September 20, 2013
Beginning October 1, 2013, individuals across the entire county will be able to sign up for new health insurance options under an open enrollment program made available by the Patient Protection and Affordable Care Act, or ObamaCare as it is frequently referred to. Coverage begins as early as January 1, 2014. The new Health Insurance Marketplace will offer different types of health plans to meet a variety of budgets and coverage needs for persons seeking health insurance without the benefit of an employer sponsored plan. This is especially important to persons and families affected by changes in the 2014 State of Wisconsin BadgerCare Plus eligibility allowances. Most significantly, the BadgerCare Plus Basic program is ending on December 31. Enrollees who no longer qualify for this program are encouraged to apply for private health insurance through the Health Insurance Marketplace.
Persons with employer sponsored health insurance coverage can keep their current coverage. Individuals who do not currently have health insurance will need to purchase insurance from the Marketplace. Nationwide, nearly 16 million uninsured Americans will be able to enroll in the newly offered health insurance plans, with Health Insurance Marketplaces opening in all 50 states and the District of Columbia. Seventeen states and the District will operate their own marketplace, seven will be in partnership with the federal government and 27 have elected to do neither, standing aside for the federally-operated marketplace. All of them will have the same basic mission: to help individuals and small businesses select the most suitable health insurance plan from an extensive menu of options.
The State of Wisconsin has elected to not create a Health Insurance Marketplace, and instead will rely on the plans made available through the federal government. In an effort to provide health insurance coverage for more persons and to reduce the number of enrollees in the State Medicaid Program, the Wisconsin Department of Health Services plans to send letters to many current Medicaid recipients and waitlisted individuals, regarding possible changes to their enrollment that could occur on January 1, 2014. The letters describe the changes in eligibility for the Medicaid program and encourage recipients who are no longer eligible to make application for private insurance coverage under the Health Insurance Marketplace.
Persons and families interested in signing up for health insurance plans in the new marketplace must complete an application by December 15 and make payment on the first premium to ensure coverage beginning January 1. Accounts can be established on the website www.HealthCare.gov or by calling 1-800-318-2596 (TTY: 1-855-889-4325).
Applicants will be asked to provide some basic information and then establish a secure user name and password. On or after October 1, enrollees will then provide personal information regarding size of family, income, household size, and more. The website will also then publish information specific to the various plans and coverage available to Wisconsinites. Applicants will be able to view the plans and programs they are eligible for and compare them side-by-side.
A variety of local resources exist to assist new applicants and others to better understand the health insurance options available through the Health Insurance Marketplace. Fort HealthCare’s Business Services department (920-563-4443), UW Health Partners Watertown Regional Medical Center’s Patient Financial Services department (920-262-4396) and the Southern Consortium- Medicaid and BadgerCare Plus office in Jefferson (1-888-794-5780) have certified application counselors on staff. The counselors are specially trained to help people understand, apply, and enroll for health coverage through the Marketplace. Counselors cannot make recommendations related to specific plans as they are not licensed insurance brokers or agents. Contact information for these organizations and others that can assist in the application and enrollment process can be found at www.LocalHelp.HealthCare.gov, although the public should be able to enroll via the www.HealthCare.gov website without direct assistance.
Health insurance, a contract between an individual or family and an insurance company, provides coverage for the costs of medical care, and protects those individuals from many out of pocket expenses, which can be very high. Under the contract, the insurance company agrees to pay a substantial portion of the medical costs should the insured become ill or injured. Many insurance plans pay expenses for hospitalizations, pregnancies, free preventive care such as vaccines, check-ups and prescription medications. Health insurance plans contract with networks of hospitals, doctors, pharmacies and other health care providers to take care of the people in the plan. Depending on the policy one purchases, the plan may only pay for care delivered by a provider in the plan’s network.
The www.HealthCare.gov website allows applicants to compare four different health insurance plans, each with different levels of benefits structured according to how the applicant expects to share in the cost of coverage. They are categorized as Bronze, Silver, Gold and Platinum. The category chosen affects how much premium is paid each month and what portion of the bill for hospitalizations, medical office visits, prescriptions and more are paid either by the insurance company or the subscriber. It also affects out-of-pocket costs for health care services throughout the year.
What a policy covers is often directly related to how expensive the health insurance policy is. Premiums are usually higher for plans that pay more of the out-of-pocket costs. For example, Platinum plans likely have the highest monthly premiums and lowest out-of-pocket costs. The higher the premium, the lower the out-of-pocket costs. All plans must offer a comprehensive set of essential health benefits including doctor visits, preventive care, hospitalization, prescriptions, and more. Plans won’t be able to deny you coverage or charge you more due to pre-existing health conditions, including a pregnancy or disability.
The Patient Protection and Affordable Care Act has four primary goals. They are:
• Provide access to health coverage for millions of Americans, including those with pre-existing conditions who have in the past been denied health insurance;
• Increase competition among insurers and therefore make health insurance more affordable, with greater common benefits such as preventive care and adding younger, healthy people into the mix to spread the risk and costs associated with those risks among a larger pool of subscribers;
• Provide consumers with greater control over which insurance plan they select, rather than being dependent upon whichever plan their employer selects for them;
• Encouraging regular visits with primary care doctors and nurse practitioners and putting great emphasis on preventive services to make nationwide changes that result in healthier lifestyles for all.
The establishment of the Health Insurance Marketplace on October 1 will make the first three goals a reality, while 100 percent coverage for preventive care by insurance companies is gradually becoming the rule as requirements of the healthcare reform law becomes effective. There are now dozens of preventive services that are covered fully by insurance plans, requiring no office visit co-pay. Even more fully-covered preventive services will be required by health care reform with the new plans available in the Health Insurance Marketplace.
The health care reform law also requires private insurers to continue dependent coverage of children until age 26. Both married and unmarried young adults can qualify for the dependent coverage extension. Consumers are guaranteed the right to choose any available doctor in their health plan network as their primary doctor. Parents can choose any available pediatrician for their children, as long as the physician is in the plan network. Last, women can seek care from in-plan obstetricians and gynecologists without having to get a referral or prior authorization.
The “individual mandate” component of the health care reform law requires most uninsured individuals who can afford health insurance to purchase insurance. The penalty for not getting insurance, which applies to most people, in 2014, is one percent (1%) of yearly income or $95 per person for the year, whichever is higher. The fee increases every year. In 2016, it is 2.5 percent of income or $695 per person, whichever is higher. In 2014 the fee for uninsured children is $47.50 per child. The most a family would have to pay in 2014 is $285. Those who pay the fee will not be covered by health insurance and will be responsible for 100 percent of the cost of their medical care. Individuals who use the Marketplace to buy insurance may be eligible for tax credits to use toward the cost of their premium.
For more information on the Patient Protection and Affordable Care Act, visit these helpful links:
Local Enrollment Resources are available.
The Patient Protection and Affordable Care Act establishes an on-line Health Insurance Marketplace. Persons without health insurance can now enroll in the program and after October 1, begin making selections as to which insurance plan offering best meets their budget and coverage needs. While consumers seeking to enroll in the Health Insurance Marketplace program should be able to do so without assistance, a number of local agencies and organizations have arranged for staff to be trained as Certified Application Counselors (CACs). These individuals can assist consumers in the application and enrollment process available at www.HealthCare.gov. They cannot make recommendations regarding which coverage should be selected. For more information, please contact these agencies and healthcare providers:
Fort HealthCare Business Services
UW Health Partners- Watertown Regional Medical Center
Patient Financial Services
Southern Consortium, Medicaid and BadgerCare Plus
1 888-794-5780 (toll free)
1 800-362-3002 Option #7 (Español)