Health Care MarketplaceNews & Research

Will Every County Have Coverage in 2018? Yes – But Options Will Be Limited

As open enrollment for Obamacare in 2018 approaches, insurance companies are still examining whether to offer coverage in the health insurance marketplace. Some companies may decide to stay, and some may decide to exit, but data released by the Centers for Medicare and Medicaid Services shows every county in the U.S., barring any last-minute exits, will have at least one insurance company to choose from.

Anthem, one of the nation’s largest insurance carriers, recently announced it would continue to offer coverage in 63 counties in Virginia. The company also said it will remain in cities and counties that were at risk of not having any Obamacare coverage options in 2018. By offering coverage in so-called “bare counties,” Anthem will possess a monopoly in regions with only one coverage choice.

Limited insurance company participation, especially in counties with only one option, could cause premiums to skyrocket. Additionally, the uncertainty over the individual mandate and cost-sharing subsidies has many insurance companies pricing in premium increases for 2018.

For example, Michigan expects to see a premium increase of close to 28 percent in 2018. The huge spike in monthly premiums is due in large part to ambiguity over whether the Trump administration will continue cost-sharing payments to help subsidize insurance for low-income Americans.

In Tennessee, premiums will increase by 42 percent on marketplace plans offered by Cigna. In addition, BlueCross BlueShield of Tennessee received approval by the state’s insurance commissioner to raise premiums by 21 percent. The state also cited uncertainty over what the federal government plans to do about cost-sharing payments and the individual mandate. Most low-income Americans receive subsidies to help offset any increases in monthly premiums.

A last-ditch effort by the GOP this week to repeal and replace Obamacare did not succeed. Reports indicate that the bill sponsored by Republican Senators Lindsay Graham and Bill Cassidy did not have enough votes to move on to the floor of the House of Representatives. However, any legislation that repeals and replaces Obamacare would take some time to implement even if Republicans had enough support. Most analysts say that a transition period would be in effect until there is any full repeal of the Affordable Care Act.

Open enrollment for health insurance coverage required by the Affordable Care Act starts on November 1, 2017 and ends on December 15, 2017. In the past, participants had until January 31 of the following year to apply for coverage through the healthcare exchanges. The shorter time frame means that customers have just six weeks to find, choose and enroll in coverage for next year.

Overview of Insurer Participation on the Exchange in 2018 

Across the country, consumers are finding that their options for health insurance through the exchanges under the Affordable Care Act (ACA) will be significantly reduced in 2018. Several large insurers have chosen to bow out of the marketplace over uncertainty involving cost-sharing reduction payments as well as financial losses incurred over the last three years. Enrollment for next year will run from November 1 through December 15. Here’s what you need to know.

Dwindling Options

A map released earlier this year and updated weekly by the Centers for Medicare and Medicaid Services (CMS) demonstrates the reduction in options across the country. As of the most recent projections, over 47 percent of counties nationwide have only one option on the exchange. This means that over 2.6 million people, about 29 percent of exchange customers, will have a choice in their insurance provider in 2018. Alaska, much of the Southeast, the Midwest and some of the Southwest will have the fewest options while those in the Northwest and Northeast will have more choices.

September 27 Deadline

Insurers have until September 27 to sign their final contracts to participate in the marketplace in 2018, but they are not required to service an entire state. Across 20 states and the District of Columbia who use the ACA marketplace, an average of just over four insurers have indicated they intend to participate, which is down from the five that said they would participate in 2017. In 2014, an average of six agreed to participate. Participation varies among insurers because one insurer is not required to cover an entire state, which is why the CMS uses counties instead to determine participation.

Premium Deadline

Although insurers have until September 27 to decide if they will participate, most states require that carriers submit their premium and service area information in May or June of 2017. This allows the market to have those services in place for January 1, 2018. Once the final contracts are signed at the end of September, premiums are locked for the entire year. Insurance companies cannot change premiums or service areas until 2019.

