how to navigate health insurance in the age of obamacare

How to Apply for Health Insurance in the Age of ObamacareYour guide to finding, comparing and enrolling in a plan that’s right for you

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By Jeff Smedsrud Chief Executive Officer HealthCare.com

2015 Edition

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Table of contents

Jeff Smedsrud’s biography

About HealthCare.com

Copyright 2014, HealthCare, Inc.


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Founded in 2006, privately-owned HealthCare.com is the nation’s leading unbiased search and comparison engine for personal health insurance, including virtually all of the state-based exchange plans, federal exchange plans and many private, off-exchange plans. Using powerful proprietary technology and tools, HealthCare.com helps consumers compare costs and subsidies for free, and enables them to purchase their insurance online, over the phone with a licensed advisor, or in person with a local insurance agent.

HealthCare.com’s goal is to help consumers easily research information and compare health insurance quotes from insurance carriers using interactive tools and an intuitive interface. The company’s website offers trusted recommendations and a comparison shopping experience to simplify decision-making, allowing consumers to find the right health insurance plan that fits their lifestyle. It also offers online calculators and shopping tools to make buying easier and more efficient. With more than one million visitors each month, HealthCare.com partners with, and integrates industry-leading health insurance companies to help consumers enroll into plans. For more information, visit www.healthcare.com.

HealthCare.com is a private, non-government comparison tool and search engine.

About HealthCare.com




The Affordable Care Act, also known as Obamacare, changed health insurance and how individuals who must purchase their coverage shop for insurance. We now live in at time when the law requires most Americans to have minimum essential coverage, and it is important that we familiarize ourselves with the marketplace created as a result.

Simply keeping track of healthcare reform aregulations and coverage options can be overwhelming. Individuals who purchase their own health insurance need to enroll in new coverage or change their health plan benefits between November 15, 2014 and February 15, 2015, and learn about things like income-based financial assistance, metal levels, narrow networks and other elements that make up today’s health insurance landscape.

And then there is the task of actually selecting and enrolling in a health insurance plan. To find coverage you will be happy with for the next year, you will need to do more than pick the lowest premium. This ebook will guide you through the application process from beginning your search to using your new benefits.

Introduction Your guide to health insurance enrollment


Where to find health insurance plans


The state-based and federally facilitated health insurance exchanges created under Obamacare get a lot of publicity, but there are other places to buy qualified health plans.

Minimum essential coverage may be purchased from the following:

Your state’s exchange or HealthCare.gov, the federal marketplace.

Websites such as HealthCare.com

Health insurance carrier websites

Licensed agents and brokers

All health insurance plans that qualify as minimum essential coverage must fulfill Affordable Care Act requirements. They:

Must include essential health benefits

Are required to cover certain preventive care at no additional cost

Cannot deny applicants or charge them more based on health history.



http://info.healthcare.com/states



Again, these plans are found both on and away from the health insurance exchanges. Their key differences may lie in monthly premium rate, out-of-pocket expenses and network.

Premium tax credits may only be applied to health insurance plans sold through state-based and federally facilitated exchanges. However, you can shop websites such as HealthCare.com to learn about health insurance plans in your area, calculate your premium tax credit, and determine whether or not to buy on or away from your state’s exchange or the federal marketplace.

A subsidized price estimate will appear with your HealthCare.com search results, and you can use the HealthCare.com Obamacare tax credit subsidy calculator to see how much you can lower your monthly rate. If you decide you want to take advantage of these income-based subsidies, you can then shop for, apply and enroll in a health insurance plan through the state or federal exchange.



Compare coverage at a glance


This is where shopping for health insurance may begin to feel overwhelming. Perhaps you’ve browsed plan options available through the federal marketplace, your state’s exchange or HealthCare.com. They can all start to look pretty similar. But they aren’t. And you may be tempted to pick the plan with the lowest monthly premium. But that might not be the best outcome for your overall financial wellbeing.

First, here are some key elements to look at when you begin to compare coverage and narrow your options:





Carrier What health insurance company provides the plan?

Metal level What is the actuarial level—bronze, silver, gold, platinum?

