: What is Medicare?

All policies must match one of Medicare’s 10 standardized plans — from basic coinsurance to coverage of skilled nursing. Learn more at Medicare.gov.

TIME Healthcare

Tiny Share of Doctors Get Big Slice of Medicare Pie

Newly released data that details how Medicare pays doctors for specific procedures shows the top 2% of the highest-paid doctors who accept Medicare accounted for a significant portion of the federal program's costs, likely leading to changes in insurance practices

A single Florida ophthalmologist was paid $21 million by Medicare in 2012, according to federal data released Wednesday that shows a tiny sliver of U.S. doctors who accept Medicare account for an outsize proportion of the insurance program’s costs.

Medicare payments to 880,000 doctors nationwide totaled roughly $77 billion in 2012. But the top 2 percent of highest-paid doctors who accept Medicare accounted for about $15 billion in payments under the system, almost a quarter of the total not including commercial entity payments, according to data analyzed by the New York Times.

The data shows in detail for the first time how Medicare pays doctors for specific procedures. Fraud investigators, health insurance plans and researchers will sort through the new data with a fine-tooth comb in the upcoming weeks, likely leading to lawsuits and changes in insurance practices.

“There’s a lot of potential for whistle-blowers and justified worry for fraudsters,” Steven F. Grover, a lawyer who represents whistle-blowers who sue doctors they claim have committed Medicare fraud, told the Times. “There’s going to be a lot of litigation over this.”

In 2012, 100 doctors received a total of $610 million from Medicare payouts, and about 3,300 ophthalmologists were paid $3.3 billion from Medicare, the Times reports. Medicare paid $12 billion for 214 million office and outpatient visits—most of them outpatient visits between 15 and 25 minutes long. The doctors and nurse practitioners were paid an average of $57 per visit.

Ophthalmology and oncology both accounted for a large chunk of Medicare spending.

The doctor’s group the American Medical Association has withheld Medicare data for decades, but a federal judge ruled last year the information could be made public. This release marks the first time since the 1970s that detailed figures on Medicare reimbursements have been made available.

[NYT]

 

TIME Budget

New Paul Ryan Budget Cuts Trillions in Spending, Faces Difficult Vote

Paul Ryan
House Budget Committee Chairman Rep. Paul Ryan, R-Wis., speaks at the Conservative Political Action Committee annual conference in National Harbor, Md., March 6, 2014. Susan Walsh—AP

House Budget Committee Chairman Paul Ryan has released his fiscal year 2015 budget that would cut $5.1 trillion in spending by repealing Obamacare, eliminating USAID and set aside less funding to fight climate change, among other big reductions

Updated at 4:50pm to include comment from Paul Ryan.

House Budget Committee Chairman Paul Ryan on Tuesday released his fiscal year 2015 budget, in which he cuts $5.1 trillion in spending, mostly from health care, to balance the budget by 2024.

The budget would repeal ObamaCare, including the money-saving Independent Payment Advisory Board, cutting $1.2 trillion in federal outlays. It turns Medicaid into a block grant program for states, which would save $732 billion over 10 years. It essentially aims to privatize Medicare, offering enrollees in 2024 the choice of a private plan, while raising the age of eligibility and means tests for high income seniors. All told, more than half of the $5.1 trillion would come from health care savings. The document, provided on an embargoed basis to reporters, did not provide detailed budgetary outlays, but rather an overview of the budget’s goals.

As in past budgets, Ryan leaves the Pentagon and the Veterans Affairs Department largely untouched, including only those cuts recommended by the Pentagon itself. In fact, he criticizes President Obama from cutting too much in military spending in his 2015 budget, calling the President funding level “irresponsible.”

While all of this may sound like a Republican, or at least Tea Party, dream, Ryan is expected to have a tough time getting his bill through the House. The measure assumes a 2015 spending baseline as prescribed in the deal he made with Senate Budget Committee Chair Patty Murray earlier this year. That baseline mitigates the sequester cuts and assumes a higher level of spending than House Republicans like. Sixty-two Republicans voted against that deal, which passed on Democratic support. There will be no Democratic votes for the Ryan budget as it includes drastic cuts to programs Democrats seek to protect, which means Ryan must convince those 62 nay votes to support his budget despite the short-term increase in spending.

