loading.gif

Getting Covered

This is your guide for understanding year 2 of Pennsylvania's new healthcare system, how to access health insurance, and how to make the most of your plan to ensure positive health outcomes for you and your family.

Tailor this guide to your specific needs by choosing a category at the top that describes you.  

Then, explore the chapters of the guide for resources, tools, personal stories, and expert advice from health professionals across Central PA.

We'll help you learn how to secure the health insurance plan which best meets your needs as well as meets the requirements set out in the Affordable Care Act.


Getting Covered is a special interactive feature produced by witf's Transforming Health initiative.

See the continuing coverage on Transforming HealthTransforming Health's Facebook Page

Getting Covered: I'm a senior

If you're a senior, this is your guide for understanding the changes that are taking place in Pennsylvania's healthcare system, how to access health insurance, and how to make the most of your plan to ensure positive health outcomes for you and your family.

Explore the chapters of the guide for resources, tools, personal stories, and expert advice from health professionals across Central PA.

We'll help you learn how to secure the health insurance plan which best meets your needs as well as meets the requirements set out in the Affordable Care Act.


Getting Covered is a special interactive feature produced by witf's Transforming Health initiative.

See the continuing coverage on Transforming HealthTransforming Health's Facebook Page

Getting Covered: I'm a small business owner

If you're a small business owner, this is your guide for understanding the changes that are taking place in Pennsylvania's healthcare system, how to access health insurance for your employees, and how to choose the right coverage.

Explore the chapters of the guide for resources, tools, personal stories from business owners, and expert advice from health professionals across Central PA.

We'll help you learn how to secure the health insurance plan which best meets your needs as well as meets the requirements set out in the Affordable Care Act.


Getting Covered is a special interactive feature produced by witf's Transforming Health initiative.

See the continuing coverage on Transforming HealthTransforming Health's Facebook Page

Getting Covered: I'm a young adult

If you're a young adult, this is your guide for understanding the changes that are taking place in Pennsylvania's healthcare system, how to access health insurance, and how to make the most of your plan to ensure positive health outcomes.

Explore the chapters of the guide for resources, tools, personal stories, and expert advice from health professionals across Central PA.

We'll help you learn how to secure the health insurance plan which best meets your needs as well as meets the requirements set out in the Affordable Care Act.


Getting Covered is a special interactive feature produced by witf's Transforming Health initiative.

See the continuing coverage on Transforming HealthTransforming Health's Facebook Page

The Affordable Care Act & seniors

senior-tennis.jpg

For those who are 65 or older, The Affordable Care Act strengthens Medicare, offers eligible seniors a range of preventive services with no cost-sharing, and provides discounts on drugs when in the coverage gap known as the “donut hole.”  source: HHS.gov

The Affordable Care Act & young adults

ACA-changes-young-adult.jpg

Under The Affordable Care Act, young adults can now stay on their parents’ insurance plan up until 26 years of age. This is valuable not only because of the current state of our economy where it may be hard to find a job right after college, but many are going to advanced schooling, and are not earning an income. They would have to go out and purchase insurance on the open market, which could be a challenge.


Many young adults will qualify for lower costs at the Health Insurance Marketplace through government subsidies.

Read more

The Affordable Care Act & employers

sm-bus-aca.jpg

The Affordable Care Act includes key provisions specifically for small businesses that help to decrease premium cost growth and increase access to quality, affordable health insurance.


According to the U.S. Small Business Administration, depending on whether you are self-employed, an employer with fewer than 25 employees, an employer with fewer than 50 employees, or an employer with 50 or more employees, different provisions of the Affordable Care Act may apply to you.  Take a look:

Read more

Getting Covered: Family

If you're looking for coverage for your family, this is your guide for understanding the changes that are taking place in Pennsylvania's healthcare system, how to access health insurance, and how to make the most of your plan to ensure positive health outcomes for you and your family.

Explore the chapters of the guide for resources, tools, personal stories, and expert advice from health professionals across Central PA.

We'll help you learn how to secure the health insurance plan which best meets your needs as well as meets the requirements set out in the Affordable Care Act.


Getting Covered is a special interactive feature produced by witf's Transforming Health initiative.

See the continuing coverage on Transforming HealthTransforming Health's Facebook Page

Key messages in Getting Covered

  • You need health coverage in 2015 or you'll likely face a penalty
  • PA's Health Insurance Marketplace is HealthCare.gov
  • You might qualify for lower costs on insurance at the Marketplace
  • There's local help for enrollment

Affordable Care Act: What is it?

loading...

C. Richard Schott, MD, President of the Pennsylvania Medical Society, explains that the ACA is a mandate that requires individuals to purchase health insurance or they must pay a penalty to opt out.

“The Affordable Care Act addresses access for some potentially 30 million people that otherwise would be without health insurance.” 

So, what are some key features of the law and how will this impact people?

Read more

Confusion, frustration

confused-computer.jpg

Many Pennsylvanians are worried about not being able to successfully enroll in plans at HealthCare.gov by the deadline due to the rocky rollout of the Marketplace website. Many remain confused about the impact of the massive law itself.


And, 250,000-plus Pennsylvanians have received cancelled insurance policy notifications and don’t know how to proceed- Like David in Central PA:

“This whole issue is stressful enough as it is, but having the system working against us as it is only compounds the problem. I just don't think that this system was ready to be rolled out on October 1st, and now a lot of people are being burdened by it.” 

If you’re uninsured and confused- Don't worry. You’re not alone.  Read on to get help.

The goal of the Affordable Care Act is to implement a set of comprehensive health reforms aimed at driving down the number of Americans without health insurance, improving health outcomes, and cutting healthcare costs.

The Affordable Care Act, Obamacare, health reform

obama-sign-act.jpg

It is important to understand that many different names have been applied to the The Patient Protection and Affordable Care Act, but they are all referring to the same legislation that President Obama signed into law on March 23rd, 2010.  The law will be implemented over the next several years.


Learn more about the law in this summary of the Affordable Care Act from the Kaiser Family Foundation.

approved-obama-signature.jpg

"Today, after almost a century of trying; today, after over a year of debate; today, after all the votes have been tallied –- health insurance reform becomes law in the United States of America."

-President Barack Obama; The White House, March 23, 2010

HealthCare.gov

healthcaregov-screen.jpg

It's year two for the site, which gives Pennsylvanians who are uninsured, underinsured, or who have been denied insurance in the past due to pre-existing conditions, the opportunity to comparison-shop for affordable health insurance plans at the federally-run Health Insurance Marketplace.  

Pennsylvania's marketplace is HealthCare.gov

Small Business Health Options Program

welcome-to-SHOP.jpg

The Small Business Health Options Program site (SHOP) is an online marketplace for small businesses employers to shop for health insurance plans for their employees.  But, the focus on improving HealthCare.gov for individual consumers has led to a 1-year postponement of this business exchange. 


Employers will have to buy health plans through insurance agents and brokers offline until the site is ready in November of 2014.


But, tax credits to help lower costs are still available for small businesses that enroll employees in health plans that meet new standards of the Affordable Care Act.  Read more.

The ACA & employer responsibility

male-employer.jpg

The law places new responsibilities on employers — those with under 50 employees, and those with over 50 employees. Over time, these just may change the face of employer-provided health care coverage. There may be tax implications or penalties for large and small employers alike. You need to know just how they are tied to that number of 50 employees.


At this time, the health care law itself will continue to unwind through 2018. That means ongoing change these next few years.

Download and print this free booklet on how the Affordable Care Act affects employers. (Capital BlueCross)

ACA timeline

timeline.jpg

Some of the changes dictated in the Patient Protection and Affordable Care Act have already been implemented, and other key milestones for the law are coming into focus.  

Interactive timeline: Key features of the Affordable Care Act


The ACA has already has brought significant changes to the American health care system and caused some companies to trim their benefits.

The law of the land

The new laws governing health insurance are not hypothetical- these are the rules that we are now living by.  

So, now’s the time to empower yourself with information about your options so that you can avoid facing a penalty for not having insurance, choose the right plan for you, and most-importantly, make the most out of the new health landscape.    

