Affordable Care Act Q&A
What do I need to do?
Probably nothing. If you are like most Oklahomans, you get your insurance through your employer or through a program such as Medicare or SoonerCare. People who already have health insurance can keep it and satisfy the law’s requirement to have insurance as long as the plan meets minimum coverage requirements. If you are uninsured, you can log onto Oklahoma’s insurance “exchange” — www.healthcare.gov — or call 1-800-318- 2596 to find out what plans are available and whether you qualify for a discount. If you already buy an individual plan, you may be able to save money by purchasing a plan through the exchange, depending on your income.
How long do I have to decide?
Enrollment in health insurance plans offered under the law begins Tuesday and continues until March 31, 2014. Coverage starts Jan. 1.
What is the “exchange” or “marketplace?”
The exchange or marketplace are other names for websites where consumers can compare health-insurance plans. Oklahoma is one of 27 states that will have a federally created exchange. The site — www.healthcare.gov — is designed to allow side-by-side comparisons of plans offered by different companies and at different levels of coverage. Federal officials believe this type of presentation will encourage competition.
How will the exchange work?
You will be able to log onto the website and see what insurance options are available to you. You need to set up an account with a user name and password, and fill out an online application. The form will ask about your household size, income, whether you currently have insurance available to you and other information. After you complete the application, you will be able to see what options you and your family qualify for, including private insurance plans, Medicaid or an insurance program for children whose parents do not qualify for Medicaid. You will also find out if you qualify for a discount off the monthly premium for coverage and for cost sharing to lower the price of out-of-pocket costs such as deductibles and co-payments. Once you review your options, you can enroll in a plan. If you need help enrolling, the website has a list of ways to get help.
What types of plans will be offered?
Five companies are offering insurance coverage through Oklahoma’s exchange: Blue Cross Blue Shield of Oklahoma, Aetna, Coventry, CommunityCare and GlobalHealth. (Aetna acquired Coventry in May but the two companies had already filed their plans.) There will up to 65 different plans available, grouped under four levels: bronze, silver, gold and platinum. If you are under 30 or on a low income, you may qualify for a “catastrophic” plan that protects you from very high medical bills. On average, the bronze plan pays 60 percent of your health care costs; silver, 70 percent; gold, 80 percent; and platinum pays 90 percent. The bronze plan has lower monthly payments but you have to pay more when you receive medical care. The platinum plan has the highest monthly costs and very low outof- pocket costs for care.
How much will the plans cost?
The cost of plans offered in Oklahoma’s marketplace varies depending on your age, smoking status, residence, income and plan you choose. Individuals making up to $45,960 per year and families with incomes of $94,200 can qualify for a subsidy to purchase insurance under the law if their employers do not offer affordable insurance. These subsidies can dramatically reduce the cost of insurance. A family of four with a household income of $50,000 would pay $657 per month for a silver plan before the subsidy is applied and $280 per month after. For a 30-year-old non-smoker earning $24,500 per year, monthly premiums in Oklahoma would be $73 for a bronze plan or $138 for a silver plan.
How do I know whether I qualify for a subsidy to buy insurance?
You can go to tulsaworld.com/healthcarelaw to find a link to the Kaiser Family Foundation calculator, which will estimate your annual subsidy based on income and household size.
What if I have a pre-existing condition?
Starting in 2014, you cannot be turned down for insurance due to a pre-existing health condition, even if you have been turned down before. One exception is for people on individual plans known as “grandfathered” plans. People on those plans can buy a plan through the exchange that covers their pre-existing condition.
Can I keep my doctor?
Plans sold through the marketplace will have approved “networks” of doctors, hospitals and other providers that members can use for covered medical expenses. Before you choose a plan, it is very important to examine the network of providers and see if your doctor is in the network. There may be another plan that includes your doctor or you can ask your doctor for more information. It is also important to determine how many of the network’s providers are in your area. If you currently have health insurance, you can keep your plan and keep your doctor.
What do these plans have to cover?
Plans sold in the marketplace must provide people who buy them with a minimum of 10 “essential health benefits:” outpatient care; emergency services; hospitalization services; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative services and devices to help people with injuries, disabilities, or chronic conditions; laboratory services; preventive care and chronic disease management; and pediatric services.
What happens if I don’t have insurance?
If you do not have health insurance by 2014 and are not among the categories of people exempt from the “individual mandate,” you will have to pay a fine when you file your 2014 taxes, The fee in 2014 is 1 percent of your yearly income or $95 per person, whichever is higher. The fee increases every year and is 2.5 percent of income or $695 per person, whichever is higher, in 2016. There are also fines for uninsured children. People who have short gaps in coverage of less than three months may qualify as exempt from the fine.
Who is exempt from the requirement to have health insurance?
Some people will be exempt from the fines for not having health insurance. In Oklahoma, people who do not qualify for Medicaid because our state did not accept the expansion of Medicaid are among those who can apply for a “hardship” exemption. Other exemptions include people who are homeless, facing eviction or foreclosure, domestic violence victims, people who recently filed for bankruptcy or people who had a death of a close family member. Additionally, people in these categories may qualify for exemptions: uninsured for less than three months of the year; the lowest-priced coverage available would cost more than 8 percent of household income; you don’t earn enough to file a tax return; you’re a member of a recognized Indian tribe; you’re a member of a health-care sharing ministry; you’re a member of a recognized religious sect with objections to insurance; you’re incarcerated after conviction; or you are an illegal immigrant.
What if I own a business and want to provide insurance?
The requirement that large employers provide insurance to employees has been delayed until 2015. Small business owners with 50 or fewer full-time employees may offer insurance to their employees through the “SHOP,” or Small business Health Options Program. For more information, visit tulsaworld.com/SHOP.
Didn’t Oklahoma opt out of "the Affordable Care Act"?
The state decided not to accept federal money that would have expanded the number of people covered by Medicaid, a program to provide health care for lowincome people. Oklahoma also declined to create its own “exchange” — a website where consumers can compare insurance plans — and will have one created by the federal government. However, the law’s requirement that nearly all Americans have health insurance or pay a fine does apply to Oklahomans unless they fall into an excluded category.
AFFORDABLE CARE ACT
What is going to happen Tuesday?
Enrollment opens in the Affordable Care Act. People can log onto www.healthcare.gov and find out what health-insurance plans are available under the new law. The website will allow people to see how much the plans will cost, coverage details such as deductibles, and whether they qualify for a discount or subsidy available to many Americans.