3:37am

Mon September 30, 2013
Shots - Health News

Insurance Exchange 101: Here's What You Need To Know

Originally published on Mon September 30, 2013 9:36 am

The Affordable Care Act has been through two years of legislative wrangling, a presidential election and a Supreme Court test that took it to the brink.

Now, after yet another round of debate and argument, major pieces of the federal health law are expected to kick in Tuesday.

If all goes as planned, people who don't have insurance or who buy it on their own will be able to shop online or at various locations in their communities for coverage that will take effect Jan. 1.

These insurance marketplaces, or exchanges, have gotten the lion's share of attention lately, but who should be looking to buy insurance on the exchanges anyway?

Well, definitely not everyone. These exchanges are for two major groups of people: Those who don't have insurance now, and those who currently purchase their own insurance, meaning they don't get it through an employer.

And since we've had a lot of questions about this, no, the exchanges won't be selling policies that supplement the coverage seniors get through Medicare.

So, if you have insurance at your job or through a public program like Medicare, Medicaid or the VA, you don't need to pay attention to the exchanges unless you lose that coverage for some reason.

How will the exchanges work? In theory, you can do it all online. Every state will have its own website. Some of these are being run by the states, some are being run by the federal government and some are being run by a combination of the two.

But consumers won't be able to tell the difference. You'll go to the website, provide some basic information, like where you live and how old you are and you'll get a list of plans available in your area.

If you provide income information, you'll be able to get an estimate of whether you'll eligible for federal help paying for insurance or whether you might qualify for Medicaid.

So who's eligible for help buying private insurance in the exchange?

The subsidies are fairly generous. If you have income between 100 percent of the poverty level (about $11,000 for an individual) and 400 percent, you can get some help paying for premiums. A family of four can get a subsidy, although just a small one, with income up to about $90,000.

People with income less than 2 1/2 times the poverty level, or about $29,000, can also get help with deductibles and copayments. But those people would have to choose a so-called silver plan. That's the second lowest cost of the four levels of coverage that will be available — bronze, silver, gold and platinum.

How much will insurance cost? The federal government released some premium information last week that helps some but don't clarify everything.

It seems that premiums aren't going to be as high as some people had been predicting. And especially if you're eligible for a federal subsidy, as President Obama keeps saying, most people should be able to find a plan that costs not much more than their monthly cell phone or cable bill.

But there are some caveats. One is that the cheaper plans come with big deductibles and lots of other out-of-pocket costs. Now, if you don't think you're going to have much in the way of medical expenses, that may be fine. But people should be aware that if they buy a plan that only costs $40 or $50 a month, they may have a $5,000 deductible before the plan starts paying benefits.

The other is that some of these less expensive plans come with very limited lists of doctors and hospitals. So if you have a particular doctor or hospital you know you want to use, you should check that before you sign up.

Speaking of signing up, what if you need help? There are supposed to be lots of helpers out there. Most states have trained people called assisters and navigators who can walk people through the process, although in some states the training for them has been delayed. There are also call centers attached to every state website and the federal website, healthcare.gov.

It's important to keep in mind that there are likely to be lots of computer glitches at the beginning. But most people expect that the first couple of weeks are likely going to be mostly for window shopping anyway. The important date here is Dec. 15. If you sign up by then, your coverage can start by Jan. 1, which is the earliest any of these plans kick in anyway.

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

DAVID GREENE, HOST:

Now, if there is a partial government shutdown, one irony is that the program Republicans are desperate to stop, Obamacare, will be up and running. The major pieces of the federal health law are set to open for business tomorrow. If all goes as planned, people will be able to go online - or to various locations in their communities - to search, compare and sign up for health insurance that would take effect beginning January 1st.

The law has created exchanges where people can shop for insurance coverage, but that's only for those who are eligible. And to help sort that out, we brought in our resident expert, NPR's Julie Rovner. Hi, Julie.

JULIE ROVNER, BYLINE: Hey, David.

GREENE: All right, Julie, let's start with who should actually be paying close attention, here, to what we're talking about. Who's eligible to buy insurance in these new marketplaces?

ROVNER: Well, definitely, they're not for everybody. They're for two major groups of people: people who don't have insurance now - the uninsured - and people who buy their own coverage right now, meaning they don't get it through an employer. And - since we've got a lot of questions about this - no, the exchanges are not going to be selling policies that supplement the coverage seniors get through Medicare. So, basically, if you have insurance at your job or through a public program like Medicare or Medicaid or the VA, you don't have to pay attention to the exchanges, unless you lose that coverage for some reason.

GREENE: OK. Well, for people who should be paying attention, let's talk about how this is actually going to work. Let's say I don't have insurance right now. I want coverage. What should I be thinking about?

ROVNER: Well, in theory, you can do it all online. Every state will have its own website. Some are being run by the state. Some are being run by the federal government. Some are being run by a combination of the two. But as a consumer, you won't really be able to tell that. You'll go to the website, provide some basic information - like where you live, how old you are - and you'll get a list of plans that are available in your area. If you provide income information, you'll be able to get an estimate of whether you're eligible for federal help paying for the insurance, or whether you might qualify for Medicaid.

GREENE: OK. So, some people will have to buy the insurance on their own through these exchanges, some people eligible for assistance by the federal government. Who's eligible for that kind of help?

ROVNER: Well, the subsidies are pretty generous. If you have income between 100 percent of poverty - that's about $11,000 for an individual - and four times that, about $46,000, you can get some help paying for premiums. For a family of four, you can get subsidies - although small ones - with income all the way up to about $90,000. People with incomes under two-and-a-half times the poverty level can also get help paying their deductibles and copayments, but they have to choose a silver plan. That's the second-lowest cost of the four levels of coverage that will be available: bronze, silver, gold and platinum.

GREENE: So, whether or not you're getting assistance, you're going to be paying premiums on these exchanges. What do we know about how much those premiums will cost?

ROVNER: Well, we know a lot, and then not so much, at the same time. It seems that, on the one hand, premiums aren't going to be as high as some people had been predicting, and especially if you're eligible for one of those federal subsidies. As President Obama keeps saying, most people should be able to find a plan that costs not so much more than their monthly cell phone or cable bill.

But there are some big caveats. One is that particularly these less-expensive plans come with big deductibles and lots of other out-of-pocket costs. Now, if you don't think you're going to have much in the way of medical expenses, that may be just fine. But people should be aware that if they buy a plan that only costs 40 or $50 a month, they may have a $5,000 deductible before the plan starts paying benefits. The other caveat is that some of these less-expensive plans come with very limited lists of doctors and hospitals that you can use. So, if you have a particular doctor or hospital you know you want to go to, you should check that before you sign up.

GREENE: Julie Rovner, we have brought you into the studio so many times to help people through this very complicated law. If people can't call up Julie Rovner personally and they need help sorting through these numbers and what sort of help they might be eligible for, I mean, where can they find that kind of help?

ROVNER: There are lots of other people who can help you sign up. Most states have trained people called assisters or navigators who can help people fill out applications and walk them through the process. In some states, the training's been a little bit delayed, but those people are getting trained up by the day. There are also call centers attached to every state website, and there's a federal website - HealthCare.gov - where people can help. It's important to remember that lots of computer glitches are likely at the beginning. We've already heard about some. But most people expect that the first couple of weeks are likely to be mostly for window shopping, anyway. The important date here is December 15th. If you sign up by then, your coverage can start by January 1st, which is the earliest any of these plans kick in, anyway.

GREENE: We've been talking to NPR's Julie Rovner. Thanks, Julie.

ROVNER: Thank you. Transcript provided by NPR, Copyright NPR.

Related Program