What is ObamaCare?
How does it affect those who do not currently have health insurance? And, how does it affect those who do? Is there anyone I can talk to if I have questions about the law, enrolling in services or selecting the health care plan that’s best for me?
If you’ve found yourself asking any of these questions, rest assured, you are not alone. Since the open enrollment phase of President Obama’s Affordable Care Act (the ACA) rolled out on Oct.1, 2013, millions of people across the nation have enrolled in health insurance coverage—but, millions of people have not.
The law is expected to help 48.6 million Americans who otherwise would not have health coverage, including an estimated 3 million families in Pennsylvania—so why are there still so many people who haven’t enrolled? With millions of people holding out, there are millions of reasons and excuses, but one of the most frequently proffered explanations has been that people simply do not understand the law, or are befuddled by the enrollment process.
But, as the saying goes, ignorance of the law is no excuse—and, with words like “deadline” and “penalties” floating around the ACA, it is crucial the American people learn about this new law, how it applies to them, and what they must do to comply with its requirements.
In an effort to inform and educate the constituency he serves, State Representative Jake Wheatley (D-Allegheny) recently hosted a series of information sessions in some of the districts he represents, where residents were invited to learn more about ObamaCare and directed to resources to help them navigate enrollment.
On Tues., Dec. 17, staff from Rep. Wheatley’s office convened at the Allentown Senior Center for such a meeting, and opened the floor for a presentation by Leslie Bachurski from Consumer Health Coalition.
Consumer Health Coalition is a nonprofit organization dedicated to inspiring a consumer movement to enhance access to quality, affordable health care in Southwestern Pennsylvania, and it is one of many designated local “navigators” that can help you understand ObamaCare and guide you through the enrollment process.
Ms. Bachurski began her presentation with a brief background of the ACA, explaining the comprehensive plan became legislation in 2010, with different programs rolling out each subsequent year. Open enrollment, she said, represents one of the last major phases of the ACA, and introduces a key component to health care management in this country—the Marketplace.
In Pennsylvania, the Marketplace is facilitated through the federal government website at http://www.healthcare.gov, which is essentially a network from which qualified individuals can shop for, and enroll in, a qualified health insurance plan. Described by Ms. Bachurski as “a highly sophisticated site,” it interfaces with other agency systems, such as Experian and the IRS, to verify identity, U.S. citizenship status and the accuracy of other information provided, and then uses that information to determine if subsidies are available and generate premium and coverage alternatives from a variety of providers.
Under the ACA, an individual is qualified to purchase insurance through the Marketplace if he or she is a U.S. citizen or legal immigrant who is a resident of the state facilitating their enrollment, and who is not incarcerated at the time of enrollment. The threshold income for an individual is $11,500, meaning that only those who make this amount, at minimum, are qualified for enrollment through the Marketplace.
Though the Marketplace was designed chiefly for those who do not currently have health insurance through their employer or through another government program (such as the state welfare system), there are certain situations where someone unhappy with their current insurance can purchase through the Marketplace. For example, Ms. Bachurski said individuals on COBRA can shop the Marketplace for better rates, as well as those who pay for insurance through their employer at an annual premium that exceeds 9.5 percent of their annual income.
Having clarified who is qualified to enroll through the Marketplace, Ms. Bachurski next addressed what a qualified health plan is, defining it as a plan that covers a minimum set of benefit standards the federal government has deemed essential health benefits. Essential health benefits include ambulatory service, emergency room services, hospital stays, maternity care, mental health services, drug and alcohol rehabilitation, certain medical equipment and supplies, lab tests, and preventive care.
“If a plan doesn’t cover these things,” Ms. Bachurski noted, “you will not find it in the Marketplace.”
The premium rates the Marketplace generates are determined based on various factors such as household income, family size and age. Additionally, according to Ms. Bachurski, states were given the option to ask whether qualified individuals smoke, and Pennsylvania has opted to ask—so smokers should expect higher premium quotes than nonsmokers.
Consumers whose total household income is between 100 and 400 percent of the federal poverty level will receive government subsidies that will allow them to pay a reduced rate for coverage. But, since subsidies are calculated using past IRS information, only those consumers who have filed tax returns are eligible for the reduced rates, Ms Bachurski said.
Regardless of subsidy eligibility, qualified consumers can chose between different cost-sharing levels to accommodate a balance between their income and their health care needs. Plans are offered at different metal levels, which represent different ratios of coverage to out of pocket expenses, and come at different premium heights.