Congressional Debates

Although Congress did not repeal or replace the ACA, there were several bills, one of which passed the House of Representatives, that would significantly change healthcare in the United States. Although the Senate bill did not pass, it contained provisions that would not only have changed the healthcare law, but could have done so retroactively. Even though the bills did not move out of Congress, there are still questions about how the current administration will address the individual mandate as well as how insurance companies will be reimbursed for providing coverage required under the ACA.

Individual Mandate

One portion of the ACA that has been hotly contested in Congress and was a key part of the presidential campaign is the individual mandate. The individual mandate is a critical part of the ACA as it requires all Americans to have health insurance or face an IRS penalty. The idea was that people without medical problems would pay the same premiums as people with pre-existing conditions. Because healthy people need less medical care, their premiums could be used to offset the higher cost of care for sicker enrollees.

Although the efforts to repeal and replace the ACA failed, the House Appropriations Committee’s Financial Services and General Government Subcommittee passed an appropriations bill that could still go into effect. This bill would ban the IRS from using money from the budget to enforce the individual mandate. Employers and insurance companies may also be able to forgo reporting health insurance coverage to the IRS. According to experts, this would basically eliminate the mandate.

In January, President Trump signed an executive order rolling back the enforcement of certain aspects of the ACA, and the IRS appeared to be easing off enforcement in the months that followed. More recently, the IRS has insisted that it will be upholding the current law’s mandate to have coverage and collecting penalty payments as appropriate.

With no way of knowing if the individual mandate would remain in the coming years, insurers chose to leave the marketplace in 2018 rather than risk losses when healthy customers stopped paying premiums that covered people who needed costlier care.

Cost-Sharing Subsidies

Under the ACA, insurance companies receive subsidies that help offset costs for low-income customers. President Trump has promised to eliminate funding for those subsidies. Many believed that President Trump was attempting to force Democrats to negotiate with him on replacing the ACA. This led many insurance companies to increase premiums and reduce their participation in the Obamacare marketplace. The fate of these so-called cost-sharing reduction payments still remains to be seen.

Medicaid Expansion

Some have proposed that insurers would be less likely to leave the marketplace if Medicaid expansion continued. The ACA planned for Medicaid to expand in all states, but a Supreme Court decision determined that the federal government could not require states to expand their programs under new guidelines.

Under the expansion program, you could enroll in a Medicaid program if you earned up to 138 percent of the federal poverty level. People living in the 19 states that rejected expansion don’t have this option but may be able to get Medicaid if they meet their state’s specific requirements.

Because poor people are often unhealthy for various reasons – including food insecurity, lack of access to abundant medical care and lifestyle choices – having a significant number of low-income people obtaining insurance in the marketplace may have made it more expensive for insurance companies. In Alabama, for example, Blue Cross Blue Shield reports that they are spending $1.20 for every $1 they collect in premiums.

During the presidential campaign, President Trump said that if nothing was done to replace the ACA, it would eventually collapse, and the fact that millions of Americans could face limited choices for next year supports his theory. Until there is more stability from the federal government in the area of healthcare, there could be more insurers choosing not to participate in the exchanges, thus perpetuating the cycle.

Why Don’t People Keep Their Coverage? 

Exit polls conducted by the Centers for Medicare and Medicaid Services (CMS) found several reasons why consumers choose not to keep health insurance that they purchased in the marketplace under Obamacare. Although enrollment is often touted as high in media reports, states actually look at what is known as effectuated coverage when tallying signups.

When someone signs up for healthcare coverage, there may be a delay from the enrollment to the time the first bill is due. When you enroll and pay the premium, you have put the policy “into effect,” or effectuated the policy. As of February 2017, 15.6 percent of those who enrolled in health insurance did not pay the premium to keep their coverage in effect. This is up from 12.6 percent at the same time in 2016, and a recent report released by the CMS based on exit polls outlines the reasons for the drop in coverage.