No insurance? Pay a penalty

washington-dollar-bill.jpg

Under the ACA, anyone who does not have a health insurance plan that meets the requirements of minimum essential coverage, and is not given an exemption, will be assessed a fee as part of their federal income tax.

This fee will be $325 or 2% of annual income- whichever is higher.

Read more

Exemptions from paying the penalty

If you can afford health insurance but choose not to buy it, you must pay a fee known as the individual shared responsibility payment.

Under certain circumstances, you won’t have to make the individual responsibility payment. This is called an “exemption.”

You may qualify for an exemption if:

Read more

Key dates for enrollment

loading...

Familiarize yourself with these dates to make sure you are not penalized for not meeting the requirements of the law:

December 15, 2014: You had to enroll by this date if you wanted your coverage to start on Jan. 1, 2015.


Feb. 15, 2015: Open enrollment ends. You won’t be able to get coverage until the next open enrollment period starting in November 2015.

Generally the only way you can buy a health insurance plan outside of open enrollment is if you have a qualifying life event, like job loss, marriage or new baby.

By the Numbers

young-women-friends.jpg

Uninsured Pennsylvanians who are eligible for coverage through the Marketplace: (hhs.gov)  

  • 1,242,350 (12%) are uninsured and eligible
  • 928,243 (75%) have a full-time worker in the family
  • 491,258 (40%) are 19-34 years old 
  • 864,180 (70%) are White 
  • 201,028 (16%) are African American 
Read more

CHIP in Pennsylvania

CHIP-mom.jpg

About 30,000 Pennsylvania families will have the option of keeping their kids enrolled in the state's Children's Health Insurance Program (CHIP) through the end of the year.

Read more

The ACA: Where we stand

loading...

Thomas Wright, the Executive Director of PinnacleHealth Medical Group, has become very familiar with the law, but admits it is a very large piece of legislation to digest. He explains some of the reasons why in this video.

Read more

Obamacare: It's political

"In the three years since President Obama signed the Affordable Care Act into law, it has survived more than 50 votes in Congress to defund or repeal it, a Supreme Court challenge, a presidential election and, a government shutdown. Much of the spending for the law is mandatory and won't be cut off.  But now, it must survive its own implementation." 

After Years Of Political Talk, The Obamacare Fight Gets Real (NPR)

"Today, we are spending over $2 trillion a year on health care -- almost 50 percent more per person than the next most costly nation. And yet, as I think many of you are aware, for all of this spending, more of our citizens are uninsured, the quality of our care is often lower, and we aren't any healthier."  

President Barack Obama; The White House, June 15, 2009

Read more

Will American healthcare compete with the world after Obamacare?

tr-reid-booth.jpg

In this episode of witf's Smart Talk, New York Times best-selling author, T. R. Reid discusses Obamacare: what it has or could accomplish, if it goes far enough, and will it work to control costs and improve quality.

What you need to know before you start shopping

Before shopping for health insurance plan, look at your health needs and familiarize yourself with how insurance works.


You’ll also need key pieces of personal information before you begin to create your account on the Marketplace and shop for insurance that’s right for you. With these tools, you can hopefully streamline the process a little bit for yourself.

See the continuing coverage on Transforming HealthTransforming Health's Facebook Page

A note to seniors on Medicare

loading...

The Marketplace will not affect your Medicare choices and your benefits will not change. No matter how you get Medicare, whether through original Medicare or Medicare advantage, you’ll still have the same security you have now.

If you have Medicare, you’re considered covered.

Why is health insurance for children and teens important?

girl-eyes.jpg

Children who have health insurance generally have better health throughout their childhood and into their teens. They are more likely to:

  • Receive needed shots that prevent disease
  • Get treatment for recurring illnesses such as ear infections and asthma
Read more

Free Medicare counseling in PA

loading...

If you are a senior who needs to enroll in Medicare: The open enrollment period is October 15- December 7 each year.  


Brian Duke, Secretary of the PA Department of Aging, highlights the benefits of Pennsylvania's free counseling program called APPRISE, that can help you enroll in Medicare.

Read more

Insurance & the ACA

loading...

The defining part of the Affordable Care Act is that everyone is required to have health insurance. Eric Beittel, President of the Central Pennsylvania Health Underwriters Association, explains the changes and how individuals and employers can get insurance through an exchange.  

“The idea of an exchange is to make one central place where you can get information on healthcare coverage.” 

Read more

Young adults & access to insurance

young-woman-smile.jpg

Some of the people who may gain coverage under the ACA are young adults.  Young adults can now stay on their parents’ insurance plan up until 26 years of age.  

In Pennsylvania, 91,000 young adults are eligible to remain on their parents’ coverage. 

This is valuable not only because of the current state of our economy where it may be hard to find a job right after college, and many are going to advanced schooling, and are not earning an income. They would have to go out and purchase insurance on the open market, which could be a challenge.

(source: PA Health Access Network

What if I'm already insured?

already-insured.jpg

For those Americans who already have health insurance, the answer's simple: not much will change. Some changes you will see under the law are new benefits, better protections from insurance company abuses, and more value for every dollar you spend on health care. 

Grandfathered Plans: The Affordable Care Act exempts most plans that existed on March 23, 2010 — the day the law was enacted — from some of the law’s consumer protections. This preserves consumers’ rights to keep the coverage they already had before health reform. 

Am I covered?

The answer is YES if you have:
Medicare, Medicaid, CHIP, any job-based plan, any plan you bought yourself, COBRA, retiree coverage, TRICARE, VA health coverage, Peace Corps Volunteer plans, or some other kinds of health coverage.

Common ways that people obtain health insurance

yellow-insurance-folder.jpg
  • Through an employer
  • Through groups associated with employment like trade unions 
  • Through established membership associations: If you are a member of a chamber of commerce, trade association or similar organization, you may be able to obtain coverage through an association- sponsored plan. This could be a good option if you are self-employed or a small business owner. 

Read more

What if my policy was cancelled?

cancelled.jpg

In the midst of last year's enrollment period, Governor Corbett said more than 250,000 Pennsylvanians had their insurance policies cancelled, due to the Affordable Care Act.

In some cases, the insurance plans didn't include the benefits that are required by the ACA. The situation should be more stable this year, but in the event your policy is cancelled, here's some help.

Tip sheet: What to do if your plan has been cancelled (PA Health Options) 


Some PA insurance companies have extended their cancelled low-cost plans.  

Benefits of having health insurance

emergency-doc-run.jpg

Beyond the costs you will experience without health insurance, there are many ways in which having health insurance will save you money in the long term. With insurance, care will be more accessible and more affordable.

  • Peace of Mind -in case of an unforeseen medical emergency 
  • Financial Security -when you’re faced with expensive medical costs  
  • Wellness -All plans must include preventive benefits to keep you healthy 
  • It’s the law- All Americans must have insurance in 2014 under the ACA

What insurance means to me

"Insurance is the key to life as I become older and the population ages. I think it’s important for all Americans to have access to affordable and reliable health insurance regardless of income status."

-Mel; Sales Representative from Upper Darby, PA  Via The Public Insight Network

sick-hands.jpg

"The biggest change we can make isn’t how we provide health care—it’s when. Right now, we have a 'sick care' system, and we need to invest in a 'health care' system." —HHS Secretary Kathleen Sebelius

When does my insurance start?

insurance-start.jpg
  • If you enroll by December 15, 2014, your coverage was effective on or before January 1, 2015.
  • If you enroll between the 1st and 15th day of January, it's expected insurance will being on the first day of the following month.
  • If you enroll between the 16th and the last day of December - March, your plan is expected to be effective the first day of the second month.
Remember: Once a year, there will be an open enrollment period in which you can review your current coverage and change plans if needed.

Insurance Glossary

health-dictionary.jpg

Familiarizing yourself with these insurance terms before shopping will empower you to know what your options are and will help you make the right choice for your budget, and your health.  

