After suffering a heart attack in April that led to quadruple bypass surgery and medical bills that topped $100,000, Greg Fortune learned the value of good insurance coverage.
But since that health scare, he lost his job and his health insurance with it.
So now the 61-year-old, who found work as a part-time minister earning modest wages but no benefits, is shopping on the health insurance marketplace in hopes of finding coverage that he can afford.
“I want to see what policies are available with my limited income and if I qualify for any subsidy under Obamacare,” said the Greenville man. “I hope it’s not any more than $200 a month — $300 at the most.”
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Open enrollment for Obamacare begins today, and South Carolinians looking to enroll will find more plans to choose from and slightly higher premiums than last year.
And those who don’t sign up this time around will face much stiffer penalties.
Under the Affordable Care Act, also known as Obamacare, most Americans must have health insurance, which they can purchase from private carriers in an online marketplace often with the help of subsidies, or pay a penalty.
About 100,000 South Carolinians enrolled in a plan last year - the first year of Obamacare, said Ray Farmer, director of the state Department of Insurance.
Most got a subsidy, he said, and some were eligible for help with out-of-pocket expenses too.
But for people unused to having insurance, comparing plans and prices was something of a learning experience.
Only about half of the uninsured are familiar with insurance terms like “premium” and “provider network,” according to a new poll from the Kaiser Family Foundation. Fewer still know the amount they’d pay for a hospital stay based on cost-sharing requirements.
“It’s been a period of adjustment for everybody involved,” Farmer told The Greenville News, “the companies, the providers, and most of all the consumers.”
Even now, nine out of 10 people without insurance don’t know that open enrollment runs from Nov. 15 to Feb. 15, according to Kaiser.
And to be covered by Jan. 1, consumers need to enroll by Dec. 15. Automatic renewal is the default option, although those subscribers can change plans up to Feb. 15, Kaiser reports.
Praised by some and reviled by others, Obamacare was designed to enable affordable coverage for the uninsured.
More than 41 million Americans were uninsured in 2013, according to the U.S. Department of Health and Human Services.
And more than 16 percent of South Carolinians are uninsured, according to Kaiser.
About 7.1 million Americans enrolled in a plan in 2014, according to Kaiser, and HHS expects roughly 9 million will be enrolled by next year.
Nationwide, about 85 percent of those who signed up last year received financial assistance, according to HHS.
South Carolina consumers will have a new company to choose from this year - Assurant Health - in addition to BlueCross BlueShield of South Carolina, BlueChoice Health Plan, Consumers’ Choice Health Plan, and Coventry Healthcare of the Carolinas, according to the state Department of Insurance. And each company offers a variety of plans.
Overall, premiums will increase by about 1 percent, said DOI Director Ray Farmer.
And nationally, Kaiser reports, premium increases in most areas will be modest.
The penalty for those who fail to get insurance increases from $95 per adult and half that per child, or 1 percent of income in 2014, to $325 per adult, and $162.50 per child, or 2 percent of income in 2015.
“The penalties will be a rude awakening for people this year,” said Stephania Priester, public affairs director for New Horizon Family Health Services in Greenville. “And what they pay in penalties, they could have gotten covered for the year, with assistance.”
Last year, Farmer said, two things most surprised consumers about coverage.
One was the out-of-pocket maximums in some plans, which could run as high as $6,350 for an individual and twice that for a family, though most are much lower. Some consumers were unaware that insurance was more than premiums because they’d never had coverage before, he said.
In 2015, out-of-pocket maximums will range from $2,250 for an individual and $4,500 for a family between 100 percent and 150 percent of the federal poverty level to $6,600 for an individual and $13,200 for a family over 250 percent of the poverty level, according to Kaiser.
More than premiums
“We are encouraging our consumers to continue to shop like we do for every line of insurance, but to understand what it is you’re about to purchase,” Farmer said. “It’s not just about the premium.”
The other surprise was the narrow provider networks, though all plans must cover 10 essential health benefits including hospitalization, outpatient care and prescription drugs, as well as offer enough providers, he said. In some cases, consumers need to change providers if theirs is not in the plan.
“Companies are offering extremely narrow networks on the exchange,” he said. “We need to make sure consumers understand whether their providers are in that network. If they go out of network, it will be a higher expense.”
So even consumers who enrolled last year should compare plans because the premiums and copayments, provider networks and coverage may change from year to year, said Jessica Kendall, director of the Enrollment Assister Network for the consumer group Families USA.
“It’s vital for consumers to shop around,” she said. “A lot of consumers are able to get financial assistance and there may be another plan that allows that financial assistance to go further.”
Consumers can shop at the online marketplace - www.healthcare.gov - where they can get an idea of premiums and how much assistance they may get, she said.
The federal government operates the marketplace for South Carolina, which decided not to run its own. And last year, that site was riddled with access problems for weeks making enrollment difficult. This year, HHS says those problems have been resolved.
In addition to healthcare.gov, Kaiser has a subsidy calculator, which gives users an estimate of what they would pay for a mid-range plan based on zip code.
There’s also free assistance from local experts trained to help, like the certified application counselors at New Horizon.
‘What will it cost?’
“That’s what we’re here for - to make sure everyone knows what they’re signing up for,” said Priester. “At all our locations we have trained counselors to help them.”
Nearly everyone who signed up through New Horizon last year got a subsidy, with many paying a monthly premium of less than $100, Priester said.
And the number one question consumers ask is what coverage will cost, she said. While most want the cheapest plan, someone with a chronic condition like diabetes may need a better plan that covers their medications. So she advises comparing plans as well.
“There’s an additional plan coming into the market,” Priester said. “And they may find they selected a plan that wasn’t the best for them (last time) or there may be some different plans that were offered last year that may not be offered this year.”
This time around, she said, some people are more knowledgable about Obamacare, but many still find it confusing.
New Horizon has been holding educational events in the community and extending hours at its clinics to help consumers understand the coverage.
“The most important thing,” she said, “is that if, as a consumer, you’re still uncertain, you still have questions, just pick up the phone and give us a call.”
BlueCross said it’s increased the plans it’s offering this year and expanded its provider networks. And in addition to its retail stores, it’s also added a second bus to reach uninsured consumers around the state and set up information tables at Bi-Lo and Goodwill stores.
“People are still confused about what’s required under the law and whether they can qualify for assistance to offset the cost,” said BlueCross President Jim Deyling. “So this year we’ve doubled the number of health plans we’re offering, we’ve added family plans, we’ve expanded our networks, and we’ll go into more communities statewide to help educate and enroll people.”
Consumers’ Choice, the state’s only health insurance CO-OP, has also been holding community outreach events. Officials said most of its current members will see just a slight increase in their rates while some will see a decrease.
“We’ve worked very hard to stay true to our mission of offering high-quality, affordable coverage,” said CEO Jerry Burgess, “ ... shoppers will be able to get the coverage they need for themselves and their families with a substantial provider network to support that.”
Meanwhile, among the uninsured, four in 10 say they still won’t get insurance next year, most because they believe they can’t afford it, according to the Kaiser poll.
About six in 10 are from households with family income of less than $30,000 a year and nearly half have been without health insurance for two years or more.
Fortune, who was at the BlueCross store in Greenville Friday, said his wife’s insurance may soon be eliminated as well. And he can’t imagine what they would do if one of them suffered another illness like he had last spring.
“I was really blessed to have insurance at the time,” he said. “That’s why it’s so important that I get some now.”