On average, cost sharing by metal level breaks down as follows:

Bronze The insurer pays 60 percent of covered medical expenses; you pay 40 percent

Silver The insurer pays 70 percent of covered medical expenses; you pay 30 percent

Gold The insurer pays 80 percent of covered medical expenses; you pay 20 percent

Platinum The insurer pays 90 percent of covered medical expenses; you pay 10 percent




Plan network Three common network types include HMO, PPO and EPO. Typically, these network types can function as follows:

Health maintenance organizations (HMO) require you to select a primary care physician who serves as your first point of contact for all non-emergency healthcare. This doctor must refer you to specialists and other providers. HMOs will typically cover in-network care only.

Preferred provider organizations (PPO) do not require you to select a primary care physician. You may seek healthcare out of network; however, you will likely experience reduced benefits and pay more out of pocket.

Exclusive provider organizations (EPO) do not require you to select a primary care physician but do require you to see in-network providers.




Deductible What amount must you pay out-of-pocket for covered healthcare expenses before your benefits kick in?

Coinsurance after deductible Once you reach your deductible, what percentage of covered healthcare expenses will you pay out of pocket?

Copay Does the plan include copays for doctor office visits, urgent care and other services? What is the amount?

Monthly premium What will you pay monthly for the health insurance plan?

Here is where you can begin to select the “maybes” and the “definitely nots.” For instance, if you know your healthcare needs are minimal and a gold or platinum plan would be overkill, narrow your focus to bronze and silver plans. Make a list of the plans you want to consider more seriously.

Also, don’t rule out plans with premiums you feel are too high. You will want to look into premium tax credit eligibility, which will lower your monthly payment if you buy from a state-based or federally facilitated health insurance exchange.


See if you can reduce your cost



The Affordable Care Act was designed to make health insurance accessible and affordable to more Americans. Three main ways individuals and families can lower their health insurance costs include the following:

Step 1. Premium tax credits As mentioned earlier, if you buy health insurance from your state’s state-based or federally facilitated exchange, you may be eligible for an income-based premium tax credit. In general, these are available to individuals and families who are between 100 and 400 percent of the federal poverty level. Federal poverty level guidelines are established annually and published at aspe.hhs.gov/poverty.

To find out if you qualify for an Obamacare tax credit, use HealthCare.com’s tax subsidy calculator.

If find you are eligible for financial assistance, visit your state or federal exchange to shop and enroll in health insurance coverage.


http://aspe.hhs.gov/poverty/index.cfm

http://info.healthcare.com/subsidy-calculator

http://info.healthcare.com/subsidy-calculator



Step 2. Cost-sharing subsidies Furthermore, if your annual income is less than 250 percent of the federal poverty level and you buy a silver plan, you may be eligible for cost-sharing subsidies that reduce the amount you pay out of pocket for deductible, coinsurance and copay.

Step 3. Medicaid You may also want to see if you qualify for Medicaid. Adults 19 through 64 who live in states where Medicaid was expanded to those who earn to 133 percent of the federal poverty level—which ends up being 138 percent due to the calculation methods—may be eligible for free or low-cost health insurance through the national program.

Visit the HealthCare.com state pages or visit Medicaid.gov to learn more about Medicaid where you live.


http://info.healthcare.com/states

http://medicaid.gov/



Be sure to report income and household size changes to your state’s exchange throughout the year. If you fail to do so, you may owe the IRS money at tax time or learn you missed out on additional assistance.

When you file your federal income tax return, the earnings you reported upon enrolling in your health plan will be compared with your actual earnings for the year. If you made more than reported, you will have to pay back some of your subsidy. If you made less than reported, you may get a tax credit. This works with household size as well, if you gain a dependent, you may be eligible for a larger subsidy. If you lose a dependent, you may not qualify for as large a subsidy.


How to select the right plan



Narrowing down your options is half the battle. Now you must select the health insurance plan that strikes the right balance between healthcare needs and household budget. Some key things to consider:

1. Family healthcare needs

What are your healthcare needs in a typical year? Do you have medical conditions that require ongoing care or prescription medications?

From there, consider which metal plan cost-sharing percentages best suit your healthcare needs. For instance, if you seek the doctor frequently or have chronic conditions, you may find a gold or platinum plan best meets your needs because it pays a higher percentage of covered medical expenses. If you are relatively healthy and tend to see the doctor for preventive care alone, you may find a bronze or silver plan is adequate.




2. Prescription drug formulary

Prescription drug coverage is an essential health benefit, which means all qualified health plans will include it. However, formularies will vary. You still have to pay for medications, and not all medications will be covered by all insurance plans.

