Buying insurance • Politics aside, here's insight into the nuts and bolts of how the new health law works.
This is an archived article that was published on sltrib.com in 2013, and information in the article may be outdated. It is provided only for personal research purposes and may not be reprinted.
Annie King has been a healer and a teacher for decades, using yoga and massage to relieve chronic pain in her students and clients. Now King herself is in pain, in need of a hip replacement she can't afford.
Her monthly insurance premiums jumped above $800 following a previous surgery on her left hip. So the Salt Lake City 55-year-old dropped her insurance and was putting off surgery this fall, eager to see her choices on the online insurance marketplaces created by the Affordable Care Act and learn whether she qualifies for a subsidy.
In the meantime, she reluctantly agreed to let her friends launch a fundraising campaign.
"I've never asked for help. I've always worked," King said. "But this is the situation: Is it better to wait and possibly damage my body even more?...I'm just going to have to wait and see what my options are."
Angie Jackson pays cash to see a doctor every six months for high blood pressure medication and otherwise is a "home remedy kind of gal." She works full-time as a customer-service representative, earning $10 an hour, but as a new hire, she's not eligible yet for her company's $190-a-month health plan and says she couldn't afford it anyway.
Jackson, 51, is unabashedly skeptical about health care reform. "I think the government is sticking its nose where it does not belong when comes to insurance."
Her suspicions stem from her free-market philosophy, but also from a knowledge gap.
"We've all heard stories about socialized medicine. Is that what it's going to be? Are we going to have to wait in line? Can I see my doctor?" Jackson asked. "I want to find out more about it."
Whether Utahns like the ACA or not, many consumers are confused about the law and how it will work. Setting aside the political debate, here's an attempt to answer some basic questions.
Who is affected by the ACA?
The short answer is everyone, because the law puts new standards in place for the private insurance industry. Almost all plans will cover a minimum level of care with an emphasis on prevention and wellness (immunizations, annual checkups and the like). Denying coverage based on pre-existing conditions, such as King's congenital hip problem or the chronic disc misalignment in her spine, will be a thing of the past.
And almost everyone will have to sign up for an insurance plan by 2014 or face a tax penalty.
It's big change, to be sure, but come Jan. 1, 2014, most people won't feel it.
More than 80 percent of Americans already have insurance from various sources. Utahns with Medicaid, Medicare and military coverage will stay on their plans; the vast majority of Utahns who already have insurance through an employer will stay on those plans.
Part-time employees, seasonal workers, the unemployed and sole proprietors who may have been priced out of the private nongroup insurance market can shop on the federally-run individual marketplace at healthcare.gov.
Workers who have employer-based plans can shop on the marketplace, too, but according to healthcare.gov, "If you choose a Marketplace plan instead, your employer does not need to make a contribution to your premiums."
And such employees won't qualify for subsidies, even if they meet the income requirements, unless the workplace premiums cost more than 9.5 percent of their income.
Who gets a subsidy?
Whether Utahns qualify for a subsidy will depend on their income: the help is provided only to those earning between 100 percent and 400 percent of the federal poverty level. That means between $11,000 and $44,000 for individuals and between $33,000 and $92,000 for a family of four.
Most families should get a tax credit of $5,548 for health insurance, according to estimates by the Kaiser Family Foundation. Subsidies are based on the second-cheapest silver-level plan available, one of four levels sold in the exchanges: bronze, silver, gold and platinum.
What are the differences between a bronze plan and a platinum plan?
Each level of coverage offers the same essential benefits, but the monthly premiums will differ and so will the out-of-pocket expenses. For instance, on a gold plan you'll pay more per month, but less when you visit the doctor. Monthly premiums will also be calculated based on factors such as your age, where you live and whether you use tobacco.
I need a health plan. Where do I start?
You can visit healthcare.gov, where Utah consumers will be able to compare the costs and benefits of 96 plans offered by six insurers. You can also call the help line at (800) 318-2596.
If you're looking for a health plan to cover employees of your small business, you can shop at the state-run exchange called Avenue H. There are 70 plans available on AvenueH.com. Read more here.
You can also shop in the commercial marketplace through an insurance agent, but be sure you're looking at Qualified Health Plans (QHPs), which meet ACA standards, to avoid the tax penalty.
As I'm shopping, what should I look for?
First, think about your health needs. Are you generally healthy and just need emergency coverage, or do you require regular doctor visits? If you have consistent medication needs, look for plans that cover those prescriptions..
Make sure the plan covers the doctors you want to see. "Even with a healthy family, you'll want to see if your children's pediatrician or the hospital you prefer are on the list," said Tanji Northrup, assistant commissioner of the Utah Insurance Department.
Make sure you understand terms such as copays (short for copayment, the amount you pay when you see a doctor), coinsurance (health plans where insurance pays part of the cost for specific care and you pay the rest) and deductibles (the amount of money you have to pay per year before your insurance kicks in).
Keep in mind that under ACA, preventive care is covered automatically and free of charge, so you won't need to worry about copays or deductibles for that.
When will my coverage start?
In the healthcare.gov marketplace, your start date depends on when you sign up. The open-enrollment period continues through next March. But "if you want coverage on Jan. 1, you need to sign up by Dec. 15," Northrup said.
What if I don't comply?
If you can afford insurance, but choose not to buy, you'll have to pay. In 2014, the tax will be $95 or 1 percent of income for an individual and $285 for a family.
By 2016, the penalty for an individual will be $695 or 2.5 percent of income while a family could face a $2,085 tax or 2.5 percent of income, whichever is greater.
Who is exempt from the mandate to have insurance?
Those who would have to pay more than 8 percent of their income on health insurance, those whose income falls below income-tax thresholds and Americans living in other countries are exempt from the mandate tax. You also are exempt if you're an undocumented immigrant, a member of a federally-recognized Indian tribe or you belong to a religion that can't accept health care.
What's my deadline, if I want to avoid a penalty?
The law sets a Jan. 1, 2014 deadline. But a short coverage gap of less than three consecutive months is allowed under the rules, so the Obama administration recently clarified that people have until March 31 to be covered in order to avoid the fine.
Keep in mind, however, that to get an exchange plan that starts March 1, consumers must generally sign up by Feb. 15. And if you want coverage to begin Jan. 1, you must enroll by Dec. 15.
Tribune reporter Kirsten Stewart contributed to this report.
TribTalk: How to buy health insurance
Benefits expert Dave Jackson and health care advocate Randal Serr spoke with Trib Talk's Jennifer Napier-Pearce to provide tips on selecting the health insurance plan that's right for you and your family. Find the video at http://bit.ly/1anFJsR.
Health insurance checklist
Whether through your employer, an insurance agent or an exchange (healthcare.gov for individuals, AvenueH.com for small businesses), what you need to know before buying a health plan:
Social Security numbers for everyone you want on your insurance policy.
Gross salary for you or your family.
A list of doctors and providers you want. Note the copayments for in-network providers and for those out-of-network.
A list of medicines your family needs. Check the drug formulary for any plan you're considering and note copays for each prescription.
A summary of benefits for any health plan you're considering. Look for services you need, such as infertility treatment or gastric-bypass surgery.
Know how much you can afford for monthly premiums.
If you are having difficulty using healthcare.gov and are waiting to shop until fixes are made, you can use the calculator at kff.org to get an estimate of how much you can spend on a health plan and what kind of subsidies you could be eligible for.