Patients trust their doctors. Polls show that when the public is asked which professions rate highest on honesty and ethical standards, physicians appear towards the top of the list.i So when patients have questions about health insurance, they're likely to ask their physician for advice on picking the plan that best suits their needs.
As a recognized Champion of Coverage, the American College of Physicians has agreed to provide unbiased and understandable resources to its physician members on ways you can help your patients obtain coverage through the Affordable Care Act (ACA). This guide provides specific information for Pennsylvania internists and patients on the resources that are available to them.
The ACA will make health insurance more affordable by providing health insurance tax credits and cost-sharing to the uninsured, underinsured, and small businesses; creating health insurance marketplaces to make shopping for health insurance easier; and implementing insurance reforms to make the market more accessible, predictable, and fair. In many states, the Medicaid program will be expanded to serve more people and health insurers in all states will no longer be able to deny insurance to those with pre-existing conditions.
According to the Institute of Medicine, being uninsured poses a hazard to one's health. Adults without health insurance are less likely to receive clinical preventive services that can reduce the likelihood of developing serious illness. Those with chronic disease are more likely than the insured to forego necessary therapies. Uninsured adults are also more likely to die from serious acute conditions than those with insurance. Lack of health insurance also takes a financial toll, as 60% of all bankruptcies are connected to the cost of medical care.ii
Over 1,358,000 Pennsylvanians under the age of 64 were uninsured in 2010 - 2011. Most individuals are now required to have health insurance. Patients who need health insurance will be able to purchase it through the state's health insurance marketplace and may be eligible for financial assistance to help with premiums and out-of-pocket costs. Others may be eligible for Medicaid coverage. This brief guide will provide information and useful links to resources that can help patients obtain coverage that is right for them.
Pennsylvania's health insurance marketplace will make it easy for patients to shop for the insurance that fits their needs.
Navigating the health insurance market can be a daunting and confusing experience, especially for people who don't receive health insurance through their employer and must buy it on their own. Pennsylvanians and their families who need affordable coverage can shop, compare, and enroll in health insurance through Pennsylvania's health insurance marketplace. The marketplace can help patients and their families make apples to apples comparisons of health plans and provide accurate, understandable information about provider availability, benefits, and costs. Patients will be able to see what their premiums, deductibles, and out-of-pocket costs will be before they enroll. If they qualify for Medicaid, the marketplace will guide patients to the appropriate enrollment resources. Health plans offered in the marketplace must meet an array of criteria including essential benefits, limits on cost-sharing, adequate provider networks, and follow new insurance market rules like prohibitions on capping pre-existing condition coverage. Plans will also be assigned "metal tiers" of Bronze, Silver, Gold, and Platinum, with the Platinum level plan providing the most generous benefits.
- Enrollment in Pennsylvania's health insurance marketplace begins in the fall season. More information can be found here.
- Your patients may be able to enroll in coverage outside of the open enrollment period. Individuals who experience a qualifying life event (such as the birth of a child, marriage, divorce, or employment change) or were unable to enroll in the marketplace during open enrollment due to certain complex situations (such as an enrollment website error) may be granted a special enrollment period. Your patients can check with your state's marketplace for more information on applying for coverage during special enrollment periods.
Health insurance plans can be confusing. Community organizations can help your patients enroll.
Choosing a health insurance plan is an important decision and patients may need assistance to pick a plan that fits their needs and budget. Consumer assistance organizations, called Navigators or in-person assisters, are on hand to raise awareness about coverage options; help your patients fill out application forms; determine if your patients are qualified for financial assistance; provide impartial advice on choosing a plan; and refer your patients to the state Medicaid agency, ombudsmen or other assistance organizations as needed. Other entities include certified application counselors - defined as a community health center or other health care provider, hospital, a non-federal governmental or non-profit social service agency in a state with a State, Federally-facilitated, or State Partnership Marketplace that receives training to assist people applying for coverage, may also provide insurance information and assistance. If your patient has a question about health insurance enrollment, refer them to the appropriate consumer assistance organization.
Pennsylvania has certified health insurance navigators who are trained to help your patients understand and choose among available health insurance plans. Find a local organization with certified navigators here.
More information about certified application counselors can be found here.
In addition, some marketplaces have granted permission for several online insurance brokers, like eHealth, to enroll eligible persons in plans offered through health insurance marketplaces.
- Pennsylvania's health insurance marketplace has a call center staffed by health insurance experts to provide help and information. Community-based organizations throughout the state will be there to provide in-person help to answer questions and assist with enrollment.
The call center number is 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325)
- Information on how your patients can prepare for applying and enrolling in health insurance coverage.
Patients may qualify for financial assistance to lower the cost of health insurance.
Health insurance can be very expensive, especially for those who don't receive coverage through their employer. Eligible individuals are now able to receive tax credits to buy insurance through Pennsylvania's health insurance marketplace.
How does it work? Uninsured patients will be able to apply through www.healthcare.gov, by phone, by mail, or in person at an establishment that provides enrollment assistance. All patients need to do is fill out the application, provide their Social Security number (or documentation stating that they are a legal resident), family size, employer and income information (such as a paystub or W-2 form), and the marketplace will determine whether a person is eligible for premium and cost-sharing assistance. If eligible for subsidies, the applicant will then pick a health coverage plan offered through the marketplace and the exchange will pay the subsidy directly to the insurer each month. The applicant pays the difference to the insurer.
- This subsidy calculator can help patients determine whether they're eligible for premium or cost-sharing discounts.
Small businesses can buy coverage and get financial assistance to provide insurance for their employees.
Small businesses have a particularly difficult time providing health insurance benefits to their employees due to the high cost, lack of plan uniformity, market volatility, and other factors. To help address these issues, the ACA requires the establishment of Small Business Health Options Programs (SHOP) in every state. Like the health insurance marketplace for individuals, Pennsylvania's SHOP marketplace will give small businesses the opportunity to select from a variety of plan options, compare costs and standardized benefits, and receive enrollment assistance.
To help make insurance more affordable, small businesses that offer insurance benefits and meet employee and average income qualifications can receive a tax credit that cuts the cost of premiums. The small business tax credit provides 50% of the cost of insurance purchased through the SHOP marketplace.
- SHOP marketplace call center: 1-800-706-7893 (TTY users: 1-800-706-7915). Available Monday through Friday, 9 a.m. to 7 p.m. EST.
- SHOP website
- Small business health insurance tax credit information
Pennsylvania Medicaid coverage is expanding to provide low-cost, comprehensive health insurance to more people.
Starting in 2015, all Pennsylvanians under age 65 and whose income is less than 138% of the federal poverty level (that's about $33,950 for a family of four) will be eligible for the state's Medicaid program. Patients can sign up for and renew Medicaid coverage through healthcare.gov (via website, phone, or in-person) and their local Department of Social Service or Health Department. Patients can receive a real-time notification regarding their application status. Eligible individuals can enroll in Medicaid coverage at any time throughout the year.
iGallup. Honesty and Ethics in Professions. November 2012. Accessed at http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx#1 on July 24, 2013.
iiInstitute of Medicine. America's Uninsured Crisis: Consequences for Health and Health Care. Report Brief. February 2009. Accessed at http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2009/Americas-Uninsured-Crisis-Consequences-for-Health-and-Health-Care/Americas%20Uninsured%20Crisis%202009%20Report%20Brief.pdf on July 24, 2013.