Out-of-pocket expenses
Deductible — The annual cost of health care you must pay before your insurance begins covering you. For example, if your deductible is $2,000, you must pay that full amount out of your pocket. After that, depending on the plan, your insurer will begin covering a portion of your cost. Some people, particularly healthy young people, may go the whole year without satisfying their deductibles; others may pay that and more by the end of January. However, under the law, many important preventive services, including vaccines and cancer screenings, are covered with no out-of-pocket expenses charged to you, even if you have not yet met your deductible.
Coinsurance — The part of a medical bill that you pay. Say your insurer covers 80 percent of your expenses (once you have satisfied your deductible). If it costs $1,200 to treat your son's broken arm, the insurer will pay $960 (80 percent). You pay the remaining 20 percent, or $240, as your coinsurance. Your network comes into play on this. These are just examples: If the hospital is in your network, you may only have to pay 10 percent, with the insurance company picking up 90 percent. If it's out of network, your share may jump to 30 percent.
Copayment — A fixed fee for a medical service, usually charged at the time you get the service. Copays typically are $15 to $25, more for specialists.
Q. What is Obamacare?
A. Obamacare is the nickname of the Patient Protection and Affordable Care Act of 2010, the most sweeping reform of our health care system since Medicare in the 1960s. Oct. 1 is opening day for the Health Insurance Marketplace in each of the states, one of the most significant milestones in the life of the law. (Obamacare began as a derisive reference but has since been adopted by just about everyone.)
Q. What is the Health Insurance Marketplace?
A. The Health Insurance Marketplace, also known as an exchange, is a website on which people who don’t have health insurance through an employer may shop for coverage. The exchange is supposed to be the “affordable care” part of the law. In Georgia, five insurers are offering dozens of plans to choose from. They vary in cost depending on age, family size, whether you smoke and what part of the state you live in.
Q. How do I get to the marketplace?
A. Go to HealthCare.gov and follow the links. If you can. The marketplace has not functioned properly since it opened Oct. 1. At first, the administration blamed heavy traffic for slowing down the system and creating access problems, and that may be a factor. But reports in recent days have blamed bad software design, too-tight deadlines and poor management of the massive federal system. A number of states created their own exchanges (Georgia didn't), and many of them have been operating more reliably than the federally run Health Insurance Marketplace.
Q. Does everyone in the country need to go the marketplace?
A. No. Anybody can shop on the exchange, but most people will not need it. It is designed mainly for people who have to buy an individual insurance policy: the self-employed, the unemployed and workers whose employers don’t provide affordable insurance.
Q. What, exactly, is “affordable?”
A. The law defines affordable as insurance that doesn’t cost more than 9.5 percent of your annual income. Important notes: the 9.5 percent threshold applies to the cost of your premiums only and doesn’t include out-of-pocket expenses. Also, when determining whether an employer’s plan is affordable, the threshold applies only to the cost of the employee’s plan, and not to the total cost of insuring his or her family.
Q. Do I have to buy insurance today?
A. No. The “open enrollment” period on the Health Insurance Marketplace lasts for six months, from Oct. 1 to March 31. (It won’t be as long next year.)
Q. Do I have to buy insurance at all?
A. No. But you could face a penalty if you don’t. Probably the most controversial provision of Obamacare is the “individual mandate,” which requires nearly every U.S. adult to carry health insurance or face a tax penalty. If you don’t earn enough to file taxes, you will avoid the penalty. Otherwise, on your 2014 taxes you’ll face a penalty of $95 or 1 percent of income, whichever is greater. That cost escalates: in 2016, the penalty will be the greater of $695 or 2.5 percent of income.
Q. How much will I have to pay for it?
A. Depends on your circumstances and on what plan you choose. The plans are offered on “tiers”: platinum, gold, silver and bronze, with platinum being the most expensive and offering the most comprehensive coverage. Bronze costs the least and offers the minimal level of coverage allowed by law – although consumers under 30 also have the option of a high-deductible “catastrophic plan” that would be the cheapest option for them. Your income will determine whether you can qualify for a tax credit and other public assistance to help pay for your insurance.
Q. Does it cost the same everywhere?
A. No. Georgia is divided into 16 regions. Not all five insurers on the exchange will offer plans in all 16 regions, and costs may vary widely from region to region. For example, insurance in metro Atlanta will be substantially less expensive than insurance in rural South Georgia. Costs also will vary from state to state. Insurance companies had to submit their proposed rates to each state for approval. Some states bargained for better prices. Other states just said, “OK.”
Q. Are there discounts available on the exchange?
A. Yes. If your income falls between 100 percent and 400 percent of the federal poverty level, you may qualify for a tax credit to help pay your premiums. This is an “instant” credit that you can take when you pay the premium each month, so it effectively functions as a discount. Some people on the exchange may qualify for additional help in covering deductibles and copayments.
Q: What if my income falls below the poverty line?
A: The law envisioned that you would be covered by an expanded Medicaid program, the health plan that already covers many low-income children, pregnant women, disabled adults and others. A Supreme Court decision allowed each state to decide whether it wanted to expand Medicaid, even though the federal government would pay at least 90 percent of the cost of the expansion. Georgia opted not to expand. That means the poorest Georgians who are uninsured will not get Medicaid and they also cannot qualify for a tax credit to help pay for private insurance.
Q. How do I find out whether I qualify for the tax credit?
A. The Health Insurance Marketplace will tell you, when it's working.
Q. If I do get a new plan, when will it take effect?
A. Plans purchased by Dec. 15 take effect Jan. 1.
Q: Is the exchange the only place where I can buy an individual policy?
A: No. Not all insurers that sell plans directly to consumers will be selling on the exchange this year, and even those who will also will continue to offer plans outside of the public exchange. The great benefit of the exchange is the chance to get a tax credit. If your income is too high to get a credit, then you may have better choices outside of the exchange. Plans sold outside of the exchange have to offer the same required benefits as plans sold on the exchange.
Q. So, I have to buy this insurance to avoid a penalty. Does my doctor have to accept it?
A. No. Each insurance plan will have a "network," or the doctors and hospitals and other health care providers who have signed agreements with the insurance company to care for you. These agreements include a list of prices for thousands of procedures. Providers that haven't signed such a deal with your insurer are "out of network." You may still choose to see them, but in most cases they will be substantially more expensive than providers in your network. That extra cost comes out of your pocket. The AJC has found that plans sold on the exchange are likely to have smaller networks than the regular commercial plans offered by the insurers.
Q. How will I find out which doctors and hospitals are in my network?
A. The Health Insurance Marketplace should have information on your network, since that will figure into your decision on which plan to buy. You can also call the insurance companies directly to find out more about their networks before deciding on a plan.
Q. What do I do if the nearest doctor in my network is 50 miles away?
A. You’d most likely want to choose a different plan that has a different network, although it may be more expensive. And there’s no guarantee that there will be another plan available in your area. The public is just learning how the insurance companies on the exchange have constructed their networks. And don’t forget there may be more plan options sold outside of the exchange to explore if you’re not concerned about getting a tax credit.
Q. How can I get help shopping for a health plan?
A. Speciallly trained “navigators” will be available to assist consumers at 855-899-6092. But as of Monday, only four navigators had been licensed by the state. Insurance brokers can also help you shop for a plan. They earn commissions when they sell a plan, so using a broker usually doesn’t cost anything for people who are shopping on the individual market. This link can help you find a broker in your area: http://www.nahu.org/consumer/findagent2.cfm
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