To Recap: I am retired and paying for medical insurance out of my own pocket. I am one of the types of people who the Affordable Care Act – Obamacare – was set up to address. I live in Washington state, which has fully embraced the new act and has been working hard to get its computerized Health Insurance Marketplace – AKA the Exchange – up and running. Yesterday it opened with all functions and information in place (link). I logged in and it looked good. Unfortunately the inrush of people trying to use the site crashed it fast. It’s still down. But before it went down I managed to make an initial run through. I typed in my zip code, age, estimated annual income, and specified my current doctor, who I want to keep. The site gave back 27 plans from three insurance companies that I could get. I was told the amount of premium I would have to pay for each, the deductible, the out of pocket costs, the co-pay level, and a link provided to the details of the plans. I was just starting to dig into those details when the website said “Bye-bye”. Fortunately we’ve got until March 31, 2014 to sign up for a plan so there’s no immediate deadline and I can wait until the website is up again and functioning fully. In the meantime, here’s what I’ve found out about the ACA in general and some advice I’ve been given.
Previously, comparing health insurance plans was difficult because they were different. Plan A might have moderate coverage of a lot of services, another plan might have excellent coverage of only a few services, Plan C might have good coverage of a full range of services but the premiums are large unless you specify a really high deductible: It wasn’t about comparing apples and oranges, more like apples, carrots, and cheeseburgers.
The ACA changes that by organizing health plans in four main levels: Bronze, Silver, Gold, and Platinum. The plans in each of these levels are supposed to offer the same set of 10 essential benefits: Ambulatory patient care, emergency care, hospitalization, maternity and newborn care, mental health and substance abuse treatment, prescription drugs, rehabilitative services, laboratory services, preventative and wellness coverage, and pediatric care. Here’s a link to a website that discusses these, and the ACA in general (link). There is a special level option, Catastrophic Care, for individuals under 30 who can’t afford a regular plan. It has the same 10 essential benefits but an extremely high deductible and only pays for a few visits to a doctor per year, as well as preventative care. Everything else comes out of your pocket until you meet the deductible. And Catastrophic Care plans are not eligible for the premium reduction / tax credits the other plans are (more on those, later). So those with low income may be better off enrolling in a regular plan, although Catastrophic Care premiums are supposed to be very low.
(And speaking of the regular plans, they may offer additional benefits like dental and vision care, or Health Savings Accounts, but those WILL be extra, and the idea is that this standardization will make it an apple to apple comparison. Previously not all health care plans offered all the required benefits, so this has caused massive changes in the health insurance industry.)
What sets these ‘metal’ levels apart from each other is how much of the costs of these services you will have to pay, personally. It’s 40% for Bronze up to 10% for Platinum. Using this system, it should be easy to look at various plans side by side and see which provides the coverage you want. Should be. The thing is, the law doesn’t specify the extent of the services offered, the cost, or the duration. The Health and Human Services Secretary is supposed to set those, but it’s not clear what he’s decided on. This may mean there will be variance on the services covered within the benefit categories, and it will be necessary to be even more on your toes than before. If you are seeking insurance through the ACA, it will now be YOUR responsibility to make sure you make the right choices.
And with that in mind, here’s some of the advice I’ve gleaned:
1. Dig out your prior year tax forms and determine your household income. There is a calculator on the Washington Exchange (and here) that will calculate how close you are to the poverty line and therefore a candidate for government assistance in payment of premiums. Obamacare is designed to make medical insurance affordable even for the lower middle class and the poor, even if the government has to help with the payments. Use the calculator to see if you and your family may qualify. Some states have also expanded their Medicaid coverage under the ACA; if you’re old enough and poor enough, you might be eligible for additional benefits.
2. Make sure you understand how insurance works. Deductibles, out of pocket expenses, co-pays: These aren’t just words, they’re potential booby traps that can cost you a fortune even if you have insurance. Start here for an explanation of possible pit-falls that can trip you up. Once again, remember: Under the ACA, you get to chose your own insurance plan, but the responsibility for choosing the right one is on YOUR shoulders.
3. Make up a list of question you want the answers to. Can you keep your current doctor under whatever plan you wind up under? What is covered under the plan and what is not? For example, consider that common preventative procedure of middle age, the colonoscopy. Since it IS preventative care, it should be covered. But what about the fee for the anesthesiologist who puts you under so the doctor can do the unspeakable? This can often be more than the cost of the colonoscopy itself; is it covered? If the doctor finds a polyp he doesn’t like the looks of while ‘upriver’ and snips it off for analysis, does that change the whole thing from a covered preventative to a non-covered surgical procedure? Is the polyp analysis covered under laboratory services? Question as much as you can and insist on answers; it’s important.
4. Study the various plans being offered through the Exchange. Consider your medical needs, your questions, your budget, and which plans meet all those the best at what level, before making a decision.
There will be insurance brokers, and special trained ‘assisters’ called Navigators, available to help. It would appear they may be necessary.
(first part of this series, here)