What's the Health Insurance Marketplace? We've got your answers [Austin American-Statesman]
(Austin American-Statesman (TX) Via Acquire Media NewsEdge) Sept. 27--Tuesday is the big day -- the day when people can start signing up to get insurance through the Health Insurance Marketplace created by the Affordable Care Act. We know there are a lot of questions about the marketplace, how it works and who should look at it. Below are answers to some of the most frequently asked questions.
What is the marketplace?
The marketplace houses all the insurance programs that will be offered through the Affordable Care Act. It's located at healthcare.gov.
I thought Texas doesn't have a marketplace? Can Texans still get insurance through the Affordable Care Act? Yes, Texas, like many states, does not have its own marketplace, but Texans can buy insurance through the federal marketplace.
Why is everyone talking about the marketplace right now?
On Tuesday, the marketplace opens for the first time, allowing you to see which insurance companies are available to you and what is offered in each plan. You'll also be able to see if you qualify for subsidies to offset the cost.
If I already have health insurance, should I go to the marketplace?
If your employer provides health insurance, the marketplace is not really designed for you. Your employer is offsetting your costs. Under the Affordable Care Act, if your employer purchased your insurance after March 23, 2010, or has made significant changes to it since then, your insurance now has to provide the same essential benefits as the plans in the marketplace.
If you are buying private insurance or have expensive pre-existing condition insurance, you'll want to take a look to see if you can get a better rate or better coverage.
If you are the owner of a business that employs fewer than 50 people, you can look at providing employees insurance through the marketplace. Your employees will become part of a larger risk pool, which could lower your rates.
If you are covered under Medicare, Medicaid or Children's Health Insurance Program, the marketplace is not for you. You'll stay with what you have.
If I don't have insurance, why should I go to the marketplace?
Starting Jan. 1, you'll be required by law to have insurance unless the cost of insurance is more than 9 1/2 percent of your income. You won't go to jail if you don't get insurance, but you will pay a fine on your tax return that will be $95 per person or 1 percent of annual income the first year. It will go up annually. By 2016, the fee is $695 per person or 2.5 percent of the annual income.
What kind of insurance will be offered through the marketplace?
While we don't know the exact insurance companies that will be part of the marketplace, we expect to see major well-known companies. On Wednesday, the U.S. Department of Health and Human Services said people in the Austin area will have access to 76 plans.
The insurance plans cannot discriminate because of gender or a preexisting condition. The plans have to cover these things: ambulance, emergency room, hospital, maternity and newborn care; mental health and substance abuse treatments; prescription drugs; rehabilitative and habilitative (occupational therapy and physical therapy for those with disabilities) services and devices; laboratory testing; preventative and wellness services; chronic disease management, and pediatric services.
There's also a list of preventative care items that will not require co-pays. Birth control and breast-feeding support has to be offered.
There are no annual limits.
Is it one-size-fits-all-insurance, or do I get choices?
You get choices. There are four basic levels: bronze, silver, gold and platinum. The deductibles will vary with each plan, but the levels determine what the percentage of out-of-pocket expenses will be after you reach your deductible.
Bronze: Insurance covers 60 percent; you pay 40 percent.
Silver: Insurance covers 70 percent; you pay 30 percent.
Gold: Insurance covers 80 percent; you pay 20 percent.
Platinum: Insurance covers 90 percent; you pay 10 percent.
There's also catastrophic coverage, but that's really designed for young adults who are between 26 and 30 who are no longer covered by their parents but cannot afford better health insurance and can prove it.
How much will I pay?
Every person will be an individual case, and you will not know until after you apply when the marketplace opens Tuesday. If your income is between 100 percent of the federal poverty level and 400 percent of the federal poverty level, then you will be eligible for federal subsidies to help you buy insurance. The federal poverty level this is year is $11,490 for one person, $23,550 for a family of four. So, 400 percent is $45,960 for one person and $94,200 for a family of four.
If you make below poverty level, you might qualify for other programs. The enrollment process is supposed to be designed to automatically funnel your application to the Children Health Insurance Program or Medicaid if you qualify for those. There's also the Medical Access Program through Central Health.
Is there a rough estimate of what plans will cost?
On Wednesday, the U.S. Department of Health and Human Services released these figures for Austin: A 27-year-old adult who makes $25,000 a year will pay $85 a month for the bronze plan after tax credits or $145 a month for the silver plan after tax credits. A family of four who makes $50,000 a year will pay $64 a month for the bronze plan after tax credits and $282 a month for thesilver after tax credits.
How do I decide which plan is right for me?
You have to decide what you can afford versus what you can risk. Think about how much insurance you use in a typical year. If your family gets sick often or has chronic illnesses, you might want to pay more each month to have a lower deductible or choose lower out-of-pocket expenses. If everyone's been healthy, maybe you take a risk and choose a higher deductible and higher out-of pocket expenses for lower monthly payments.
Don't forget to check if your doctors are in the plan, since that could also be a deciding factor.
Read the fine print carefully. Plans are now by law supposed to be written using universal language and with a glossary of terms, and while there are the essential benefits they all have to have, other services also might be important to you. You'll want to make sure you understand what's covered and what's not.
What will I need to apply?
You'll need to provide your family's Social Security numbers or document numbers if you are legal immigrants; employer and income information found on pay stubs and W-2 forms; policy numbers for your current insurance and a form to verify whether insurance coverage is available through your employer.
The forms will look similar to filling out an income-tax return.
How long do I have to decide if I want to use the marketplace?
The open enrollment period is Oct. 1-March 31. Coverage can begin as soon as Jan. 1. It will take about two weeks from the time you apply to the time coverage begins, so enroll by Dec. 15 to get coverage that will begin New Year's Day.
After March 31, you cannot apply for coverage for 2014. You'll have to wait until next fall to get coverage for 2015.
Where do I get help if I'm still confused?
Local health clinics and some nonprofits are offering people who have been trained as navigators to help you. You can call 211 to get a list. You also can go to Foundation Communities' two Affordable Care Act Enrollment Centers at 2600 W. Stassney Lane and at Highland Mall, 6001 Airport Blvd. in the upper level across from the food court. Beginning Tuesday, the south location will be open 9 a.m.- 7 p.m. Monday through Thursday, 9 a.m.-4 p.m. Friday and Saturday and 1 p.m.-4 p.m. Sunday. The north location will be open 10 a.m.-7 p.m. Monday through Thursday, 10 a.m.-4 p.m. Friday and Saturday, and 1 p.m.-4 p.m. Sunday. You can schedule an appointment at www.foundcom.org. A third location is in the works.
See more of our coverage of the Affordable Care Act at http://www.statesman.com/s/affordable-care-act/.
Sources: healthcare.gov; U.S. Department of Health & Human Services; Kaiser Family Foundation; Dr. James Rohack, director of health care policy at Scott & White; Jesus Garza, president and CEO of Seton Healthcare Family; Kim McPherson, program officer for Healthy Minds of St. David's Foundation; Dr. Ari Brown of 411 Pediatrics; Nora Cadena, media and marketing coordinator for Insure Central Texas of Foundation Communities; and Anne Dunkelberg, associate director of the Center for Public Policy Priorities.
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