Diabetes Forecast

Your Guide to the New Health Insurance

By Erika Gebel Berg, PhD , ,

There's a new market in town, and you'll probably want to check it out. A central component of the Affordable Care Act (ACA) is the creation of an online Health Insurance Marketplace in every state, sometimes referred to as exchanges. In short, the Marketplace will allow consumers to purchase health insurance, obtain federal subsidies, and compare plans based on price, benefits, quality, and other factors.

Beginning this month, anyone except undocumented immigrants and incarcerated people can purchase a plan in the Marketplace, regardless of any preexisting medical conditions. Plus, eligible people can get financial assistance to help pay for their health insurance.

According to the Congressional Budget Office, some 9 million people will have enrolled in Marketplace plans by the end of next year, a number that is expected to rise to 25 million by 2022. Half of those who now buy their own health insurance will qualify for discounted or free plans, says the Kaiser Family Foundation. The enrollment for 2014 coverage begins Oct. 1, 2013, so it's time to take action.

What Is My Market?

Where you live will determine what specific Marketplace you'll have access to. Under ACA, each state was allowed to establish its own Marketplace for its residents; you will shop in your state's Marketplace. "If a state chooses not to set up their own Marketplace, the residents of that state can use the Marketplace set up by the federal government," says Tarnisha Brown of the Centers for Medicare and Medicaid Services (CMS).

Essential Health Benefit Categories

  • Ambulatory patient services, such as a primary care visit to treat illness or injury
  • Emergency services, such as trips to the emergency room
  • Hospitalization
  • Maternity and newborn care, such as prenatal care
  • Mental health and substance-use-disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices, such as durable medical equipment
  • Laboratory services
  • Preventive and wellness services and chronic disease management, such as screening for diabetes for people with high blood pressure
  • Pediatric services, including oral* and vision care
*In some states, pediatric oral care will be available as a stand-alone plan, purchased separately, and does not need to be included in the main health insurance plan.

Insurance companies have created plans that meet the criteria established by that state's Marketplace. These are called qualified health plans (QHPs), and they must include services in 10 essential health benefit categories (see "Essential Health Benefit Categories," right), though states may differ in how they define these benefits. "How they're defined is one of the main differences between plans from state to state," says JoAnn Volk, MPP, research professor at the Center on Health Insurance Reform at Georgetown University. Other differences arise from how the insurers interpret those definitions.

How Do I Apply?

For people interested in buying insurance (satisfied with your current plan? No need to shop), start with an application. You can apply in any one of four ways: online, in person, by phone, or by mail.

To fill out the application for coverage in 2014, you'll need your household's Social Security numbers, employment and income information, policy numbers of any current health plans, and a completed employer coverage tool, available through CMS, which asks whether your employer provides you with insurance. Your household is generally the same as defined in your federal tax returns. However, young adults can stay on their parents' insurance plan until age 26 if the policy covers dependents—even if they don't live in the same household, are not financially dependent on their parents, and, beginning in 2014, are eligible to enroll in an employer's health plan.

Most people who have access to employer-provided health insurance won't be eligible for financial help, says Jenny Sullivan, MHS, director of the Best Practices Institute at Enroll America, a nonprofit organization whose goal is to help people get health coverage through ACA. "We don't want to be scooping people out of that system and putting them into this," says Sullivan. But if, based on your application, your employer-based health care plan is deemed to be unaffordable (premiums cost more than 9.5 percent of your income) or inadequate (it covers less than 60 percent of medical costs), then you'll be eligible to buy a subsidized plan in the Marketplace. The employer coverage tool will help you figure that out. "Answering those questions will help you fill out the application accurately," Sullivan says.

If all this seems a little overwhelming, help is available 24-7 through online chat services and a call-in line (1-800-318-2596), or you can get in-person assistance at certain community centers and through nonprofit organizations. Go to healthcare.gov or your state's Marketplace site for the latest information on where to get help.

Expanded Medicaid

You qualify for Medicaid based on income and family size. If you're eligible, you get free or low-cost care and don't need to buy a health insurance plan in the Marketplace.

These states, and the District of Columbia, will expand their Medicaid programs in 2014:
District of Columbia
New Jersey
New Mexico
New York
North Dakota
Rhode Island
West Virginia

These states have enacted or were debating a different approach to expansion:

These states were considering expansion but hadn't made a final decision at press tim e:
New Hampshire
Source: Kaiser Family Foundation

Can I Get Financial Help?

Once submitted, your application is reviewed to see if you are eligible for state health care programs and how much assistance, if any, you can receive. You cannot be denied coverage or charged more because you have a preexisting medical condition, such as diabetes. This is true for new plans sold inside or outside the Marketplace. Plans can set higher premiums based only on age, tobacco use, family size, and where you live.

