A Ky. guide to the Patient Protection and Affordable Care Act

By Molly Burchett
Kentucky Health News

Few laws have generated as much confusion, opposition or news coverage as the Patient Protection and Affordable Care Act. Despite the flood of news stories about the law widely known as Obamacare, there is still much confusion about it.

That’s not surprising. The 906-page law is complex and is accompanied by 10,535 pages of regulations. This guide to the law is designed to clear up confusion and offer various perspectives about how the law may affect you, your family or your business.

What does the Affordable Care Act do?

The law is a set of reforms that impose many requirements on insurance companies and requires all Americans, with very few exceptions, to have health coverage or pay a penalty starting Jan. 1.

Kynect home page

In addition to those mandates, the law created online health-insurance marketplaces and encouraged states to expand the federally subsidized Medicaid program for the poor and disabled. Gov. Steve Beshear expanded Medicaid and decided the state would run its own marketplace or exchange, Kynect, which launched Oct. 1.

Why did Congress pass the law?

The law is designed to extend health coverage, either through private insurance or Medicaid, to Americans without health insurance. More than 47 million Americans were uninsured in 2012, says the Kaiser Family Foundation, and about 640,000 of them were Kentuckians.

The law’s rules for insurance will increase costs for many, so it provides Medicaid or subsidized coverage to help qualifying individuals pay for coverage. Those with incomes under 138 percent of the federal poverty threshold qualify for Medicaid, and those with incomes up to 400 percent of the poverty line get premium subsidies. The line for a family of four is $23,550, so such a family would qualify for subsidies if it makes less than $94,200 a year.

Who will be affected by the law?

Obamacare will affect almost everyone, but it will have less impact on people 65 and up because they’re eligible for Medicare. Virtually everyone must have health insurance coverage by 2014 or pay a penalty. Beginning in 2015, employers of 50 or more full-time workers (defined as working at least 30 hours a week) must provide coverage for their employees.

Insurance companies can no longer deny coverage because of pre-existing conditions such as a disability, pregnancy, or chronic disease. Under one part of the law that took effect early, parents are able to keep their children on their insurance until the children turn 26.

The law aims to help people who can’t get affordable insurance through an employer or who aren’t ineligible for public coverage through Medicare or Medicaid. It also affects the self-employed, small businesses and employees of businesses that don’t provide coverage.

Because the law is making fundamental changes in the health-insurance system, “In the long run, pretty much every American will be affected by Obamacare,” reports Abby Hayes of The Dough Roller, a financial-advice site. “Next year, employer-sponsored insurance premiums are likely to fluctuate as insurance companies adjust their offerings.”

Will the law lower health costs?

It’s too soon to tell what impact the law will have on costs. Remember, there are two types of health costs: the country’s overall cost and the cost that you feel in your pocketbook from the money your household spends on health services.

If you buy an insurance policy through the state exchange, www.kynect.ky.gov, your cost will depend on your individual situation, such as the size of your household and the number of smokers in it, and your income, which will determine your eligibility for subsidies or Medicaid.

Most people who buy coverage in the individual market will pay higher premiums in 2014, mainly because companies are required to cover people with pre-existing conditions and a broader range of services, such as prescriptions, than many people have been paying for.

Rates in the individual market will change yearly, as explained in a report from the Kaiser Family Foundation. It says the broader coverage, and limiting surcharges due to age, will spread the overall cost of care across the insurance marketplace, tending to lower premiums for people who are older and sicker and raise them for people who are younger and healthier. Thus, the trade-off for pre-existing coverage is the individual mandate, which requires everyone to purchase coverage to spread the cost.

Think of it this way: When you go out to eat with two grade-school children, they can order off the kids’ menu, so you pay less for their smaller portions. The total bill is $30. Your kids’ chicken finger platters are $5 each, and you and your spouse both have $10 items. However, if the restaurant must charge all patrons equally for the same meal, the $30 cost would be assessed differently. The cost for each individuals would be $7.50; the cost of your kids’ meals would be higher and you and your spouse’s meal would cost less.

Many Kentucky businesses have expressed concern about rising premiums for employee coverage. Some are moving to high-deductible plans that require employees to pay a larger share of their costs, and some may drop coverage, letting employees obtain insurance and subsidies through the government exchanges.

