By Emily Wolfe Explore Big Sky Managing Editor
HELENA – On a six-city tour explaining and answering questions about Obamacare Sept. 26-Oct. 1, Montana Insurance Commissioner Monica Lindeen drew hundreds to town hall-style meetings in Butte, Bozeman, Billings, Great Falls, Missoula and Kalispell.
In March 2010, President Obama signed into law the comprehensive health reform law, the Patient Protection and Affordable Care Act, and two years later, the U.S. Supreme Court upheld key provisions of the law.
Some parts of it have already been enacted, and others are set to go into effect between now and 2018, with many of the largest provisions beginning January 2014.
Among other things, Obamacare also sets a baseline of required services for health insurance plans; changes laws for large businesses providing insurance; provides tax credits for low-income citizens; removes insurance companies’ ability to deny insurance for people with pre-existing conditions, or charge consumers more based on their current health (aside from tobacco use and age); allows children to remain on their parents’ policies until age 26; and limits insurance companies’ profits.
The town hall meetings were in advance of the Oct. 1 opening of new government-regulated health insurance marketplaces, which allow citizens to shop for policies online at healthcare.gov.
In Montana, Lindeen said, the marketplace will help the approximately 185,000 uninsured residents – or 22 percent of the state population – get coverage, many for the first time.
Requiring all citizens to have health insurance, the law has been controversial and divisive, with many Republican legislators seeing the ACA as an example of government overreach with possible high expense and increased federal debt.
“The whole point of the health insurance market is to get insurance for the uninsured,” Lindeen told Explore Big Sky in a phone interview. “The uninsured are part of the problem for why our costs are rising – they’re getting their healthcare coverage through the emergency room and hospitals. Their coverage is much more expensive as a result, which increases costs for everyone.”
Lindeen stressed that although this is a federal marketplace being created by the government – the 2013 state legislature voted against creating a Montana-regulated marketplace – private insurance companies will continue offering private policies.
The commissioner said she has fielded hundreds of questions at both the town hall meetings and online at her website, montanahealthanswers.com.
Most of the questions have been specific to an individual or family situation, she said, ranging from V.A. benefits to Medicare.
The tax credits were a common question, she said. Anyone making between 100-400 percent of the poverty level – which includes most of the middle class – qualifies.
However, this leaves out individuals and families making less than 100 percent of the poverty level, Lindeen said.
“The issue is that they would have gotten coverage through Medicaid expansion, but the Montana legislature chose not to expand Medicaid. We’ll have a gap in about 50,000 Montanans who will not be able to afford coverage – the working poor. This will be someone like a family of three making less than $19,500.”
While the marketplaces are already open, insurance will not be available until Jan. 1, 2014. Penalties for being uninsured will not be enacted until March 2014.
Small businesses with fewer than 50 full-time employees are not required to offer health insurance coverage under the ACA. Larger businesses with more than 50 are mandated to provide insurance, but have until Jan. 1, 2015 before they’ll be fined for not doing so.
“The overwhelming number of businesses in Montana are small businesses,” Lindeen said, “so this does not really affect them.”
“What’s great about [the ACA] in Montana, and is not always the case in other states, is that we’ve already required in state law almost every one of those benefits,” Lindeen said, referring to the “10 Essential Health Benefits” required by the law. “As a result, it didn’t increase the premium cost for Montanans.
“What matters most to me is getting out accurate information to people in Montana, so those who are uninsured can make educated decisions about how to take advantage of the opportunity to get insurance. For many, it will be affordable for the first time in their lives, especially for people who’ve had preexisting conditions who were never able to get insurance.”
The basics on healthcare reform for Montanans
Information from montanahealthanswers.com
Insurance industry reforms
After September 2010, insurers were required to do the following:
• Spend at least 80 percent of the premiums collected on customers’ health care, with those offering policies to large employers spending 85 percent of collected premiums on healthcare.
• Send rebates to customers spending less than the required percentage of premiums on healthcare.
• Extend coverage for dependent children to age 26.
• Could not rescind a customer’s coverage unless the customer submitted fraudulent information or intentionally misrepresented a material fact.
• Could not impose lifetime limits on insurance benefits or annual limits on what the insurer will spend on healthcare in 10 categories called “essential health benefits.”
• Could not deny coverage to children under age 19 because of a pre-existing condition. In 2014, insurance companies won’t be able to refuse insurance to anyone.
Insurance benefit reforms
Obamacare also requires health insurance to cover a basic range of services. By 2014, all insurance products must cover services in the following categories, known as “10 essential health benefits”:
1. Hospital visits and surgery
2. Doctors office visits
3. Prescription drugs
4. Maternity and newborn services
5. Mental health and chemical dependency services
6. Lab work and imaging
7. Rehabilitation services and services intended for skill acquisition, like speech therapy for a child who is currently non-verbal
8. Dental and vision care for children
9. Preventive care and management of chronic diseases, like diabetes
10. Emergency services
If buying insurance for yourself, your family or the employees of your small business in the marketplace, every policy must cover these benefits. However, large employers – business with 50 or more employees – don’t have to offer insurance that necessarily covers services in all 10 areas to be considered adequate.
Fulfilling the individual mandate
If you already have health coverage through any of the following sources, you’ve met the requirement of the individual mandate and won’t pay a penalty:
• Medicaid or Healthy Montana Kids (aka the Childrens Health Insurance Program or CHIP)
• TRICARE (for members of the U.S. military, retirees and their families)
• The veteran’s health program
• A plan offered by an employer that offers “minimum essential coverage” and is affordable
• Insurance bought on your own that meets the “minimum essential coverage” standard
You are exempt from the individual mandate if:
• You have to pay more than 8 percent of your income for health insurance, after taking into account any employer contributions or tax credits.
• Your family income is below the threshold for filing a tax return.
• You’re part of a religion opposed to acceptance of benefits from a health insurance policy or are a member of a recognized healthcare-sharing ministry.
• You’re an American Indian, an Alaska Native, or are married to an American Indian or Alaska Native.
• You’re not a citizen or not lawfully present in the U.S.
• You are incarcerated.
Individuals who choose to go without healthcare coverage face tax penalties enforced by the IRS. The penalty is phased in over time as follows:
• In 2014, the yearly penalty is $95 per adult, $47.50 per child (up to $285 for a family) or 1 percent of family income, whichever is greater.
• In 2015, the penalty is $325 per adult, $162.50 per child (up to $975 for a family) or 2 percent of income, whichever is greater.
• In 2016 and beyond, penalty is $695 per adult, $347.50 per child (up to $2,085 for a family) or 2.5 percent of family income, whichever is greater.