Michigan guide to the Affordable Care Act
By Robin Erb, Detroit Free Press | |
McClatchy-Tribune Information Services |
And that means an increasing scramble by consumers, agents and advocates onto www.healthcare.gov as well as worry that -- as
"It's going to be a long week," said insurance agent
With few exceptions, those who don't find insurance by
So agents, federally trained enrollment staff and others are keeping offices open well past normal quitting time. They're still working the phones late at night. And in the daytime, they're perched on folding chairs at community centers and in church basements -- laptops and coffee within arm's reach -- trying to help consumers weigh their options.
They were thrilled.
"I've heard people say, 'I can't afford it,' but they don't even look into it," said
For still others, like
As a parts inspector,
The downside: The plan had high deductibles -- "a rip-off,"
There's little doubt that thousands of Michiganders have left it until the last minute, said
"We see it all the time. People will procrastinate as long as you allow them to," she said. With the complexity of the law and the disastrous, glitch-ridden rollout of www.healthcare.gov in October, it's not surprising, she said.
It's worth the time to sort it all out.
Through
10 essential benefits all insurance policies must carry
All new insurance plans -- whether sold on
The 10 essential benefits are:
-- Ambulatory patient services: It includes visits to your doctor's office, home health care services and hospice care, although some carriers might limit these services to no more than 45 days.
-- Emergency services: Emergency room visits and the transportation to get there must be covered. Plus, you can't be penalized -- as you can under some policies now -- for going out of network or for not having prior authorization.
-- Hospitalization: Hospital stays must be covered, though you may have to pay 20% or more of your bill if you haven't reached your plan's out-of-pocket limit. Surgeries, transplants and care in a skilled nursing facility also are included, though some carriers may limit the latter to no more than 45 days.
-- Maternity and newborn care: Policies must cover costs for prenatal care, delivery and care for the mother as well as postnatal care. Many plans in the individual market previously excluded this coverage.
-- Mental health and substance abuse services: All policies must provide coverage for both inpatient and outpatient care, though some carriers may limit this to 20 days each per year.
-- Prescription drugs: At least one drug in every category and classification of federally approved drugs must be covered by plans.
-- Rehabilitative and habilitative services and devices: Plans must provide 30 visits per year for either physical therapy, occupational therapy or chiropractor services, 30 visits for speech therapy and 30 visits for cardiac or pulmonary rehab.
-- Laboratory services: Preventive screening tests -- including those for prostate exams and breast cancer screenings -- must be provided free. You may have to share the cost of other tests, depending on your policy.
-- Preventive and wellness services: Policies must cover dozens of screenings to help prevent chronic disease. Among them is testing for diabetes, colorectal cancer, high blood pressure, depression and HIV for those at risk. Plus, those who are overweight must have access to dietary counseling, and smokers must have access to programs to help kick the habit.
-- Pediatric services: Dental and vision care, previously not covered by many health policies, must be offered to children younger than 19. That means they will be able to get their teeth cleaned twice a year and get X-rays and fillings, for example. They also must be able to get an eye exam and one pair of glasses or set of contact lenses a year.
If I am not eligible for tax credits, could I find a better deal off the exchange?
The biggest draw to the
If you're not eligible for those credits, experts say you might find a better deal off the exchange.
Be aware of subtle differences. For example, an exchange plan might be required to provide pediatric vision benefits directly through the plan rather than in a stand-alone supplemental policy, according to the consumer website Health Pocket.
Some
--
--
-- Flint-based HealthPlus. Go to www.healthplus.org or call 877-562-0907.
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Highlights of plans offered by 13 insurers on the
Thirteen insurers offer plans on the Michigan Health Insurance Exchange, or state exchange. Priority sells products under two licenses. Below are some highlights.
