By Moses Leos III
It’s open season in Texas, but the hunting in this case is for affordable health care.
Yesterday was opening day for the Patient Protection and Affordable Healthcare Act (PPAHA). It’s also known as the Affordable Care Act (ACA), or more commonly, “Obamacare”, which was passed by Congress in 2010.
The Republican-controlled U.S. House of Representatives has tried more than 50 times to defund the act, but it is still the law and is effective Jan. 1, 2014.
Several provisions of the law are already in place, such as covering adult children up to age 26.
The ACA was designed to provide healthcare insurance for the uninsured. In Texas alone, that figure is estimated at six million, or about 25 percent, according to U.S. Census data released in 2012. In Hays County 31,933 residents younger than 65 (23%) are uninsured, according to census data released in August.
Tuesday marked the opening of the Health Insurance Marketplace, or the marketplace exchange, where consumers can go to shop for qualified health plans (QHPs).
What’s it all about and who can sign up?
People can view qualified health insurance plan options under the new act in the “Marketplace.” Individuals, families and small business owners can compare plans and find how much they cost before purchasing one. Consumers can also find out if they are eligible for tax credits, or subsidies, which can be applied to help lower monthly premiums.
Sam Richardson, Assistant Professor of Public Affairs at the University of Texas, who has researched the rollout of the Marketplace, called it the “Orbitz” of the health insurance world.
Open enrollment runs Oct. 1 through Mar. 31 – the last day to sign up for 2014 coverage. Consumers must sign up and pay the first premium by Dec. 15 for coverage to begin on Jan. 1, 2014.
The marketplace exchange is an online tool, found at www.healthcare.gov. Consumers should have their tax information on hand, such as W-2s, tax returns, or pay stubs. They should also know how deductibles, out-of-pocket maximums and copayments work.
Who is eligible for health insurance under the exchange?
American citizens who are currently uninsured can apply for health coverage through the exchange. Some consumers may not qualify for insurance under the exchange, based on factors including household income. They may still qualify for Medicaid and Medicare coverage, however, Texas did not expand its Medicaid program, which could leave some consumers without an affordable health insurance option.
In addition, some large national employers recently announced reductions in many of its employees’ hours to less than 30, which is the threshold for the new ACA law. Beginning in 2015, employers who don’t offer health insurance to employees working 30 or more hours a week will pay $2,000 per employee after the first 30 workers.
Employers such as WalMart, Olive Garden, Trader Joe’s, Subway and UPS are included in that list. Trader Joe’s will offer some employees at least $500 toward finding coverage on the exchange. Another firm, Forever 21, recently informed employees that hours would be cut but denied it was in response to the pending law.
Individuals who don’t have health insurance in 2014 will also pay a penalty, called a tax by a U.S. Supreme Court decision that upheld the ACA.
In Texas, Health and Human Services Commission spokesperson Stephanie Goodman said a technical glitch will hold up getting an application to the federal marketplace to the state, which she said should be resolved by November. Parents can still visit the exchange to see if they qualify but then can also visit yourtexasbenefits.com for dependents who may be eligible for CHIP or Medicaid.
Who is not eligible for health insurance under the exchange?
In general, persons with private or employer-based health insurance need not visit the Marketplace. Individuals whose employers offer “affordable” health insurance – defined as not more than 9.5 percent of an individual employee’s salary – are not eligible.
Employees with Hays County, for example, would not be eligible for insurance in the marketplace because their health plan was deemed affordable, according to Dee Dee Baen, a human resources manager with the county. Hays County employees do not pay a monthly premium for health insurance, though they must pay the premiums for spouses and dependents.
The particulars of plans in the exchange
Professor Richardson said plans, premiums and costs under the marketplace exchange are based on income, age and the size of household. Other factors such as tobacco use will be used to determine costs. However, health insurance plans will no longer hinge on preexisting condition – a detail that has caused millions of Americans to be previously denied coverage or forced to pay high premiums.
“[People] are given a list of standardized health plans, with different levels of premiums … without the worry of being denied due to preexisting conditions,” Richardson said.
According to Richardson, as many as 76 plans will be included in Texas over seven different insurance companies.
The plans fall into four categories, Bronze, Silver, Gold and Platinum. The ratio of coverage increases with each step up in plans.
All insurance plans, even those not on the exchange, are required to cover ambulatory care (e.g., a visit to your doctor’s office), emergency services (including ambulance transportation), hospitalization, maternity and newborn care, mental health and substance abuse services, prescription drugs, rehabilitation, lab services, preventative and wellness services and pediatric care.
In terms of premiums, Bronze will be least expensive premium, with Platinum the most expensive. However, those with Bronze will pay the highest out-of-pocket costs.
Richardson said as many as four catastrophic plans will also be provided. A catastrophic plan is a “worst-case scenario” that will pay very high medical costs. They have a low premium, but most require a patient to pay up to several thousand dollars out of pocket before insurance kicks in.
According to Richardson, Obamacare might not be able to help everyone. Some consumers might not be able to afford a plan, he said. The only option is to go through Medicaid, which is open to those with low incomes, pregnant women, the elderly and people with disabilities.
Texas Governor Rick Perry recently rejected an expansion to Medicaid. Under current guidelines, a family of four would have to make at or below 100 percent of $23,000 – which is the federal poverty line – to qualify. The expansion would have extended the poverty line for Medicaid assistance to 138 percent.
Unemployed individuals must make at or below 12 percent of the poverty line. Employed individuals must make at or below 25 percent.
Infants must fall below 185 percent of the poverty line, and children ages 1 to 5 below 133 percent. Some children may be eligible for the Children’s Health Insurance Plan (CHIP), but families must make at or below 200 percent of the poverty line to qualify.
Feasibly, Richardson said, many will be unable to pay for insurance, but not qualify for Medicaid.
Despite the issues, he feels a good majority of Texans will benefit from the ACA, especially in the Central Texas area. Richardson said the ACA could possibly cut Texas’ uninsured rates by nine percent.
Still the prospect of a “doughnut hole” of people falling through the cracks is real. Richardson said several nonprofits are clamoring for change. It will be up to the state to make those changes.
“[Those unable to get insurance] will need to wait until there is some sort of fix,” Richardson said. “There will be a fair number of people that will fall into the doughnut hole.”
According to a five-year study done from 2007-2011 by the American Community Survey, roughly 12,000 of over 52,000 families in Hays County fell below the poverty line. The median household income for a family in Hays County was $58,247.
Officially, the Marketplace opened enrollment on Oct. 1. However, for coverage to begin on Jan. 1, people must sign up before Dec. 15. The final deadline for signing up for 2014 coverage is Mar. 31. Those wanting coverage on April 1 will have to sign up by Mar. 15.
Those who do not obtain insurance, and do not qualify for an exemption, are required to pay a fee after April 1. The fee is $95 or one percent of one’s income for the year – whichever is higher. Uninsured children have a fee of $47.50 per child; the most a family would have to pay is $285 dollars. Those fees will increase each year.
