Healthcare.gov is booming since the Federal Health Care Exchange and State Health Care Exchanges opened on October 1st. There have been so many hits, about eight million unique visitors, that the system has had trouble and crashed repeatedly. People are getting frustrated with the inability to check out their options and learn how much plans are going to help them. There has been some talk that some of the volume, may be from suspected “hackers.” However, after investigation, the NY Exchange has concluded that at least for their exchange they do not think hackers have infiltrated their marketplace. (http://www.wgrz.com/news/article/228302/37/Experts-NY-Health-Exchange-Website-Unprepared-For-30M-Visitors) The NY State Exchange has had over 30 million visitors as of October 24th.
People who are able to access the site and look at the plans are at times incredibly excited, or frighteningly depressed about what they learn or as you are about to find out think they learn. The Affordable Care Act is not perfect, but it is better than what we had; a system controlled by the big Health Insurance Companies with premiums for plans spiraling out of control, while denying coverage to anyone and everyone who had a pre-existing illness, unless they or their spouse had insurance through an employer. The Affordable Care Act is changing the “lay of the land” when it comes to health insurance coverage. Anyone who is considering getting health insurance through the health care exchange, or wants to help family or friends will benefit from this step by step discussion of the exchanges. The reader will learn about the Affordable Health Care system, the different types of plans available through State and/or Federal Exchanges; helpful hints to insure you get the best price for plans when using the exchange; as well as an overview of the falsehoods being spread to keep people from signing up for The Affordable Care Act.
After President Obama was elected in 2008, he indicated that health care for all Americans was one of the priorities of his presidency. (http://www.nydailynews.com/news/national/high-hopes-political-realities-obama-term-retrospect-article-1.1243468) By 2009, both the Republicans and the Democrats were involved in discussions about the design of a national health care system. The Democrats favored a single payer system, while the Republicans were unwilling to consider this “road to socialism.” After months of discussion, both parties agreed to a plan that was initially suggested by Republicans in the 90’s developed by the Heritage Foundation as an alternative to a single payer system. Following much compromise and negotiation, the House and Senate, voted for The Affordable Care Act and it was signed into law in March, 2010. Refer to https://progressiveandproud.wordpress.com/2013/10/05/another-acaobamacare-myth-no-negotiation-between-democrats-and-republicans-on-acaobamacare/ for information on the negotiating process in regard to ACA. Let’s review how to sign up for health insurance using the Federal or State Exchanges. While there may be minute differences between the two, the process is similar. It should be noted that even if you think your state may have a program, the sign-up page at http://www.healthcare.gov will connect you with either the federal sign-up for those living in the 26 states that refused to run their own exchange or to the individual State Exchange page in the state in which you reside. Please make sure you ONLY use http://www.healthcare.gov to initiate the sign-up process for insurance because some companies have set up private exchanges that look similar to the Federal or State Exchanges but do not offer the enrollee any subsides or cost-sharing which may be the difference between a plan being affordable or out of reach.
- The first thing a person who wants health care insurance should do is go to http://www.healthcare.gov. (http://b-i.forbesimg.com/robertpearl/files/2013/10/Healthcare.gov_2-e1380635876183.png) The home page will have different choices. Choose the one that best serves your needs such as individual/family or business. This is a red alert. Always start from the http://www.healthcare.gov website even if you think you have a State Exchange. Healthcare.gov will link you to your State Exchange, if available, but people have been fooled by looking up Federal Health Exchange or State Health Exchange in search engines. In order to get around the rules, companies including insurance companies have formed “private exchanges”. It looks like a real exchange until you get to the costs. It may even have plans that are similarly named to the official ACA plans, but the enrollee will not be offered any subsidies to assist in paying for the plans. In order to protect yourself and get the best rate ALWAYS begin your process to apply for health insurance at http://www.healthcare.gov.
- When you get to the healthcare.gov website click on your state and it will take you to a new screen. There you will be told whether your state has it’s own exchange or if you will be getting insurance through the Federal Exchange.