Coverage area: HMO plans cover
For more information: www.chooseHAP.org or 855-948-4427
Number of individual plans: 1 gold, 1 silver, 1 bronze and 1 catastrophic
Number of small group plans: 2 platinum, 3 gold, 3 silver and 1 bronze
Blue Cross Blue Shield of
Coverage area: All of
For more information: www.HealthCareReformBasics.com or 855-890-2410
Number of individual plans: 2 gold, 2 silver, 1 bronze and 1 catastrophic
Number of small group plans: 1 gold and 1 silver
Blue Care Network of
Coverage area: All of
For more information: www.HealthCareReformBasics.com or 855-890-2410
Number of individual plans: 3 gold, 3 silver, 3 bronze and 3 catastrophic
Number of small group plans: 2 gold, 2 silver and 2 bronze
Coverage area:
For more information: www.consumersmutual.org or 855-492-9020
Number of individual plans: 2 gold, 2 silver, 2 bronze and 1 catastrophic
Number of small group plans: 2 gold, 2 silver and 2 bronze
Health Alliance Plan,
Coverage area: HMO plans will cover
For more information: www.chooseHAP.org or 855-948-4427
Number of individual plans: 1 platinum, 1 gold, 1 silver and 1 bronze
Number of small group plans: 1 platinum, 2 gold, 2 silver and 1 bronze
Coverage area:
For more information: www.humana.com/health-care-reform or 877-229-6285
Number of plans: 1 bronze, 1 silver, 1 gold, 1 platinum and 1 catastrophic
McLaren Health Plan, Flint
Coverage area:
For more information: www.mclarenhealthplan.org or 888-327-0671
Number of individual plans: 7 platinum, 7 gold, 13 silver and 1 catastrophic
Small group plans: 1 platinum, 1 gold and 1 silver
Meridian Health Plan of
Coverage:
For more information: www.mhplan.com/meridianchoice/mi or 313-324-3700
Number of individual plans: 1 gold, 4 silver, 2 bronze and 1 catastrophic
Molina Healthcare of
Coverage area:
For more information: www.molinahealthcare.com/marketplace or call 877-751-0848
Number of individual plans: 1 gold, 4 silver and 1 bronze
Coverage area:
For more information: www.priorityhealth.com/getcovered or 800-528-8739
Number of plans: 6 gold, 8 silver, 4 bronze and 1 catastrophic
Coverage area:
For more information: www.thcmi.com or 313-871-2000
Number of plans: 5 individual; 14 group
UnitedHealthcare
Coverage area: Did not disclose
For more information: www.uhc.com or 800-782-3740
Number of plans: 1 gold, 1 silver and 1 bronze
How to get help: Insurance agents, counselors, navigators
Insurance agents, counselors, navigators -- each can help consumers sort out their options under the Affordable Care Act. Who to contact depends on what you need and how close you are to a decision.
-- A navigator is trained by the
-- Certified applicant counselors , based in the same locations as navigators, also are federally trained and can help you sort through options. They can also help you fill out applications.
Neither a navigator nor a counselor can push a specific product or insurance company, and they must not be financially connected to an insurer. A navigator or certified application counselor can be found in your area under "local help finder" at www.healthcare.gov.
-- An independent insurance agent may be licensed in some, but not all, products. Unlike a navigator, an agent can recommend plans based on your income and special needs. An agent can help enroll you in the marketplace, where you can get tax credits, but unlike a navigator, can also help you explore products off the marketplace.
Many agents have longtime careers in insurance and are well-versed in the strengths and weaknesses of policies, including the size of networks and a company's reputation for customer service.
To find an agent with the
If you have a preferred company or product, you can contact that insurer's customer service directly. Sales staff may know that company's products better than navigators or agents, but can only talk to you about that company's products. Like an agent, they can help you explore options off the marketplace, too.
How to get help in person: Live events, meetings to help you buy insurance
Four
--
-- Community Bridges Management helps enroll consumers
--
(ACCESS) helps consumers enroll
--
-- Consumers also can locate a navigator at www.healthcare.gov. Click on "find local help."
A full list of documents, including a form to help you understand your employer's role, can be found at www.healthcare.gov. Search for "application checklist."
