Quite possibly the most confusing mandate of our time is about to hit.
The health insurance landscape has never looked more confusing. There are lots of rules and more changes are definitely coming down the pipeline.
There are many decisions to be made when considering open enrollment in this new era of healthcare reform. It is important to be well informed.
Exchanges: They truly provide a unique, new marketplace for individuals and small businesses with 50 or fewer employees to shop for coverage. The big fundamental question is, “If you build it, will they come?”
The key to success rests with the public’s buying behaviors and whether these exchanges will ultimately meet the public’s need. The public exchange is the only option for people to qualify for a tax subsidy based on income.
Not all carriers will participate in the exchanges, and by visiting with your broker/navigator or going to the Washington HealthPlanFinder website (www.wahealthplanfinder.org) you can find the listed carriers and their respective plans.
A “navigator” is a person certified to assist with the exchange programs and carriers. The navigator is not allowed to sell you a private health plan outside the public exchange and cannot offer advice about satisfying personal needs or recommending insurance, benefits or plans.
Open enrollment: The individual mandate requires all Americans to purchase insurance beginning in 2014, if not already covered by a plan. For Americans who lack coverage, they may be subject to a fine, which starts at $95.00 in 2014 and increases to $695.00 in 2016. This is the time period where all Americans can buy a guaranteed issue health plan. The dates for open enrollment are Oct. 1, 2013 to March 31, 2014. If you do not buy during this time, you will not be allowed to buy a plan from the exchange until the next open enrollment, unless you have a life-changing event.
Private carriers: Insurance companies writing health insurance with all the new reform rules. These carriers will offer four metal plans (Bronze, Silver, Gold and Platinum). At this time we don’t have rates on all the carriers, but we do anticipate the rates to be roughly 25-50 percent higher than current health rates. Rating of these policies will now be determined based on age, zip code, tobacco use and number of family members.
Open enrollment outside the exchange: For enrollment in a health insurance plan outside of the exchange, individuals can enroll anytime up to the day before the effective date, just as they do today. Some of the carriers will be offering the 1st and the 15th of the month effective dates.
All of the new plans will include the 10 essential health benefits required by the Affordable Care Act, including ambulatory patient services; emergency services; hospitalization; maternity and newborn care; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; mental health and substance use disorder services.
How much you’ll pay for a health plan depends on the plan you choose. All plans sold in the Washington Healthplanfinder will have different levels of cost sharing. These are called the “metal levels” as mentioned previously to choose from. The difference between the metal levels is based on how much of the medical costs your health plan picks up and how much you pay through copays and coinsurance.
For example, a Bronze Plan will pay 60 percent and you will pay 40 percent of medical costs.
A Silver Plan will pay 70 percent and you pay 30 percent; Gold Plan will pay 80 percent and you pay 20 percent and the Platinum plan will pay 90 percent and you will pay 10 percent. The percentages you the consumer are responsible for will include deductibles, coinsurance and co-payments.
Bronze plans have the minimal level of coverage you need to meet the requirement to have creditable health insurance. Out of pocket costs, such as deductibles and copays, are limited to the same costs allowed in a health saving account (HSAs). The amount changes each year, and is currently $6,250 for an individual and $12,500 for a family.
To help cover the cost of insurance, premium subsidies are available to those who qualify for financial assistance. These subsidies are available only to individuals, only when coverage is purchased through the individual exchange, only when employer sponsored coverage is deemed unaffordable and only when the individual’s income is below a certain threshold. If you are an individual or family earning between 133 and 400 percent of the Federal Poverty Level, you could get help paying your premium. This also changes each year, but today, this is $15,282 to $45,960 for an individual and $31,321 to $94,200 for a family of four.
Stay tuned for more information regarding small business health insurance, tax incentives and penalties.
Ron Copple, RHU, LUTCF, is a career insurance specialist with Copple Insurance Group (www.copplepro.com), which has served King and Pierce counties for 43 years.