- The computer will redirect you to your State Exchange home page or continue in the process of signing you up for the Federal Exchange.
- The next screen will ask you for your name, email address and zip code. In some cases, it may ask you what you expect your 2014 income will be. It may also ask if you are eligible for and have insurance through your employer. If insurance is a benefit offered by your employer, you may not be eligible for the exchange. Why? ACA was enacted to insure those who did not have insurance through their job, those who are unable to purchase health insurance due to pre-existing conditions, and those who are unable to afford health insurance. (http://www.bcwac.org/pdf/Health-Care-Comm-Report-on-ACA-to%20Coalition-11.30.12.pdf)
- You may also be asked to identify 3 security questions and their answer. Please make note of your user name, password, and the 3 questions you chose in addition to their answers. After you have completed this and clicked on “continue” you will see a screen that tells you to go to your email and verify your internet identity by clicking on the link.
- Click on the link, contained in the e-mail, and you will go back to the exchange and most likely land on a page with one of the following messages: You have successfully signed up” and you will be able to proceed with the sign up for insurance, or “The system is very busy”, and then you will be taken to a page that tells you to wait, the exchange is busy, but you will be sent to the next step as soon as possible. http://www.fbnstatic.com/static/managed/img/fb2/news/healthcare_exchange_error.jpg People have reported quite long waits, up to 45 minutes and sometimes the site crashes and you have to put your user name (email) and password in to log in again. Please do not leave this page, as you will lose your place in line. If you are unable to wait, save your information and simply return at a better time. The web site is so new, and people are eager to check out the costs for health insurance plans, so the site is very busy and the best time to access the health exchanges seems to be after midnight and before 6:00 AM. Remember you have until Dec. 15, 2013 to sign up and have the insurance start coverage on 1/1/2014 and even longer if you decide after January 1st but before March 15th that you want coverage. If the site is busy, you will also be given a number you can call and a navigator will help you sign up or you can have an application form sent to your address to complete and mail to the place they request. Most of the people I have talked to, indicate they get through to a navigator by phone faster and the navigator is very helpful in completing the application.
- At any point between steps 4 and 6 you will be asked if you want to enroll in the plan or see an overview of the plans. If you choose to review the plans, be aware you will be given an overview of the plans and none of the subsidies or cost -sharing information will be available. This is causing a problem for many folks because, they do not see any cost sharing or subsidies on these plans, so they panic and immediately assume they do not qualify for subsidies from the federal government and will have to pay the full cost of the premium, deductibles and co-pays. This is not necessarily true. People who choose to review their possible plans prior to completing their application will have “artificially” high deductibles, premiums, and out of pocket expenses. You will not be able to see the plans with any subsidies or cost sharing applied until you complete the enrollment process. (**As a note, this is the point where I am often contacted by email, phone, twitter or facebook because someone is frantic that the premiums are too high and not affordable and the deductibles and out of pocket maximums are often several thousand dollars.) They seem “sure” that they have been lied to and the rates are not what President Obama promised.
- Remain calm and check to insure you have completed your enrollment in the program. You will know if you have completed it because you will get a screen explaining what your subsidy is for the premium and it will tell you, if you are eligible for cost sharing and what types of programs are available for you. If you choose to view the plans at the start of the application, you will be shown possible subsidies and absolutely no cost-sharing, so the moral of the story is be sure and complete the enrollment process.
- The next step will be to fill out an application. There will be several sections. This is pretty straightforward and simple. You will be asked to identify the members of your family, and put in their dates of birth and social security numbers. Be sure to include everyone in your family, you, your spouse and the children for whom you are responsible for obtaining insurance. (Don’t forget children can remain on your policy until they reach the age of 26, regardless of whether they live at home, are in college, or are working.)
- Another page will ask you about your income. There are three different types of income: employment income, small business income, and other income which could include retirement, unearned income from investments etc. These questions are very specific and if you are married you will have to complete it for both spouses. and if you have children for each of them as well.
