Ever since Marci Lieber, a part-time social worker in Brooklyn, learned she was pregnant, she and her husband have been scrambling to find health insurance. But insurers consider pregnancy a pre-existing condition, and won’t sell anyone a new policy that covers it.
That changes on Jan. 1, 2014, when insurers will no longer be permitted to deny coverage of pre-existing conditions — and all Americans will be required to have health insurance under the Affordable Care Act. Ms. Lieber, 37, hopes to purchase a policy through New York State’s new health exchange as early as this October.
Just in time: the baby is due Jan. 25.
“I hadn’t paid super close attention to the A.C.A. I didn’t realize it would apply to my life,” Ms. Lieber said. She learned she could purchase a policy through the new exchange from a counselor at Community Health Advocates, a consumer assistance program that helps New Yorkers find health coverage.
Ms. Lieber isn’t alone. Many Americans still don’t realize the A.C.A. is coming into effect, including 6 out of 10 low-income workers who especially stand to benefit, according to a study by the Kaiser Family Foundation. Many mistakenly believe the law has been overturned and few have any idea how they are to go about purchasing health insurance from the online exchanges being set up in each state — or that the federal government intends to help many of them pay for it.
But many efforts are being made to simplify the process of buying insurance and to make the exchanges as user-friendly as possible.
For starters, the state exchanges are Web sites designed to make it possible to purchase health insurance if you don’t get it from your employer. If they work as promised, the exchanges will let consumers compare different options as easily as they would booking a trip on Travelocity or researching a car on Edmunds.com. You can find a link to your state’s exchange at www.healthcare.gov.
All health plans offered on a state exchange must provide comprehensive coverage that includes doctors’ visits, lab work, hospital stays, emergency room services, maternity care, prescriptions, mental health services and children’s dental and vision care. Presumably, this means fewer consumers will be stung by minimal coverage and unexpected denials — the fine print of health policies that everyone dreads.
But not all the plans will offer the same level of coverage. Shoppers will find four broad categories. Policies with the most generous benefits will be “platinum” plans; they will have the highest monthly premiums but fewer out-of-pocket costs and lower deductibles. The “gold” and “silver” plans will be somewhat less generous, while those in the “bronze” category will have the cheapest premiums but may require high out-of-pocket costs and deductibles.
The idea is that you will be able to make an apples-to-apples comparison of the prices, provider networks and other details to see which policy best fits your needs. Be aware that the plans may have narrow provider networks — your favorite doctor or the hospital down the street may not be a participant. You’ll need to check to see if a certain provider is in the network, advised Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reform.
The exchange should be able to tell you exactly what each plan will cost, given individual circumstances. Be prepared for sticker shock. A 40-year-old nonsmoker may be able to buy a plan for about $4,000 annually or less; someone in his or her 50s may pay double. “Health insurance is an incredibly expensive product,” Ms. Corlette warned.
What many consumers don’t realize is that even if you earn well above the minimum wage, you may get help purchasing the policy you want. People who earn up to four times the federal poverty level — roughly $45,960 a year for a single person and $94,200 for a family of four — can receive subsidies to help pay for the new coverage. Those earning 250 percent of the poverty level are eligible for additional cost-sharing subsidies.
“The vast majority of currently uninsured are going to be eligible” for some form of subsidy, said Elisabeth Benjamin, vice president of health initiatives with the Community Service Society of New York.
To see if you’re eligible for subsidies, and what portion of the cost you will be expected to carry, try this calculator: kff.org/interactive/subsidy-calculator/.
Americans who work at minimum wage jobs, earning less than 138 percent of the federal poverty level, which is $15,856 for a household of one and $32,499 for a household of four, will qualify for free government coverage under Medicaid — but only if they live in a state that is expanding its Medicaid program. The Kaiser Family Foundation has a list of what each state is doing on its Web site.
Medicaid is going to be the safety net for more people in the years to come. “It’s free, you don’t pay anything, it’s comprehensive and it turns out to be the easiest thing to apply for,” said Karen Pollitz, senior fellow at the Kaiser Family Foundation.
In many states, all of these transactions are to be handled by the online exchange (Medicaid may require a separate process in some states). You fill out an application, providing your Social Security number and information about your income and family. The exchange will tell you if you are eligible for Medicaid or for a subsidy.
If so, it will tell you the amount, as well as what your share will be (the calculation is based on the price of a midrange “silver” plan). You select a plan, and you can decide whether you want the subsidy paid directly to the insurer or not.
The new system will be a radical departure from the byzantine and often bewildering insurance market we have now. Critics say the exchanges will cost the government a fortune, and warn that the plans may provide access only to a limited number of doctors and hospitals.
Supporters acknowledge that there will be glitches initially and that it may take a while to iron out all the details. And health insurance has never been cheap.
“Out-of-pocket costs are still high, even with the financial assistance,” said Jennifer Sullivan, of Enroll America, a nonprofit group that aims to get as many Americans coverage as possible. “People need to see it in context and realize the annual savings they are getting. that moves them to say, ‘Ah, this is a pretty good deal.’ ”
Open enrollment on the new exchanges will run from October 1 through March 31. You will not be able to sign up for insurance after March 31 unless your circumstances have changed, and you are suddenly without coverage because of a divorce or job loss.
Help will be available online or via telephone. Given how difficult insurance purchases have always been, many Americans are likely to need it.