Oct. 1 generally brings with it a flurry of handouts, information packets, and benefit details for American workers who get insurance through their employers. But this year, they’ll have even more information to sift through thanks to the Affordable Care Act, and workers who were previously unable to get insurance through work will have an easier way to compare their options. People who get their insurance through work won’t be required to go through this process, but local experts recommend that everyone should take a look at the new options that will be available. That’s because of the new health care law that requires most Americans to purchase health insurance. Though it was designed to be as simple as possible, it’s new and maybe scary. Here are answers to some common questions.
What is ACA?
The Affordable Care Act was signed into law in 2009, and was designed to create a system that allows more Americans to have health insurance. The key to making it work—and keeping insurance relatively affordable—is making health insurance mandatory. The idea is that if more healthy people purchase insurance, and rarely need large expenses covered, insurance companies will be able to cover more people who do have more medical needs. The ACA also made several requirements for insurance plans, which have been rolling out over the last year. The ACA has 10 “essential health benefits” that insurance plans must cover. The ACA also requires insurance companies to accept people with pre-existing conditions (such as chronic diseases). A lot of these new protections come from the Patient Bill of Rights, which is a major part of the ACA.
What’s a health insurance exchange?
An exchange is an online marketplace where people looking for health insurance can compare prices and choose a health-insurance plan. It’s run by the federal government. You can go to HealthCare.gov starting on Oct. 1 to shop for health insurance. If someone says “health-care exchange,” they are talking about the Health Insurance Marketplace, and vice versa.
Ranee Randby, the communications director for Tennessee’s new health-insurance co-op Community Health Alliance, says the marketplace should feel pretty intuitive to people who regularly use the Internet.
“We’ve always heard the comparisons to Travelocity, or any kind of online shopping. If you’re used to online shopping, this will look very familiar to you. It’ll really be pretty simple,” she says.
Who is selling the insurance?
Several big insurance companies are selling insurance plans through the exchange in Tennessee. Cigna, Humana, and Blue Cross Blue Shield of Tennessee are selling plans on the exchange. In addition to those private companies, each state is required by the ACA to have a health-care co-op, which will receive an initial government investment. Co-ops are owned by the people who pay to be insured by them, so they’re not run by the state or federal government, and they provide competitive insurance plans. The Tennessee co-op is Community Health Alliance, which will also sell health-insurance plans. However, some companies may not sell insurance where you live. If you live in one of Tennessee’s metropolitan areas, you’ll have more options. But only Blue Cross Blue Shield is selling insurance to people in every county. Community Health Alliance will sell insurance to all of western Tennessee and the counties surrounding Knoxville. Chattanooga, the Tri-Cities, and counties along the Cumberland Plateau will be added next year.
What and who can be covered?
The ACA’s 10 “essential health benefits” are covered by most insurance plans, and all plans purchased through the exchange will cover them. That means that any insurance plan you buy must cover outpatient care, emergency services, hospital stays, lab tests, pregnancy and newborn care, mental-health and substance-use disorder care (including behavioral-health treatment), prescription drugs, rehabilitative care, preventive, wellness, and chronic-disease management services, and pediatric services, including dental and vision care. The plans can either be for individuals or for families.
One of the ACA’s requirements that has already been rolling out is that children can stay on their parents’ plans until they are 26 years old. That means recent high-school or college graduates can stay on their parents’ plans while they search for a job, and beyond.
And if you have a pre-existing condition, you cannot be rejected for health-insurance coverage.
Where, when, and how do I sign up for it?
Open enrollment for health insurance (like at many companies) starts Oct. 1. But since it’s the inaugural year for the exchanges and co-ops, enrollment through the exchange will be extended to March 31. To sign up, you’ll have to log on to the Marketplace website (HealthCare.gov). If you don’t have access to the Internet or a computer, there are resources for you. (See: “I think I need a real human to explain this.”)
To sign up, you’ll need to have your Social Security number handy (or documents for legal residents), employer and income information (from a pay stub or W-2 form), policy numbers for any current insurance plans, and an Employer Coverage Tool form (completed). All of these forms are on the Marketplace website. Every member of your household who wants or needs to be covered must have all of these items in order to get health-insurance coverage. (Obviously, children will not have some of those forms.)
You’ll also need to make a Marketplace account on the website.
There is a Spanish-language version of the website.
Paper applications will be available at places like doctors’ offices, if you prefer those.
How do I pick an insurance plan?
You’ll be able to compare prices on the Marketplace website, including prices for private company insurance policies. Different plans will all offer the essential health benefits, but some may offer additional benefits. That’s where the Marketplace website comes in—you can compare benefits and costs, and pick the one that best suits you and/or your family.