- Once you enter your income, the program will attempt to verify your income and your identity. This is very similar to the process that occurs when you apply for a credit card, renting a home, or buying car insurance just to name a few. The big three credit companies are used to verify your identity and your last income tax form will be used to verify your income. Although, in this situation, your credit does not impact your premium or cost sharing alternatives. The computer program is programmed to access your last tax return to compare the income you reported on your last return in comparison to the amount you are projecting you will earn in 2014. ( find it very interesting that so many Republicans indicate an enrollee does not have to verify income. For people apply for health insurance through the State or Federal Exchange must verify their income before they will be able to fully complete the application process. These conservative and/or Republicans seem to assume people will cheat and/or under report their income and I am sure some will, just like some people cheat on their taxes. However as noted in a previous blog the number of people who cheat on their taxes is much higher than those who cheat on entitlement programs. If your income is significantly less or more than your most recent tax return, you may be asked to verify your income by submitting documents that support your reported income. You will be given several choices on how to document your income and how to get it to the health care exchange. As a personal note I had to do this. I know my income will be more in 2014, than in the previous 2 years, so the amount I estimated is more than what is on my previous tax return. I had to send in documentation to support this. I sent in a copy of my taxes and a written explanation as to why I think my income would be significantly more. You can verify your identity by submitting a copy of your driver’s license or government ID for example. You can send your documents confirming your income by fax, mail, email. You will have many choices. You will also have a deadline by which time you must provide these documents.
- Whether you choose to send in your income documents immediately via the web or fax or decide to send them to the address provided, you will be given the opportunity to continue with the enrollment process. You will get a screen that reminds you that if you do not report your income correctly, you may have to return some or all of the subsidy or cost sharing money you received and that your enrollment will not be complete until the supporting documentation is received. (No, this is not just me repeating myself, you will see this statement 2 or 3 times during the process of enrolling in the exchange: at the very beginning, prior to giving any income amounts, after you enter your income if it doesn’t coincide with previous tax years, and finally again after you have reviewed the plans with the subsidies added in, just before you finish the application process.
- The exchange explains the consequences of under reporting your income and reminds you that you have to tell the truth and cites the law in regard to truth in reporting income. You will be asked if you want to continue or wait until after you “recheck your income,” At this point you can save your data, or you can choose to move forward after acknowledging that the income you have documented does or does not agree with the information on your last tax return, and click on the button validating that the rates they are showing you are based on self-reported income and could change when you send in the verifying documents.
- Finally, you will be asked to sign your application electronically. Your signature means that you understand the need to submit supporting documentation, which is simply a statement that says you understand the process, validate you have submitted your correct earnings, and know you need to change your reported income if there are any changes to it in 2014. Failure to notify the exchange about any change in income could result in the IRS subtracting any over payment from your next federal income tax refund. It also reviews the situations in which you can make other changes to your plan during 2014, including but not limited to, the birth of a child, retirement, quitting a job etc, in other words any situation might change your eligibility for the exchange and/or impact your premium subsidy or cost-sharing.
- After completion of the application process, even if you have to send supporting documents to verify your income or identity, you will be given the option of reviewing the insurance plans available in your state. At this point, you will be transferred to a page where you will see the plans available to you, the premium subsidy, and if you are reviewing the Silver Plan, any cost sharing for which you may be eligible.
Once you get to this point, the application is finished and you are ready to “shop in the exchange”. Don’t forget, that if you have been asked to submit supporting documents you must do so prior to setting up payment arrangements for your plan. You will not be “officially” enrolled in the Health Exchange until that time.
So what can you expect to see when you review the plans. The first thing you need to know is that beginning in 2014 every health insurance plan will offer ten essential benefits that all enrollees will have in common regardless of what plan they are enrolled in:
- Ambulatory patient services
- Emergency services
- Hospitalization; maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services
- Chronic disease management
- Pediatric services, including oral and vision care.
Regardless of which plan you choose, these benefits will be a part of the plan. In addition, even if you have used none of your individual or family deductible you will not have to pay for every medical cost until you reach that deductible. Some of the preventative services and physicals are provided at no cost to you each and every year, regardless of the plan. In addition, many services will be covered and enrollees will only pay a co-pay for services such as seeing a doctor when sick.
