A Bit of Background:
The Health Insurance Marketplace was created with the passage of the Affordable Care Act, making health insurance more accessible and affordable to individuals and small businesses. This law offers many patient protections, such as banning insurers from refusing to cover individuals with a pre-existing health condition or charging them significantly higher premiums, and stopping the practice of life-time and annual caps on health insurance benefits. The law requires every American to have health insurance or pay an additional tax if they do not enroll in a plan. Subsides to lower the cost of monthly premiums are available to individuals with incomes between 138% and 400% of federal poverty level (FPL). In states that did not expand their Medicaid programs, subsidies are offered for individuals with incomes starting at 100% of FPL. Subsidies to lower the amount people have to pay out-of-pocket for their healthcare services and medications may also be available depending on your income level and plan*.
The Marketplaces offer online enrollment and comparison-shopping so consumers can choose the plan that best meets their needs. In addition, trained navigators, in-person assistance personnel, and certified application counselors are available in many local communities to assist individuals with comparing plan options and enrolling in coverage. Here are six things to know about the open enrollment process:
- Even if you already have a plan through the Marketplace you should participate in open enrollment. Open enrollment for the health insurance Marketplaces runs from November 15, 2014 to February 15, 2015. If you enroll by December 15, 2015 your coverage will begin January 1, 2015. If you are uninsured, you may be able to find affordable health insurance coverage in the Marketplaces. New plans in several states have been added and some plans may be discontinued next year. If you purchased a plan last year or this year in the Marketplace, you should carefully review which plans will be available next year and compare to see if there is a plan that better meets your healthcare needs.
- Insurers are no longer able to deny you coverage or charge a higher rate if you have a pre-existing condition. This means if you have diabetes, chronic kidney disease, a kidney transplant or any other health condition, you can get health insurance and coverage without a waiting period once your health insurance is effective.
- Do your homework and don’t just look at the price tag for your premiums. When shopping for health insurance in the Marketplace, you may be faced with lots of options and it may be tempting to just look at the cost of the premiums and choose. But there’s another price tag you won’t know about unless you do your homework. Those costs are often referred to as out-of-pocket costs and they are the portion of your medications and healthcare services that you are responsible for paying. For example, every time you visit the doctor you may be expected to pay a copayment (a flat dollar amount) or a coinsurance (a percentage of the cost for the service).
Before you pick a plan, make a list of all of your medications, check to see if they are covered, and how much you will have to pay out-of-pocket. Check to see if you are required to meet your deductible before the plan will cover any portion of your medications or health services. If you know you visit your primary care practitioner once a year and your nephrologist twice a year look up how much your copayment or coinsurance is for each of those visits and add them up. If you can’t find this information online call the insurance company who is offering the plan and ask. You may also want to see which healthcare providers are in the plan’s network* to make sure your providers are easy to find. If you know you will eventually need dialysis or a kidney transplant, be sure to see which centers are in your network. If you choose to go to a provider who is not in-network you will likely have to pay much more out-of–pocket for those visits and they won’t count towards the plan’s maximum limit on how much you have to pay for your healthcare each year (known as the out-of-pocket maximum).
- If you are uninsured, you may be eligible for affordable coverage now. If you have recently lost insurance, moved, or had another life changing event, you may qualify for a special enrollment period and get coverage prior to January 1. You may even qualify for tax credits and subsidies to help pay monthly premiums and lower your out-of-pocket costs. Also, you could be eligible for Medicaid, which is open for enrollment all year. Click here to see if you qualify for coverage now.
- Healthcare.gov can help you get covered. Some states run their own Marketplace while others may work in partnership or rely completely on the Federal Government to run their Marketplace. In either case you can find out more about plans in your state by visiting www.healthcare.gov or calling 1-800-318-2596. Assistance is available to answer your questions and to help you choose a health insurance plan that meets your needs.
- If you can’t get insurance coverage right away, but need health care now don’t wait. There are a number of clinics that provide free or low-cost care. You can find a clinic near you here or calling (877) 464-4772.
- Bronze plans: usually offers the lowest monthly premium, but you will likely pay more out-of-pocket to get your medications and for each health service you need.
- Silver plans: usually have a higher premium than a bronze plan, and typically you can expect to pay a total of 30% out-of-pocket for your health services and medications, but if you make below 250% FPL the amount you will have to pay out-of-pocket may be substantially lowered. Only silver plans offer lower out-of-pocket maximums for those with lower incomes.
- Gold plans: higher premiums, but you can expect to pay 20% out-of-pocket for your health services and medications
- Platinum plans: highest premiums, but lowest out-of-pocket costs capped at 10%
* Network: The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Some plans will allow you to see providers that are out-of-network, but you may have to pay more to see these providers.