Help in
Ongoing enrollment assistance
Coleman A. Young Municipal Center, 2 Woodward,
Ongoing enrollment assistance
Ongoing enrollment assistance
Ongoing enrollment assistance
Advantage Health Centers, 15400 W.
Enrollment session
Enrollment event and health fair
Enrollment event
Enrollment event
Health fair and enrollment event
Enrollment event
Enrollment event
Enrollment assistance
Enrollment event
Enrollment event
Enrollment event
Bert's Place (in Eastern Market), 2727 Russell,
Health fair and enrollment event
Northwest Activities Center,
Enrollment event
Help in
Ongoing enrollment assistance
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What is my penalty if I don't get insurance?
Under the 2010 Affordable Care Act, nearly every American must carry health coverage or face a penalty. That means going without insurance might cost you, even if you go the entire year without seeing a doctor.
Those who refuse to get coverage face a tax penalty of
But there are exceptions to the law, including these:
-- People with uninsured periods of less than 3 months.
-- Members of religious groups opposed to having health insurance coverage.
-- Undocumented immigrants.
-- Incarcerated persons.
-- Members of Indian tribes.
-- Members of health care sharing ministries.
-- People with family incomes below the tax filing threshold (
-- People without access to affordable insurance (premiums for available plans cost more than 8% of income, after accounting for employer contributions or premium tax credits).
-- Family members of those with affordable employee-only employer-sponsored insurance (premium costs less than 9.5% of income) but unaffordable family coverage.
-- People who live in a state that is not expanding
-- People whose insurance policy was not renewed (canceled) and consider their replacement coverage to be unaffordable.
-- People who experience financial or domestic circumstances that prevent them from obtaining coverage, including: homelessness; eviction in the last six months or a shutoff notice from a utility company, or bankruptcy filing in the past six months; domestic violence; unexpected increases in essential expenses because of caring for an ill, disabled or aging relative -- or substantial recent medical debt from expenses in the last 24 months; disasters that substantially damaged personal property; a wait for a marketplace eligibility appeals decision (if appeal is successful), and certain children, ineligible for
Frequently asked questions
QUESTION: What if my employer already provides me with health insurance?
ANSWER: Nearly everyone has the option of purchasing a policy on the
Q: Does my employer have to carry a minimum level of coverage?
A: Employers with at least 50 employees must provide "affordable" coverage that meets a "minimum value." Those phrases are key, and most large employer-sponsored plans presently meet those requirements.
"Affordable" means that you don't have to pay more than 9.5% of annual household income for a plan that covers only the employee, even after federal discounts are applied. "Minimum value" means the plan is designed to pay about 60% of the total cost of medical services.
Employees in employer-sponsored plans that don't meet those standards may purchase their own policy on the exchange and be eligible for tax credits. Employers who offer insurance that does not meet those standards eventually will face tax penalties.
Q: Do I get credits if I don't buy a policy on the exchange?
A: No. It's only through the exchange that consumers may obtain federal tax credits. However, it's wise to see what is available off the exchange, too, especially if you're not eligible for a tax credit that would reduce your costs on the exchange.
Q: Why are plans known by metal levels, and what are the differences between them?
A: Policies might vary in the way you share the cost of your coverage, but there are four metal tiers that signal how much you'll pay in general.
Bronze plansprovide the least coverage, and you will pay roughly 40% of the cost of medical care, and the insurer will pay about 60%. If you don't expect a lot of health needs this year, a bronze plan might be a good choice because the monthly premiums are lower.
Next up are the silver plans, which pay about 70% of your costs, followed by gold plans, which cover about 80%. Finally, the platinum plans, which -- though their monthly premiums might be more expensive -- cover about 90% of your costs. That might be a wise choice if you need more frequent care.
Silver plans offer additional help for those under 250% of the federal poverty limit. For those consumers, the silver plans offer reduced co-pays and other out-of-pocket expenses.
One final note: In limited circumstances, you may be able to purchase a catastrophic plan, which -- although generally the least expensive -- offers minimal regular coverage. A catastrophic plan protects you from worst-case medical crises.