High Cost

According to the report, consumers have seen health insurance costs rise significantly since 2013. In that year, the average premium was $232 a month while in 2017, the cost rose to $476 a month, an increase of 105 percent. These numbers reflect increases in the 39 states that use HealthCare.gov as their marketplace as opposed to their own state marketplace. An increase in premiums is the reason many consumers say that they decided not to pay for health insurance. Approximately 46 percent of those who canceled coverage said that cost was the reason while 20 percent claimed a premium increase, whether it was from the previous year or because they had to change plans, for the reason they decided to cancel.

Ineligibility for Financial Assistance

Sometimes, when people apply for health insurance, they believe they will qualify for financial assistance in the form of subsidies under the Affordable Care Act. However, it’s possible that once they complete all the documentation, they are not eligible for the subsidies or the subsidies aren’t enough to make a difference in premium costs. At least 17 percent of those surveyed in the exit polls cited this as a reason for canceling their policies.

Under the law, anyone making up to 400 percent of the federal poverty level qualifies for some level of assistance when buying marketplace plans, but assistance varies by income. If income rises, this can reduce the amount of subsidy available or make you ineligible for any subsidy.

Coverage Elsewhere

According to the CMS report, 49 percent of consumers who terminated their coverage after paying one month of premiums said that they found coverage elsewhere. Almost 58 percent of those said they obtained health insurance from an employer while 22 percent said they became eligible for Medicare. Often, people turn to the marketplace when their employer either does not offer health insurance or they are unemployed.

It’s possible that you could enroll in a marketplace plan and then find another job or gain employment that offers health insurance after you enroll, making the marketplace plan unnecessary. In addition, circumstances can change so that you qualify for Medicare after enrollment, which also eliminates the need for a marketplace plan.

Loss of Insurer

A map released in the summer by the CMS showed that 17 counties in the U.S. would have no insurer participation for 2018, something that has now been remedied. Despite the fact that every county now has coverage, much of the country still lacks more than one carrier option for next year. Choice plays a big role in customer satisfaction and retention.

According to the CMS report, 77 percent of those who were able to purchase and maintain coverage with one insurer were more likely to keep their insurance in effect. Even in areas where consumers have options, insurance companies are leaving the market, which means their customers must find plan options elsewhere. That coverage may not be as extensive and could have higher premiums than what they were paying before.

Unaware of Requirement

As late as 2015, about 20 percent of people who did not have insurance said that they were unaware that it was required, or they thought the requirement did not apply to them. In fact, some of those who don’t have insurance could be exempt under the law – but you need to apply or ask an insurance specialist about that beforehand rather than assuming as much.

Many of those who say they were unaware of the requirement to have health insurance live in rural areas with little access to national news media. Although the number of people who are unaware of the need for health insurance is dwindling, there are still those who remain uninsured because they don’t know that it’s required by law.

Medicaid Expansion

As of July 2016, 31 states along with the District of Columbia had agreed to expand Medicaid eligibility for nonelderly adults with incomes up to 138 percent of the federal poverty level. In states that did not choose expansion, eligibility is limited. In some areas, adults do not qualify for Medicaid unless they are 44 percent under the poverty level. Adults without dependent children also may be ineligible. In those states, millions fall into a gap of coverage because they earn too much for Medicaid but not enough to qualify for tax credits offered in the marketplace.

Immigrants also have problems getting coverage. Undocumented immigrants are not eligible for either Medicaid or marketplace coverage. Lawful immigrants who earn up to 400 percent of the federal poverty level are eligible for marketplace tax credits but only if they pass a five-year waiting period. These regulations have left many in the U.S. uninsured.

Healthy People

One final reason why some may enroll for insurance and then not put it in force is that they don’t see a need for health coverage because they are young and healthy. Even with the IRS penalty for not having insurance, some prefer to pay the penalty than pay a monthly premium for something they don’t believe they need. This has created issues in some areas as premiums for those who aren’t using health insurance for medical expenses help offset the costs of those who need costlier care. If healthy people continue to skip insurance or drop their coverage, insurance companies may be unable to cover the cost of treatments for those who have medical issues.

Lots of factors contribute to people dropping their coverage after signing up during open enrollment, just as there are plenty of reasons why people choose to forgo insurance altogether. Although the ACA was designed to eliminate some of these issues, it’s apparent that more work needs to be done to lower premiums, keep insurance companies in the marketplace and provide incentives for low-income families to obtain insurance.