Based on the data currently available, there are four levels of health care plans offered through the State or Federal Exchanges. They are named Bronze, Silver, Gold, and Platinum, so that regardless of where you live in the United States, you will be able to understand and recognize available plans. http://www.medicoverage.com/images/compare-exchange-plans.jpg. In addition, while the prices may be different, plans in various states, counties, and/or communities that are labeled as Bronze, Silver, Gold or Platinum will be essentially the same regardless of where you live. The Kentucky State Exchange, for example, offered me sixteen different plans from which to choose. Please note however, that 12 of the plans were from the same company, but had slight differences between them. Be sure to review all the plans carefully and insure they meet your needs. Plans on the Exchange range from bare bones “Bronze” plans that have high deductibles and co-pays but have the cheapest premiums, to “Platinum” plans which have the most expensive premiums but the lowest deductible and co-pays. It is also important to note that any Health Insurance Companies can participate in the Health Exchanges as long as they offer at least one Silver Plan and one Gold Plan. Companies may have different provider lists, so be sure to take this into consideration as well.(http://publications.milliman.com/publications/healthreform/pdfs/Employer-healthcare-reform-strategic-impact-study.pdf)
Before you can understand your options in choosing one of the health insurance policies, on the State or Federal Exchange, you need to understand the two cost saving measures or tax benefits in the ACA. The first tax incentive is perhaps the most widely known and popular subsidy available to enrollees. Based on the enrollee’s income they may be eligible for pre-tax incentives each year that are payable to the insurance companies to offset the costs of premiums for tax payers. Enrollees have the opportunity to anticipate their 2014 income, and based on that income receive a subsidy, that is sent to the insurance company each month as a partial payment of your premium. You can also choose to pay the full-cost of the premium each month and reconcile it on your 2015 taxes and receive a refund if you qualified for a subsidy.
The second and more confusing subsidy is a cost sharing subsidy that may help those people who make less than 400% of the poverty rate, which is about $45,000 a year for a single to about $96,000 a year for a family of four. This cost sharing subsidy is only available on the Silver Plans. While the tax incentive subsidy is available for any level of the plan, the cost sharing subsidy will only be allowed for use on the Silver Plan. The moral of this story is don’t assume the Gold or Platinum Plan is the best plan to choose, because choosing the Silver Plan may allow you to have lower deductibles and co-pays than the Platinum Plan or what is commonly referred to as the “Cadillac” plan. Let’s review each of the plans:
- Bronze Plan: The Bronze Plan has the lowest premiums in the exchange, but has the highest out-of-pocket costs and deductibles. There is no cost-sharing subsidy available for this plan. The bronze plan may be a good choice for a young adult who is just going out on their own. People who choose the bronze plan will have 60% of medical costs paid for by insurance, after meeting the deductible. They will also have certain preventative services provided free each year.
- Silver Plan: his is considered the “average” plan for most enrollees, because it is the most cost effective choice for reasonably healthy families who use medical services. Before any subsidies are figured into the equation the Silver Plan pays for 70% of the costs of medical services after the deductible is met. “After the deductible is met” can be rather frightening for any consumer viewing their health insurance benefits. Deductibles in the current market place can be high and still be “more” than most middle or working class families can afford. The Silver Plans offered to consumers through the health exchanges, have a $2000.00 deductible and a $6,750.00 out of pocket maximum per year, prior to cost sharing for a single individual. Once the out of pocket maximum is reached in a calendar year, the insurance company will pay 100% of the enrollees costs including prescription drugs for the remainder of the year. For families, the deductible and out of pocket maximum is higher. This is NOT the whole story when deciding which insurance plan is best for you and your family. Enrollees are offered another subsidy which is referred to as cost-sharing, if and only if, they earn 400% or less of the poverty level and choose the Silver Plan. For a single person 400% of the poverty level is approximately $45,000.00 per year or less and for a family is $95,000.00 per year or less. The purpose of the cost sharing subsidy is to lower the deductible, co-pays, and out of pocket maximums to more affordable rates based on income. Cost sharing is ONLY available on the silver plan. Two things are important for consumers to know:
- First, projecting your 2014 will be important, because if you earn significantly more than you projected, you will be responsible to pay back that part of the subsidy you used due to incorrect projections of your income.
