Cost, coverage varies with ACA
By KEN STEPHENS
Special to The Telegram
About 366,000 Kansans don't have any health insurance. Some can't afford it. Some can't get it because of a pre-existing condition. And some are young and healthy and haven't thought they need it.
But come Jan. 1, as major provisions of the Affordable Care Act take effect, many of those who think they can't afford it will be able to get a federal subsidy for insurance; pre-existing conditions will no longer be grounds for an insurance company to refuse to provide coverage, and the young invincibles, as well as all other uninsured people, will be required to have insurance or pay a tax penalty.
Given those circumstances, the big question on many people's mind is how much health insurance will cost under the Affordable Care Act. The answer depends on your age, your income, whether you use tobacco products and where you live.
But here are a few scenarios, based on a cost estimator available at www.InsureKS.org, a Web site set up by the Kansas Insurance Department. Each scenario is based on the average cost of a "silver" plan offered by the four companies that have applied to sell insurance on the federal insurance exchange in Kansas. There are bronze, silver, gold and platinum plans, based on the percentage of health care costs they will cover, which range from 60 to 70 to 80 and 90 percent.
Suppose, for instance, you are a married couple, ages 35 and 34, with two children, you live in Reno County and your total family income is $50,000 a year. The total monthly premium for a family silver plan would be about $561, but you would qualify for federal tax credits that would reduce the monthly premium to $280. Premiums would be higher if any members of the family are tobacco users.
If that same family had total income of $70,000, their total premium would still be $561 a month, but they would get a much smaller subsidy and would be responsible for paying $549 a month.
A 60-year-old Reno County resident, nonsmoker, living alone with $25,000 a year in income, would pay $420 a month for a silver plan, but also would qualify for a tax credit subsidy that would reduce the monthly premium to $144. A single 60-year-old making $35,000 a year would pay $277 a month for the same insurance.
A 27-year-old non-smoking Reno County resident making $30,000 a year, would pay $162 a month for a silver plan, but would not qualify for a subsidy to reduce the premium.
It's important to remember that these are estimates, based on the average cost of a silver plan. Your exact costs will depend on the type of plan you select, age, location, tobacco use and income. You'll be able shop for plans, apply for coverage and learn the exact costs on the federal exchange, www.healthcare.gov, starting today.
Of the 366,000 uninsured Kansans, the Kansas Insurance Department estimates about 60 percent will qualify for at least some federal subsidy.
The following are other frequently asked questions and answers about Obamacare:
Q: Is there a way to find out how much will it cost before the exchanges open on Oct. 1?
A: Yes. The Kansas Insurance Department has put together an online calculator you can use to get an estimate for a "silver" plan at www.InsureKS.org. There are platinum, gold, silver, bronze and catastrophic plans. All you'll need to provide is an estimate of your income in 2014, the number of people in your family, the number and age of the adults you are seeking coverage for and the number of children age 20 and under you want coverage for.
The tool will estimate the total monthly premium, tell you whether you appear to qualify for a federal subsidy and, if so, how much you will pay per month and how much will be covered by the subsidy.
The estimator is based on the average silver plan that will be offered by the four companies that will be selling insurance through the exchange in Kansas.
This should be considered only a starting point for your thinking about purchasing insurance through the exchange. Once the exchange opens, two other factors that can affect the cost will come into play: whether you use tobacco products and where you live.
At that time, you'll be able to compare the coverage and costs of a number of plans that will be available to you.
Q: What companies will offer plans through the exchange in Kansas?
A: Blue Cross and Blue Shield of Kansas, Blue Cross and Blue Shield of Kansas City, Coventry Health Care of Kansas and Coventry Life and Health. Collectively they will offer about 130 to 140 different plans. BC&BS of Kansas City does business only in Johnson and Wyandotte counties, so if you're in any of the other 103 Kansas counties, you won't see its plans offered when you start shopping on the exchange.
Q: Where do I go to apply for coverage?
A: Kansans will goonline to the federal health insurance exchange — www.healthcare.gov — or call 800-318-2596. You can go there now to create an account. Although you won't be able to shop for plans or apply for coverage until Tuesday, the site has information to help you get ready. If you don't have a computer or are uncomfortable using one, insurance agents, "navigators" and "certified application counselors" also can provide in-person or individual help.
Navigators and certified application counselors have been trained to help with applying for coverage under the Affordable Care Act and cannot sell or recommend a particular plan. For information on navigators or certified applications counselors, go to www.InsureKS.org and click on "resources."
In Hutchinson, PrairieStar Health Center, 1600 N. Lorraine, will have certified application counselors to provide in-person assistance after Tuesday.
