Updated: Navigating the Healthcare Marketplace

News November 19, 2013 0 Comments

Laura Line, corporate assistant director, Resources from Human Development (RHD), listens to a resident's question at the Affordable Care Act Information Session held at the Lutheran Theological Seminary on Nov.16. (Photo by Sue Ann Rybak)

Laura Line, corporate assistant director, Resources from Human Development (RHD), listens to a resident’s question at the Affordable Care Act Information Session held at the Lutheran Theological Seminary on Nov.16. (Photo by Sue Ann Rybak)

by Sue Ann Rybak

If you’re confused about the Affordable Care Act (ACA), you are not alone. Navigating the new online insurance exchange at healthcare.gov and deciding what plan works best for you can be a daunting task. On Nov. 16, State Rep. Cherelle L. Parker held an information session on the Affordable Care Act, at the Lutheran Theological Seminary’s Brossman Center, 7301 Germantown Ave., to help residents understand and access the healthcare marketplace.

“You can’t expect people to make logical decisions [about healthcare insurance] until they have been educated,” Parker said.

Parker said legislators need to “promote, educate and connect people” with the services they need to make informed decisions about buying healthcare insurance.

“I don’t care if you are a brain surgeon, if this is not something you do on a daily basis, shopping for health insurance can be a daunting experience,” Parker said.

Affordable Care Act 101

The Affordable Care Act also known as Obamacare was signed into law on March 23, 2010. Under the Affordable Care Act, insurance companies can no longer deny consumers coverage for pre-existing conditions or restrict coverage with lifetime or annual “caps” limiting how much care consumers can receive.

According to the U.S. Department of Health and Human Services, “5,489,162 Pennsylvanians under age 65 have a pre-existing health condition that, before the new law, put them at risk of being denied coverage or gouged on rates.”

Emily Wyner, advocacy and outreach coordinator of WOMEN’S WAY,who spoke on behalf of PA Health Access Network, discussed key changes under the ACA.

Wyner said while family incomes are down by five percent, insurance costs are up 80 percent.

“Annual premiums for employer-sponsored family health coverage reached $16,351 this year, up four percent from last year, with workers on average paying $4, 565 toward the cost of their coverage,” according to Kaiser Family Foundation/Health Research & Educational Trust (HRET) 2013 Employer Health Benefits Survey.

According to the Kaiser Family Foundation’s research, since 2003, premiums have increased 80 percent, nearly three times as fast as wages and inflation. The ACA, Wyner said, has helped curb those increases.

“Under the Affordable Care Act, insurance companies have to justify rate hikes,” she said. “Rate increases fell from 75 percent in 2010 to 14 percent so far in 2013.”

The ACA has also made gender discrimination illegal and capped age ratings. Women can not be charged more than men for the same policy.

One of the biggest changes under ACA is that all insurance policies must cover essential healthcare benefit: ambulatory patient services (outpatient care you get without being admitted to a hospital), emergency services, hospitalization (such as surgery), maternal and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills), laboratory services, preventative and wellness services and chronic disease management and pediatric services.

Also now covered under the ACA is free preventative care for women, including breast feeding supplies and counseling, contraception, additional STD testing for younger women and at risk women, cervical cancer screening, domestic violence screenings, folic acid for pregnant women, RH incompatibility screening for pregnant women, STI counseling and tobacco screening.

In order to comply with these new regulations, insurance companies can no longer offer consumers policies that don’t cover these services. This has resulted in thousands of individual policy holders receiving letters from their insurance company stating they are canceling the consumer’s policy.

Wyner said the ACA was designed to provide not only affordable healthcare insurance but to improve the quality of the healthcare system.

The new law requires insurance companies to spend at least 80 percent of policyholders’ premium dollars on actual healthcare.

“Nationally, in 2011, this saved working families and small businesses $1.1 billion,” said Wyner. “Here in Pennsylvania, over 675,000 families have gotten back more than $58 million in rebates.”

She added however that consumers did not receive a check in the mail. Instead she said insurance companies off-set the difference by lowering premiums.

