As part of the Affordable Care Act, most U.S. citizens were required to have health insurance beginning in 2014. In 2016, there is a higher penalty than last year if you’re not excluded for a particular reason. Wondering why health insurance is so important, we sat down with Devon Hyde, CEO of AllianceHealth Deaconess to find out.
Open enrollment for health coverage runs
Nov. 1, 2015 to January 31, 2016.
To make an appointment for enrollment or re-enrollment for the Health Insurance Marketplace or Medicaid, call:
(405) 604-4573
What is health insurance?
Hyde:
Health insurance is a contract between you and an insurance company. When you buy a plan or policy, you pay a monthly fee and in return, the company agrees to pay part of your medical expenses when you get sick or hurt.
Why is it important to have health insurance?
Hyde:
While no one plans to get sick or hurt, most people need medical care at some point. The average cost of a three-day hospital stay is $30,000 – and the cost to fix a broken leg can cost up to $7,500! Having health insurance helps protect you from unexpected costs like these. Your insurance policy will outline what types of care, treatments and services are covered, including how much the insurance company will pay for different treatments in different situations.
Is having health insurance mandatory?
Hyde:
Yes, with few exceptions, most U.S. citizens are required to have health insurance under the Patient Protection and Affordable Care Act signed into law in 2010. Those who do not have minimum essential health coverage – like through an employer – and don’t qualify for an exemption, will have to pay a penalty fee if they don’t get health insurance.
What is that penalty?
Hyde:
If you can afford health insurance coverage in 2016, but don’t sign up, you may have to pay a penalty ($695 per adult, $347.50 per child – up to $2,085/family or 2.5% of family income, whichever is higher). And without insurance, you’ll be financially responsible for all of your medical costs.
You are considered covered if you have Medicare, Medicaid, CHIP, any job-based plan, any plan you’ve purchased yourself, COBRA, retiree coverage, Tricare, VA health coverage.
Who is exempt from having to get health insurance?
Hyde:
The list is long, but here are a few reasons why a person might be exempt:
- Coverage is unaffordable coverage (more than 8% of household income)
- You are a member of federally recognized tribe
- You are below tax filing threshold and not required to file taxes
- You have been uninsured for less than three consecutive months during the year
When can a person purchase health insurance?
Hyde:
For the Health Insurance Marketplace, enrollment periods are only for a specified time during the year. The current enrollment period runs from November 1, 2015 through January 31, 2016. You can only purchase insurance outside of that time period if you have a qualifying life event, such as a marriage, divorce, new baby, and change of income, to name a few.
How much does health insurance cost?
Hyde:
Each plan varies in terms of overall cost and depends on the amount of premium and deductible you choose. Thepremium is the amount of money charged for a certain amount of insurance coverage each year. You may also have an annual deductible. This is the amount you must pay out of your pocket before the insurance company will pay any expenses. For example, let's say you have a plan with a $200 deductible. You go to the doctor and the total cost is $250. You pay the first $200 to cover the deductible, and then your insurance pays its share. How much you pay for your premium and deductible depends on the type of insurance you have and whether you’re purchasing individual or family coverage.
Every plan has to pay 60% of your medical bills. But from there, you can decide, do you want to pay a higher premium and get more of your benefits paid - or do you want to pay a lower premium and run the risk that, if you get sick, you'll have to pay more out of your own pocket?
So, a higher premium offers more coverage. A lower premium provides less coverage if you get sick. So if you think you are going to stay healthy, then you might want to pay a lower premium that would cover a smaller percentage of your bills.
What types of plans are there?
Hyde:
There are four levels of health plans on the Health Insurance Marketplace: platinum, gold, silver, and bronze. Each category has a different monthly premium costs, as well as deductible. There are a lot of affordable options on the Marketplace and you can compare each plan side by side so you can find the plan that meets you and/or your family’s needs.
Is there any help available if you can’t afford health insurance?
Hyde:
Through government subsidies, financial assistance to help with premium costs may be available, depending on household size and annual income: Individual consumers between $11,770 to $47,080/year (household of one); $24,250 to $97,000/year for a household of four; $40,890 to $163,560/year for a household of eight.
For example, if a family of four had an income of about $40,000 in 2014, they may be eligible for subsidy assistance on premium costs that exceed 5% of their income. If that same family of four purchases a Silver plan that might cost them around $9,400 per year, they could eligible to receive subsidy assistance of up to almost $7,400; which means they would only be responsible for about $2,000 of the insurance premium costs themselves.
What if you have a preexisting condition like a previous cancer, a diabetes diagnosis or are pregnant?
Hyde:
You cannot be excluded from coverage for any preexisting condition. And, equally important, parents can cover their children up to age 26 on their insurance plan.
What do I need to do if I enrolled last year and have coverage?
Hyde:
Consumers enrolled in a 2015 Marketplace plan will have an automatic enrollment option to select the same health plan coverage as long as the same plan is offered in 2016.
All consumers are encouraged to return to the Marketplace to make any necessary updates, as well as review all eligible health plans to make sure they have chosen coverage that best suits their needs. The Marketplace enrollment tools spell out the steps consumers need to take to either auto-enroll in the same health plan, or to shop for other choices.
What else does a health insurance cover?
Hyde:
In addition to pre-existing conditions, all qualified health plans must offer:
- Ambulatory patient services
- Hospitalization and emergency services
- Maternity and newborn care
- Mental Health and substance use disorder
- Prescription drugs
- Lab services
- Preventative and wellness services
- Chronic disease management
- Pediatric services, including dental and vision care
Of course, you have to meet your deductible before insurance pays.
I’ve also heard that qualified health plans cover preventive care services at no charge.
Hyde:
Yes, Marketplace plans cover many preventive care screenings, tests and services such as vaccinations that can help adults and children stay healthy. And the best news is, they’re free – no copays or deductibles. Depending on your age, gender and other risk factors, your doctor may tell you it’s time for a mammogram, colonoscopy or other screening that can detect cancer or disease in its earliest, most treatable stages. Or, it may be time to screen for high blood pressure or high cholesterol to give your doctor information that can help prevent a stroke or heart attack.
In total, there are 18 covered preventive services for adults, 22 covered preventive services for women, including pregnant women, and 26 covered preventive services for children.
Besides a health insurance plan on the Health Insurance Marketplace, what other types of health insurance are available?
Hyde:
Many families with limited income qualify for Medicaid or Children’s Health Insurance Program (CHIP) and they can enroll any time of the year. Medicaid provides health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. In some states, the program covers all low-income adults below a certain income level. CHIP provides low-cost health coverage to children in families who earn too much money to qualify for Medicaid. In some states, CHIP covers parents and pregnant women.
How can local, uninsured residents find help with enrollment?
Hyde:
As a service to our community AllianceHealth Deaconess can help uninsured residents review coverage options on the Health Insurance Marketplace, or determine eligibility for Medicaid. We can also assist with re-enrollment or with special enrollment if someone has had a life change, such as a marriage, divorce, job loss, etc.
All they need to do is schedule an appointment with one of our application coordinators by calling (405) 604-4573. We also have Spanish-speaking representatives available to assist.