Plans at the Bronze Level offer the lowest premium rates and pay for 60 percent of essential health benefits, leaving 40 percent to be absorbed by the consumer. Silver Level plans deliver 70 percent coverage by the insurance provider; Gold plans deliver 80 percent; and Platinum Level plans deliver 90 percent, leaving only 10 percent to be paid out of pocket, but come at the highest premium.
In selecting the metal level that’s right for you, Ms. Bachurski recommended consumers consider the frequency with which they visit their doctor or hospital; any ongoing medical concerns or conditions they may have; the amount and type of prescription medications or supplies they use; and their overall financial situation, among other things.
“If you’re a person in good general health who is looking for insurance to cover annual checkups and sick visits, the Bronze Level may appeal to you, because you’ll pay a lower premium and only pay out of pocket those limited times you use medical services,” explained Ms. Bachurski.
“But, if you have a chronic condition, like diabetes, where you need insulin, syringes, test strips, and other supplies, you may decide the Platinum Level is better for your individual needs, because, even though you will pay a higher premium, you will pay less out of pocket for your medications and supplies,” she furthered.
In response to Ms. Bachurski’s comments on coverage, one member of the audience asked how the current turmoil between UPMC and Highmark will affect coverage. While the topic itself was out of the purview of the meeting, Ms. Bachurski nonetheless addressed the concern.
Emphasizing that, as a health care advocate, she is unable to speculate on the outcome of the controversy or to voice her opinion on the matter in any way, Ms. Bachurski advised those in attendance that this is yet another factor they should consider when choosing their plan and metal level.
“Whether or not a particular doctor or hospital will be included in your network is something you should definitely think about when you visit the Marketplace,” she said. “If something happens over the next year that affects your network and makes you unhappy with your coverage, you may want to consider changing plans when your renewal date comes around next year.”
But before consumers can renew or change their plans, they must first enroll in them—and Ms. Bachurski acknowledged this can be a daunting task. The entire process of entering information, exploring options and making an informed decision can be lengthy, she noted, and typically takes approximately 1.5 to 2 hours to complete.
Consumers can complete the enrollment process themselves online (at http://www.healthcare.gov), over the telephone (by calling 1-800-318-2596), using a traditional paper format, or one-on-one with a navigator, such as Consumer Health Coalition.
Representatives from the Allegheny County Department of Public Welfare and the Office of State Senator Jay Costa (D-Allegheny) were also in attendance at the meeting, and each stressed how important the help of a navigator can be. From answering any questions you may have in your efforts to enroll on your own to guiding you through the entire enrollment process, navigators can help you understand your options and sort through many of the roadblocks that have thus far stood in the way of completing your enrollment, they agreed.
And, for those who haven’t enrolled yet, Ms. Bachurski pointed out the clock is ticking. She stated the deadline for open enrollment is March 31, 2014, and reminded the audience of the penalties associated with the ACA.
By law, she said, if someone who can afford health insurance does not have coverage in 2014, unless they meet strict exemption guidelines, they will be penalized at the greater of 1 percent of their income or $95 per uninsured adult person living in the household ($47.50 per uninsured child under 18), and will be responsible for paying for all of their health care expenses. Each additional year the person or family remains without coverage, the penalty rate will increase.
After discussing deadlines and penalties, Ms. Bachurski broached another sensitive issue that has received a lot of attention recently—the Medicaid expansion gap, commonly referred to as “the working class poor.” There exists a distinct slice of the American population who earn too much income to qualify for their state welfare services, but who do not make enough to qualify for enrollment in the Marketplace.
To compensate for this disparity, ObamaCare called for the expansion of Medicaid in all 50 states, and the federal government offered to fund state Medicaid expansion through 2016. A number of states, however, rejected the expansion—and Pennsylvania was one of them. As a result, the gap will exist in Pennsylvania unless and until the governor decides differently, Ms. Bachurski said.
Consumer Health Coalition is currently scheduling appointments for January, and will continue to answer consumer questions and assist in enrollment until the open enrollment period ends. To schedule an appointment, call Ms. Bachurski at 412-456-1877, extension 200. Additional navigators can be found online, at http://www.healthcare.gov, by clicking on the “Find local help” button, where you’ll be prompted to enter your city and state, or zip code, to find assistance near you.
Also on hand at Tuesday’s session was Kevin Progar of the Regional Health Literacy Coalition, a nonprofit organization that works together with over 60 other groups, offices and agencies to help individuals better understand their health and health care.
Mr. Progar supplied those in attendance with various handouts, including a glossary of terms used in the health insurance industry and pamphlets on things such as preparing for a doctor’s visit and taking a more proactive role in your health care. To learn more about how the Regional Health Literacy Coalition can help you make better health care choices, visit http://www.ahealthyunderstanding.org, or call 800-704-8434.