In a Florida Matters show first aired Tuesday night on WUSF 89.7 FM, a panel of experts answers reader and listener questions about the Affordable Care Act.
Our panel includes Health News Florida Editor Carol Gentry, attorney Linda Fleming of Carlton Field Jorden Burt in Tampa and Jodi Ray, program director of Florida Covering Kids & Families.
Here are the questions and answers:
CARSON COOPER: Linda Fleming, who is required to have health insurance?
LINDA FLEMING: Just about everybody is required, unless you’re exempt. There are some exemptions people should be aware of. If you’re incarcerated, you’re automatically exempt. If you don’t make enough income that you don’t need to file an income tax return, you’re exempt. If you’re a member of a recognized Indian tribe…there are several exemptions.
COOPER: The slight nuance to that is required to have insurance, not necessarily to buy it. So everybody has to have the insurance. Whether or not they pay for it is another thing?
CAROL GENTRY: Most people get their insurance from their workplace or through the government, as a veteran or a Medicare patient or whatever. And so if you already have insurance, don’t worry, we’re not talking to you, we’re talking about your cousin or your brother or whatever.
COOPER: Let’s get right to the questions now, and this one was among the many that came into our hotline, from Chris Newman of Bradenton:
"I don't have any medical insurance, I used to but eventually it became too expensive for me. So I haven't had it for a number of years now, but I do plan on buying it. My question is...I'm having great difficulty comparing one plan with another. Many companies are contacting me, usually by mail. Unless there's some sort of spreadsheet where all the companies are listed, and I can compare one against the other...I just don't have the time to do it. So I don't know how one does it without physically speaking with every company that's out there offering health care. So that's the question: how does one choose which company to pick from when there's not some sort of spreadsheet where you can compare one against the other one, what services they are and what the prices are?"
COOPER: Alright, Jodi Ray, what about that? We’ve heard a lot about this, that it’s just hard to compare plans and prices specifically?
JODI RAY: Yeah, so we see that a lot with the consumers that we’re assisting, filling out the form and applying isn’t really where the challenges are. It’s sitting down and going through all the information about the health care coverage plan options that folks are being offered. I strongly recommend, and that’s the advantage of, using one of the trained assisters like a certified application counselor or a navigator, who have gone through a significant amount of training to be able to sort through the plans and explain them to the consumer and sort of ferret down to the key priorities that an individual has, and those differ from person to person.
But the navigator is able to actually help them narrow down what they’re looking at and then make a choice. They’re very neutral, they’re not recommending plans and they don’t work for a plan. They don’t get paid for recommending a plan. So they’re able to go through all the plans and give very impartial information to the consumer so they can understand why they’re making choices and what choices they’re making around deductibles, co-pays, provider networks, sometimes they’re looking at prescriptions that are covered.
COOPER : And Carol Gentry, the biggest questions are: is my doctor in this particular plan? What are my out-of-pocket costs? That’s what a lot of people really want to know.
CAROL GENTRY: One of the things you can do is go from healthcare.gov, you can actually click and go to a company’s site and see who the providers are. The trick is that most people who haven’t had health insurance in the past don’t understand that doctors and insurance companies are in a contract relationship and they can end that contract at any time. And so you’re signing up for a plan based on your doctor being in it but that could change, and there’s nothing we can do about that. That’s been the situation for years.
COOPER: Linda Fleming, have doctors had any questions about whether or not they are in a plan or are they clear on that?
LINDA FLEMING: I think they’re pretty clear on that. As Carol just said, there are contracts between the insurance companies and the providers, and that’s what these networks are, whenever we’re talking about networks and provider networks. So, who has the insurance company contracted with? One thing I would recommend, if you have a particular doctor, and you really want this to be your doctor, call her office, and see what plan she’s in before you make the decision of which insurance company you’re going with.
COOPER: Alright, back to the hotline now, Robert in New Port Richey:
"My question is why are the deductibles for these plans so high? On the one hand, I'm offered a low premium because my income is low, but the deductible is such that I find the plan to be unaffordable by virtue of the deductible being so high. What can possibly be done to fix the problem of the deductible? Because I find that they're high even with the lower prices through the health care marketplace."
COOPER: Well, Linda Fleming, we’ve heard this a lot. What about that?
FLEMING: We have. And the premium is a function of the deductible, so the higher the deductible, the lower the premium. And while health insurance for some people is still going to be out of reach, the only way to get more regulation is to have the government regulate more and actually go into insurance companies and say, you can only charge this much, and I think at this point, all of us pretty much feel we have enough government regulation.
COOPER: Explain the difference between deductible and co-pay. There is a difference, right?