“Members who may not have supproted the Ryan Murray deal will see this is a much bigger picture, balancing the budget and paying off the debt,” Ryan told reporters on a call Tuesday afternoon. “The good clearly outweighs any other concerns that they might have had.”

Of course, this budget is going nowhere in the Democratically-controlled Senate, which has already announced it would not pass a budget this year citing the two-year deal Murray and Ryan forged earlier this year. Democrats, meanwhile, were gleefully anticipating the Ryan budget, hoping to use some of its more extreme positions against GOP candidates in a midterm election where they are portraying Republicans as unsympathetic to the working class. “The Ryan budget wouldn’t do a thing to help the middle class, and simply attacking Obamacare won’t get them the political victory they seek,” Senator Chuck Schumer, a New York Democrat, said in response to Ryan’s budget on Tuesday. “We’ll put our agenda to give everyone a fair shot by creating jobs and raising wages, against a plan that guts the middle class and replaces Medicare’s guaranteed benefits any day of the week.”

The plan eliminates USAID, moving international aid to the Millennium Challenge Corporation. It also cuts international education exchanges and programs like the East-West Center. In a nod to Benghazi, it maintains increased spending on diplomatic security—8% over 2013 levels.

The budget drastically cuts clean energy and technology funds and funding to fight climate change, while expanding oil and gas drilling on and offshore. It also recommends approval of the controversial Keystone XL pipeline from Canada and drilling in the Arctic National Wildlife Refuge in Alaska.

It cuts $23 billion in agriculture subsidies and turns the food stamp program into a block grant program for the states. It trims funding to Low Income Home Energy Assistance Program, which Ryan says is being abused by the states. It would also slash federal pensions by $125 billion over 10 years. It would eliminate a program to repay federal employees’ student loans, and would encourage attrition in the federal workforce. It would cut welfare programs by $5 billion over 10 years. And it would bar people from receiving both unemployment and disability benefits at the same time, saving $5.4 billion over 10 years. It also eliminates printing costs by switching most records to electronic copies. And it would end election assistance.

The budget would cut funding to the Securities and Exchange Commission, restrict the FDIC’s authority to bail out bank creditors. It would privatize Fannie Mae and Freddie Mac, and slashes $19 billion from the struggling U.S. Postal Service.

Ryan did not include his “Road Map” recommendation from 2010 to essentially privatize Social Security. In this budget he simply notes the problem in long-term projected shortfalls and calls on Congress and the President to begin working on solutions.

It ends support for Amtrak, cuts some funding for the Transportation Security Administration, eliminates the Community Development Program, cuts funding to the Federal Emergency Management Program, noting that in the last three years 2,400 emergencies have been declared many of those decisions were “not made judiciously.” Ryan recommends reducing FEMA expenses by instilling per capita thresholds.

The budget would streamline job training by getting rid of nearly 50 duplicate and overlapping programs. It would cut funding to Pell Grants by imposing a maximum income eligibility cap, ending funding for less than half-time students and capping the maximum award to $5,730. It would streamline Education Department programs, particularly the 82 programs focusing on teacher quality and calls for major reform to elementary and secondary programs. It would end all federal funding to the National Endowment for the Arts, the National Endowment for the Humanities, Federal Institute of Museum and Library Services, and the Corporation for Public Broadcasting.

In a nod to Ryan’s anticipated move to become House Ways and Means Committee chairman, Congress’s top tax writing committee, Ryan included the bones of a tax reform plan he’s likely to push in the next session. That plan repeals the alternative minimum tax, cuts corporate tax rates to 25% and consolidates the seven personal income brackets to just three with a top rate of 25% and a bottom rate of 10%.

TIME Congress

House Passes Medicare ‘Doc Fix’

The House passed legislation to avoid a nearly 24 percent cut to the reimbursement rates that Medicare pays to doctors, just days before an important April 1 deadline. The "Doc Fix" will cost approximately $20 billion

The House voted Thursday to avoid a nearly 24 percent cut to the reimbursement rates that Medicare pays to doctors, just days before a critical April 1 deadline.

