The second round of open enrollment in the federal health insurance marketplace established by the Affordable Care Act begins Saturday.
The basics are the same, but there have been enough changes to keep insurance shoppers on their toes. The first change most will notice? The Obama administration pledges the www.healthcare.gov website won’t have the problems that bogged it down in the early going last year. Even better, the streamlined enrollment process requires users to work their way through 16 pages, compared to 70 pages last year.
Here are some basic questions and answers on the marketplace Round 2:
When is the enrollment period?
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Nov. 15 through Feb. 15, which is much shorter than the six-month window last time around. The Obama administration stretched the period last time because of the early problems with the website. Of course, if you want coverage for the full 2015 year, you’ll need to enroll by the middle of December.
Who is eligible for a federal health insurance marketplace policy?
Just about anybody who isn’t offered affordable coverage by their employer or through a government program such as Medicare, Medicaid or TRICARE. Anyone 65 or older doesn’t need to worry about marketplace enrollment. If you have insurance through your work, your human resources office will let you know if it qualifies as “affordable” under the federal standards. Hint: Most large companies go out of their way to make sure full-time employees are offered insurance that qualifies as affordable. They’ll face penalties otherwise.
I got insurance on www.healthcare.gov last year. Can’t I just re-up?
Yes, but you really should take the time to check on a few things. First, if your income has changed, you have to acknowledge that to help determine changes in any tax subsidy you received to help pay your premium. Second, the details of most insurance plans have changed, and many more have been added. You might find a better deal by shopping around.
There were so many choices last year, with platinum, gold, silver and bronze level policies from four different companies. Will it be as confusing this year?
If the number of policies contribute to the confusion, yes. The choices have expanded from four to five insurance companies and from 52 to 126 plans in South Carolina this year. On the other hand, the new company in the SC market, Time Insurance Company, is unlikely to draw many customers with premiums that are much higher than the other companies. The average premium cost for the four returning companies went up 1 percent from last year, but other expenses such as deductibles and co-pays could have as much or more impact on overall cost as premiums.
Can I just go on the website and research my choices?
Absolutely, and that process is much easier this year. You can simply type in your ZIP code, age and approximate annual income, and you get a list of all of the plans available to you. No need to go through the full registration process if you decide the marketplace plans don’t work for you.
Explain the platinum, gold, silver and bronze levels.
Those are based on the cost of the premium and the extent of coverage – with platinum being most expensive and bronze being the least expensive. For the nearly 90 percent of people who receive tax subsidies, the system is set up to encourage them to get silver-level plans. Check those plans first, then compare the costs and benefits with the more expensive or less expensive plans. More often than not, silver plans will be the best deal for people who qualify for tax subsidies.
What about the catastrophic level plans?
Very few people signed up for those last time. They are only for people 30-and-younger, they provide few services and they don’t qualify for tax subsidies. The catastrophic plans are designed to prevent a medical emergency from bankrupting policy holders. But unless you’re younger than 30, have a high income and don’t have a company insurance plan, experts say you’re almost always better off paying only slightly higher premiums for a bronze or silver plan.
How does the tax subsidy system work?
It’s actually an advanced tax credit. Based on your projected income, the government agrees to pay a portion of your insurance premium. It pays the insurance company monthly throughout the year. The subsidy is available to anyone making from 100 percent to 400 percent of the federal poverty level – so an individual making from $11,670 to $46,680 per year. The subsidy is highest for those in the lower end of that income range. For instance, most people making less than about $23,000 qualified to have their full premium paid by the subsidy last year. The income levels eligible for subsidies increase based on family size, so a family of four with income of $95,400 would be eligible for a small subsidy.
Wait a minute – what about people making less than $11,670? They aren’t eligible for a subsidy?
Nope. This is the group left out when South Carolina leaders opted not to accept the expansion of Medicaid. The original concept of the Affordable Care Act was to cover these lowest income residents with Medicaid, but about half of the states decided not to go along with that plan. That group still can sign up for insurance on the marketplace, but with such low income and no tax subsidies available, it’s unlikely they could afford to pay for the insurance.
Will I be able to keep going to my family doctor?
Maybe. One of the more difficult parts of the shopping process is checking the provider network for each plan. Insurance companies keep prices down by including only physicians who agree to their rates in their networks. Once you’ve narrowed down your plan choices, click on the provider lists for each of those plans. You’ll be taken to the insurance company website’s provider list, which has a search box. Don’t just search for your family doctors, check on any specialists you typically see and the hospital you prefer. For instance, Lexington Medical Center isn’t in-network for the federal marketplace plans from BlueCross BlueShield, but Palmetto Health and Providence hospitals are. Lexington Medical Center appears to be only on some Coventry One plans. If you end up getting care from a hospital outside your network, it’ll be much more expensive than an in-network hospital.
Where can I sign up?
If you feel comfortable on the internet and know your stuff on insurance terms, you can go to www.healthcare.gov and enroll online. There also will be plenty of groups offering free help with enrollment. The federal government awarded a grant to the Palmetto Project to train and provide navigators to help people through the process. Go to www.signupsc.com for more information on the Palmetto Project navigator events in your area. If you prefer to use a phone, call (888) 998-4646. Richland Library plans to offer enrollment sessions throughout the three-month period. Based on the last enrollment period, many churches and community groups also will provide help sessions.
Can I enroll through an insurance agent?
Absolutely. And it costs you nothing to get the advice of a professional. But be careful because there are unscrupulous people who claim to be insurance agents but aren’t. The South Carolina Association of Health Underwriters has a website, www.schealthagents.com, with an inventory of agents.
What if I don’t enroll?
If you don’t have health insurance at all, you face a penalty. And, it’s much larger next year than it was this year. The penalty in 2015 is $325 per person (children are 162.50) or 2 percent of household income, whichever is greater. For a husband, wife and two children, that’s $975. But there are some exceptions. If your income is so low you aren’t required to file an income tax form, you’re exempt from the insurance penalty. (That means the folks who weren’t covered by Medicaid expansion in South Carolina at least won’t face a penalty for not having insurance.) Members of federally recognized Native American tribes or organized groups with long-standing objections to health insurance and some health procedures also are exempt from the penalty.