We are now in the Open Enrollment period for individual health coverage under the Affordable Care Act (AKA “ACA” or “Obamacare”). But let’s be honest: many of the individual health plans offered under the ACA do not seem particularly affordable.
For example, a 40-year-old male living in Essex County has a choice of plans with monthly premiums ranging from $289 to $711. An older person will pay more; a younger person less. The ACA keeps the price range between 21 year olds and 64 years olds from being too great, but the older you are the more expensive it gets. Benefits and cost-sharing (what you have to pay yourself) can vary considerably.
However, this is not the entire story. Part of the affordability of health plans comes in the form of several ways in which the government helps out with the cost of health coverage. Such help is income-based and designed to assist people whose income is considered to be low to moderate.
(Note: People who have or who are eligible for employer group plans – such as those through the Episcopal Church, Medicare, Medicaid, TRICARE and other such plans – are not eligible for plans through the ACA. The ACA plans are strictly for those who do not have other coverage. I might add that typically these group plans are much less expensive than those through the ACA.)
The three primary ways to make health coverage more affordable are:
Medicaid and CHIP: New Jersey has expanded Medicaid which allows more eligible people to get into very low cost or even zero premium plans. New Jersey also has CHIP (Children’s Health Insurance Program), which provides coverage for children under 18 years old. The income levels to qualify for Medicaid and/or CHIP are quite low. However, anyone who is in Medicaid is in a limited network. Many physicians and facilities do not participate in Medicaid.
Premium Tax Credit: A premium tax credit (AKA “PTC”) is a refundable credit that helps eligible individuals and families with certain levels of income afford health insurance purchased through a Health Insurance Marketplace. The premium tax credit is a credit given to help those eligible pay for health insurance. It is income-based, but the level of income is significantly higher than that for Medicaid eligibility. If a person is eligible for a PTC, she or he may take it in advance as payment toward the premium of a health plan or take it when she or he files income tax with the IRS. If taken in advance there is a reconciliation when the person files with the IRS. If a person received too much money in advance, she or he will have to pay the difference to the IRS; if the person received too little, the government will make up the difference. In any case, the premium tax credit can provide significant help in paying for health coverage.
Cost Sharing Reduction: Cost Sharing Reduction (AKA “CSR”) is the third way people can get a break with their health coverage through the Affordable Care Act. These are subsidies which lower the cost of the out-of-pocket expenses associated with any health plan, specifically deductibles, copayments and coinsurance (the percentage amounts). CSR subsidies can be paired with premium tax credits to make a health plan even more affordable.
A key point is that to get a premium tax credit and/or CSR subsidiary a person must go through the ACA Marketplace. The Marketplace can also be used to find your eligibility for Medicaid or CHIP. Using the Marketplace means going online at HealthCare.gov (not .com) or calling the Marketplace Call center (800-318-2596).
You can also get personal assistance either through an insurance agent or broker or through an assister. Assisters are not licensed, but are trained to assist without actually signing someone up for a plan. Agents and brokers are licensed by the state and certified by the Center for Medicare and Medicaid Services to help people apply.
This year the Open Enrollment started November 1, 2015, and ends January 31, 2016. In case you did not notice, this is a shorter period than last year. If you want health coverage to start January 1, you should enroll not later than December 15.
Diocesan canons mandate that churches provide health benefits through the Episcopal Church Medical Trust for (a) all lay employees scheduled to work a minimum of 1,500 hours annually and (b) all clergy working half time or more. Eligible clergy and lay employees may opt out only if they have comparable coverage through another source, such as a spouse or previous employer.
