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HEART Insight:
doi: 10.1097/01.HEARTI.0000443046.43627.f1
Features: Heart-to-Heart

Navigating the Insurance Sea

MacReady, Norra

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Abstract

What you need to know about the Affordable Care Act Marketplaces

It's had a turbulent beginning, but the Patient Protection and Affordable Care Act will provide a port in the storm for millions of people who were unable to afford health insurance before. Anyone with a history of cardiovascular disease or stroke has particular reason to cheer, because under the Act, insurers no longer can turn away people with pre-existing conditions, nor can they charge them higher premiums because of their medical condition.

However, people trying to find the best insurance plan may still encounter rocky waters. Here is some information on making the voyage as smooth as possible.

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BASIC FACTS

The cornerstone of the Act has been the establishment of Health Insurance Marketplaces, also called exchanges, which make it easier for people who buy their own private health insurance to shop for the plan that best meets their needs. To ensure a minimum level of quality and coverage, all of the plans must meet minimum standards and provide coverage for 10 categories of Essential Health Benefits: preventive screenings and services; outpatient care such as office visits, prescription drugs and laboratory tests; rehabilitative services such as speech and physical therapy; hospital care; emergency care; maternity care; mental health care and pediatric services.

Plans are grouped into four basic categories, based on the percentage of costs they cover. Bronze plans have the lowest premiums and cover, on average, 60 percent of costs, followed by Silver plans, which cover an average of 70 percent of costs. Gold plans, which cover 80 percent of costs and Platinum plans, which cover 90 percent of costs, also have the highest monthly premiums.

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To help make those premiums more affordable, tax credits called the Health Insurance Premium Tax Credits are available for households with an income from 100 percent to 400 percent of the federal poverty line, or $23,550 to $94,200 for a family of four. Eligibility for these tax credits is pegged to the cost of insurance as a percentage of household income, so a family of four with an income of 100 percent to 133 percent of the federal poverty line ($23,550 to $31,322) will receive tax credits if insurance costs exceed 2 percent of their income. For a family earning 350 percent to 400 percent of the federal poverty line ($82,425 to $94,200), the credits kick in when costs exceed 9.5 percent of annual income.

Most people who currently receive coverage through their employer will continue to do so under the law. People whose company plan's premium exceeds 9.8 percent of their family's income, or whose employer pays less than 60 percent of the premium, may also be eligible to shop in the Marketplace and to receive the health insurance premium tax credit.

As originally envisioned, under the Act each state would create its own Marketplace, where consumers could go to perform apples-to-apples comparisons of the different plans available in each of the price categories. However, as of this writing, only 14 states plus the District of Columbia have established their own Marketplaces. For people in the other 36 states, the federal government has a Marketplace that will allow them to find plans available in their state. “The most important thing to remember is that regardless of the state you live in, there will be a Marketplace for you, with plan options and premiums tailored for you in those states,” says Stephanie Mohl, the American Heart Association's senior government relations advisor.

The law also offers each state generous subsidies to encourage them to expand Medicaid eligibility to people whose income is below 133 percent of the federal poverty line. However, as of this writing, only 24 states are participating or leaning toward participating in the Medicaid expansion, and a few others (five) are considering alternate plans for expansion.

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QUALITY CONTROL

Quality of care is an important component of the Affordable Care Act. It encourages healthcare providers to provide care that meets or exceeds a certain standard. For example, hospitals will be penalized if a predefined percentage of their patients are readmitted for an avoidable reason within 30 days after discharge.

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Special considerations for people with heart conditions

People with medical conditions often develop close relationships with certain doctors or other practitioners. Each plan offered in the Marketplace provides a list of the doctors and hospitals participating in that plan, so potential enrollees can determine if they can continue seeing their favorite doctor, says health economist Robert D. Lieberthal, Ph.D., assistant professor at the Jefferson School of Population Health, Thomas Jefferson University, in Philadelphia. His research has shown that hospitals reporting the lowest mortality rates for conditions such as heart failure, heart attack and pneumonia were ones that treated the greatest number of patients with those conditions.

“When people look at plans on the exchanges, they should check to see if the plan includes providers that they're currently seeing, or if the providers that are included have been demonstrated to deliver the highest quality of care.” For example, “people who have had a heart attack or stroke might be interested in looking at the available data on outcomes in different hospitals that treat patients with those conditions, and whether those hospitals are included in any of the plans that they're shopping for on the exchange.”