Premium

The amount that you’ll pay for health insurance, usually on a monthly basis. You’ll pay this even if you didn’t have any medical expenses that month.  Usually, you pay a lower monthly premium if you have a higher deductible.

Out-of-pocket costs

These are your expenses for medical care that are not covered by insurance. These include deductibles, co-insurance, and co-payments for covered services plus any medical care that isn't covered by your plan.

Deductible

This is the amount that you are responsible for paying when you receive medical services before your health insurance plan kicks in to help pay. So, if your deductible is $1,000, for example, that means that your plan will begin covering medical costs only after you've reached that initial $1,000 in expenses. For each doctor visit or drug that is prescribed, you may have a copayment or co-insurance.

Co-payment (co-pay)

This is a fixed amount that you'll pay for a covered health care service, and it's usually paid at the time of that service. Usually, copays don't count towards your deductible. Co-pays vary by type of service. For example, a co-pay for a doctor visit might be $25, and $150 for an ER visit

Co-insurance

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan's allowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Formulary

This is a list of drugs that are covered by your insurance plan.

In-network and out-of-network

Health insurance plans contract with networks of hospitals, doctors, pharmacies, and health care providers to take care of people in the plan and offer less expensive rates for services. If will cost you more to get care that's out-of-network.

Learn more at HealthCare.gov's Glossary of terms 

How you and your insurer share costs

insurance-costs-graphic.jpg

Source: healthcare.gov

Checklist for Marketplace

checklist-marketplace.jpg

In order to optimize your experience shopping on the Health Insurance Marketplace, there are some key pieces of information that you will need to have close at hand. 

  1. Social Security Numbers (or document numbers for legal immigrants) for each member of the family
  2. Employer and income information for every member of your household who needs coverage (for example, from pay stubs or W-2 forms—Wage and Tax Statements)
  3. Policy numbers for any current health insurance plans covering members of your household
  4. A completed Employer Coverage Tool for every job-based plan you or someone in your household is eligible for. (You’ll need to fill out this form even for coverage you’re eligible for but don’t enroll in.) 


Get personalized content, a checklist, and next steps.

Estimate your household income

money-calculator.jpg

If you want to see if you're eligible for cost-saving subsidies to help cover Marketplace coverage, you’ll need to estimate your income for 2015.


Start by adding up the following items for:

You and your spouse, if you are married and will file a joint tax return
Any dependents who make enough money to be required to file a tax return

Read more

Assessing your options

This step in the process requires you to think about what your health care needs are and compare that answer to the provisions of each insurance plan. It is very important that you end up with the health care insurance that you will get the most out of. In order to do this, it is important that you know how much coverage you will need.


If you do not plan on going to the doctor often than it would be impractical and expensive to pay for the gold level plan. And if you, knowing your own health status, anticipate using services provided by your insurance fairly regularly, than it would make very little sense for you to purchase a plan that does not accommodate your needs.

See the continuing coverage on Transforming HealthTransforming Health's Facebook Page

Is my child eligible for CHIP?

boy-doctor-checkup.jpg

The Children’s Health Insurance Program (CHIP) provides coverage for children of some families in Pennsylvania who have a low income but are not eligible for Medicaid.

There are 2 ways to see if your children qualify:

  • Visit www.insurekidsnow.gov, or call 1-877-543-7669.
  • Fill out the Marketplace application at HealthCare.gov. When you finish this application, you'll be notified about programs that you and your family qualify for. If it looks like anyone is eligible for CHIP, the CHIP agency will be notified so that your coverage can start right away.

CHIP update in Pennsylvania:

Read more

Assessing options for your business

The Obama administration announced recently that it is delaying the launch of an online health insurance marketplace for small businesses, known as the Small Business Health Options Program (or SHOP) exchange.


But employers can still choose to buy the coverage offline, and they're still paying close attention to other provisions in the Affordable Care Act.

See the continuing coverage on Transforming HealthTransforming Health's Facebook Page

How do I choose coverage that's right for my business?

business-owner-options.jpg

As with all health plans, you and your employees have to pay a monthly premium. You can decide up front exactly how much you can afford to contribute towards your employees’ premium costs, so you have more control over your company's health coverage spending.

When comparing plans, just as important as the premium cost is how much your employees have to pay out-of-pocket for covered services. The plan with the lowest premium may not provide you or your employees with the best overall value.

Read more

Coverage tips for seniors

senior-man-face.jpg

Obamacare was primarily directed at young populations. Still, there are some changes for Medicare and new options for some retirees. 


Next Avenue shares tips to help Boomers make the best coverage decisions in the health insurance marketplace. 

"Not only will insurance become more accessible, it will also be cheaper than comparable coverage today for those who qualify for government subsidies. That’s a combination of benefits that some experts have called a 'game-changer' for early retirees and self-employed boomers."  

Read more

What's covered?

new-mom-benefits.jpg

The new ACA guidelines for health insurance stipulate that every individual (with the exception of those who have qualified for an exemption) must have a health plan that meets the qualifications for minimum essential coverage.  All plans offered in the Marketplace must include coverage for 10 Essential Benefits. 

Read more

Expert tip: Choosing a plan

“The big thing I think that people need to really focus on is the network. ‘What networks are out there?’ If you have a specific doctor that you use and you really like and you want to continue to use, make sure that doctor is in your plan.” 

-PinnacleHealth’s legal services director, John DeLorenzo

How to get coverage for adult children

adult-child-man.jpg

Your adult child (under the age of 26) may be enrolled directly in new Marketplace plans during the open enrollment period or during other special enrollment opportunities.  Be sure to include him or her on the list of people to be covered.

Open enrollment closes on March 31st, 2014.

Ask yourself:

medication-bottles.jpg
  • Are my current medications covered in my plan?
  • Is my child’s pediatrician in the network?
  • Is it easy to add a spouse to my insurance plan? 
  • Do I plan on getting pregnant?
  • Does the plan cover me while I am away traveling?
  • Does this fit my budget? (Learn how to budget for health insurance in the next chapter)

The plan that works for your family

marketplace-pediatrician.jpg

In this fact sheet on the Affordable Care Act, The American Academy of Pediatrics recommends that families, especially those who have children with special health care needs, can make sure the plan they purchase includes:

  • Access to pediatric specialists and pediatric surgical specialists 
  • Preventive care, such as well-child check-ups and immunizations 
  • Habilitative services to help a child keep, learn, or improve functioning 
  • Rehabilitative services such as physical or speech therapy 
  • Vision and dental care (dental plans may be sold separately)

Where to get insurance

insurance-cart.jpg

There are four ways that Pennsylvanians can buy health insurance: 

Insurance company

You can contact any health insurance company and see plans available in your area. Many have websites that let you compare all plans available from that company.

Insurance agent or broker

Agents generally work for a single health insurance company. Brokers generally sell plans from a number of companies. They can help you compare plans based on features and price and complete your enrollment. You don’t pay more by using an agent or broker. They’re generally paid by the insurance company whose plans they sell.

Online health insurance seller

These online services offer health plans from a number of insurance companies. They let you compare prices and features and then enroll with the insurance company.

The Health Insurance Marketplace

It’s the second year of the federal Marketplace, a way to explore quality health coverage options, whether you don’t currently have coverage or if you are covered but want to look at other options. With one Marketplace application, you can compare your health insurance options side-by-side, see if you qualify for lower costs based on your income, and enroll in a plan. www.healthcare.gov

Source: healthcare.gov

Business size

business-size.jpg

The line of demarcation with the ACA is 50 employees. Companies with 50 or more full-time equivalent employees will have to play by one set of rules. Businesses with fewer than 50 workers will play by another.


Rob Glus, a consulting actuary at Conrad Siegel, says new restrictions are being placed on small group health insurance ratings. No longer can insurance companies vary rates based on health status, health experience or gender.  He says:

“Having those limited variables now really changes the dynamic.  Depending on where you fall in that category, if you're a predominantly very young, very healthy group, you may see your costs go up a little bit. If you're a predominantly older, sicker, less healthy group, you may see your costs go down a little bit because there's no more medical underwriting for those groups anymore.”

