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Unraveling health insurance enrollment

Oct 12 2014

The Virginian-Pilot
By Elizabeth Simpson

Slick insurance packets in the mailbox and websites swimming with new numbers can mean only one thing:

It's open enrollment season for many people fortunate enough to have health insurance.

Whether through Medicare, the Affordable Care Act marketplace or companies sending employers their latest offerings, consumers soon will be floating in a sea of questions.

Go for a high premium with low deductibles and copays, or the reverse? What's different from last year's plan? Favorite doctors, hospitals and pharmacies still in your network? Is it worth it to pay a penalty and skip insurance all together?

The second year of the ACA marketplace should be less chaotic, but there are still plenty of new elements on the exchange to keep things hopping.

For instance, the open enrollment period, Nov. 15 through Feb. 15, is half as long as last year's.

Also, 2015 will be the first year people will be paying penalties for not having insurance in 2014. Those will be settled up at tax time, with fees of $95 per adult, plus $47.50 per child under 18 or 1 percent of income, whichever is greater. That penalty goes up over time, with year two bringing a fine of $325 per person or 2 percent of income, whichever is larger.

Some can receive an exemption from that penalty. That's important to know in Virginia because those who would have qualified for Medicaid had the commonwealth expanded will be exempt.

A revamped website - www.healthcare.gov - is being touted by the government as easier to use than last year's glitch-ridden version. It has a streamlined application process and a list of agencies closest to you, with counselors to help you navigate the system over the phone or in person.

In the world of company-sponsored insurance, expect more wellness initiatives, some offering electronic wristbands such as Fitbit to not only lure you into good health, but track how you're doing with exercise.

Another theme will be cost transparency and more tools to help you figure out the cost of care in a country that has seen a 47 percent increase in average deductibles since 2009. Optima Health, for instance, has launched a Web-based "treatment cost calculator" where you can key in 300 procedures, such as X-rays, lab work or sick visits, to find out how much it will cost and compare estimates for various health providers.

Insurance members also can find out how much they will pay according to their specific plan and how much of their deductibles have been spent down.

Also expect nudges to use more cost-appropriate services. Anthem Blue Cross and Blue Shield launched a Web-based doctor service - LiveHealth Online - this summer and is encouraging members to use it for mild illnesses to reduce the cost and inconvenience of an office visit.

Expect some cancellation notices, as companies come into compliance with ACA requirements - 2015 will be the first year businesses with more than 50 employees in Virginia will be penalized for not offering health insurance - and switching of insurance providers as companies look for the best deal.

As the system moves toward more comprehensive plans and prices that don't penalize by age and health, someone has to pay more, and that often is the young, healthy and high-income people. It also can mean shifting networks of care.

"There's a misconception that you have the right to access any doctor, any product, any time," said Doug Gray, executive director of the Virginia Association of Health Plans. "If everyone could do that, the cost of that would be immense. In an environment where we're trying to control costs, you have to have trade-offs."

A guide to the health insurance landscape

What is open enrollment?

It's the period when you sign up for next year's insurance plan and make changes if you think there's a better option. Medicare drug plans, Medicare Advantage plans and the ACA exchanges have open enrollment at the end of the year. Companies with insurance plans that run the calendar year do, too, but some companies offer open enrollment at other times of the year.

What if I miss it?

There are certain events that qualify you to sign up during a "special enrollment." That includes a marriage or divorce, having a baby or adopting a child, moving, losing health coverage because of a job change or loss, aging off a parent's insurance plan, insurance cancellation, and losing eligibility for Medicaid, the federal-state insurance for low-income and some disabled people.

For the ACA exchanges, that period lasts for 60 days after the event, which is typical of company-sponsored insurance.

Any exceptions to the rule?

You can apply at any time for Medicaid and FAMIS, the health insurance program in Virginia for uninsured children from birth through age 18. Visit www.medicaid.gov, and click on Virginia for information about those programs. You also can apply by filling out an ACA marketplace application on www.healthcare.gov.

If I'm already signed up for insurance, how do I find out about changes?

Your insurance company should send you a renewal notice, which outlines next year's plan and any changes. Check to see whether your preferred doctors, pharmacies and hospitals are still included.

Affordable Care Act marketplace

What if I signed up last year and don't want to make changes?

Those who signed up last year will be automatically renewed if they do nothing, but you should log on and update your income information and contact details.

Insurance counselors advise taking a close look at your plan because deductibles, copayments, provider networks and premiums might have changed, and it might not be as good a deal as another plan.

If your income or family size has changed, that also needs to be adjusted, especially if you receive a subsidy. A different income could change that, which means money could be taken out of your tax return, or the government could owe you money.

Counselors also advise changing mailing or email addresses to prevent problems with change notifications.

If I've never signed up on the ACA marketplace, how do I get started?