The so-called “Doc Fix” will cost approximately $20 billion, but it’s just the latest in a long run of band-aids Congress has applied to the complex formula that is used to determine Medicare reimbursement rates. The cost is being covered through an accounting sleight-of-hand, by slightly moving up automatic cuts to Medicare that were part of so-called sequestration. The Senate is expected to take up the legislation soon, possibly the same day. Temporary patches to the reimbursement formula have now cost more than $150 billion over the last decade, the Washington Post reports.

Some Republicans, whose leaders pushed through the legislation by using an unusual procedure known as a voice vote, decried the accounting maneuvers used to offset the cost.

“It’s just another form of fake money we have around here,” Rep. John Fleming (R-La.) said of the vote. Fleming was off the House floor during the voice vote, but said he would have voted against the legislation. “Basically, the question was: do we let it lapse and have across-the-board cuts, or do we pass this one year patch?” Fleming said. “We didn’t want to vote for it, and we didn’t want to vote against it.”

A voice vote is one method the majority party can use to push through controversial legislation. It requires the acting Speaker to decide that verbal yes votes outnumber votes in opposition. Individual lawmakers’ votes aren’t tallied during a voice vote, making it easier to pass politically charged legislation. Democrats and Republicans agreed beforehand to not ask for a recorded vote, even though members of both parties have opposed a temporary Medicare fix. The decision to hold a voice vote appeared to be a closely kept secret until the last minute—one junior Republican member didn’t hear about the vote until after it already happened, and Fleming said there were less than 100 members on the floor.

“Oh, that was a voice [vote],” Rep. James Lankford (R-Okla.), a member of the GOP leadership team, said when asked how he voted. “I wasn’t even on the floor.”

MONEY Ask the Expert

When Do I Stop Paying Social Security Taxes?

Any earnings greater than $117,000 are not subject to Social Security taxes. Photo: Josh Randall/Shutterstock

Q: If you earn more than $117,000, do you keep paying Social Security taxes on wages above that amount? — Patrick, Houston

A: No, you don’t. The maximum amount of earnings subject to Social Security tax this year is $117,000, up from $113,700 in 2013.

Beyond the new limit, you’re done with the 6.2% Social Security tax (12.4% if you’re self-employed) for the year.

You’re not done with all wage taxes, though. You’ll owe a 1.45% Medicare tax (again, double that if you’re self-employed) on total earnings, no matter how much you make.

Quiz: Road to Wealth: Are you on track?

And there’s one more tax, points out Michael Eisenberg, a certified public accountant in Los Angeles. Starting with 2013, couples making more than $250,000 and singles earning at least $200,000 also owe a 0.9% Medicare tax on any earned income above those thresholds.

TIME Domestic Policy

Paul Ryan Critiques War on Poverty In New Report

Paul Ryan
House Budget Committee Chairman Rep. Paul Ryan, R-Wis. is seen on Capitol Hill on March 18, 2013 J. Scott Applewhite / AP

Wisconsin Republican Congressman Paul Ryan is taking aim at government programs he says haven't done enough to lower the United States' poverty rate

House Budget Committee Chairman Paul Ryan released Monday a Republican critique of the War on Poverty begun by President Lyndon B. Johnson 50 years ago, in an election-year counterpunch to the Democratic Party’s claim that it can better provide for the most vulnerable Americans.

Ryan’s report says that federal healthcare, nutrition and education programs have failed to adequately address the country’s poverty rate, which it states has only fallen 2.3 percentage points—from 17.3 percent to 15 percent—since 1965.

The report documents what it says are a multitude of overlapping federal programs on food aid, housing and education, with $799 billion spent on a total of 92 separate federal anti-poverty programs. It states that Medicaid, which was expanded under the President’s new healthcare law, has “little effect on patients’ health” and “increases use of the emergency room inappropriately.” The education program Head Start, an Obama Administration priority, “does not improve student outcomes,” it says, and is “vulnerable to fraud.”