Read more
The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

What if even the Bronze plan is too expensive for me?

young-woman-search-insurance.jpg

People under the age of 30 have the option of purchasing a catastrophic plan.  This "bare bones" plan covers only minimal services until they meet a deductible of roughly $6,400. The premium is usually much lower than the other plans.


After the deductible is reached, the plan will cover 10 Essential Medical Benefits, in case of a medical emergency or illness.  This plan doesn't typically cover prescriptions.  

Read more

Save money

piggy-bank.jpg

There’s one very important difference between plans sold inside and outside the Marketplace:
the only way to get lower costs on your monthly premiums based on your income is through the Marketplace.

We’ll help you find out if you qualify for lower costs on your insurance in the next section: Costs→

medical-purple.jpg

Under the Affordable Care Act, all health insurance plans will offer the same set of essential health benefits, free preventive services, and coverage of pre-existing conditions.

Metal levels

metal-plans-placeholder.jpg

"Metal levels" in the Marketplace represent different levels of coverage. These categories do not reflect the quality or amount of care a plan provides, but are designed to help consumers easily compare plans when shopping. They also are designed to help promote competition on premiums.


Consider your health status and finances as you compare plans in the Marketplace:

  • If you anticipate lots of doctor visits, treatments, and regular prescriptions each year, you might benefit from enrolling in a Gold or Platinum plan that pays a higher percentage of the costs.
  • Consider a Silver or Bronze plan if you’re healthy and do not think you will use a lot of health services like doctor visits, tests, and prescriptions each year.

Read more

Types of plans

healthinsurance-plan-types.jpg

You’ll want to familiarize yourself with the different types of plans so that you can choose the best plan for your budget and your health needs. 

When you compare options, it's important to understand how they are structured.  HealthCare.gov provides the following descriptions of plans:

Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs)

HMOs and EPOs may limit coverage to providers inside their networks. A network is a list of doctors, hospitals, and other health care providers that provide medical care to members of a specific health plan. If you use a doctor or facility that isn't in the HMO’s network, you may have to pay the full cost of the services provided. HMO members usually have a primary care doctor and must get referrals to see specialists. This is generally not true for EPOs.

Preferred Provider Organizations (PPOs) and Point-of-Service plans (POS)

These insurance plans give you a choice of getting care within or outside of a provider network. With PPO or POS plans, you may use out-of-network providers and facilities, but you'll have to pay more than if you use in-network ones. If you have a PPO plan, you can visit any doctor without a referral. If you have a POS plan, you can visit any in-network provider without a referral, but you'll need one to visit a provider out-of-network.

High Deductible Health Plan (HDHP)

High Deductible Health Plans typically feature lower premiums and higher deductibles than traditional insurance plans. As of 2013, HDHPs are plans with a minimum deductible of $1250 per year for individual coverage and $2500 for family coverage. If you have an HDHP, you can use a health savings account or a health reimbursement arrangement to pay for qualified out-of-pocket medical costs. This can lower the amount of federal tax you owe.

Catastrophic Health Insurance Plan

A catastrophic health insurance plan covers essential health benefits but has a very high deductible. This means it provides a kind of "safety net" coverage in case you have an accident or serious illness. Catastrophic plans usually do not provide coverage for services like prescription drugs or shots. Premiums for catastrophic plans may be lower than traditional health insurance plans, but deductibles are usually much higher. This means you must pay thousands of dollars out-of-pocket before full coverage kicks in. In the Marketplace, catastrophic plans are available only to people under 30 and to some low-income people who are exempt from paying the fee because other insurance is considered unaffordable or because they have received "hardship exemptions". Marketplace catastrophic plans cover 3 annual primary care visits and preventive services at no cost. After the deductible is met, they cover the same set of essential health benefits that other Marketplace plans offer. People with catastrophic plans are not eligible for lower costs on their monthly premiums or out-of-pocket costs.

Expert Q & A: Catastrophic plans

pink-q-a.jpg

Q:  Email from Mark:

"Since the exchange does not include "catastrophic" plans like the one I currently can afford, what options do I have for comparison shopping for this level of insurance? 
Read more

Summary of benefits

summary-benefits-sample.jpg

Each plan is required to give a short summary of the coverage it will provide—take the time to go over these carefully and put it in the context of your own life. (high resolution .pdf)

Explore plans in your area

watercolor-map.jpg

By answering a few simple questions, you can "window shop" for the plans and prices that are available in your area before completing a Marketplace application.  

Explore health plans and prices in your area  


This tool allows you to compare plans, understand the benefits that are covered, review physician and hospital networks, as well as discounts on premiums and other costs that might be available to you.  Log on to HealthCare.gov and click “See Plans.”  

*Important note: To find out the actual costs for your personal situation, you need to apply.

Government programs

loading...

Consumers who seek health insurance through the new marketplace may qualify for: Free or low-cost coverage through public coverage programs like Medicaid and CHIP.

Find Insurance Options: See which public, private and community programs meet your needs 

Here's an update on Medicaid in PA:

Read more

Expert Q & A: Medicaid gap

pam-parson.jpg

Q: Pamela Parson asks: 

"There are some people who will not be covered because Governor Corbett has chosen NOT to expand Medicaid. I am one of those people.  So what do I do now?

Read more

The "coverage gap" in Pennsylvania

medicaidpa-map-kff.jpg

The Affordable Care Act (ACA) provides coverage options for people at various income levels.  But, there's big difference in eligibility for coverage depending on whether a state expands Medicaid or not.

In states that do not expand, like Pennsylvania, many adults below poverty will fall into a “coverage gap” with no assistance.

Take a look at this interactive illustration of the coverage gap in states not expanding Medicaid. 


According to the Kaiser Family Foundation:

281,000 Pennsylvanians could be stuck in the Medicaid gap until at least 2015. 

Expert Q & A: PA Fair Care

Q: Gale V. asks: 

I am currently unemployed and was able to purchase Pa Fair Care after six months of unemployment with pre-existing conditions. How will this policy be affected in 2014 when the ACA goes into effect?

Read more

Can I get dental coverage in the Marketplace?

dental-care.jpg

Starting in 2014, you must have health coverage or pay a fee.  But, you do not need to have dental coverage to avoid the penalty.

Health insurance plans often do not include vision and dental insurance, but separate plans are available to help cover those costs. In the Health Insurance Marketplace, you generally can get dental coverage as part of a health plan or by itself through a separate, stand-alone dental plan.

Preview Marketplace dental plans and prices.


According to HealthCare.gov, dental coverage for children is an essential health benefit- This means it must be available to you as part of a health plan or as a free-standing plan. Insurers don’t have to offer adult dental coverage.

Read more

Dental coverage

child-dental.jpg

Adults: Starting in 2014, you must have health coverage or pay a fee.  But, you do not need to have dental coverage to avoid the penalty.

Health insurance plans often do not include vision and dental insurance, but separate plans are available to help cover those costs. In the Health Insurance Marketplace, you generally can get dental coverage as part of a health plan or by itself through a separate, stand-alone dental plan.

Preview Marketplace dental plans and prices.


Children: According to HealthCare.gov, dental coverage for children is listed as one of the 10 essential medical benefits.

But, according to this NPR story, some legal loopholes could leave some kids without coverage in some states.

The article explains:

"While the ACA requires that pediatric dental coverage must be offered in each state exchange, families who don't buy it won't be penalized for having substandard coverage."

Read more
faces-test.jpg

There is a great diversity in the types of plans that are available and in the providers of those plans. And, throughout the process of securing insurance, recognize that your personal situation dictates your particular needs, and it will also lend itself better to certain types of plans.

Your unique needs

We'll highlight some specific areas where your demographic and circumstances will predispose you to certain options in the FAQ's, resources and tips below.

I have a pre-existing condition

Insurers are no longer able to deny adults coverage or charge them higher premiums because of pre-existing conditions. 5,489,162 Pennsylvanians under age 65 have a pre-existing health condition that, before the new law, put them at risk of being denied coverage or gouged on rates. Who's Eligible for PCIP? PCIP coverage is for people with a pre-existing medical condition who’ve been without health coverage for at least 6 months, no matter what your income is. See full eligibility requirements. 