Q: Do I get a break on premiums if I'm a student?
A: Probably not. On the exchange, premiums are based on four things: your age, where you live, your family size and whether you smoke or use other tobacco products. Like others who purchase on the exchange, you may be eligible for tax credits depending on your income.
Q: I have
A:
Q: I'm retired but too young for
A: If you have retiree health benefits, you don't need to do a thing. You're considered covered and won't face a penalty for not having insurance.
For this section, we turned to
QUESTION: I don't get any tax credits, and I feel like the cost of these plans might bankrupt me. Help!
ANSWER: No doubt: Insurance isn't cheap. But an exemption can be provided if the lowest coverage cost exceeds 8% of income.
Even the least expensive insurance guards against catastrophic costs. Under the federal Affordable Care Act, there also are maximum out-of-pockets costs --
It's important to know that premiums do not count toward this maximum out-of-pocket. The good news: Some policies have lower out-of-pocket limits. It's important to look at all your costs: premiums, co-pays, deductibles and coinsurance. You should double-check your options at Healthcare.gov to make sure you are not eligible for tax credits and to see what plans are available to you.
Q:
My 25-year-old son is currently living in
A: Most people will need to enroll in coverage by
However, your son's move back home will be considered a qualifying life event and he will be eligible for special enrollment, meaning he will be able to enroll at that time. He will want to check out his options and get enrolled in a policy before he moves back to make sure there is no gap in coverage.
Q:
A: Maybe, but time is running out. If you have enrolled in a plan but the enrollment has not yet taken effect, you can switch until
If you don't have one of these special reasons for changing plans and your enrollment has already taken effect, you will have to wait until next open enrollment season to make a change. Open enrollment begins
Q: I signed up for health insurance through the marketplace last month and it was effective
A: You can cancel your marketplace insurance by notifying the health plan.
Usually, you have to give the plan 14 days advance notice to end your coverage, so the plan may charge you for premiums until the 14 days are up. You can talk to the plan about whether it will waive those premiums.
If you are getting tax credits, notify the marketplace. That's because you're not eligible for tax credits in the marketplace when you have adequate employer coverage. Talk to the marketplace about what steps to take and when your disenrollment will be effective.
Q:
A: Yes, so long as you both qualify for a tax credit. The amount of this tax credit will be based on the second-least expensive silver policy in your area that would cover you both if you were purchasing a single plan. If you live in different areas, you'll get credits based on the second-least expensive silver policies that could cover each of you.
Assuming you live together, you can put that credit toward buying two separate plans, but it might not go as far if the cost of two plans is more expensive than the cost of one policy together.
Q: I am turning 65 on
A: Your tax credit is based on your annual income.
As you go through the online application, it will calculate your annual income based on your current monthly income or based on last year's income. But a screen will ask you if the information is correct. Be sure to correct the information to reflect your projected adjusted gross income for 2014, including the part of the year when you receive your pension. Also include both the taxed and untaxed portion of your
Finally, when
Q: My plan has high deductibles and high co-pays, but preventive care is stated as
A: Not necessarily. For adults, insurers must provide 15 preventive screening and counseling services at no cost. These services are among the current recommendations of the
If you have no symptoms and no reason to think you aren't healthy when you have these tests, it's a "preventive service." And if your doctor orders a preventive service more often than these guidelines suggest, it's still a preventive service.
But when you have some risk factors or symptoms and your doctor orders one of the tests, it's a "diagnostic service" to determine what's wrong. Yes, it's the same service, but it's not preventive care. That means it will be subject to deductibles and co-pays.
Thyroid testing is not on this list, but many insurers do cover it 100%. Check your insurance policy.
Q: I live half the year Up North in
A: When considering policies, pay close attention to how they handle out-of-network services and schedule doctor visits in your area whenever possible.
When you travel out of your immediate area, care might cost you more. It's also important to know that your cost-sharing for out-of-network services is not subject to the out-of-pocket maximum established by the federal law.