Your best bet is HealthCare.gov. That's where you can find information about plans available in your area, do comparison shopping, key in your personal information to see whether you qualify for a subsidy and enroll.

All of the information will be updated by Nov. 15, the first day you can enroll, but you can go on early to get a sense of how the website works.

Deepak Madala, project manager of Enroll Virginia, advises signing up for email alerts that will let you know when the information you need is available: www.healthcare.gov/subscribe.

How can I get help with all this?

A key feature on HealthCare.gov is the "Find local help" tab. Click on it to key in your city and get a list of agencies and counselors certified to help people navigate the system.

What if I don't have a computer?

The federal government has call centers that will help you start or finish applications, compare plans, enroll or ask a question. They're available 24 hours a day, seven days a week, but closed on Thanksgiving and Christmas.

Last year, these numbers got overloaded, so keep that in mind. The number is 1-800-318-2596, and The Text Telephone number for people who are speech- and hearing-impaired is 1-855-889-4325.

You also can call the number to find an agency close to home that can help.

Besides the federal website, is there another website to go to for help?

Enroll Virginia is a nonpartisan, community-based effort to educate Virginians about the ACA marketplace and Medicaid and provide free, unbiased help in enrolling: Call 1-888-392-5132, or go to www.enroll-virginia.com.

Medicare

Why is there an open enrollment period?

Since 2006, Medicare beneficiaries have been able to get prescription drug coverage offered by private plans, either through stand-alone prescription drug plans or Medicare Advantage plans, which include hospitalization and other health care treatment in a managed care setup.

How do I figure out which one is best for me?

Medicare.gov has a "Plan Finder" that allows you to key in the drugs you need, to find the various plans that are available and their cost.

Can I just stick with what I signed up for last year?

Some plans have been discontinued, which you should receive a letter about, so it's worth getting online to make sure yours is still available.

Brenita Linder, who supervises insurance counseling at the Senior Services of Southeastern Virginia, said there also might be plans that are less expensive, depending on your prescription drugs, so she encourages people to review their plans during open enrollment.

A Kaiser Family Foundation study found that 46 percent of people who switched their Medicare plans during open enrollment saved at least 5 percent the next year.

Can someone help me?

The federal toll-free number is 1-800-633-4227.

If you want to speak to a local Medicare counselor, you can call Senior Services of Southeastern Virginia at the following phone numbers:

Residents of Norfolk, Chesapeake, Virginia Beach and Portsmouth: 222-4512 or 461-9481. In Franklin, Smithfield, Suffolk, Isle of Wight or Southampton County: 449-8706.

Senior Services of Southeastern Virginia also will have Medicare presentation and enrollment workshops on Oct. 18 and Nov. 22, from 9 a.m. to noon, at 6350 N. Center Dr. in Norfolk.

To sign up or schedule an appointment, call 222-4512, or email blinder@ssseva.org.

What's new this year?

The so-called doughnut hole will continue to shrink. That's the gap where you have to pay the full cost of prescription drugs. In 2015, people will have to pay 45 percent for brand names and 65 percent for generics in the doughnut hole, a percentage that will continue to shrink until it reaches 25 percent in 2020.

There also will be fewer stand-alone drug plans this year.

Private company insurance

How will I know what my options are?

Your company will provide you a list.

What should I keep in mind?

If you have chronic health conditions, are a big user of health care or are planning an expensive elective procedure, look closely at the amount of cost-sharing, such as copayments, in your plan. It might be worth paying a higher premium for lower cost-sharing.

If you have specific doctors, hospitals, clinics or pharmacies you want to use, make sure your plan includes them.

Deductibles have been increasing across the board, so educate yourself on yours, and make sure you can afford it, or set up a health savings account to offset the expense.

What's new this year?

This will be the first year in Virginia when businesses with 50 or more full-time employees must provide coverage to workers or face fines. Some companies made changes last year, but expect a new group to come into compliance this year to avoid penalties of $2,000 per employee.

John DeGruttola, senior vice president at Optima Health, said that insurer has been working with companies to set up compliant plans, and some are using private exchanges. The insurance company launched Optima BusinessEDGE earlier this year, which is a self-funded plan for small businesses with 20 to 50 enrolled employees.

The Hampton Roads Chamber of Commerce has joined other chambers throughout Virginia to create Virginia Benefits Market, a private health insurance and benefits exchange. The private exchange allows employers to pick plan choices they can make available to their employees and provide an amount toward employee benefits. Employees then select their plans through an online platform.

The exchange, called the Virginia Benefits Alliance, will be managed by the Virginia Chamber of Commerce and ChamberSolutions, which is based in Norfolk.

Private exchanges are expected to grow in coming years, particularly among small and mid-sized companies, as the system moves away from traditional health care plans that tend to be more costly.

Elizabeth Simpson, 757-222-5003, elizabeth.simpson@pilotonline.com

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