I'm pregnant

All Health Insurance Marketplace plans cover pregnancy and childbirth. All Marketplace health plans and many other plans must cover this list of preventive services for women without charging you a copayment or coinsurance (with an in-network provider): Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women; Folic Acid supplements for women who may become pregnant; Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk; Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users; Urinary tract or other infection screening for pregnant women

I'm an immigrant

What if I am an immigrant in the U.S. legally? Legal immigrants are permitted to use the marketplaces — and may qualify for subsidies if their income is less than about $46,000 for an individual and $94,200 for a family of four. Legal immigrants may qualify for Medicaid if their income is low enough. The laws governing benefits to lawful immigrants are quite complex. The federal Department of Health and Human Services has a guide to Medicaid and other benefits for immigrants. What if I am an undocumented immigrant? Immigrants who are in the country illegally are barred from buying insurance on the exchanges.

I'm interested in Medicaid

You can see if you qualify for Medicaid by completing an application at HealthCare.gov

I'm an early retiree

Too often, Americans who retire without an employer-sponsored insurance and before they are eligible for Medicare see their life savings disappear because of high rates in the individual market. To preserve employer coverage for early retirees until more affordable coverage is available through the new Exchanges by 2014, the new law creates a $5 billion program to provide needed financial help for employment-based plans to continue to provide valuable coverage to people who retire between the ages of 55 and 65, as well as their spouses and dependents. For more information on the Early Retiree Reinsurance Program, visit www.ERRP.gov

I'm self-employed

If you run an income-generating business with no employees, then you're considered self-employed (not an employer) and can get coverage through the Marketplace. You’re not considered an employer even if you hire independent contractors to do some work. If you have employees (generally, workers whose income you report on a W-2 at the end of the year) you’re considered an employer.

I have HIV/AIDS

About one in four people with HIV in care in the U.S. are currently uninsured and many more are underinsured. This new portal, Greater Than AIDS, helps people living with HIV navigate their insurance options under the Affordable Care Act.

I'm a cancer patient

Pre-existing conditions:Individuals cannot be denied coverage for insuance. This will allow cancer patients to have portability of coverage. Many cancer patients feel locked in to insurance and might even feel locked into an employer as they don't want to risk losing their insurance; Abolition of lifetime caps:There are more and more survivors of cancer, and many of those survivors wish to remain in touch with their doctor as they may need lifetime surveillance of their disease; Preventive screenings:The law will also increase access to and coverage for preventive screenings like mammograms and colonoscopies.

We're a military family

If you are a service member, retiree, family member, or survivor covered by TRICARE, you have MEC. There is no need to purchase additional health insurance. If you are using any of the following health plan options, you have the coverage required by the Affordable Care Act: TRICARE Prime, TRICARE Prime Remote, TRICARE Prime Overseas, TRICARE Prime Remote Overseas, TRICARE Standard and Extra, TRICARE Standard Overseas, TRICARE For Life, US FamilyHealth Plan, Martin’s Point Health Care, Brighton Marine Health Center, Saint Vincent Catholic Medical Centers of New York, Johns Hopkins Medicine, Christus Health (source- National Military Family Association)

The Uninsured: An interactive tool

ununsured-intractive-kff.jpg

This interactive tool from Kaiser Family Foundation, examines the impact of the ACA on various groups of uninsured people by analyzing how many are uninsured, the main reasons why they lack coverage, and how they may gain coverage under the ACA.

A PA small business story

ventre.jpg

At Hively Landscapes in York County, late November is typically a time for planting and hardscaping jobs. But this year, its 27 employees are also making important health care enrollment decisions.

Owner Ted Ventre has opted for an early renewal on the company's existing employer-sponsored health insurance plan. He says the good news is premiums are only increasing by three percent; the bad news is he won't be permitted to provide Health Reimbursement Accounts (HRAs) next year.

As a small business owner, Ventre is not required to provide insurance for his employees. But he thinks it's the right thing to do.

Read more

John Orris As far as hours being cut, once employees no longer have to stay at a job for health coverage, I think it will lead to more people leaving job and starting their own business. Ted via PIN
40 years old- self employed- landscaping; Dover, PA What are your impressions of the price and selection of the plans being offered on the PA exchange?
As a small business owner who provides insurance to my employees (myself included) I have not had any experience with the exchanges, yet. I have noticed several changes to my options as a small group provider that will have a direct impact on my business and my employees. I'm not sure if they are positive changes or not but I am sure that there will be some winners and some losers.

Understanding costs

Of course one of the most important considerations in this entire process is the cost. Exactly how much is this going to cost you?

There are a number of online calculators that can be used to estimate what your eventual cost of insurance will be. Additionally, making an account on the federal insurance marketplace will mean that you are notified of all subsidies or cost-sharing arrangements that you may qualify for before you purchase any insurance plan.

See the continuing coverage on Transforming HealthTransforming Health's Facebook Page

“My wife is a cancer survivor. Health insurance through the high risk plans in PA are very expensive and most treatment in the first year is not covered. Getting treatment for preexisting conditions at a reasonable price will help us stay in our home.”

-Doug, IT Professional-Retired; Hanover, PA Via The Public Insight Network

Calculate your health needs

calculate-health-needs.jpg

Knowing how much you actually spend on medical services now can help you budget for health care expenses in the future.

The Health Partners Cost of Care Calculator helps you estimate your costs based on your state and your current health.


You may want to ask yourself these questions:

Read more

Drug discounts for seniors

seniors-prescriptions.jpg

The Affordable Care Act provides discounts on drugs when in the coverage gap known as the “donut hole:” 

Medicare Drug Discounts
Eligible seniors who are in the coverage gap known as the “donut hole” automatically receive a discount on prescription drugs in 2011 and beyond.

$250 “Donut Hole” Rebate (2010)
If you were in the prescription drug coverage gap in 2010, you may have qualified for a rebate.

Source: HHS.gov

"Doughnut Hole" Calculator

doughnut.jpg

If you're a senior who has Medicare Part D, you might be at risk of falling into the coverage gap, or "doughnut hole."

Use this 4 step "Doughnut Hole" calculator from AARP to save money.


What is the "doughnut hole?" 

Read more

How to budget for health insurance

man-budget.jpg

Budgeting for health care expenses is personal and it depends on your family size, unique health needs, lifestyle and priorities.  

The first step if to calculate your net income.  Then, explore these two models of budgeting to help you figure out how much you can pay for health insurance (via WebMD).

Read more

Can you afford not to have insurance?

infographic-afford.jpg

Anyone without a health insurance plan will themselves be responsible for paying all costs associated with any medical care they receive.

Explore the full Infographic- WebMD

What if I can't afford insurance?

scale-money.jpg

Many low- to moderate-income Americans will get help paying their premiums thanks to subsidies from the federal government- a provision of the reform law that aims to make health coverage more affordable.


The government will help pay for your health insurance in the Marketplace in one of two ways:

Premium tax credits

This helps you pay for monthly premiums. Money in the form of tax credits will be given to you in advance if your income falls between 100% and 400% of the Federal Poverty Level (FPL). ($11,490 to $45,960 for an individual.)

Cost-sharing Reductions

This helps pay for copays, deductibles, and other out-of-pocket costs. You may be eligible for this subsidy if your income falls between 100 and 250% of the federal poverty level ($11,490 to $28,725 for an individual) *To take advantage of the cost-sharing subsidy, you must purchase a Silver plan on the Marketplace.

Who's eligible for lower costs?

Households with yearly incomes up to about $46,000 for individuals or $94,000 for a family of 4 will qualify for lower costs.

Read more
715,000 Pennsylvanians are eligible for premium tax credits.

Source- Kaiser Family Foundation 

How much will Obamacare cost me?

obamacare-calculator.jpg

In addition to estimating the kind of health care you are likely to use and therefore the kind of health insurance you will need, it's important to know that you may you qualify for lower costs on health coverage based on your income and household size.