The good news: In cases of medical emergency, your plan must cover care without regard to whether the provider is in your network. Moreover, the insurer generally cannot impose any co-payment or coinsurance greater than what you'd face if you were still in network.
One final caution: Your insurer must cover out-of-network emergency care only at the same level it would if you were in-network. If the out-of-network provider charges more, you might have to pick up the balance.
Q: I am in a retiree plan and I'm told my adult children aren't covered until age 26. My understanding was that the new law meant they could stay on my plan until age 26. Am I wrong?
A: Under the law, policies that cover families must cover children until they are 26, even if they're married, have coverage through their own employer or no longer live with their parents.
But retiree-only plans are exempt from many requirements that apply to other policies under the Affordable Care Act. For example, they don't have to cover adult children until 26, nor do they have to provide free preventive care or remove lifetime limits on coverage.
Q: I understand that my house and my car will not be used against me to determine my eligibility for
A: No.
Q: Over the past several months I have been working in the marketplace to get insurance for my family of three. I finally came out the other side only to find out that the cheapest insurance is nearly
A: The marketplace most likely indicated you are not eligible for tax credits because you will be eligible for
Consider working with a federally trained staffer (a navigator or certified applicant counselor), an independent insurance agent or the federal call center to double-check your work. Though officials say most glitches have been ironed out at www.healthcare.gov, there are lingering problems.
Q: Since Michigan's expanded
A: Unlike coverage purchased in the marketplace, enrollment in
Once the expanded program opens, consumers can apply online, by phone or in-person at local DHS offices or health departments, health centers and tribal health facilities operated by the
Applications can also be made through Healthcare.gov, but state officials warn that the process will take longer and suggest using MIBridges.
Q: If a person receives
A: Most Michiganders who are already covered under the current
Michiganders covered by the Adult Benefits Waiver program, which provides very limited
In short, only those who are not covered by the current
Q: My daughter, who is unemployed, recently had a child. She refuses to name the father because she doesn't want this man involved with her daughter, my granddaughter. She is disqualified for the current
A: The biggest difference in eligibility between the current
Other rules don't change. So a person who refuses to help establish paternity for a child, without good cause, may be denied benefits under current
Because your daughter will have no coverage, she may face a tax penalty for lack of coverage, unless she qualifies for a hardship exemption because of low income, for example.
Q: I am 44 and recently lost my out-of-state job. I moved back to
A: Their income does factor into your eligibility for premium tax credits and for expanded
The key question is whether you anticipate your parents will claim you in 2014, or whether you will find a job. If you anticipate your parents will claim you, then their income would count. If they do not claim you, then you would be a household of one, and assuming you have little or no income, would likely be eligible for Healthy Michigan Plan in April.
Q: I am one-quarter Seneca Indian but not a tribal member because the Seneca Nation is a matrilineal society and recognizes as members only those whose mother is Seneca Indian. My father, who is one-half Indian and a member of the
What are my options?
A: American Indians and Alaska Natives do have different options under the health reform law. For example, they do not face co-pays and deductibles if they are under 300% of the federal poverty level, nor are they limited to the open enrollment period that ends
And certain protections apply only to members of federally recognized tribes, and tribes determine membership.
If you are not recognized as a Seneca Indian member and will not receive benefits above, you may be eligible for health care through Indian health care services. That is based on descendancy, which can be determined at a local
Q: I have been told that some health insurers do not terminate coverage for 26-year-olds on their 26th birthday, but at the end of the year of their 26th birthday. I'm not sure if that is true. What are the rules for getting coverage after 26, and how do I make sure that I don't lose coverage?
A: Under the law, policies that cover children must do so until they are 26, even if they're married, have coverage through their own employer or no longer live with their parents.
Health insurers are free to offer more generous benefit designs, such as covering dependents until the end of the month or even the year in which the child attains the age of 26. But under the law, insurers only need to provide coverage until the last day they're 25.
To make sure you have no gap in care, check out your options and enroll in a new policy early so that it's effective the first day you're 26. And remember, for a policy to be effective the first day of the month, you must enroll on the 15th of the previous month.
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