“The best plan for someone with a cardiovascular condition is probably the best one they can afford, not necessarily the cheapest,” says Ferdinand. “If a patient has a history of stroke, heart failure or a heart attack, there's a good chance that they're on medications and may have another event, even if they're getting the best of care and are controlling their risk factors. If their finances can support getting a Gold or Platinum-level plan, that's what I would suggest, because the chances are great that that they are going to need those medications for a lifetime, and the chances are also good that they are probably going to need more medical care and possibly hospitalization.” Some Bronze-level plans may have co-pays and deductibles amounting to 40 percent of certain types of care, which can add up very quickly, he warns. “That being said, if someone can't afford a Gold or Platinum plan, where the medical costs and deductibles are going to be much less than with a Bronze or Silver-level plan, Silver would be best.”

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CHOOSING A PLAN

After they meet the basic requirements, insurance plans in a given category can differ in the cost-sharing they require, so it's important to take the time to determine if a plan really is right for you. For example, a 45-year-old single person living in Southern California and earning $22,000 per year might find three plans at the Silver level, with monthly premiums ranging from $88 to $108 (after a tax credit of $188). A quick glance suggests that all of the plans require a $50 deductible for brand name drugs, a $20 copay for a specialist visit and a $15 copay for visits to other practitioners.

However, when it comes to imaging studies such as computed tomography or positron emission tomography (CT or PET scans), the copay for two of the plans is $100, while for the third you are responsible for 15 percent of the total bill after the deductible has been met.

This may seem daunting, but don't despair. The best place to start is at the Marketplace website maintained by the federal government, www.healthcare.gov. Although the website has experienced well-publicized problems in its first month, as of this writing, its operation has improved and will continue to improve over time. At the website, you will find a series of questions that will allow the site to guide you to the appropriate place, whether you live in a state that has its own Marketplace or if you're shopping on the federal exchange. Filling out a single three-page application on the site will allow individuals to find out if they qualify for tax credits or for free or low-cost coverage through Medicaid or the Children's Health Insurance Program. The website and application are available in both English and Spanish.

In addition to the website, every state will have assisters, or navigators, who have been specially trained and certified to help you through the process, says Cheryl Fish-Parcham, deputy director of health policy for Families USA. In addition, “there are call centers in both the state and federal exchanges that can help,” she says, “and paper applications are also available, so the website should not hinder someone from being able to apply.”

For someone with no Internet access or who needs assistance in a language other than English or Spanish, Fish-Parcham suggests calling the federal call center at 1-800-318-2596 to get started. There, you can get help in up to 150 additional languages. “They can direct you to a state call center,” she says, “if you're in a state that's running an exchange.” From there, you can connect with a navigator or other qualified person who can help you make an informed decision.

Your local public library is also an excellent resource, says Keith Ferdinand, M.D., a cardiologist and professor of clinical medicine at the Tulane University Heart and Vascular Institute in New Orleans. Libraries have free internet access, and librarians can help with Internet navigation.

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BETWEEN THE CRACKS

Options are even available to people who earn from 100 percent to 133 percent of the federal poverty line and live in a state that is not participating in the Medicaid expansion. First, they may qualify for tax credits toward premiums for plans sold in the Marketplace, which may soften the blow somewhat. Also, says Mohl, “There is a great network of community health centers across the country that provide free or low-cost care to people regardless of their insurance status. The Affordable Care Act greatly increased our country's investment in those centers, so those people are not entirely without options. Those centers mostly provide primary care, but they may be able to arrange for someone to see a specialist for free or a reduced fee.”

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ACT NOW

The open enrollment period to sign up for insurance through the Patient Protection and Affordable Care Act ends on March 31, 2014, so you still have time. Once the initial enrollment period ends, however, people without insurance will have to wait until the next open enrollment period to sign up for coverage and may have to pay a fine when they complete their income tax returns in 2015. There are special circumstances, such as if you lose your health insurance, get married or move, that will allow you to enroll even once the open enrollment period ends. Those who qualify for Medicaid can sign up at any time.

To find out more about the plans offered and how to sign up, visit heart.org/healthinsurance and heartsforhealthcare.org.

© 2014 by the American Heart Association

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