How do I get coverage from the exchange?

The Kynect website will determine your eligibility for Medicaid or subsidies, allow you compare plans and process the insurance application. If you don’t have a computer, you can call toll-free to 1-855-459-6328 to apply or locate a local “Kynector.”

Unless you qualify for a special enrollment period, you must enroll in a health plan by March 31, 2014. A “life-changing event,” such as moving to a new state, major changes in income and changes in family size, can make you eligible for a special enrollment period, says Healthcare.gov, the federal website. (Kentuckians do not use the federal site because the state has its own site, Kynect.)

The date coverage starts depends on when you buy it. If you enroll before Dec. 15 and pay your first premium, your coverage starts Jan. 1. Likewise, in succeeding months, if you enroll between the 1st and 15th, your coverage starts on the 1st of the next month. If you enroll after the 15th, coverage starts the month after the next one.

What do the health plans cover?

Regardless of which plan you chose, the law requires all plans offered by any insurance company to cover these essential health benefits:

  1. Ambulatory patient services (outpatient care)
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance abuse services (including behavioral health treatment)
  6. Prescription drugs
  7. Rehabilitative and habilitative services/devices
  8. Laboratory services
  9. Preventative, wellness, and chronic disease management services
  10. Pediatric services (including oral and vision care) 

What will I pay for a plan?

Premiums depend on individual circumstances, such as income and the level of coverage, such as the amounts of deductibles and co-payments. Kynect is connected to federal databases — including Internal Revenue Service databases — to determine whether you qualify for assistance in paying a premium. People on Medicaid do not pay premiums.

Plans on Kynect vary widely. In addition to comparing premiums, it is important to consider deductibles, co-payments and other plan details. Kynect offers four basic types, labeled bronze, silver, gold and platinum. Bronze plans have the lowest premiums but have a $6,300 deductible. As you move up the plan spectrum to platinum, your premiums increase and your deductibles decrease. The exchange also offers people under 30 a plan that provides only catastrophic coverage with a “very high deductible” and no subsidy.

Let’s consider a basic example. A 45-year-old Floyd Countian named John Smith earns $36,000 a year, which means he is eligible to buy subsidized insurance through Kynect.

The individual market in Floyd County is limited to two companies, Anthem Blue Cross and the non-profit Kentucky Health Cooperative; Humana Inc. isn’t offering individual coverage there. Depending on the type of plan John chooses, his premiums will range from $182 (bronze) to $421 (platinum), with deductibles ranging from $6,300 (bronze) to $500 (platinum).

Kynect shows selected plans’ ranges of premiums, 
deductibles and out-of-pocket limts.

John has several options. Let’s say he decides that he needs to keep his premium payments below $250 per month because he just bought a house and is on a tight budget. He doesn’t expect to have many doctor visits because he’s pretty healthy, but he doesn’t have enough money saved to afford a $6,300 deductible if things went south.

Considering his obligations, John decides to set aside 15 percent of his monthly income for health care. Based on this budget, he narrows his options down to three plans. The Kynect website displays them.

After eliminating the gold plan, John decides he would prefer to pay an additional $40 per month to reduce his deductible to $2,000, so he purchases the cooperative’s PPO Silver plan. About 7 percent of his income each month will go toward the premium. He will save the other 8 percent ($240) to apply to his deductible, prescription drug costs and co-pays for office visits.

A $2,000 deductible means that John must pay all of his medical costs, excluding certain preventive services like immunizations and screening, until he reaches this threshold. Co-payments and premiums cannot count toward the deductible.

John really likes his family doctor, whom he’s been seeing for 20 years, and the doctor is in the cooperative’s network. This plan has a $30 co-pay for primary care and mental health services, and he feels comfortable paying this amount for an office visit. If he were to see an out-of-network doctor, he would pay co-insurance: 60 percent of the doctor’s full charge for the visit. For prescription drugs, there is a $500 deductible, and John will pay $20 per prescription for generic drugs after reaching this amount.