Other certified application counselors in the region are at: the Center for Health and Wellness, GraceMed Health Clinic and Hunter Health Clinic in Wichita; Health Ministries Harvey County in Newton; Salina Health Education Foundation in Salina; United Methodist Western Kansas Mexican-American Ministries in Garden City; or First Care Clink in Hays,
Q: Will I qualify for federal tax credits to reduce the cost of coverage purchased through the federal health insurance exchange?
A: If your income falls within the following ranges you'll qualify to save money on your premiums in 2014. The lower your income within these ranges, the more you'll save. These amounts are based on 2013 income and are likely to be slightly higher in 2014.
$11,490 to $45,960 for individuals
$15,510 to $62,040 for a family of 2
$19,530 to $78,120 for a family of 3
$23,550 to $94,200 for a family of 4
$27,570 to $110,280 for a family of 5
$31,590 to $126,360 for a family of 6
$35,610 to $142,440 for a family of 7
$39,630 to $158,520 for a family of 8
If your income falls below the amounts shown, you may qualify for coverage under Kansas' Medicaid program. However, Gov. Sam Brownback and the Legislature decided not to expand Medicaid. The Kansas income eligibility standard remains well below the level where subsidies kick in. If you have very low income but not low enough to qualify for Medicaid and not low enough to qualify for a federal subsidy, you will be able to purchase insurance from the exchange but you will have to pay the entire premium.
Q: What kind of income counts?
A: Wages, salaries, tips, net income from any self-employment or business, unemployment compensation, Social Security income, rental income, dividends, capital gains, annuities, alimony, some retirement and pensions and foreign income.
Q: What if my estimate is off?
A: If you estimate your income too high, you'll get a refund when you do your 2014 taxes in 2015. If you estimate your income too low, you will have to repay part of the subsidy when you do your taxes.
Q: The subsidy is a tax credit. Does that mean I have to pay the cost of the insurance up front and then I get the tax credit when I do my taxes the following year?
A: No. The Affordable Care Act provides a new tax credit called the Advance Premium Tax Credit, which can be applied directly to your monthly premiums so you get the lower costs immediately. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you're due, you'll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.
Q: Will I be buying insurance from the federal government?
A: No. You'll be buying insurance from one of a number of private insurance companies that have created plans satisfying the essential benefits established by federal law. The federal government's role is to provide the online marketplace where you can shop for and evaluate the various plans and to pay part of the premium costs if you qualify for a subsidy based on your income.
Q: When is the enrollment period on the federal exchange?
A: Open enrollment is from Oct. 1, 2013, to March 31, 2014. After the open enrollment period ends, you cannot purchase coverage through the exchange until the next open enrollment period unless you have a "qualifying event," such as moving to a new state, certain changes in your income or changes in your family size (for example, if you marry, divorce, or have a baby). In future years, open enrollment will be each year between October 15 and December 7. During this time, consumers will be able to change plans, change insurance companies or stay with the plan they have, if it is still available.
Q: When would coverage become effective?
A: For those who enroll between Oct. 1 and Dec. 15, 2013, coverage becomes effective on Jan. 1, 2014. For people who sign up between December 16, 2013, and January 15, 2014, coverage will be effective on February 1, 2014. For those who enroll after Jan. 15 but before March 31, 2014, coverage will be effective on the first day of the following month if a consumer enrolls by the 15th. If after the 15th, coverage will be delayed an additional month.
Q: What kinds of plans will be available?
A: Details for each available plan, including deductibles, co-pays, co-insurance and out-of-pocket maximums will be available when the exchange opens Tuesday. But all plans sold through the exchange must provide certain essential benefits. To help consumers compare costs, plans available through the Health Insurance Marketplace will be organized in four tiers, based on the degree of cost-sharing that each plan includes:
Bronze level -0 The plan must cover 60 percent of expected costs across a standard population. This is the lowest level of coverage.
Silver level — The plan must cover 70 percent of expected costs across a standard population.
Gold level — The plan must cover 80 percent of expected costs across a standard population.
Platinum level — The plan must cover 90 percent of expected costs across a standard population. This is the highest level of coverage.
A less expensive, catastrophic plan also will be offered and will cover the same services. But, its coverage will be less generous than the Bronze level plans. Only young adults under 30 and individuals who have a hardship exemption from the individual mandate are allowed to purchase catastrophic plans. Catastrophic plans are not eligible for subsidies.
Stand-alone dental plans also will be available through the exchange.
Q: What are the essential benefits required in all plans?
A: Essential health benefits include the following: Ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services, including chronic disease management; pediatric services, including oral and vision care.
