“If you like your doctor, you can keep your doctor.

” Keeping your doctor under the Senate Democrats’ bill* is as easy as . . .

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