TUPELO • Getting sick or injured without health insurance can break anybody’s bank.
Through Dec. 15, folks without access to employer-based health insurance or Medicare can shop the federal health care exchange created by the Affordable Care Act, commonly called Obamacare.
“People assume I can’t afford it or it’s not a good plan, but that’s not true,” said Veronica Bell of Tupelo-based Bell Associates, which is certified to serve as a broker for the exchange. “We’ve gotten good reports all around.”
Most people can shop on the exchange; you have to be a U.S. citizen or legal resident. The federal marketplace is the only venue where Mississippi insurance shoppers can access income-based subsidies and use tax credits to pay for premiums if they fall between 100 and 400 percent of the federal poverty level. For a family of four, that would range from $25,100 to $100,400.
Premiums are capped at a percentage of household income between 2.08 percent and 9.86 percent based on the cost of a benchmark plan.
If insurance premiums offered through an employer are greater than 9.7 percent of income for single coverage or the insurance doesn’t meet minimum requirements, those individuals and families can also access the tax credits and subsidies on the exchange, Bell said.
Folks who normally automatically re-enroll may want to comparison shop. This year, Molina began offering policies on the exchange in 19 Mississippi counties, including Lee, Lafayette, Marshall Pontotoc and Union. Ambetter by Magnolia continues to offer plans in all 82 Mississippi counties.
All the plans offered on the marketplace have to cover services in 10 essential benefit categories, including mental health care. Pre-existing conditions are covered by the policies.
Preventive care is completely covered by the the policies sold on the exchange. That includes immunizations, check ups and recommended screening tests like mammograms and colonoscopies.
Both Molina and Ambetter are also offering telehealth services as part of their exchange plans.
Especially for people with incomes above 400 percent of the poverty line, it is important to comparison shop off the exchange. Insurance brokers do offer ACA complaint policies that cover the same benefits as plans offered through the exchange. However shoppers need to make sure they are comparing apples to apples.
Short term policies, which are exempt from ACA requirements, are much less expensive, but come with fewer benefits and exclude pre-existing health conditions.
“They are very picky,” about pre-existing conditions, Bell said.
Navigating the marketplace
The marketplace is accessible online at healthcare.gov. People can also apply by phone or request paper applications. Most people will find it fairly easy to use the online exchange, said Valerie Long, executive director of CATCH Kids in Tupelo and a certified navigator.
“They have simplified it,” said Long, whose organization partners with Oak Hill Ministries to offer navigators locally. “It’s very self-explanatory.””
For people who want help, there are certified navigators like Long and certified insurance brokers like Bell who can help people work through their options.
Regardless of the route, people need to have the Social Security numbers for all of the people who live in their household. They need to know their total household income, which can be computed from tax documents or paychecks. For people with variable incomes, they need their best estimate, Long said.
“Even if one spouse isn’t applying for health care, they will need both (spouses’) incomes,” Long said.
Family size and household income are important because they are used to compute subsidies and premium caps.
Shoppers should also have a list of their health care providers and medications, so they can check networks and prescription drug formularies.
Shoppers need to look at more than just the monthly premium to understand the costs of insurance, Bell said.
The deductible is the amount of health care costs the individual is responsible before the insurance starts picking up the tab.
Co-insurance kicks in after the deductible is met. The insurance company pays a percentage of the costs and the individual pays the remaining percentage. For example, if the co-insurance is a 75/25 split, the insurer picks up 75 percent of the cost after the deductible is met and the individual is responsible for the rest.
Co-payments are fees that are due when you see a health care provider. If a plan has a $5 co-pay for a primary care provider, the individual pays $5 and the insurer picks up the rest of the cost of the office visit. Lab tests, treatments and procedures are not covered by copay and fall under the deductible or co-insurance. Co-pays and premiums do not count toward the deductible.
The out-of-pocket maximum sets the limit of how much an individual or family would pay for covered health care services. Once the maximum is reached, the insurer pays the rest of the costs.
Preventive care services are fully covered without meeting the deductible.
To make it easier to comparison shop, health insurance plans are divided into platinum, gold, silver and bronze tiers, which are based on cost sharing.
Bronze plans have the highest deductibles and other cost sharing and typically lowest monthly premiums. The plans step up with platinum having the highest level of cost-sharing, usually with the highest premiums.
Silver plans offer the sweet spot for most exchange shoppers, offering them the best balance between premiums, deductibles and coinsurance, Bell said.
Shoppers need to decide what is most important to them and how they use health care, Long said. A higher monthly premium with low co-pays and deductibles may be the most predictable way to manage costs for some. Others may be willing to trade higher cost-sharing for lower premiums.
“Some people don’t mind a higher deductible,” Bell said.
Shoppers should look at the networks offered, to make sure the clinics and hospitals they wish to use are covered. Likewise, shoppers can check the insurers’ websites to see how they cover certain prescription drugs to help them make the best choice.
The final decision is up to the individual.
“We can’t chose the plans for them,” Long said.
In the early days of the current open enrollment season, Bell said she and her colleagues at Bell and Associates, which enrolled the most people on the exchange in Mississippi last year, are generally seeing Ambetter offering slightly lower rates than Molina.
“It’s not a big difference,” Bell said, but it has been consistent.
Both companies are offering zero deductible plans in the silver tier. For families at higher income levels, Ambetter is offering a Balance Care 14 plan that offers a zero deductible with a 50/50 co-insurance split.
They are seeing variation between different counties in terms of premiums.
Because of the tax cuts enacted last year, some people have fewer tax credits to apply to monthly premiums, Bell said.
“For a lot of folks, the tax credits are less than the insurance premiums,” Bell said.