The document also hits at food stamps, which are now claimed by over 47 million Americans at a cost of nearly $80 billion. The Ryan report states that food stamps administered by the Supplemental Nutrition Assistance Program have only a “modest effect on poverty” and “discourages work” among female-headed households and married men.

The document does not suggest concrete solutions, although it puts forward broad outlines for reform. On education, for example, the report cites an academic study suggesting a “consolidated, well-funded system would be better” than the current slate of early-care and education programs. The report also praised the Earned Income Tax Credit, a tax credit for lower income workers.

Ryan’s aides said the report was never intended to be a policy blueprint. “The purpose of this report is to inform the public debate,” says a Ryan aide. “It challenges critics of reform to defend the status quo—to go beyond mere intentions and focus on results. I would expect Paul Ryan to have more to say in this area in the year ahead.” Speaker of the House John Boehner said Thursday that he expects Ryan to produce a complete, balanced budget this year, which may include reforms to anti-poverty programs.

Democrats have had ample time to prepare for a Republican pivot towards poverty. Republican Senators Marco Rubio and Rand Paul, and House Majority Leader Eric Cantor have all given major addresses on the subject in the past few months. “If past is prologue, this report is simply laying the groundwork to slash social ­safety-net programs,” said Rep. Chris Van Hollen (D-Md.), the ranking Democratic member on the House Budget Committee, in a statement. “I hope this time is different, but I fear it won’t be—this one-sided report was put together without any effort to reach across the aisle.”

You can read the full report here.

MONEY Health Care

How Obamacare Affects Your Bottom Line

A patched-up insurance exchange is only one of the ways health care is changing with the Affordable Care Act. illustration: tiffany baker / cnnmoney

A patched-up insurance exchange is only one of the ways health care is changing. More and more of Obamacare is kicking in this year. Here's what it means to you.

When the Affordable Care Act, a.k.a. Obamacare, passed four years ago, Jan. 1, 2014, was the law’s D-day.

Some changes kicked in earlier—preventive care fully covered, the right to keep kids on your health plan until they turn 26. But most major provisions were scheduled to take effect by this date, including the law’s centerpiece requirement that nearly everyone must carry insurance or owe a fine, which will escalate in the coming years.

Since then, a few features have been postponed for 12 months, including the rollout of most small-business insurance exchanges and the rule that large employers must offer coverage or pay a penalty. But Jan. 1 remained a key turning point for health care in this country.

Of course, what’s gotten the lion’s share of attention in recent months is the flawed federal insurance exchange, not to mention canceled policies and premium shocks. What you may not realize, though, is that the law is prompting other significant shifts in the system.

Spurred on by the ACA, insurers, doctors, and government agencies are quietly embarking on a sweeping experiment, trying to change how care is delivered and paid for in hopes of controlling costs. “Individual insurance reform is one of 10 titles in the statute,” points out Timothy Jost, a law professor at Washington and Lee University. “There’s a lot more in there.”

No matter how you get your insurance, you could feel the effects of Obamacare in the months to come. Come tax filing time, for one, couples earning above $250,000 ($200,000 for singles) will see how much a surcharge that helps fund the law has cost them. That’s just one of five key ways reform could touch you and your family in 2014 and beyond.

1. No matter how you buy insurance, you now have a stronger safety net

One of the goals of health reform was to close the loopholes that could let costly care or a chronic illness devastate your finances, even if you had coverage. Since 2010 insurers have no longer been able to cap how much they paid out on your policy over your lifetime. In 2014 two more protections take effect, both for individual policies and group plans.

Insurers can no longer impose an annual coverage cap. Plus, once you spend $12,700 out-of-pocket with a family plan in 2014 ($6,350 for singles), your insurer must pick up every dollar of in-network medical care.

“For people with chronic conditions, this is one of the most important advances,” says Marc Boutin, chief operating officer of the National Health Council, which represents advocacy groups for patients with chronic conditions. Those with serious illnesses picked up another safeguard: You can no longer be turned down for coverage because of your health.