Locate each plan’s prescription drug formulary to see what medications are covered and at what percentage. Make sure the medications you prefer and use are included and at a coinsurance percentage you feel comfortable with.

Drugs may be tiered by brand name, specialty and generic, and each tier may be covered at a different amount. Note that some plans have separate prescription drug deductibles and Rx copays. If you are having trouble finding the formulary or have questions about prescription drug benefits under the plan you are considering, be sure to contact the carrier and ask.




3. Network design

When choosing the right coverage, check the network. If you have a preferred doctor or hospital, make sure they are included in-network. If you do not have a preference, you should still investigate the network to be sure the doctors and hospitals available to you are conveniently located and that in-network clinics have hours that work with your schedule.

One of the ways carriers keep exchange-based plans affordable is through narrow networks. This means there may be a smaller pool of hospitals and providers available to you. This may not be a bad thing, but for the sake of avoiding unpleasant surprises, it is an important thing to realize before you buy. For example, the insurance company may have an affiliated hospital just down the street from where you live, but it may not be in your specific plan’s network. The plan may include one hospital, and it’s a 20-minute drive from your house.




Think back to earlier in the book when we talked about HMOs, PPOs and EPOs. Consider these differences as well. HMOs and EPOs may offer lower monthly premium rates, but provider choice may be limited and, in the case of HMOs, you must coordinate care with your primary care physician. PPOs offer more freedom, but their premium rates tend to be higher.

As with the prescription drug formulary, if you have questions about plan networks or providers, contact the carrier.




4. Household budget

What can you afford to pay each year for healthcare? Remember to think about monthly insurance premium, deductible, and out-of-pocket costs associated with covered and non-covered medical expenses. This is your annual healthcare budget. Look carefully at the plans you have selected, and consider the dollar amounts associated with:

Monthly premium

Annual deductible

Coinsurance

Copays

Generally, lower monthly premiums equal higher deductibles and out-of-pocket costs and higher monthly premiums equal lower deductibles and out-of-pocket costs. However, to really compare health insurance plans from a dollars and cents standpoint, you will need to analyze and calculate costs beyond monthly premium.




Get out your calculator and crunch the numbers. This can prevent you from paying too much for the wrong coverage or winding up with excessive out of pocket costs for which you are not prepared.

Add up your monthly premium for the year.

Factor in your deductible.

Consider your typical healthcare expenses in a given year and compare them as covered by a copay plan versus a high-deductible plan. Do not generalize; be sure to look at the plan-specific benefit details when making the comparison. If you have medical invoices from the previous year, consult them for a more concrete estimation.

Compare your monthly premium, deductible and out-of-pocket costs combined for each plan scenario.

Then, determine which plan type seems most cost-effective and manageable for you and your family.


What you need to apply for health insurance


What you need to apply for health insuranceOnce you determine which health insurance plan is best for you and your family and where you will buy it, it’s time to apply and enroll.

Documents and information you need may include:

Social Security numbers and birth dates for each applicant

Income-related documents for all applicants

Federal W-2 form

Recent pay stubs

Previous year’s tax return

Policy numbers for each applicant’s current health insurance coverage

Information about employer-sponsored health plans for which you or your family members are eligible, whether or not you are enrolled in this coverage

Banking information to pay the first month’s premium



Gather this information ahead of time and place it in an electronic or paper file. It will make the enrollment process go more quickly and smoothly and it will help prevent any delays in getting coverage.

What you need to apply for health insurance


Where to get help


Where to get help

Fortunately, you are not on your own when shopping for health insurance. Many certified and licensed individuals can assist you in navigating the health insurance landscape.

Exchange-based helpers These trained and certified individuals may assist you in person and over the phone. Locate them through your state’s health insurance exchange website or the federal marketplace.

Carrier customer service personnel Find contact information at the carrier’s website.

Agents and brokers These licensed, local professionals can be located through your state’s health insurance exchanges website, referrals from family and friends, and online searches.

The National Association of Health Underwriters’ Find an Agent tool is another resource.


http://www.nahu.org/consumer/findagent2.cfm


Websites such as HealthCare.com

HealthCare.com can connect you to licensed health insurance agents to help you select the right health insurance plan, calculate your tax credit subsidy, answer your health insurance questions, and assist you with enrollment. Call (877) 275-0485.