FLEMING: There is. A co-pay is, under certain plans, usually HMO or PPO, and you walk in the door and you pay this much. Usually it’s a minimal amount, $20, $30, $35. A deductible is a much higher amount and where this really comes into play is in the high deductible health plans, Carson. And your deductible may be as high as $500, $1,000 and while you get the insurance company’s contracted rate, that still could be several hundred dollars or more out of your pocket whenever you walk into a physician’s office.
COOPER: Jodi Ray?
RAY: I just wanted to point out, in terms of the deductibles, it’s important to know that the plans are laid out on these four metal tiers. They have bronze, silver, gold and platinum. And generally speaking, that means they go from a bronze which is a 60-40 plan, to a platinum which is a 90-10 plan. But folks who come in whose incomes fall between 100 percent and 200 percent of the federal poverty level for their household can qualify for some additional sort of discounts or cost reductions, so what we’re seeing is, particularly people who come in under that range, if they pick one of the silver plans, we’re seeing people who are walking away with 90-10 plans. As a silver plan, their deductibles are $500 and they’re paying $20 a month for a premium. So, the deductibles across are not necessarily always high, it’s based on the household, the taxable household for the folks that are applying for coverage.
COOPER: OK, 60-40? 90-10?
RAY: That means the insurance company is gonna pick up 60 percent, generally, of the cost and the out-of-pocket is gonna be about 40 percent in a bronze plan for an individual and then you look at things like, what the deductibles are in those plans. And when they look at them…in Hillsborough alone there are probably 102 plans across the board that individuals pick from, but we’re seeing a lot of folks, if they fall in that 100 percent to 250 percent, they have actually very low deductibles and also very low premiums that they’re paying as well. So their out-of-pockets actually end up being very, very small if they fall in that range in a lot of cases.
COOPER: Here is a call from Dianne Wood in Hudson:
"My question is about the new provision against denying coverage for preexisting conditions. A person may select a low cost plan which features limited coverage and high co-pays because the lower premiums and their personal history of good health seems to make that a good fit. If that person eventually develops a serious medical condition, could that person, on the next year in open enrollment, choose to change to a higher fee plan which has more comprehensive coverage without experiencing discrimination or denial based on the new preexisting condition?"
COOPER: Alright, Jodi Ray, what about that? I always heard that you can’t deny anyone for a preexisting condition no matter what?
RAY: Right. That is one of the provisions of the health care law that kicked in, and that kicked in early for children and now applies to everyone. All the health plans, I think it needs to be clear, have a set of essential basic requirements that they have to provide coverage for anyway for everyone, so the plans all have a set of at least 10 different items that they cover on all individuals in all plans. In addition, during an open enrollment period, an individual can change their plan, and the preexisting condition issue still does not apply. They cannot be denied coverage and their premium is not based on their preexisting condition.
COOPER: Now, a number of folks with questions did not want to appear on tape with us or give their names, like this person, a woman whom we met recently at Curtis Hixon Park in Tampa. And she asks, and this is about the requirement to have coverage, wondering if the requirement applies to 18-year-olds so she can take her son off her plan? Sounds like somebody wants to push somebody out of the nest a little early. Obviously, a person, an offspring, can be covered up to the age of 26. What about that, Linda Fleming?
FLEMING: Since he’s an adult, he’s 18, he’s responsible for his own coverage. So really, it becomes a money decision. If both parents are working and they’re covered under their employer plans, it may not be that much to keep him on the plan, so it really is a matter of economics and figuring out which way makes the most sense to go, even if he is employed and could potentially be covered under his own employer’s plan.
COOPER: So if a parent chooses not to cover their adult age kids, that’s their prerogative?
RAY: Eighteen-year-olds still get coverage in Florida under CHIP, which is the Children’s Health Insurance Program. Florida KidCare covers kids until they turn 19. So depending on the income and the cost to insure him on her plan, may qualify him for coverage under CHIP, so that is a factor that needs to be considered by the mom.
COOPER: So it sounds like if you want to kick your kid off your plan, you’re going to be able to do it.
Here’s a question from Tamina Johnson, age 29:
“I like to travel, and I travel for conferences, and I need to know, am I going to be covered when I go out of state if something was to happen?"
RAY: Some of the plans have national networks, national provider networks, so when they’re picking their plans if this is an issue, and this is important to a family, they may want to look at whether the plans are offering a national provider network, so they have access to a provider if they travel a lot.
More resources to help you understand the Affordable Care Act:
· The federal government’s website HealthCare.gov
· Find a navigator or in-person assister: localhelp.healthcare.gov
· Coverage from Health News Florida