The government gave employers that use separate firms to administer medical and drug benefits an extra year to comply with the out-of-pocket max. But most companies set lower limits than the law mandates. So the delay will mainly affect people in plans that don’t cap prescription drug costs and who need a very costly drug, such as chemotherapy pills.

2. You may pay more for office visits, thanks to your doctor’s new job

In hopes of tamping down health care costs, the ACA aims to change how doctors and hospitals do business, and you could notice the fallout soon. One approach is to create so-called accountable care organizations, typically doctors and hospitals that team up to coordinate treatments with the goal of delivering quality care for less. If successful, the doctor and hospital may be eligible for a bonus from Medicare. Private insurers are turning to similar models.

This incentive to team up is one reason a big hospital may soon take over your local facility (if it hasn’t already) or scoop up physicians, particularly primary care doctors. Another catalyst behind consolidation: Starting in 2015, Medicare reimbursements drop for doctors who haven’t made inroads with electronic medical records, which can be expensive or onerous for standalone practices to install.

On the surface nothing may change when your doctor joins a larger system. You drive to the same office and see the same familiar faces. You may even encounter some improvements, like free access to a nutritionist or wellness coach. The difference may show up on the bill.

Health economists worry that mergers could end up increasing what you pay. Hospital systems can often negotiate higher rates with insurers for the same care.

“Small practices are price takers, but large groups and hospitals are price setters,” says Robert Berenson of the Urban Institute’s Health Policy Center. Health insurer Cigna has seen bills for cardio procedures done in a doctor’s office, such as stress echocardiograms, jump 300% to 500% after the office is acquired. You may notice a “facility fee” of $75 to $150 for a routine office visit. If so, check with your insurer. Some have negotiated no fees with certain providers.

3. You still have time to buy coverage, and doing so is easier

If you buy insurance on your own, you had until Dec. 23 to sign up on an exchange to ensure coverage by Jan. 1. Given the widespread glitches, confirm that your enrollment went through with your insurer. And pay promptly: Insurers can drop you if you fail to make a first payment.

If you’re not yet enrolled, do so by March 31 to avoid a penalty. Healthcare.gov, after undergoing serious repairs, is performing better. Window-shopping is easier too. Before you apply, you can now get an idea of the premiums, deductibles, and co-insurance rates you’ll pay, as well as an estimate of any subsidy you might qualify for.

You may have heard that you can hold on to your previous policy, even if it falls short of the law’s requirements. After hundreds of thousands of policies were canceled, President Obama announced in November that insurers can extend those plans. But state regulators must agree, and many, including officials in New York and Washington, did not; Texas and Florida officials did. Even then, insurers must sign on, and not all have.

4. Buying on your own, though, may involve some big tradeoffs

Now that health plans are for sale on the exchanges, one thing is clear: To accept everyone regardless of health, cover all the law’s essential benefits, and keep prices competitive, insurers have had to cut corners. One way is by setting high deductibles.

Another is limiting how many hospitals and doctors are considered in-network much more than a typical policy does. “There are only so many levers you can push, particularly in a short time frame,” says Sabrina Corlette of the Georgetown Health Policy Institute.

According to a recent McKinsey study of mid-priced exchange policies being sold in 20 urban areas, 70% of plans exclude at least a third of large hospitals in the area from their networks. Narrow networks are almost three times more common than they were among individual plans in 2013, the study found. The one insurer selling so far on the New Hampshire exchange has deemed more than a third of the state’s hospitals out of network. In Washington, Seattle Children’s Hospital has sued the state’s insurance commissioner because the facility is excluded from many exchange plans.

Before policies reached the exchanges, state or federal regulators had to agree that the networks were broad enough to cover necessary services. Still, you may not be able to find an in-network provider that you consider suitable. Or you may want to use a local children’s hospital or university cancer center that’s been left out. To have an out-of-network facility or doctor covered at in-network rates, you can appeal to your insurer. Enlist the doctor to help you make your case, says Boutin. You could ask for a letter, say, spelling out how often he or she does the procedure annually and the outcomes.