Ask for help anytime you feel lost in the process. No question is too basic or complicated. It is important to understand the health insurance coverage you are buying, so you can be sure it is the right for you. Once you have selected coverage, it is highly unlikely you can change plans unless you have a life event that qualifies you for a special enrollment period—examples of qualifying events include getting married or divorced, moving to a new region, or having a baby.

Where to get help



After you enroll


After you enroll

There are a few simple things you should do once you’ve selected and signed up for health insurance coverage. Taking these actions will help ensure everything is in place and that you can get the most out of the coverage you purchased.

Step 1: Look for membership materials in the mail or email. This will include your health insurance ID card as well as additional literature including benefits information.

Step 2: Get to know your health insurance plan. Read the membership materials you received upon enrollment. Re-familiarize yourself with the benefits you learned about while shopping for coverage. Make note of important phone numbers and addresses, as well as expenses beyond monthly premium.



Step 3: Be sure your premiums are being paid. Your coverage can be cancelled if you fail to make your monthly premium payments. Look for your statements in the mail, and be sure to make your payments on time. If you selected an automatic payment method, you should still check your bank account to be sure withdrawals are being made. Everyone, including exchanges and carriers, is adjusting to changes resulting from the Affordable Care Act.

If you are not receiving monthly statements or your automatic payments are not processing, contact the insurance company to investigate. Don’t risk finding out you don’t have coverage the next time you visit the doctor.

Step 4: Register at your carrier’s website. Member portals offer lots of convenient features including specific plan benefit information, provider correspondence, access to your health history, electronic prescription refills, online appointment scheduling, a provider directory, general health information and more.

After you enroll



Step 5: Use your benefits. Don’t wait until you are sick. Take advantage of your health insurance coverage when you are healthy. Remember earlier, when we mentioned preventive benefits at no additional cost?

Preventive benefits can help ensure you are not at risk for illness or disease and help catch illness and disease early on when they are more treatable. You can access these benefits before your deductible has been met. These benefits are free at least in the sense that they will not cost you anything on top of the monthly premium you pay.

Schedule an annual wellness visit. Your doctor will advise which screenings and services are recommended for you.

Visit hhs.gov to see a list of preventive services covered under the Affordable Care Act.

If you are sick, visit the doctor to get the care you need before your condition worsens and becomes more expensive to treat.

Mark your calendar. Open enrollment runs November 15, 2014 through February 15, 2015, and you will need to look at your current coverage, explore additional options, and recalculate your premium tax credit. Make sure you truly have the best health insurance benefits for the year to come.

After you enroll


Get educated


Get educated

I hope this ebook has been helpful, and you have a better understanding of how the enrollment process works.

Visit HealthCare.com to explore your health insurance options under the Affordable Care Act and learn more about selecting the right health insurance benefits.




Jeff Smedsrud, Chief Executive Officer HealthCare.com

Jeff has built and grown health insurance marketing and business companies for nearly 30 years, and served as a healthcare reform advocate for much of his career. He has been a provider of expert testimony on healthcare issues before national and state committees. Jeff was also one of the founders of the National Association of State Comprehensive Health Plans (NASCHIP), and helped sponsor programs to assist those denied health insurance for medical reasons.

Previously, Jeff was Chief Marketing Strategy Officer and Senior Vice President of The IHC Group (NYSE: IHC), a publicly traded insurance holding company. He joined IHC in March 2006 following the acquisition of his marketing companies by IHC. He was also President of IHC’s fully insured division, which he grew from $0 to nearly $300 million in revenue in seven years. He also led IHC Health Solutions, IHC Specialty Benefits and Independent Producers of America, Chief Executive Officer, and served as President of American Independence Corporation (NASDAQ:AMIC).



http://www.healthcare.com/about-us


Jeff has built many small healthcare businesses over the years, four of which have been acquired by publicly traded companies, including healthinsurance.org, which he helped launch.

A member of Seven Continents Club, Jeff is an active runner and one of only 200 individuals to run a marathon on all seven continents. Jeff is also a cancer survivor, charity activist and motivational speaker, residing in Minneapolis.

Read more about Jeff.



http://blog.healthcare.com/healthcare/qa-with-healthcare-com-ceo-jeff-smedsrud/

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how to navigate health insurance in the age of obamacare

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