- Second, when you view the plans available to you through the exchange, you will not be able to see the cost-sharing component until you complete the application, verify your identity and income, and electronically sign your application.
- Gold Plan: The Gold Plan is the second most expensive plan and has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you. It has lower deductibles than the Silver or Bronze Plan as well as lower co-pays, and out of pocket maximums per year. People who do not meet the criteria for subsidies and/or cost-sharing may well find a Gold Plan that will offer them similar benefits to those who qualify for cost-sharing under the Silver Plan.
- Platinum Plan: The Platinum Plan or “Cadillac Plan” is the plan with the highest premiums offered on the insurance exchange. In this plan 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid for by the enrollee. This plan may be appropriate for those with high incomes and those in poor health. Although coverage is more expensive up front, the 90% coverage of costs will help those who use medical services frequently but do not qualify for cost-sharing on the Silver Plan due to their income.
Not every health insurance provider in the exchange has to offer each tier of the plans outlined by the federal government, however, all participating health insurance companies must offer at least one Silver Plan and one Gold Plan to potential enrollees. There is one more type of Health Insurance offered by the State and Federal Exchanges called the Catastrophic Plan. This plan is primarily for those people under 30 years of age who are in good health and do not plan or need to use medical services very often. It protects this group of consumers from very high medical costs should the “unexpected” occur, such as an accident or catastrophic illness. The Catastrophic Plan includes 3 primary care doctor visits per year as well as free preventive benefits at no additional out of pocket cost. Cost sharing and premium subsidies are not available for the Catastrophic Plans. People 30 and over or those with low incomes, that even with premium subsidies and cost sharing does not make health insurance affordable or who have received a hardship exemption from the fee may also be eligible for Catastrophic Plans. (http://www.advisory.com/Daily-Briefing/2013/06/27/Who-will-be-exempt-from-the-ACA-mandate-The-final-list) Hardship exemptions include but are not limited to:
- Undocumented immigrants
- Indian tribal members, living on an Indian reservation will be exempt from the penalties. This exemption is probably due in large part to the fact that Indian Reservations in the United States have an extensive public health system provided by the federal government.
- Members of some religious organizations or health care sharing ministries also can apply for a religious exemption.
- Other people or organizations may be granted a hardship exemption including but not limited to:
- Those who cannot afford coverage, or live in states that have opted out of the Medicaid expansion;
- People who have no plan options in their state’s health insurance exchange;
- Individuals who have suffered a hardship or a coverage gap of three or fewer months;
- Finally, exemptions may also be offered to individuals on a case by case basis.
As you can see, there is much information to take into consideration when you sign up for health insurance through the State or Federal Exchanges. It is true that the process may be frustrating at times, overwhelming, and even maddening, however the outcome for the vast majority will be well worth the “pain” in getting covered. How do I know? In 2010, when the Affordable Care Act became law it included an amendment directing the federal government to set up a plan, the Pre-Existing Condition Insurance Plan (PCIP), through which people with pre-existing conditions could apply for and receive health insurance prior to the Affordable Care Act being available nation-wide in 2014. I signed up and was approved for PCIP health insurance in 2011. (https://progressiveandproud.wordpress.com/2013/09/30/obamacare-the-health-insurance-that-saved-my-life/) Premiums were not based on health, gender, or the ability to pay. It was simply based on age. PCIP served as the “guinea pig” for the roll-out of the Affordable Care Act. If you have read my previous blogs, you would know my application process was not without it’s problems, however once I was approved, the health insurance turned out to be better than 95% of the plans I had ever had, even when I was employed. (https://progressiveandproud.wordpress.com/2013/10/23/sometimes-the-best-things-in-life-arent-easy-dont-give-up-on-the-health-exchanges/) I understand that people are impatient to get insurance. I certainly felt that way, however the end clearly made up for the means. This was a huge undertaking for the government, to solve a huge problem in the United States. It may take several weeks or several months to work out the “glitches”, but that doesn’t mean we should “throw the baby out with the bath water.” The administration is taking steps to correct the problems. Bill Gates, one of the smartest and richest men in the world sent Americans a message on Facebook: https://www.facebook.com/photo.phpfbid=10200210418781672&set=gm.10151722315393861&type=1&theater which is self-explanatory.