Why are the insurances color-coded?
There are five levels of insurance coverage, and most of them are color-coded. They all cover the 10 essential health benefits, and all but catastrophic insurance policies will adhere to the health savings account law, which limits the amount policyholders can pay out of pocket. They all still involve deductibles, co-payments, and possibly other out-of-pocket costs, like most insurance plans currently do.
Bronze plans are minimal coverage policies. They’ll cover 60 percent of benefit costs. Silver plans will have slightly higher premiums, and cover 70 percent of benefit costs. Gold plans cover 80 percent, and platinum plans cover 90 percent. They’ll be incrementally more expensive as well.
Catastrophic plans will only be available to individuals (not families) and will essentially be emergency health coverage in drastic situations for those people up to 30 years old or those who are otherwise exempt from required health-insurance enrollment.
I’m a business owner. Do I have to provide insurance for my employees?
First of all, if you employ more than 50 full-time equivalent workers at your business, you are considered a large business, and must adhere to large-business guidelines for providing health-care coverage to your employees. However, starting in 2016, businesses with 100 or fewer employees will be able to purchase plans through the Marketplace.
Small businesses are those with 50 or fewer full-time equivalent employees. There are some options for small-business owners who are worried about the costs of providing health insurance. You can send an application to the Small Business Health Options Program, which will let you compare prices on the plans you can offer your employees. You may also be eligible for a tax credit that can deduct up to 50 percent of the premium cost, plus you can get more tax credits to offset insurance premium costs. However, the small-business health-care tax credit will only be given to businesses who buy insurance through the Marketplace, starting in 2014.
If you are self-employed and have no employees, you can purchase insurance through the Marketplace as an individual.
What if I can’t afford exchange insurance?
If your income is higher than 400 percent of the poverty level, you are not eligible for health-insurance subsidies. That said, if health insurance is still too expensive for you, you could decide to go without insurance and pay the “individual mandate” fee. This is the part of the ACA that is supposed to keep insurance costs down. If you go without insurance for more than three months in 2014, you will have to pay either 1 percent of your salary or $95 per adult (whichever is higher). If you have children, you’ll have to pay $47.50 per child who is not insured. That fee will rise to 2.5 percent of income or $695 in 2016. The fee for uninsured children will be half of the adult fee. People who decide to pay the fee will pay when they file their 2014 tax return in 2015.
However, you may be able to get an exemption from the fee. If insurance is unaffordable based on your income, or if you have a religious-conscience objection, you can fill out forms to see if you can get an exemption from the fee.
When you go to sign up for health insurance via the exchange, it will determine, based on your income, whether you are eligible for subsidized health insurance, which will come in the form of tax credits. The program will also essentially “triage” your application every step of the way, Randby says, and will determine what kind of coverage you’re eligible for.
“What’ll happen is when you go to the Marketplace, it’s basically a one-stop application, so it will put you in whatever method of coverage—whether it’s Medicaid, [Children’s Health Insurance Program], or some sort of private insurer—based on the information you give,” Randby says.
I think I need a real human to explain this to me.
There are ways to get one. The federal government has funded what’s called a “navigator” program, which basically trains people to walk others through the process of getting health insurance through the Marketplace. East Tennesseans will find the navigator program at the Knoxville Area Project Access, a program sponsored by the Knoxville Academy of Medicine Foundation.
Erin Hill, who is in charge of KAPA’s navigator program, says they’ll be available to help people one-on-one to fill out the necessary forms, learn what each plan has to offer, and whether they’re eligible for subsidies.
“In addition to working with patients one-on-one, we’re also going to be doing things such as open enrollment events—we’re working with the health department on that—and we’ll have a day for four hours or so, where we can assist them. Kind of like a health fair,” she says.
Though no dates have been set for those events, Hill says at least some of them will take place at libraries around town, so that navigators can help people on computers. These library events will be opportunities for people who don’t have Internet access to get some assistance in signing up for an insurance plan.
Cherokee Health Systems will have a similar program called Certified Application Counselors. They’ll essentially perform the same services. As with navigators, CACs are “not allowed to advise on what benefit package someone should choose, what company someone should choose. We’re just there to help them through the process,” says Joel Hornberger, the chief operating officer of CHS.
CHS will also be doing outreach events around town (dates have yet to be determined), as well as “in-reach.” Hornberger says current patients will be notified that the CAC services are available.
Cherokee Health System
Knoxville Area Project Access
Community Health Alliance
For Individual and Family Plan Questions: 1-800-318-2596
For Small Business Owners’ Questions: 1-800-706-7893
Kaiser Family Foundation Subsidy Calculator
Health Insurance Marketplace