Finally, don’t rely on the exchange listings or even your insurer’s website to find out what’s in network. “Even before the ACA, provider directories were notorious for being unreliable,” says Corlette. Instead, pick up the phone and confirm that a doctor accepts your insurer as well as your specific plan.

5. You can find out a lot more about your doctor and your hospital

The ACA also sets out to collect more info on the quality of care Americans are getting, and those efforts are bearing fruit, giving you improved tools to judge a hospital, doctor, or Medicare plan — and the government more ammunition to push for improvements. In 2012, Medicare began tying reimbursement rates for private Advantage plans to the star ratings it earns.

You can visit the hospital compare tool on Medicare.gov and see how a facility stacks up against state or national averages for readmissions, complications, and patient satisfaction. In December, the site added outcome data for knee and hip replacements.

Last year for the first time, Medicare penalized more than 2,000 hospitals with excessive readmissions—a possible indicator of a poor discharge process. That move could make it less likely that you or a family member will be ushered out the door without a full explanation of your medications, says Jim Chase, president of Minnesota Community Measurement, a nonprofit that reports on quality of care.

A similar physician comparison tool, relaunched in 2013, is set to go live with its first quality measurements this year. Also on deck: metrics for psychiatric facilities and hospice providers. Private insurers are working on similar disclosures, using their own and Medicare data.

The ratings aren’t so solid that you should drop any doctor with a poor showing. But you can use them to tell whether a practice is staying on top of developments like electronic records and evidence-based treatment protocols, says Reid Blackwelder, president of the American Academy of Family Physicians.

And by looking at what the ratings deem important, such as whether heart-disease patients get certain services, you can know what to ask your doctor about your care, says Chase.

With ratings on the road to becoming the norm, health reform is poised to change how you shop for care—one more way that this 2010 law will play out for years to come.

MONEY health insurance

What’s Next for Retiree Health Care

Fewer companies are offering retiree health care benefits. Even if you get benefits from a former boss, you'll see some changes. Photo: Shutterstock

When it comes to getting health coverage from your old boss, the landscape is changing fast, and not just for early retirees.

Companies have been cutting back on retiree health benefits for years. Indeed, the latest survey by the Kaiser Family Foundation (KFF) found that among large firms with employee health coverage, just 28% offer some form of retiree benefits, down from 66% in 1988. Among smaller firms, help is even scarcer.

Disappearing corporate benefits is one reason the new public exchanges created by Obamacare will be such a boon to early retirees. But even for seniors who still get help from a former boss, change is afoot, no matter your age.

Here’s what to watch for:

Early retirees: If the public exchanges succeed, firms that offer pre-Medicare coverage may give those ex-workers funds to buy a policy on one, says Tricia Neuman, director of KFF’s Program on Medicare Policy. Employers are taking a wait-and-see approach, but that could change fast.

Retirees 65 and up: About a third of Medicare recipients have supplemental coverage from a former employer, says Neuman, and some of them are already seeing changes. Several major companies, recently IBM and Time Warner (MONEY’s parent company), are shifting retirees 65 and older from company-run plans to private exchanges operated by benefit consultants and insurance brokers.

On a private exchange, you’ll be able to pick supplemental Medicare coverage from a host of options, using funds your employer contributes to a tax-free health-reimbursement arrangement, or HRA.

For now, companies making this shift aren’t necessarily cutting back on how much they’re spending on your health care, says Paul Fronstin, a senior research associate at the Employee Benefit Research Institute (though IBM capped its contribution years ago). But how you’ll fare over time will depend on the employer subsidy keeping up with premium hikes, says John Grosso, health care actuary at Aon Hewitt. If not, you’ll pay more.

You or your parents may leap at the chance for more choices, or be overwhelmed by the sign-up process. It’s similar to open enrollment, but with potentially more options.

“Make use of all the tools out there,” says Sandy Ageloff, Southwest health and group benefits leader for Towers Watson, which owns Extend Health, the biggest private exchange. Tools include phone counseling at the exchange; the typical initial call runs about 80 minutes, Ageloff says.

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