Kaiser Subsidy Calculator

This tool is designed to give you an idea of what sort of cost-cutting measures you may qualify if you purchase insurance using the federal Health Insurance Marketplace.

3 premium subsidy scenarios under Obamacare

obamacare-subsidy-scenarios.jpg

This infographic illustrates the cost of health insurance under the Affordable Care Act for families in different circumstances, both before and after premium subsidies (in the form of a tax credit).  -source JAMA and Kaiser Family Foundation  

Free or low-cost coverage

young-woman-half-face.jpg

Consumers who seek health insurance through the new marketplace may qualify for: Free or low-cost coverage through public coverage programs like Medicaid and CHIP.

Find Insurance Options: See which public, private and community programs meet your needs 


Here's an update on Medicaid in PA:

Read more

Tax credits for small businesses

scale-money.jpg

According to PA Health Access Network:

"Small businesses with less than 25 employees and average wages of less than $50,000 now qualify for tax credits to help with the cost of coverage for their workers.

In 2011, 131,900 Pennsylvania businesses (68.3% of all businesses with 25 or fewer employees) took advantage of this new tax credit.

These tax credits currently cover up to 35 percent of the cost of coverage, and the maximum value of these credits will increase to 50 percent in 2014."

Save money

savemoney2014.jpg

Some provisions under the ACA may save you money:

  • Plans within the Marketplace cap out-of-pocket, in-network expenses. The most that you’ll pay is around $6,300. For a family, it's double that. Your deductible counts toward this cap.
  • Free preventive care. No copayments for new baby care, well-child visits, screenings for early signs of disease, like mammograms, and many other services.

Expert Q & A: Estimating salary

paycheck.jpg

Q: Janelle emails:

I have heard that insurance costs will be based on 2014 anticipated income of the individual but as a student graduating in May how am I supposed to know how much money I will make ? Should I try to base my insurance costs on estimated salary expectations?

Read more

PA plans cheaper than national average

Pennsylvania-counties-map.jpg

Figures released by the Obama administration indicate Pennsylvania’s average individual premium will be $286 per month for a mid-range plan. That ranks as the 10th lowest rate nationwide. Read more

The average individual plan in Pennsylvania's exchange is cheaper than the national average, according to information released recently by the federal government. 56 plans are approved for the state's exchange. 

Reason enough to quit?

smoker.jpg

Under the ACA, insurance providers in Pennsylvania are given the right to charge smokers up to 50% more than they would charge a non-smoker for the same plan.

This is due to higher health risks they face compared to non-smokers.

Factors that affect Marketplace plan prices

family-smiles.jpg
  • Where you live: Due to competition, cost of living, and local regulation.
  • Age: Older people can be charged up to 3 times more for premiums than younger people.
  • Family size: Insurers can charge more for a plan that covers a spouse and/or dependents.
  • Plan category: (metal plans in the Marketplace) categories based on how you and the plan can expect to share the costs of care.
  • Tobacco use: Insurers can charge tobacco users up to 50% more than non-tobacco users.

Women pay less

loading...

The Affordable Care Act prevents insurers from charging women higher premiums than they charge men.

Insurance companies can also not deny coverage to a woman because of a pre-existing condition like pregnancy.

Plans in PA's exchange: Personal impressions

money-roll-bottle.jpg

Emily K.- 35-year-old from Carlisle, PA

"The price for the plans offered to me was significantly cheaper than what I currently pay for individual health insurance. This takes into account that I do not qualify for any type of Federal subsidy to purchase coverage. The benefits are much better as well. I don't have prescription drug coverage now, and the plans offered to me on the PA Marketplace did include this benefit. I am very happy with the selections and am currently comparing provider networks and out-of-pocket costs for 4 different plans at the silver and gold levels."

Mel- Sales representative from Upper Darby, PA

"I am not impressed with the prices and selections. I think the more money one makes, then the more I will pay because the government healthcare subsidies do not apply to the higher income brackets."

Erica- 33-year-old market analyst from Birdsboro, PA

"Coming from the individual insurance market, I found the prices in Berks County to be very reasonable. Paying what I pay now for essentially catastrophic coverage, I can get a silver plan for myself and my two kids. Same price, better plan, with preventative care coverage - that's what's important to me.  Also, I was surprised to see several different insurance structures available - from the co-insurance route, to HSA-eligible plans - to plans with fixed fees for certain services like Dr. visits. I'm also going to be able to keep my primary care dr, so I'm happy for that.  It's important to note, I found pricing information while not logged in to the site. For many who are doing preliminary research, an account is not needed.  I think a lot of frustration could be alleviated if people knew that they could go to https://www.healthcare.gov/find-premium-estimates/ to get a ballpark estimate of prices and the plans available. Now, this doesn't give detailed information on the deductibles and benefits, but I've found valuepenguin.com to be helpful in cross-referencing."

Art- Harrisburg, PA

"The selections were excellent. I was able to narrow down to three choices each of which included my doctors in their network. Price was a little higher than I had hoped but still much lower than I could have found a few months ago given my age and preexisting conditions. I did enroll in a plan."

Susan B.- Direct Support Specialist-Mental Health from Hershey, PA

"It took way too long to finally get to see the plans and prices. I am not eligible for a subsidy, but the BIG advantage of the Marketplace for me is to be able to see prices and compare plan features without having to make multiple phone calls and wade thru' sales talks to get quotes from different companies. Many plans have priced themselves at ridiculous amounts for a single person household. But there are enough affordable ones that offer decent coverage."

Expert Q & A: The ACA & retirement planning

401k-planning.jpg

Q: PIN: Crystal in Carlisle, PA asks:

"How does the law impact retirement planning for young people?"

Read more

Expert Q & A: Why is insurance so expensive?

dollar-faces.jpg

Q: Robert in Harrisburg asks:

"Insurance costs are rising every year, why is that? Why can’t the insurance companies provide AFFORDABLE insurance to those that need it? 

Read more

Expert Q & A: What if I'm divorced?

divorce.jpg

Q: Mary from Lancaster, PA asks:


What provisions are available between divorced and/or separated people?


Read more

The cost of not getting covered

loading...

Not having medical coverage means that you'll have to pay for the entire cost of all your medical care. 


And remember- there’s a cost to NOT getting covered.  In 2014, the penalty is $95 or 1% of your yearly household income – whichever is greater.  

Insurance broker John DiVito at Flexible benefit, a Chicago-based insurance wholesaler, advises to calculate the Obamacare penalty before foregoing coverage. Here's why.

Read more
penalty-calculator.jpg

If you don't plan on purchasing a plan before the March 31, 2014 deadline, you can use this penalty calculator created by Turbo Tax, to help estimate how much your penalty will be for 2014. 

Expert Q & A: Spending down & Medicaid

money-rolled-pink.jpg

Q: John Patterson in Chambersburg emails:

I understand Pennsylvania hasn't chosen to expand Medicaid under Obamacare yet. If the state does choose to accept the federal funds, would the asset limit (around $2000 for a single adult) for current and expanded Medicaid recipients be eliminated? 
Read more

Employer-sponsored insurance trends

loading...

As health insurance premiums rise for the 67 percent of Pennsylvanians who are getting health insurance through their jobs, employers are looking for ways to contain costs.

The average employer-based family premium in Pennsylvania surpassed the $15,000 mark in 2011, and most businesses now require their employees to share in those costs -- meaning the average worker is paying close to $4,000 in annual health insurance premiums.

But, behind the round numbers is volatility from workplace to workplace.

Read more

The ACA: Employer impressions

open-dress.jpg

Here's what some Central PA employers have to say about the Affordable Care Act:

Sassy T.; Administrator- small rural health clinic, Chambersburg

As an administrator of a small rural health clinic near Chambersburg for many years, the doctor (my husband) and I saw both sides of the insurance and healthcare issue, purchaser of insurance for employees and healthcare provider. The office is now closed. The biggest item in our budget was health insurance for 5 employees (not family members): nearly $50,000 per year, with a $1000 deductible in 2010. Our employees mostly lived paycheck to paycheck. We included them in our decisions. Ethically, we refused to drop their insurance. Capital Blue Cross did their best, I'm sure, but even as a non-profit, you can see that the cost is untenable. Then there were the patients who couldn't get insurance: pre-existing conditions, self-employed small business people, etc. I look forward to individuals and small businesses being able to access affordable insurance.