Many documents about the Kansas essential health benefits can be found at http://www.ksinsurance.org/EHB. For more detailed information about essential health benefits in the Health Insurance Marketplace, visit the National Association of Insurance Commissioners website at http://www.naic.org/index_health_reform_section.htm under Essential Health Benefits Data from The Center for Consumer Information and Insurance Oversight (CCIIO).
Q: What are preventive services and how are they covered?
A: Preventive benefits are designed to keep people healthy by providing screening for early detection of certain health conditions or to help prevent illnesses. The Affordable Care Act requires that all plans except grandfathered plans cover many preventive services with no out-of-pocket costs (meaning no deductibles, co-payments, and coinsurance). Some of these covered preventive services are:
Colorectal cancer screenings, including polyp removal for individuals over age 50
Immunizations and vaccines for adults and children
Counseling to help adults stop smoking
Blood pressure screening for adults
Cholesterol and diabetes screening for certain adults
Well-woman checkups, as well as mammograms and cervical cancer screenings
Well-baby and well-child exams for children
Unless an insurer does not have an in-network provider to perform a particular preventive service, plans are permitted to charge for these preventative services when performed by an out-of-network provider.
For more detailed information about covered preventive services, visit the federal government's website at: https://www.healthcare.gov/what-are-my-preventive-care-benefits.
Q: How will I know if my doctor or hospital is an in-network provider under the available plans?
A: The exchange will include a link to the insurance company website that will let consumers look up whether their doctor is in the plan's network.
Q: WHAT IF MY doctor or hospital isn't in the network?
A: NOT ALL PLANS will cover out-of-network services. When they do, your share of the cost is higher than for using an in-network provider. Though the Affordable Care Act limits how much you have to spend on your health care, out-of-network services do not count toward the limits. An exception to this rule is for emergency services. All plans must provide benefits for emergency services regardless of whether the provider belongs to the plan's network. Plans also cannot charge a higher copayment or coinsurance for out-of-network services provided in an emergency. Kansas law also prohibits billing out-of-network rates for emergency care.
Q: What if I decide not to buy any insurance?
A: The individual mandate requires that every person have medical insurance. Most people will be covered by plans provided through an employer, Medicare, Medicaid, TRICARE or CHIP or the Veterans Administration. Some also have individual plans purchased directly from insurance companies. Others will buy insurance through the exchanges.
If you don't get insurance, you will have to pay a penalty each year for each uninsured member of your family. In 2014, the penalty will be $95 per adult or 1 percent of taxable income above the filing limit. The penalty is half that amount for each child.
In 2015 the penalty goes up to $325 per adult or 2 percent of taxable income, and in 2016 the penalty is $695 per adult or 2.5 percent of taxable income. The total penalty for a family is capped at 300 percent of the individual adult penalty.
Some people, including those whose income is so low they don't have to file a federal tax return, will be exempt from the penalty. Other exceptions include members of recognized American Indian tribes, prison inmates and those who are members of religious groups that object to insurance coverage.
Q: Can I get dental coverage, too?
A: Dental (and vision) coverage are a required essential benefit for children 18 and under and will either be part of the general health insurance plan or offered as a separate stand-alone plan. Dental and vision are not required benefits for adults. However, some plans may offer adult dental insurance. Stand-alone dental plans for adults also will be available through the exchange. If you choose a stand-alone dental plan, you'll pay a separate, additional premium for dental coverage.
Q: I have high blood pressure and have not been able to get medical insurance. Can I still be turned down?
A: No. As of Jan. 1, 2014, being sick won't keep you from getting health coverage. An insurance company can't turn you down or charge you more because of a pre-existing condition, whether it's high blood pressure, diabetes, cancer or any other condition. Once you have insurance, it can't refuse to cover treatment for pre-existing conditions. Coverage for your pre-existing conditions begins immediately. This is true even if you have been turned down or refused coverage due to a pre-existing condition in the past.
The only factors that are a basis for a higher premium are age, tobacco use and where you live. Some states, even some counties within states, have higher medical costs, which can translate into higher premiums. According to the Kaiser Family Foundation, Kansas ranks 27th among the 50 states and the District of Columbia in per capital health care spending and slightly below the national average.
Q: If insurance is available through my employer, can I still get insurance through the exchange instead?
A: A consumer who has access to employer-based coverage can still buy a plan through the exchange, but he or she may not be able to get tax credits to subsidize the cost of the premium. Subsidies are still possible if the employer-based coverage costs more than 9.5 percent of the employee's annual household income or if the plan doesn't provide minimum value, which means it must pay for at least 60 percent of the costs of medical services covered by the plan.