For one veteran’s family – and millions of other people across the country – Tuesday will reveal whether the Affordable Care Act really can give them access to affordable health insurance through the new online health marketplace.
“The big question is will we be able to afford comparable coverage to what we have now and what will our options be?” said Lindsey Stillwell, 29, whose husband, Matt, is a veteran of Operation Iraqi Freedom.
For those without insurance or who want to shop around, the new online health marketplace – the open enrollment for which begins Tuesday – will be a one-stop online store to see what insurance is available and how much it will cost.
Stillwell, of Valley Center, said she now pays about $650 a month for health care for herself and their three children, one of whom has a congenital heart defect. Her husband served as a combat medic in Iraq and was on a routine patrol in December 2009 when he was ejected from a truck, she said, suffering severe lower-back injuries and post-traumatic stress disorder.
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Lindsey Stillwell worked for 10 years before quitting to take care of her husband and to take classes at Wichita State University.
“The things he saw as a medic were horrible things that nobody wants to see,” she said.
His ongoing medical care is covered by veterans benefits. But Lindsey Stillwell will be looking to the health marketplace for coverage for herself and their children after finding out that her current plan under Blue Cross Blue Shield is no longer considered comprehensive coverage and therefore doesn’t meet the requirements of the federal law.
She has been researching as much as she can and is hoping the rates will still be affordable for her family. But she has her doubts, because her family seems to fall into the new Medicaid doughnut hole.
The Stillwells may have too much money to qualify for Medicaid in Kansas but not enough to receive subsidies on the new federally facilitated marketplace. Her husband’s veterans benefits are counted as income under Kansas Medicaid, but they aren’t counted as income on the marketplace, she said.
“We’re in the gap, and there are a lot of people in that position. ... I’m disappointed that Kansas has been as conservative as it has. There are so many people struggling.”
The new health insurance marketplace isn’t for everyone.
“This only affects between 15 and 20 percent of the population that doesn’t have health insurance,” said Kit Wagar, Affordable Care Act specialist for the regional Health and Human Services office in Kansas City. “Most people still get it from their employer.
“The marketplaces are mostly for people with modest incomes who cannot afford the employer plan they’re offered. Affordable coverage means it is no more than 9.5 percent of their income. It’s also for people who don’t have job-based insurance or who are looking for a better deal on the private market.”
About 365,000 Kansans, or about 13.1 percent of the population, were uninsured in 2011, according to data from the Kansas Health Institute.
More than half of Kansans are covered by employer-based insurance, while about one-third are covered by a public program such as Medicare or Medicaid, according to the institute.
Of all the uninsured, about 59 percent are ages 19 to 44, and two-thirds are white non-Hispanic. About 75 percent of the uninsured are working.
Small employers can also look for plans on the marketplace. Only employers with 50 or more employees are required to offer insurance under the law. However, federal officials said last week that delays in the system would keep small businesses from actually signing up for a month or so, although there will be information online that allows them to do some comparison shopping.
For the first year, open enrollment will last six months, until March 2014.
“As long as people sign up for coverage on the marketplace by Dec. 15, their coverage will start on Jan. 1, 2014,” Wagar said.
“For a lot of people, this might be the first time in years they’ve had a chance to buy insurance. There’s no reason to hurry. They have two months to look over the options and pick a plan that works best for them. ... The bigger date is Jan. 1, when people start to see the benefits of this law.”
Wagar compares the website for signing up, www.HealthCare.gov, to Amazon.com. First, you have to create an account with basic information. It also will ask what kind of policy you’re looking for and whether you’re eligible for other programs, like Medicaid. People will have to put in their Social Security numbers and estimate their income for 2014.
Federal officials announced last week that an average of 37 health plans will be available in Kansas as part of the online health insurance marketplace.
But despite rate and subsidy calculators created by the Kaiser Family Foundation and the Kansas Department of Insurance, consumers still are not able go online – or elsewhere – to get actual pricing and coverage information about the plans until Tuesday.
What is known about the plans is that each, by law, must cover what government has deemed essential health benefits: emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, laboratory services, preventive and wellness services, chronic disease management and services for children, including oral and vision care.
Insurance companies are allowed to take certain factors – with limits – into consideration when setting rates. Those factors include an individual’s age, family size, tobacco use and location. Pre-existing conditions can no longer be used to determine coverage or costs under the law.
Data released last week showed some average premium costs based on age and location for seven regions in Kansas. The data showed the Wichita area had the lowest rates in the state and that rural areas had the highest rates.
Consumers will have the option of buying bronze, silver, gold or platinum plans, which describe how much cost-sharing – deductibles and co-pays – will be included in the plan design. There will also be catastrophic plans that have a lower cost for people younger than 30 or with low incomes.
For 55-year-olds, the lowest-cost bronze plan premium is about $257 per month for someone in the Wichita area but $340 for someone in southwest Kansas. The minimum gold plan premium is $380 in the south-central region, compared to $501 in the southwest region. Those rates are before government subsidies or tax credits.
The trend is the same for other ages. A 22-year-old in Wichita could pay $170 for the minimum gold plan, while a person of the same age in southwest Kansas would pay about $224.
“Those rates depend on different provider networks and the deals the insurers cut with local hospitals and providers,” Wagar said.
The law also caps the total out-of-pocket expenses consumers can pay, so every plan includes a limit at which insurance picks up virtually all medical expenses.
Wagar said he encourages people who are looking at the plans to set a monthly budget and determine whether they want higher or lower deductibles and to pay attention to co-pays. He also said people should check to see whether the prescription drugs they require are covered under the different plans and whether they need to have coverage out of network.
No Medicare impact
Senior citizens and others who are on Medicare are basically unaffected by the new law, Wagar said.
“They just need to enroll and choose their plans like they always have,” he said. “Medicare supplement plans are heavily regulated because we didn’t want older people getting ripped off. Those are what some people buy to pay for parts that Medicare does not cover, and they aren’t affected by the Affordable Care Act either.”
Wagar said the rates for older people should also come down because there is now a rule that insurance companies can’t charge older people more than three times what they would charge a younger person. On the flip side, that means rates will likely increase for younger people seeking coverage.
One major concern about the Affordable Care Act is that healthy young people won’t sign up to get coverage to offset the costs of the older and sick people who need more care.
One of these young invincibles is Sara Utley, a Wichita State University graduate who is an accountant.
Although the health law has a provision that dependents can stay on their parents’ health plans until age 26, it wasn’t an option for Utley.
She said she had health insurance through an employer for a couple of years at the beginning of college but was paying about $150 every pay period and seeing a doctor only once or twice a year.
“I just felt like I was spending way too much money on health insurance for being relatively healthy,” she said.
Utley said she is interested in looking at the rates on the marketplace, as well as seeing if she can get vision and prescription coverage.
“I’m very much looking forward to getting back on health insurance since I’ve had a few issues that I haven’t been able to get treated and didn’t even know where to go.”
She’s not sure whether most young people will be like her and look into the marketplace. For the first year, those who forgo health insurance will be faced with a tax penalty of $95 for an individual or 1 percent of their income, whichever is greater. The penalty increases over time.
“Honestly, I don’t think the first-year penalty is much money for the first year,” she said. “It seems like the penalty is more of a slap on the hands to say ‘Please get insurance next year.’ ”