Bill; Central PA employer

Not a shopper. I am an employer who is seeing a 15% increase in my premiums under a BS law that was supposed to LOWER premiums. This will be a train wreck on jobs and a lot of people are going to see their spouses and families dropped from employer plans. And those companies with 58 employees will probably let 9 go to get under 50. Why the idiots in D.C. think they can add layer and layer of mandated expenses to businesses and think we will put up with it is beyond me. And oh yes, how many people are seeing a 25% pay cut when their hours are being slashed from 40 to 29? Why the media isn’t doing a report on how this will be a train wreck of a law is beyond me.

Employer responsibilities

employer-flowchart.jpg

The Affordable Care Act does not require businesses to provide health benefits to their workers, but larger employers face penalties if they don’t make affordable coverage available.  

This simple flowchart from Kaiser Family Foundation illustrates how those employer responsibilities work. 


Enforcement of those penalties will begin in 2015, a year later than originally scheduled.

How to make the best use of what you now have

Under the ACA most people will be required to carry some level of health insurance, with very few exceptions. Once you have secured your coverage you have the opportunity to make the most of it.

This section of Getting Covered is designed to help you do just that. Get everything you can out of your health insurance, familiarize yourself with the benefits you are entitled to and the responsibilities of the insurance companies. 

See the continuing coverage on Transforming HealthTransforming Health's Facebook Page

Health insurance vocab

loading...

Here are some need-to-know health insurance terms so that you can make the most of your new plan.

You have the most invested in your personal health so you should be your own biggest advocate.

ACA benefits for new moms

loading...

Pregnancy is an exciting time! You’re busy taking care of yourself and preparing for the arrival of your baby. The last thing you want to do is worry about health insurance and the cost of care.

Under the Affordable Care Act, moms will feel more support in this area.

Read more
"A lot of people think of insurance as a 'sickness benefit.' And yet, it should be look at it as a health benefit. And, there's great opportunity to maintain health and improve health rather than only seeking services when you're ill."

-Andy Seebold; Director of Business Services for WellSpan Health

Understanding your health benefits

loading...

Andy Seebold, Director of Business Services at WellSpan Health, says that newly-covered Pennsylvanians should educate themselves about how to make the most of their new health benefits. Because, health insurance not olny protects them financially in case of an emergency, but it can actually help them stay healthy and save money in the long run.

Tips for understanding your health coverage:

Read more

Preventive care and young adults

young-woman-obgyn.jpg

Many young adults only go to the doctor when they're sick.  And, they may carry insurance in case of an emergency.

But, under the ACA, young adults now have access to free preventive benefits, with no co-pay.  An annual check-up not only builds a relationship with your doctor, but may catch a disease early when it's most treatable.  

The bottom line is, these services can improve your quality of health and help you live longer.  In fact, it could save your life.


Keeping on top of your health and taking advantage of free screenings also saves on healthcare costs down the road.

Making sense of your insurance card

Your insurance card is kind of like a driver's license for health coverage. You need to show it every time you get any type of health or medical care. Every health plan has its own type of card. Yours will have your own personal information and ID numbers.

Here's how to read it:

understandbenefits.jpg

  • A. Certain medical services or medicines will require approval prior to you receiving them. These services will be listed in your health insurance policy
  • B. Type of local provider network you belong to
  • C. Co-payment amounts you owe at time of service
  • D. Shows you have coverage for health care services outside your local network when you seek care from a Blue Card PPO Provider
  • E. Shows if you have a wellness program through an employer's health plan
  • F. Shows if you have Dental and/or Vision coverage
  • G. Shows if you are enrolled in a "Health Reimbursement Arrangement" plan
  • H. Codes used by doctors to file prescription claims
  • I. Your Primary Care Provider Name will show here (if applicable to you)
  • J. Your Member Identification Number

understandbenefits.jpg

  • K. Info your doctor uses if they file claims on your behalf
  • L. Phone numbers to call for specific help
  • M. Company and logo of Pharmacy Benefits provider

Resource provided by Capital BlueCross


understandbenefits.jpg

Employee wellness programs

loading...

Incentives for healthy employees
 John Hickey, the president of Sutliff Chevrolet in Harrisburg says a new wellness program is already making a difference in the lives of his employees.

“Our entire program is about making people more aware and then providing them incentives to improve.” 

The Affordable Care Act will allow employers to increase such incentives starting next year.

“We have a discount for the employee contribution portion of the health care insurance premiums and there’s a discount for nonsmokers, there’s a discount for people whose BMI falls below a certain number, and there’s a discount for people who agree to participate in the healthcare assessment, which that latter category is, by far, the vast majority of our employees,” he explains.

Read more

A new focus on prevention

loading...

Wanda Filer, the founder of the Strategic Health Institute, says that patients will be encouraged to take an active role in prevention of illness.

“Prevention is not simply getting a mammogram or having your colonoscopy. It means you get your flu shot. It means you talk to your doctor about your dietary choices. You talk to your doctor about other preventive strategies based on your personal health, based on your family history.“ 


Along with covering the 10 Essential Benefits, all Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible. This applies only when these services are delivered by an in-network provider. 

Read more

Birth control benefits

birth-control.jpg

Plans in the Health Insurance Marketplace must cover contraceptive methods and counseling for all women, as prescribed by a health care provider.

These services must be covered without charging a copayment, coinsurance, or deductible when they are provided by an in-network provider.

Healthy habits

weight-lifting.jpg

As a patient, focusing your energies on maintaining healthy habits and regularly visiting your doctor will increase the likelihood that you are able to preserve good health for longer.


Additionally, you are more likely to detect any sickness earlier which will increase the likelihood that you can be successfully treated for that illness.

prev-disease.jpg

75% of healthcare costs are spent on preventable diseases- Escape Fire  Learn more

ACA basics for business

business_ACAinfographic.jpg

Under The Affordable Care Act, large businesses must provide affordable health insurance to all full-time employees or pay a monthly "Employer Shared Responsibility Payment" on their federal tax return. 

Understanding out-of-pocket insurance costs

insurance-dictionary.jpg

Premium

The amount that you’ll pay for health insurance, usually on a monthly basis. You’ll pay this even if you didn’t have any medical expenses that month.  Usually, you pay a lower monthly premium if you have a higher deductible.

Out-of-pocket costs

These are your expenses for medical care that are not covered by insurance. These include deductibles, co-insurance, and co-payments for covered services plus any medical care that isn't covered by your plan.

Deductible

This is the amount that you are responsible for paying when you receive medical services before your health insurance plan kicks in to help pay. So, if your deductible is $1,000, for example, that means that your plan will begin covering medical costs only after you've reached that initial $1,000 in expenses. For each doctor visit or drug that is prescribed, you may have a copayment or co-insurance.

Co-payment (co-pay)

This is a fixed amount that you'll pay for a covered health care service, and it's usually paid at the time of that service. Usually, copays don't count towards your deductible. Co-pays vary by type of service. For example, a co-pay for a doctor visit might be $25, and $150 for an ER visit

Co-insurance

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan's allowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

High costs

broken-leg.jpg

The average cost of a 3-day hospital stay is $30,000? Or that fixing a broken leg can cost up to $7,500? Having health coverage can help protect you from high, unexpected costs like these.

–Healthcare.gov

Preview plans and prices

watercolor-map.jpg

Preview available plans and prices for your small business:  See the database

By answering a few quick questions at HealthCare.gov you'll see:

  • plans you may be able to buy for your small business
  • estimated prices based on employee age-ranges and where your business is located

The prices you'll see are for people who don't use tobacco. You'll get final quotes when you contact a licensed agent or broker, or insurance company.


