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Changing Care: Your Guide to the Affordable Care Act

By Linda Laarman and Karen Nordahl

Illustration by Ryan Miller.

Part 5:  If you missed Parts 1 – 4, read them at ppulse.com

The Affordable Care Act (ACA) created health care exchanges so that individuals and small businesses who previously could not obtain affordable health care insurance could do so, starting in 2014.

The exchange marketplace generally makes insurance available using group-type pricing and without imposing pre-existing condition limitations. A variety of plans with different mixes of benefits and costs are available on an exchange, with potential cost subsidies based on income levels.

Although some states established their own exchanges, the Wisconsin government (like several others) decided that Wisconsinites should use a federally created exchange. The primary means to access the federal exchange – the healthcare.gov website – was supposed to be fully operational for one-stop shopping on Oct. 1. But it has suffered from technical problems, frustrating all affected. The federal government and its contractors continue to work on the site.

Information on plans specific to our area

Although problems with purchasing insurance via healthcare.gov remain, valuable information is still available. Individuals and small businesses can answer a few simple questions on the healthcare.gov site and obtain fairly specific information on the plans that will be available to them, their families and their businesses.

To access this feature, go to the healthcare.gov site and type “get plan information in your area” into the search box. According to the input you provide, a synopsis of available plans will be presented, identifying (1) insurance company, (2) metal tier, (3) type of coverage – i.e., health maintenance organization, point-of-service, or preferred provider organization (see sidebar), and (4) estimated premium. Searches for individuals, families and small businesses will yield different results, depending on how the questions are answered.

For example, we sought information for an individual age 50 or older, living in Door County. Results indicated availability of 99 plans for individual coverage in the bronze through platinum levels, with premiums ranging from $283.47 to $839.19 per month. The same search for an individual age 49-or-under also identified 99 plans, with premiums ranging from $135.99 to $492.42.

The tool does not provide details regarding out-of-pocket costs such as deductibles, co-payments and co-insurance. Results are estimates only, and do not reflect potential subsidies, although some indication of additional costs or applicable subsidies may be provided. Despite these shortcomings, the resource is easy to use and helpful in getting an idea of the number and types of plans available and the range of potential premiums.

Insurers offering exchange coverage in area counties

Another way to obtain information may be to check with the insurers offering exchange coverage in our area. According to The Wisconsin Office of the Commissioner of Insurance website (oci.wi.gov), this includes: (1) Common Ground Healthcare Cooperative, (2) Dean Health Plan, (3) Compcare Health Services Insurance Corporation (related to Anthem Blue Cross and Blue Shield), (4) Arise Health Plan (an offering from WPS Health Plan, Inc.), and (5) Molina Healthcare of Wisconsin.

Coverage in Door County on the “SHOP” exchange for small businesses (see Part 4 in this series) will be available from Common Ground and Arise/WPS. In Kewaunee County, those offering coverage are the same, with the exception of Molina Healthcare.

Parts 3 and 4 in this series discuss and identify healthcare exchange navigators, application counselors, and others (including insurance agents and social service agencies) providing help.

Linda Laarman has practiced law for almost 35 years. A key area of practice has been advising employers on employee benefits and compensation matters. 

Karen Nordahl has worked in the medical industry for more than 20 years, with a focus on providing educational resources and strategic support to providers and manufacturers on the topics of health policy, economics and reimbursement.

Health Care Plan Terminology

 

In the health care exchange, as in other private insurance, companies package benefits and costs in a variety of ways. Consumers should review plan features carefully and consult experts. In general, however, here are plain-English definitions of three terms commonly used to describe health care plans. The plans and related terminology are not a creation of the ACA but have been around for many years.

HMO:  A health maintenance organization typically is the most restrictive type of health care plan in terms of the consumer’s right to choose physicians, hospitals, and other health care providers, essentially requiring that all providers be “in-network.” 

POS:  A point of service arrangement generally involves a primary care physician, chosen by the consumer, who acts as a gatekeeper (i.e., point of service) when a patient needs or seeks the care of providers other than that primary care physician. The primary care physician in this function and some other physicians and health  care providers will be “in-network,” while others will be “out-of-network.”

Generally, co-insurance (the split of cost-sharing between the plan and the individual, such as 80 percent/20 percent or 60 percent/40 percent) and, perhaps, other costs will be more favorable to the consumer when services are obtained from in-network providers than when they are obtained out-of-network.

PPO:  Unlike a POS arrangement, a preferred provider organization arrangement generally won’t involve a gatekeeper. Similarly however, costs to the consumer for services from in-network (i.e., “preferred”) providers typically will be less than out of-network costs.

Contact Information for Door, Kewaunee County Exchange Insurers*

Anthem Blue Cross & Blue Shield/Compcare:  anthem.com

 Arise Health Plan (WPS):  wecareforwisconsin.com, 866.841.6575

Common Ground Healthcare Cooperative:  commongroundhealthcare.org, 855.494.2667

Dean Health Plan: deancare.com, 800.279.1301

Molina Healthcare of Wisconsin:  molinahealthcare.com, 888.560.2043

*We cannot guarantee success in finding need-to-know information at these addresses and telephone numbers but provide them as starting points.

Still Have Questions?

The authors welcome feedback and comments regarding this series of articles. Over the coming weeks, readers are encouraged to submit their questions regarding the ACA and the health care exchanges to the Peninsula Pulse at [email protected] or by calling 920.839.2121. The series will then resume with articles geared to address the specific questions and needs of our community.