Healthcare Insurance: Common QuestionsPosted: November 12, 2014
Why is there an open enrollment period?
Who is eligible to sign up during open enrollment?
How much more will the marketplace plans cost?
Are people losing the plans they have?
Is the website going to work this time?
How hard is it to pick the right plan?
Are there places to get help picking a plan?
What happens to people who enrolled last year?
What happens to people who don’t get insurance?
Can people get insurance even if they’re already sick?
How many more people will get health insurance?
How does a new Supreme Court case affect all of this?
For people who don’t get health insurance from an employer, Medicare or Medicaid, the health law offers a three-month window to shop for health insurance. It is intended to encourage people to get insured and not wait until they’re sick to seek coverage. People who don’t enroll between Nov. 15 and Feb. 15 will have to wait a year to get coverage, unless they experience a major life change, like losing their job, having a child or getting divorced.
People who qualify for Medicaid can sign up all year long. In states that have expanded Medicaid under the health law, anyone earning less than 138 percent of the federal poverty level — or about $16,000 for a single person — is eligible. In states that have not expanded, eligibility rules vary, but tend to include poor children and their mothers as well as people with disabilities.
Current estimates suggest that there are still about 32 million uninsured people in the United States, and nearly all of them are eligible for some form of coverage under new Affordable Care Act programs. Compared with the country’s population as a whole, the uninsured are more likely to be low-income, young, Hispanic and live in states that have declined to expand their Medicaid programs. People who are eligible for open enrollment fall into three main categories: the uninsured, people who bought marketplace plans last year (7.1 million), and people who have other forms of individual health insurance (8 million to 12 million). People who already have health insurance from work or a government program don’t need to worry about this enrollment period.
Yes, some people who bought individual health insurance after the health law passed in 2010 will find those plans canceled by the end of the year. All individual plans are now required to cover a minimum package of benefits and a minimum percentage of expected health costs. Precise estimates are difficult, but as many as several hundred thousand people have received cancellation notices from their insurance companies. Those people will be able to switch to different plans that comply. Many will be eligible for subsidies if they go shop for new coverage on the exchange.
Some people with employer-based coverage are also losing their health insurance. The Affordable Care Act provides new options for people who lose workplace coverage, and it requires employer plans to cover certain benefits, but it didn’t require any employers to cancel their insurance. However, those people may have lost their coverage anyway. The percentage of employers who offer health plans to their workers has been slowly declining for years.
Kevin Counihan, who is running the federal marketplace website, told Bloomberg News that he expects an online experience so positive that it will create “raving fans.” Many of the major problems that caused the federal marketplace site, healthcare.gov, to crash last year have been addressed. The site has also been redesigned to make it a little easier for customers to window-shop for plans before entering all their information. State exchanges with the biggest problems have also retooled for this year, or handed over responsibility to the federal government.
But there are still some reasons to worry that the process may not work seamlessly. “We will have outages,” said the Health and Human Services secretary, Sylvia Mathews Burwell. Administration officials acknowledge that the back end of the marketplace, where the website verifies information and communicates with insurers, is still unfinished. State exchange officials have signaled some concernabout the relaunch of their websites. No new tools have been added that might help customers compare the networks of doctors and hospitals covered by various plans. To find out what doctors, hospitals and drugs are covered, customers will still need to contact each insurance plan individually.
The marketplaces do a good job of sorting plans into categories based on what percentage of a typical patient’s medical bills will be paid by insurance. All plans in the “silver” category, the most popular plan type, must cover 70 percent of the average patient’s bills, for example.
But the details of what each plan in the category covers varies quite a lot. A recent study showed that silver plans had widely different systems of co-payments and deductibles. The plans also differ substantially in what doctors, hospitals, and drugs they will pay for. For patients with specialized health needs or longstanding relationships with particular doctors, it’s important to research what’s included in an insurer’s network.
There are groups of people around the country who have been trained to help consumers choose the right plan, either in person or over the phone. The federal government is spending $60 million this year to pay for these helpers. A survey from the Kaiser Family Foundation found that, last year, 10.6 million people who signed up for new coverage sought some help choosing.
People who signed up for marketplace plans on healthcare.gov will stay in the plan they chose for 2014 unless they go back to the website to shop again. The Obama administration set up this auto-renewal process to make it as easy as possible for people to remain insured. But auto-renewing without reviewing the options could mean big premium increases for some consumers, and hidden charges, too, that won’t become clear until tax time. Many markets will have cheaper options and new products on the marketplaces. It pays for nearly everyone to go back to the website and update information, even if they end up staying with the same plan.
Some states didn’t go along with that auto-renew option, meaning everyone in those markets has to shop again. And everyone who signed up for Medicaid will need to reapply. The states require that everyone establish eligibility for the program annually.
The health law contains a much-disliked provision requiring Americans to obtain health insurance or face a tax penalty. Those penalties will be higher for 2015 than they were in 2014: up to 2 percent of a household’s income or $325, whichever is higher. People who would struggle to pay for insurance, either because they earn so little that they do not file a tax return or because insurance would cost more than 8 percent of their household income, are exempt. The law also provides exceptions forcertain groups that have experienced hardship, including people who are homeless, victims of domestic violence or with religious objections to health care. But the vast majority of Americans will either need to find health insurance or pay the fine. The penalties won’t kick in until people file their taxes for 2015.
Before this year, insurance companies were allowed to decide whom they wanted to sell insurance to. This meant that people who had a history of illness often paid very high rates or simply couldn’t find a plan on the individual insurance market. Now, insurers are barred from discriminating against people with a history of health problems. As long as they sign up during the enrollment period, all Americans can buy health insurance for a price based only on where they live, how old they are and whether they smoke.
We don’t really know, but the number is likely to be in the millions. Surveys suggest that about 10 million people were newly insured this year as a result of the new options, a drop of five percentage points from 2013. Government data show that 7.1 million people were enrolled in exchange policies this fall, while about 8 million people were added to state Medicaid programs. (Some people who got coverage through new programs had been covered through work or other sources and switched.)
Obama administration officials have estimated that the total number of people in the marketplaces will increase to between 9 and 9.9 million people at the end of 2015. Other forecasters have estimated higher: The Congressional Budget Office says 13 million will have exchange plans by the end of the year. The C.B.O. estimates that the total number of people without insurance will decline by an additional 7 million in 2015.
The Supreme Court has agreed to hear a case called King v. Burwell, which challenges the validity of the subsidies in 36 states where the marketplaces are being run by the federal government. Ultimately, the case could mean that people in those states who are getting subsidies to help pay for health insurance will no longer be able to receive them. But the case is a long way from being decided and won’t take money away from people who sign up for insurance now. People who live in states that established their own exchanges — all the states called “state-based”here — are very unlikely to be affected by the case, regardless of its outcome.