Minimum Essential Coverage Under Obamacare: What Does It Mean?

Under the Affordable Care Act passed in 2010, nearly every American citizen must hold qualifying health insurance or face a penalty at tax time. In order for a plan to be approved under Obamacare, it must meet several “minimum essential coverage” regulations.

If you have insurance through your job or use government or private coverage, you most likely meet the minimum essential coverage standards already. If you’ve been allowed to keep the same insurance you had before the passage of the Affordable Care Act, you’re probably also in the clear. When filing your federal income taxes, you must state how many months of the year you and any of your dependents have been with or without minimum essential coverage. Common plans that are acceptable for minimum essential coverage include:

  • Any “grandfathered” plan that you’ve had since before March 23, 2010
  • Medicare Part A and C (part B by itself isn’t enough)
  • The Children’s Health Insurance Program (CHIP)
  • Coverage provided to Peace Corps volunteers
  • TRICARE plans (United States Military insurance)
  • Certain plans provided by the Department of Veterans Affairs
  • Most student health plans
  • Most Medicaid plans (except limited coverage plans)
  • Any plan that you get from your employer
  • COBRA coverage
  • Retirement plans provided by a previous employer

Some plans not listed above are still acceptable under the Affordable Care Act. In fact, you’ll notice that private coverage — plans you buy outside of a job and pay for yourself — isn’t on the list, but many private insurance plans are also considered minimum essential coverage under the law.

To qualify as ACA-compliant, which is a term used to describe plans that meet the law’s requirements, a current health insurance plan must meet specific guidelines put in place by the law. Here are a few requirements under Obamacare:

Coverage

All major medical plans sold today must cover certain essential health benefits. These include outpatient care; maternity before, during and after labor; hospitalization; rehabilitation services and equipment; laboratory testing; preventive and wellness screenings; mental health services; prescription drugs; emergency care; and pediatric care, including dental and vision. The degree to which insurers have to cover these services varies, but preventive care is now included at no added out-of-pocket cost, meaning yearly checkups shouldn’t cost you anything.

Cost

Premiums for ACA-compliant plans must be reasonable. In addition, copays and other out-of-pocket expenses must have a maximum. That means individuals will be capped on what they have to pay out of pocket for covered medical care in a year.

Insurance Regulations

The plan must cover at least about 60 percent of healthcare-related costs, leaving about 40 percent of the cost (in out-of-pocket expenses) up to the plan holder. There are four metal tiers under Obamacare, ranging from bronze to platinum. Bronze plans have low premiums and high deductibles while platinum plans include high premiums and lower out-of-pocket costs. ACA-compliant plans must also guarantee coverage for all persons regardless of pre-existing condition. Inability to pay is the only reason to be denied coverage.

Plans must also be renewable for every person no matter the health status of the applicant or whether it’s changed since the previous year.

If an insurance carrier fails to spend at least 80 percent (85 percent for the large group market) of the money they make from premiums on consumer services, they must rebate those individuals a portion of their premiums.

What Plans Aren’t Accepted?

Some types of health insurance are great as supplemental coverage to major medical plans but don’t meet the minimum essential requirements to exempt you from a fee. These include worker’s compensation insurance, Medicare part B by itself, standalone dental and vision coverage, coverage only for a specific disease or disability, short term insurance plans, and disability or accident insurance.

How to Get Coverage

Under the Affordable Care Act, there are several methods you can utilize to acquire insurance. You can:

  • Use an agent or insurance broker who can introduce you to plan options
  • buy a plan directly from an insurance company through a private market
  • Use an online marketplace or buy a plan directly from the Obamacare website at HealthCaregov.

Each year, there are specific enrollment dates for signing up for an ACA-compliant health plan. For coverage starting next year (2018), enrollment runs from November 1 through December 15.