Important: The prices you see here won't reflect savings you may qualify for from the expanded small business health care tax credit, which is available only for Small Business Health Options Program (SHOP) coverage beginning in 2014.

Using your benefits to stay healthy

loading...

“Our lifestyle and behavior choices impact overall health and the Affordable Care Act places an emphasis on preventive care. It’s believed that if we can properly manage healthcare and chronic conditions, in the long-term, it will reduce costs for us,” says Andy Seebold, Director of Business Services at WellSpan Health.

Tips for using your benefits to stay healthy and the importance of prevention:

Read more

Tobacco cessation is an essential health benefit

cessation.jpg

Under the ACA, your insurer must cover tobacco cessation services at no cost.  

"According to the National Health Interview Survey, people on Medicaid and people currently without health insurance smoke at much higher rates than their counterparts."

Read more

How to organize your health

loading...

Getting organized in your life can lead to better health for you and your family. In this video, Dr. Glenda Cardillo, Acting Physician General for the PA Department of Health, shares some important tips.

Read more

Expert Q & A: How can I find a good doctor?

doctor-partnership.jpg

Christopher from Jonestown, PA asks:

How to find a good family practice physician--Are there resources out there with reviews of doctors?

Read more

Participating in healthcare

loading...

One of the goals of the Affordable Care Act is to keep people well. There will be incentives for doctors to reach out to their patients and work with them to keep them healthy. But in order to make the doctors’ efforts a success, patients need to be active participants in their health as well.

Doctor relationships

find-a-doctor.jpg

E-mail from Kim:

"I hope there will be an component to this (health reform) to encourage ALL people to have well-patient appointments, especially for people in their younger years."

Read more

Saving money with your health plan

loading...

Understanding what your insurance plan covers is the first step to making the most of your health benefits in order to stay healthy. But, these tips from WellSpan Health can also help you save money in the long run.

Read more

Top 6 cancer-fighting provisions in the ACA

mammogram.jpg

The American Cancer Society has prepared a list of the top six cancer-fighting provisions in The Affordable Care Act that will meaningfully improve the health care system for people touched by cancer. 

Read more

Employees on employee wellness programs

employee-wellness.jpg

Email from Angela:

I completely support it. I think that prevention is key to reducing health care cost. At the end of the day, if you don’t agree you have the option to not participate and pay the fine. 
Read more

Mental health benefits

mental-health.jpg

Health advocates are already hailing greater access to care - insurance plans offered in the exchange will have to cover bases like preventive medicine.  And, all Marketplace insurance plans cover mental health and substance abuse services as an essential health benefit.

Read more

Looking to the future

lok-future.jpg

The implementation timeline is an interactive tool designed to explain how and when the provisions of the Affordable Care Act will be implemented over the next several years. 

Health Reform Implementation Timeline 

Community-based care transitions

loading...

According to the Centers for Medicare and Medicaid services, nearly 1 in 5 Medicare patients who is discharged from the hospital is back at the hospital within 30 days. The Community Based Care Transitions Program, created through the Affordable Care Act, is targeting those readmissions. 

One key thing no one knows about Obamacare

bandaid.jpg

No one really knows who is going to sign up — not the Obama administration, not the insurance industry, not the president's critics. Yet the success of the law hangs on this question: Will the right mix of people sign up? In particular, will healthy people buy health insurance?

 

Read more

Compare care providers

compare-couple.jpg

Many tools are available to help you search, compare, and assess providers, hospitals, and other care facilities so you can make better decisions.  HealthCare.gov provides the following:

Compare Providers

Search for and compare physicians and other health professionals. You can see information on medical specialty, clinical training, foreign languages spoken, and more.

Compare Hospitals

Compare the quality of care that hospitals deliver. You can see a list of U.S. hospitals that includes hospital demographics (location, hospital type) and 44 quality-of-care measures. You can also find data on some Department of Veterans Affairs medical centers.

Compare Nursing Homes

Compare the quality of care in nursing homes. You can see a list of U.S. nursing homes, demographics (location and type of facility), ratings, health inspection reports, staffing data, and quality measures.

Compare Home Health Agencies

Compare the quality of care provided by home health agencies. You can see a list of U.S. home health agencies, including demographics, services provided, and quality measures.

Compare Dialysis Facilities

Use this tool to help you compare the quality of care in dialysis facilities. It provides a list of U.S. dialysis facilities, services provided, quality measures, and resources.

Healthcare vocab

loading...

Learn a few of the buzz words you'll need to know to stay up to speed when it comes to the way that care is delivered.

As an oncologist, every time a new cancer is diagnosed I always ask myself "Did we find this as early as we could? Were screening opportunities missed? Was this preventable?" 

Daniel Ekaha, M.D.
 Hematologist and Medical Oncologist

York Cancer Center, WellSpan Health

Read more

Businesses coping with change

openbusiness.jpg

Everything seems to be operating smoothly at the family-owned Butcher Shoppe fresh food markets in Chambersburg.  But behind the scenes, significant changes are underway.

Adam Keath is the vice president of marketing for the company, which has been in his family for three generations.  He says his business has had to make some major changes in light of the Affordable Care Act, including scaling back some employees' hours so they're no longer full-time.   


Take a look at how a couple of midstate businesses are coping with the changes:

Business costs survey

money-pile.jpg

A 2012 study from the Kaiser Family Foundation and Health Research and Educational Trust shows on average, premiums for employer-sponsored health insurance are about 5,600 dollars and more than 15,000 dollars for families -- and rising.


94% of businesses with between 50 and 199 workers offered health insurance last year.

Barriers to care

theresa-sellers.jpg

“Many barriers prevent patients from getting the proper care that they need. Often, these barriers can seem insurmountable to the patient in need of care and lead to patients abandoning treatment or not seeking treatment at all."

Theresa Sellers, RN, BSN, MHSA, MBA, CMSRN, Community Health Nurse Navigator, PinnacleHealth

Read more

“Bankruptcies resulting from unpaid medical bills will affect nearly 2 million people this year—making health care the No. 1 cause of such filings, and outpacing bankruptcies due to credit-card bills or unpaid mortgages, according to new data.”

-CNBC

Prevention

senior-preventive-care.jpg

Since the ACA now mandates that individuals have health insurance, focus on trying to get the most use out of your insurance in order to secure positive health outcomes for you and your household.

With access to effective preventative services individuals will be less likely to suffer from preventable chronic diseases and will not be subject to the costs of managing those “lifestyle diseases."  Managed correctly, health insurance can be a very good value.

Thank you for exploring Getting Covered

We hope that guide has answered your questions about the Affordable Care Act, and has empowered you to make very important choices about your health.


We invite you to share this guide, using the social media buttons at the top, with your family, friends, and anyone who you think may benefit from this information.  

Use the social media sharing buttons at the top.
See the continuing coverage on Transforming HealthTransforming Health's Facebook Page
Read more

"Had an individual plan after my COBRA ran out 5/12. Had to take money out of a retirement account to pay for the individual plan. The marketplace plan will cost me about $300 LESS per month in premiums while offering the same coverage or better than my old individual plan. This is without any subsidy. They say I make too much money. Why don't I feel rich?"

-Susan B. from Hershey, PA 

green-biker.jpg

If you did not have insurance until now, what does having access to insurance mean to you?


”This means I can make an appointment to see my doctor without thinking that some terrible illness or injury will sideline my finances. I can start riding my bicycle more and not feel that I'll be a drain on society if I get hit by a car.”

David; Climbing Gym Instructor; Philadelphia, PA Via The Public Insight Network

I have employees in more than one state

states.jpg

An employer with employees working in more than one state has 2 options:

  1. Cover all employees from the state in which the employer has its main place of business
  2. Cover the employees in each state through the SHOP in each state, using the primary business address in that state

source: HealthCare.gov

Read more

Feedback? Questions?

Do you have feedback on the Getting Covered guide that you'd like to share with us?  Do you have a question about the Affordable Care Act that we didn't address here?  Please email us at TransformingHealth@witf.org and we will do our best to help you find the answer you need.