“Regardless of how you feel about the Affordable Care Act, people want to know what their health options are,” said Laura Line, corporate assistant director, Resources for Human Development (RHD), a consumer-focused community based nonprofit, which is Pennsylvania’s navigator grantee. “We get hundreds of calls from people asking if they will be denied coverage for their pre-existing condition. Thanks to the ACA, the answer is no.”

Shopping for insurance on the marketplace

Anyone who is a United States citizen or lawfully present can shop for health insurance at healthcare.gov.

People who make between 100 and 400 percent of the Federal Poverty Level (FPL) are eligible for the Premium Tax Credit. Currently, the FPL for a single person is $11,490 or $23,550 for a family of 4. The maximum gross income is $45,960 for an individual and $94,200 a year for a family of four. (400 percent of FPL).

Insurance plans are divided into four types: Bronze, Silver, Gold and Platinum. Bronze plans have the lowest premiums, but higher co-pays and deductibles. While Platinum plans have the highest premiums and lower co-pays and deductibles.

“It really depends your individual needs, if you are someone who goes to the doctor a lot for a chronic condition then you should consider getting a Platinum or Gold plan,” Line said.

Line strongly recommended sitting down with a navigator or a certified application counselor at a healthcare center or other social service agency. She said certified application counselors receive training from organizations such as RHD, but the training is less comprehensive than the one navigators must complete.

“I really recommend people sit down with someone, because there is a lot to think about and they [navigators and certified application counselors] can help you from a fair and impartial perspective,” Line said. “There are folks out there who are trying to capitalize on this saying ‘Oh, for $75, I can enroll you.’ We are free. You should get free help from someone who is certified.”

Line said tax credits and cost sharing subsidies are available to those who qualify. She said tax credits can be applied to your premium monthly or applied at the end of the year.

“Tax credits are based on your projected income,” Line said.

Line said people who are between 100 percent and 400  percent of the Federal Poverty Level, qualify for additional financial aid.

Healthcare Reform 

Wyner said that in addition to conventional health plans, the law also provides new benefits for seniors receiving medicare. As of Jan. 1, 2011, seniors qualify for free preventative care including colonoscopies, mammograms, annual wellness exams, annual flu shots, screenings for diabetes and more.

Wyner said provisions in the ACA are designed to eventually close the donut hole in Medicare Part D. She said most Medicare prescription drug plans have a coverage gap also called the “donut hole,” that covers prescriptions up to about $3,000. (This includes both your co-pay and the amount paid by your insurance). After that, consumers have to pay out of pocket until they reach a certain amount of money.

Wyner said provisions in the ACA, are working to close that gap. She said in 2014 consumers will qualify for a 52.5 percent discount on brand name drugs and 21 percent discount on generic drugs.

“In 2012, 222,703 Pennsylvanians saved over $168 million, an average of $753 per beneficiary,” Wyner said.

Wyner said if the state fails to expand Medicaid, “Nearly half a million Pennsylvanians will be left with no options for coverage if Pennsylvania fails to expand Medicaid.”

“Pennsylvania would save taxpayers hundred of millions to over a billion dollars on money that otherwise would go to treat the uninsured in the ER,” Wyner said. “Currently, 613,000 Pennsylvanians would qualify for insurance under the expansion.”

States that opt for Medicaid Expansion would be covered 100 percent by the federal government for 2014, 2015 and 2016. In 2017, states would be required to pay 5 percent. The percent the federal government covers would slowly decrease until 2020, when states would be required to fund 10 percent of the Medicaid Expansion.

Wyner urged attendees to call or write their state legislators in Harrisburg to tell them to expand Medicaid because everyone deserves access to affordable healthcare.

For more information about the Affordable Care Act call 1-800-318-2596. To obtain help navigating the marketplace call Resources for Human Development at 610-763-6429.

The original version of this story incorrectly attributed a quote and erroneously stated that people who make between 100 and 400 percent of the Federal Poverty Level (FPL) can shop at the marketplace.

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