Finding the right nongroup health insurance policy will be a bit of work for people who search the new state marketplaces due to open just two days from now.
The marketplaces are websites — Nebraska's and Iowa's can be found by going to HealthCare.gov — where people and small businesses can compare and buy health insurance. They also can find out whether they qualify for federal income tax credits to subsidize the cost of insurance. HealthCare.gov now includes a “quick check” on tax credit eligibility.
The government recently announced two delays: Small-business plans won't be available online until Nov. 15, and the marketplace won't be able to shift qualified applicants to the state's Medicaid system for about a month. Earlier, the Obama administration said the Spanish-language version of the website wouldn't be available for a few weeks.
No: If you have group insurance through your employer; if you have Medicare for people age 65 and older or for younger people who have disabilities; if you have Medicaid for low-income people; or if you have Tricare for military members.
Yes: If you are uninsured or if your employer directs you to the marketplace.
For more coverage: Omaha.com/obamacare
None of the delays so far are expected to prevent people from being covered by Jan. 1. People who buy insurance on the marketplace by Dec. 15 will have coverage starting Jan. 1, the deadline for individuals to be insured under the Affordable Care Act, also known as Obamacare. For those who buy insurance later, coverage begins about two weeks after purchase. Enrollment for 2014 ends March 31.
The World-Herald took a closer look at the various policies that will be available in Nebraska and found that shopping the marketplaces (previously called exchanges) to make comparisons among the policies offered can make a big difference in monthly premiums and other medical expenses starting next year.
Among notable variations:
» Premiums. A 27-year-old nonsmoker, for example, can pay $226.94 a month for one policy or $283.84 a month for a comparable policy from a different company. For a 57-year-old smoker, premiums for comparable policies range from $633.28 to $872.42 a month, a difference of $2,870 in a year.
» Benefits. Coventry's plan has a $3,750 annual deductible but a separate $1,000 annual prescription deductible that must be satisfied with some medications. One of its policies offers a $250 copay for physician maternity charges. “Coventry Compliments” offers discounts for health clubs, massage therapy, skin care, acupuncture, hearing aids and other services.
CoOportunity Health's comparable plan carries a $4,000 deductible and a $6,350 maximum but offers three free office visits and a $100 gift card for completing a health assessment. Blue Cross Blue Shield of Nebraska offers a $50 gift card that can be used on a company website in return for a health assessment, plus $250 worth of care for accidents.
With some policies, copayments for office visits and medicine count toward deductibles, but not with others.
» Providers. A midlevel plan offered by Blue Cross sets a $2,000 deductible and a $5,000 total annual spending limit if clients use medical care providers that agree to added discounts. Those who use doctors and hospitals that don't give the extra discounts will have a $4,000 deductible and $6,350 maximum. Blue Cross policies have higher benefits for “Tier I” than “Tier II” doctors and hospitals in Omaha. Check your doctor's tier to compare benefits. Not all doctors and hospitals are “in network” with all insurers.
The law bans excluding people with pre-existing medical conditions, setting caps on lifetime benefits or dropping people from coverage without evidence of fraud. Policies cover 10 “essential benefits,” although in some cases pediatric dental coverage can be skipped.
The policies can't require out-of-pocket spending of more than $6,350 for an individual or $12,700 for a family. The policies continue Obamacare's free preventive health care benefit, such as annual physicals and age-appropriate screenings.
Benefits are the same for people in the same age ranges and for both genders. But premiums are higher for smokers and older people and may vary by place of residence.
The lesson: Take care in choosing health plans once the marketplace opens up.
Other factors to keep in mind:
» Some policies provide first-dollar coverage, meaning that copayment benefits start immediately. If there is not first-dollar coverage, the policyholder covers costs until meeting the deductible before those benefits begin.
» Some plans are intended to be paired with health savings accounts (HSAs), in which pre-tax money is set aside in a bank, credit union or other financial institution and used to pay toward deductibles. Most such HSA plans have lower costs and lower benefits.
» The 10 essential benefits are outpatient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Federal authorities modified the rules to allow policies without pediatric dental coverage if there are other stand-alone dental insurance plans available on the same marketplace.
“Since we're a brand-new company and health insurance is really our core focus, not dental, that was really the deciding factor for us, not really a cost differential,” CoOportunity Vice President Dana McNeill said.
Blue Cross included pediatric dental coverage to make it more convenient for policyholders and to be sure all policies complied with the Affordable Care Act requirements, said Tom Gilsdorf, director of product development. Clients who need the coverage won't have to buy separate policies, he said. Pediatric dental coverage doesn't add much to monthly premiums because it is blended with all the other coverages in the plans.
» Most people are likely to buy bronze or silver plans, which are designed so that the insurance companies pay 60 percent of costs or 70 percent of costs, respectively. Gold plans will pay 80 percent and platinum plans 90 percent, and both have higher monthly premiums than silver. CoOportunity's gold plan has a $1,600 deductible, and its platinum plan — the only one offered on the Nebraska marketplace — has a $500 deductible. Monthly premiums for the platinum plan in Omaha range from $333 a month for a 27-year-old nonsmoker to $1,160.77 for a 57-year-old smoker.
» Besides income tax credits, lower-income people can qualify for a “cost-sharing reduction” plan, which reduces out-of-pocket spending for copayments, deductibles and coinsurance. The lower the income and larger the family size, the bigger the cost-sharing reduction. Incomes up to $28,725 for individuals and $58,875 for a family of four can qualify for a reduction. That's part of the law's goal of making health insurance affordable for every American who isn't covered by other plans.
» The marketplace also offers low-cost plans that cover only “catastrophic” medical expenses. People buying catastrophic policies will not qualify for tax credits to offset premiums.