Unfortunately, there are those who would rather “throw the baby out with the bathwater” and have consistently and continually since the law was enacted tried to proceed down that path. Americans have been drowned in “facts” that cast an evil slant on the program. In truth, these aren’t facts at all but rather either a manipulation of information or flat out lies designed to anger or frighten Americans into not supporting this program and not signing up for an insurance plan they may desperately need. Some of the most common lies and distortions include the following:
- A micro-chip will be implanted into people who purchase a plan through the state or federal health exchange that essentially is “the mark of the beast” described in the Book of Revelation in the Bible. This is a flat-out lie. No one participating in the State of Federal Exchanges will be injected with a chip. The only injections a person will receive will be no different than those they receive now such as vaccinations, flu shots etc.
- There was never any negotiation or compromise between the Republican and Democratic Party in regard to the Affordable Care Act. President Obama simply “shoved it down the throat” of the American people. Wrong! (https://progressiveandproud.wordpress.com/wp-admin/post.php?post=313&action=edit) Affordable health care was a priority of the Obama administration, and in fact, of his campaign to be President in 2008. Actually, President Obama favored a single payer system which the Republicans would not even consider. The final plan that passed the Congress and was ultimately signed into law by President Obama was first suggested by the Heritage Foundation, a conservative think tank as an alternative to the single payer system suggested by the committee headed up by Hilary Clinton during the Clinton Administration. (http://online.wsj.com/news/articles/SB10001424052970204618704576641190920152366)
- The government and the IRS will have free access to enrollees bank accounts and may use private information to spy on them. This couldn’t be further from the truth. (https://progressiveandproud.wordpress.com/wp-admin/post.php?post=98&action=edit) Enrollees will be given the opportunity to pay their monthly premium by an automatic withdrawal from their checking account. This insures that there will be no lapse in health care coverage and is no different than how millions of Americans pay their utility, phone, or cable bills. The IRS will NOT have any access to a person’s bank account with regard to ACA.
These are just a few of the distortions and absolute lies being told by conservatives in order to make Americans suspicious and afraid of the Affordable Care Act. So much time has been spent debunking these myths and countering the more than 40 repeal efforts by the Republicans that could have been better spent working together in a bi-partisan basis to anticipate any problems that might occur on a program roll-out of this magnitude. Instead Republicans appear to be gleefully having Congressional Hearings to continue to undercut the Affordable Care Act. Congressman Issa in a recent Congressional Hearing yielded the floor to a Democrat, who began to counter the implications being presented at the meeting. Congressman and other Republicans were asking questions of the witnesses that implied that questions about pre-existing illnesses and other health records would be used during the application process. The Democrat was very vocal in confronting these Republicans about their line of questioning being unnecessary, because age and whether or not the individual applying is a smoker are the only criteria on which costs for the plans are based. As a consumer, it is extremely important, that you consider the source when given “facts” about the Affordable Care Act.
There are people signing up each and every day under the Federal and State Exchanges. My best advice is to “stay calm and keep going” to quote a popular phrase. If you can’t seem to get signed up, don’t despair, complete the contact form at the end of this blog and we will be happy to help you or direct you to someone who can. Good Luck!
About the Authors: By: Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO and Lynne Smith, MSSW. Barbara is an industrial engineer with an MBA. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services. Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations. Please direct your questions and/or inquiries to firstname.lastname@example.org.