Though these are the standard dates for individuals to choose a healthcare plan, you may be able to apply outside of the open enrollment period based on your circumstances. Certain life events may qualify you for special enrollment dates, such as marriage, birth or adoption of a baby, change of address, turning 26 (being removed from your parents’ plan), leaving incarceration, becoming a U.S. citizen, death of someone on your plan, or a legal separation or divorce. You may also qualify for special enrollment if you lose insurance coverage due to any number of events.

If you have coverage through your job, you’ll have a different enrollment period depending on your company. The above dates and restrictions are for people buying private health insurance on or off the Obamacare marketplace. Note, too, that Medicaid and CHIP (Children’s Health Insurance Program) don’t have enrollment dates. If you qualify for these programs, you can apply any time of the year.

Keeping Your Healthcare Data Safe During and After a Storm

All types of storms can cause significant damage, from a tornado spawned by summer thunderstorms to heavy snows that lead to building collapses. Hurricanes like Sandy, Katrina, Harvey and Irma have created catastrophic damage in their wake, including flooding, destroyed buildings and extended power outages. As a healthcare provider, you are not immune to damage from a storm. Your buildings can flood, your roof collapse and extended power outages can cause significant issues for your organization. One of the most important things to protect is the healthcare data you store on your patients. There are things you can do to make sure that patient data is protected and safe during and after a storm.

Electronic Records

If you’re like many health organizations today, you’re storing much of your patient data in electronic form. After Superstorm Sandy in 2012, it was discovered that healthcare organizations who stored patient data electronically were better able to assist patients during disasters, even with widespread power outages. During the storm, Long Beach Medical Center suffered significant damage. The basement where the electrical, heating and communications systems were located flooded with more than 10 feet of water.

Prior to the storm’s landfall, however, the hospital backed up data stored as electronic health records so that it could be accessed after the storm passed. This critical step allowed them to access patient records after the storm, and the backup protected all records from damage when the hospital itself was inaccessible.

Personal Electronic Records

Doctors and healthcare providers are not the only ones who need to protect healthcare data during and after a storm. Medical records contain a significant amount of personal information. After tornadoes in Joplin, Missouri, paper healthcare records were found as far as 75 miles from the storm center. During Hurricane Katrina, over a million paper records were destroyed.

Although most healthcare providers now use electronic health records, it is possible that extended power outages or lack of internet service could mean that physicians can’t access vital records. It’s also possible that patients and doctors can’t communicate after a disaster due to things beyond their control, like evacuation orders.

For these and other practical reasons, patients should create a Personal Health Record (PHR), which can be completed manually or downloaded from a physician if offered. You determine who can and cannot access the information. While a PHR does not replace the legal healthcare information in your physician’s file, it can be a backup source for when you can’t access your actual record after a storm.

Patient Portals

Another way for both healthcare organizations and individuals to protect their medical records is through patient portals. During and after an emergency, patient portals allow you to access your health information no matter where you are. In some cases, the patient portal allows you to download information to your own PHR. The portal also enables you to refill prescriptions, check lab results and interact with your provider. Using the portal, a physician in another area can get the information he needs for treatment if you’re not able to return home anytime soon.

Paper Records

In rural areas where internet access is not as readily available, it may be necessary to retain records in paper form. In addition, some older people are not comfortable with electronic health records or may not be familiar with computers.

If your healthcare provider still uses paper files, request a copy for your own records. Store the records in a fireproof safe or lock box. Be sure to place the papers in a Ziploc bag if there is a risk of flooding from the storm. You will also want to have a copy of your health insurance cards, prescription records and contact information for all of your physicians, especially your primary care doctor.

Medical providers who must retain paper records should have a plan in place for getting all records out of harm’s way before the storm arrives. It may mean loading file cabinets into trucks and transporting them to a safe place. You may also need to invest in stormproof transport boxes that will allow you to move the files to a safe place prior to the storm.

The best way to protect any medical records during and after a storm is to store them electronically and to have backups of any electronic records. Quick and easy access to medical records will help you if you’re injured or sick. The last thing you want to do when you’re tired, scared or injured is sort through the wreckage of your personal belongings looking for your immunization record.

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