John has peace of mind knowing that he’s covered if he were to have an accident. The total amount he may have to pay each year is his out-of-pocket limit of $6,350, and since he has purchased this plan during the enrollment period, he will not face a penalty for not having coverage.

As he navigates the site, John sees that he qualifies for a payment assistance in the form of a tax credit that will either reduce the amount John will pay in taxes or increase his refund, depending on his personal situation; or it will reduce his monthly premiums, if he so chooses.

What happens if I don’t get covered?

The penalty for 2014 will be the larger of either $95 per adult and $47.50 per child under 18, up to a total of $285 per family or 1 percent of household income in excess of $10,000 for an individual or $20,000 for a family.

For example, let’s say an individual making $40,000 per year doesn’t buy health insurance in 2013. This person would would pay 1 percent of $30,000, or $300, in 2014. What about a family with a $50,000 household income? It would pay a penalty of 1 percent of $50,000, or $500.

The initial penalties are much less than the cost of health insurance, but will go up each year. The minimum penalty may increase to as much as $695 per person by 2016.

What if I’m on Medicare or Medicaid?

Almost nothing will change if you have coverage through Medicaid, but there are some changes for Medicare beneficiaries. The law doesn’t require Medicare beneficiaries to buy more insurance and won’t force beneficiaries to see different doctors, reports Andrea Adleman of U.S. News.

Obamacare does, however, increase premiums or prescription-drug costs for some Medicare beneficiaries, and it mandates $716 billion in Medicare payment reductions over the next 10 years. These cuts are made by changing payment formulas for hospitals, nursing homes, home-health agencies, hospice agencies and Medicare Advantage plans, says the Congressional Budget Office.

The law already affects higher-income Medicare beneficiaries. Those who earn more than $85,000 ($170,000 for a couple) are paying higher Part B premiums, which cover physician and outpatient services, and for Part D, which covers prescription drugs, says Kaiser Health News. As a result of this sliding scale, about 5 percent of Medicare beneficiaries are paying more for premiums and prescription drugs.

It is projected that by 2019, 7.8 million beneficiaries will be paying the higher Part B premiums and of that group, 4.2 million will pay the higher Part D premiums. Kaiser estimated the combined premium in 2019 would be $299 to $683 a month, depending on income.

However, typical Medicare beneficiaries, those below the $85,000/$170,000 income threshold, will pay less for their premiums since the the law closes the “doughnut hole,” the coverage gap in prescription benefits, by 2020. The National Council on Aging estimates the savings could reach $1,800 for some beneficiaries.

Also, both Medicaid and Medicare beneficiaries will qualify for more free preventive care, such as a yearly wellness visit, vaccinations and colorectal screenings, starting Jan. 1.

What if my employer covers me?

About 57 percent of Americans have health insurance through an employer with fewer than 200 employees, and those who are covered do not have to purchase a new plan on Kynect. If your employer’s plan covers less than 60 percent of allowed medical expenses, or costs you more than 9.5 percent of your household income, you can shop on the exchange.

Over the past 10 years, employers have been shifting more health costs to employees. Worker contributions increased 89 percent during the decade, and are 14 percent higher than in 2009, Kaiser Health News reports. So, while the nature of your work plan may be changing, this is not a direct result of the health law.

If you aren’t covered by your employer or if your employer decides to drop your coverage, you must obtain coverage or face a penalty. Religious conscience and hardship exemptions to this mandated coverage exist, and you will need to complete an application to request such an exemption.

What if I’m an employer?

Steve Wilson, senior vice president of Benefit Insurance Marketing in Lexington, said in an email that employers with fewer than 50 employees are facing 2014 premium increases that may lead them to drop coverage for their employees.

Wilson said unless companies act quickly to renew early based on 2013 underwriting rules, the average 2014 renewal for his company’s small business clients will increase 63 percent. He said his clients represent a broad range of industries that will, on average, pay $3,508 more per employee for coverage next year.

On the other hand, a study by the RAND Corp. says Obamacare could alleviate some of the difficulties for small employers by putting their employees into a single risk pool. The study predicts that the number of workers offered coverage will increase after the reform, mainly because more small businesses will offer coverage.

If you have a small business with 25 or fewer employees, there may be significant tax credits available through Kynect to help cover the cost of insurance.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

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