Help with affording insurance can come in different forms. People with household incomes between 100 and 400 percent of the federal poverty line (or between 138 and 400 percent in states with expanded Medicaid coverage) can get premium assistance in the form of a tax credit, which can be used right away to lower premiums or taken as a tax refund. In addition, those who earn less than 250 percent of the federal poverty line are also eligible for cost-sharing benefits, such as lower co-pays in certain plans. For example, a family of four with an annual income between $23,500 and $94,200 in 2013 would have access to lower premiums, while a family of four with an annual income of $58,875 or less may also get additional cost savings in lower deductibles, co-pays, and coinsurance.

The same application is also used to determine eligibility for the Children's Health Insurance Program (CHIP) and Medicaid, which is being expanded in about half of the states—at press time, some were still debating whether to do so—to include all individuals from the ages of 19 to 64 who make 138 percent of the federal poverty line or less. So, if you weren't eligible for Medicaid before and you live in one of these states (see "Expanded Medicaid," left), you may find out that you now qualify. CHIP eligibility is also determined by the state, though it often applies to children whose family income is about 200 percent of the federal poverty level or less. You can apply for Medicaid or CHIP at any time during the year.

There's no harm in applying and then seeing what sort of plan and help you can get, even if you decide to remain with your current plan.

How Do I Shop for Plans?

Once you know your eligibility, it's time to start browsing the plans offered in your state. Every Marketplace must offer a choice of at least two plans; some may have many more. One advantage of the Marketplace is that plans are organized into groups based on what they offer and their cost. The four groups are bronze, silver, gold, and platinum. They all must include services in the 10 essential health benefit categories, but some plans will offer additional benefits. Plans are allowed to require that you use their network of contracted doctors, hospitals, and health care providers, but they must also ensure that consumers have enough provider options.

Moving from bronze to platinum, the out-of-pocket costs get lower, while the premiums (often paid monthly) tend to get higher. Out-of-pocket costs are those you pay when you access medical care, such as co-pays made at the time of service, deductibles, and coinsurance—your share of the cost of service, calculated as a percentage.

Visit healthcare.gov to learn more about your state's Health Insurance Marketplace and how to apply for coverage.

The initial period to sign up for health insurance in the Marketplace begins Oct. 1, 2013, and ends March 31, 2014. You may switch plans for reasons including a change in family size, employment status, or state of residence.

Each plan offered in the Marketplace must provide a consistent, easy-to-understand description of the plan, called a "Summary of Benefits and Coverage." The summary includes examples of how much a person on each type of plan can expect to pay. The American Diabetes Association worked hard to make sure that one of the examples will be a person with diabetes. The example included is for someone with routine maintenance of type 2 diabetes and a well-controlled condition. To calculate the cost of diabetes care, insurance companies use the example of a person who gets regular checkups, tests blood glucose, and takes insulin glargine (Lantus), metformin, a blood pressure medication, and aspirin. Your costs are likely to differ from this example, but the estimates provided for each plan should give some idea of how generous one plan is compared with another.

Happy New Year

On Jan. 1, 2014, these provisions of the health care reform law will go into full effect:

  • Coverage through plans purchased through the Health Insurance Marketplace begins.
  • You can no longer be turned down or charged more by an insurer if you have a preexisting condition, such as diabetes.
  • Most health plans cannot set a dollar limit on what they spend on "essential health benefits" for your care during the year.
  • Advances of premium tax credits will be available, so people can use financial help right away to help pay for monthly premium costs.
  • The small business tax credit will increase, so more companies can afford to get coverage for their employees.
  • Access to Medicaid will expand in some states.

Special plans intended for younger, healthy people with low incomes will be included in every Marketplace. For example, "catastrophic" plans will be available in the Marketplace for people under the age of 30 who qualify because they can't afford a regular plan. These plans offer a low monthly premium and a high deductible. So in the event of a serious health issue, your costs for services could be high, though there are limits to the amount you might have to pay. Like other plans, the catastrophic plans also include visits to a primary care physician and preventive services.

What If I Don't Get Insurance?

People with diabetes have long recognized that in order to successfully manage this complicated disease, they need to have good health insurance. Starting in 2014, most people will be required to have some kind of health insurance policy. Otherwise, they'll have to pay a fee with their federal income tax return, starting in 2015 (the return covering the 2014 tax year). The amount of the fee will be calculated based on income or a flat dollar amount, depending on which is the larger penalty. The flat dollar amount fee for the 2014 tax year is $95; it is scheduled to increase in 2015 to $325 and in 2016 to $695. After that, increases will be based on changes in the cost of living. Some people won't need to pay the fee, such as members of federally recognized Native American tribes or people who do not purchase health insurance for religious reasons.

The Marketplace aims to bring health insurance within the reach of every American. For people with diabetes, who are all too familiar with the medical system, better plans and help when you need it most may mean better health.

See the American Diabetes Association's fact sheet on the Marketplaces and people with diabetes.

See the American Diabetes Association's fact sheet on health insurance protections for people with diabetes.



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