It’s the Patient Protection and Affordable Care Act, a.k.a Obamacare. And it’s finally arriving this week.
On Tuesday, millions of people in Florida and across the United States will, for the first time, be able to log online and comparison-shop for individual health insurance coverage under the new federal law.
Here are 10 things to know before the federal Affordable Care Act’s marketplaces go live.
Florida is one of 27 states using a federally run health insurance marketplace — also known as an online exchange — to let residents compare and shop for coverage.
Accessible at healthcare.gov, the online exchanges are set to go live Tuesday. An open enrollment period will run from Oct. 1 through March 31, 2014.
People who wish to have coverage in place by Jan. 1 must enroll in their plans by Dec. 15.
The healthcare.gov site will prompt users to input information like age, location, gender, Social Security number and current policy number (if applicable). It will then show a list of available plans, as well as coverage details and pricing, and eligibility for federal subsidies or Medicaid. You can then choose to purchase a plan from the ones available.
• Plans are split into various tiers.
Insurers will offer plans on five tiers: platinum, gold, silver, bronze and catastrophic.
The four “metal” tiers come with different costs and benefits. Platinum plans will carry the highest monthly premiums and the lowest out-of-pocket costs like co-payments and deductibles. Bronze plans will have the lowest monthly costs but higher out-of-pocket costs.
The fifth option, catastrophic coverage, is available for people 30 or under and certain low-income residents. These are high-deductible, low-premium plans that are not eligible for tax credits.
• How much will it cost? Depends.
The federal government won’t provide an under-the-hood look at specific plans until the online exchanges go live on Tuesday. With so many variables to consider — age, gender, location, income, smoking habits, coverage networks, deductibles, co-payments, etc. — it is impossible to predict exactly how much someone might pay.
However, the U.S. Department of Health and Human Services announced last week that, on average, health insurance premiums for plans purchased through the online exchanges will be about 16 percent less than originally projected. In Florida, that means a 27-year-old making $25,000 a year would, on average, pay a $218 monthly premium for a middle-tier plan, before any tax credits.
The Obama administration said prices will be especially competitive in areas like South Florida where several insurance companies are offering multiple plans. In Miami-Dade and Broward counties, premiums will be among the lowest in the state. Miami-Dade has nine insurers offering a total of 141 different plans, and Broward has at least eight insurers offering a total of 136 plans.
A 29-year-old Broward resident, on average, would pay a monthly premium of $91.62 for the lowest-cost catastrophic plan, $136.80 for the lowest-cost bronze plan, $185.62 for the lowest-cost silver plan and $201.31 for the lowest-cost gold plan, all before any tax credits. In Miami-Dade, a 29-year-old resident, on average, would pay for the same plans $116.36, $173.74, $216 and $255.67 a month, respectively, before tax credits.
Not surprisingly, the prices of premiums rise with the age of the insured.
A 55-year-old in Broward would be paying, on average, $272.62 a month for the lowest-cost bronze and $401.18 a month for the lowest-cost gold plan – the least-expensive rates in the state. The same hypothetical 55-year-old living in Miami-Dade would pay an average of $346.23 a month for the lowest-cost bronze and $509.51 for the lowest-cost gold plan, before tax credits.
• Everyone will receive 10 essential benefits.
The Affordable Care Act requires that all health insurance plans offered through the online exchanges provide at least 10 “essential benefits.”
They are: hospitalization, emergency treatment, outpatient services, maternity and newborn care, mental health and substance abuse services, prescription drugs, rehabilitative services and devices, laboratory services, preventative and wellness services and chronic-disease management, and pediatric services with dental and vision care.
• Subsidies may help cut the cost of coverage.
The federal government will defray some costs of health insurance coverage through subsidies — tax credits — that it will pay directly to insurance companies. Individuals and families who earn between 100 percent and 400 percent of the federal poverty level ($11,490 to $45,960 for an individual, and $23,550 to $94,200 for a family of four in 2013) may be eligible for sliding-scale subsidies to help pay for premiums.
Of the seven million or so people that the government projects will enroll in health insurance through online exchanges in the next six months, about six million are expected to qualify for subsidies. In Florida, an estimated 1.7 million residents will be eligible for subsidies, according to the non-partisan Families USA.
Two caveats: You may not be eligible for a subsidy — even if you fall within the income requirements — if your employer offers affordable coverage that meets federal requirements. And, the only way to qualify for and receive a subsidy is if you enroll for a health insurance plan through the online exchanges, healthcare.gov.
• Pre-existing conditions are no longer a factor — but smoking is.
Under the Affordable Care Act, insurance companies are no longer allowed to deny coverage based on pre-existing medical conditions. But smokers should expect to pay a surcharge for their coverage. When signing up through the online exchanges, people will be prompted to answer whether they smoke, and prices will change depending on how they answer.
• Patience may be necessary.
“Like any law, like any big product launch, there are going to be some glitches as this thing unfolds,” President Barack Obama said Thursday. Earlier that day, administration officials announced that at least two elements of the exchanges — a portal for small-business owners and a Spanish-language site — would be delayed.
Owners of businesses with fewer than 50 employees will still be able to compare plans and coverage options starting Tuesday, but they won’t be able to sign up workers until at least Nov. 1. And the Spanish-language site, CuidadoDeSalud.gov, will not be able to enroll people for another few weeks.
“Initially things may well be confusing and frustrating as the signup system goes live,” said Steven Ullmann, professor at the University of Miami School of Business Administration and director of its Center for Health Sector Management and Policy. “It will be interesting to see how easy individuals find it using the website or alternative ways to sign up with various aids in place to help decision-making.”
• Help is out there.
Hundreds of people and organizations in Florida have received federal funding and training to serve as “navigators,” helping consumers and businesses sort through the online exchanges and make sense of their options. Navigators must provide free assistance and may not recommend specific plans.
“We are unbiased, so we don’t recommend one plan over another,” said Karen Basha Egozi, a navigator and CEO of the Doral-based Epilepsy Foundation of Florida. “We just listen and provide the information each person is trying to access. As far as the plans go, it will be an individual situation. The one-on-one is important.”
In addition to navigators, more than 40,000 insurance brokers and agents have gotten federal certification to help walk people through the enrollment process on the federal exchanges. Humana, for instance, is beefing up its retail centers and co-sponsoring community events where information about the exchanges is available. Florida Blue has nearly doubled its agent workforce in the state and expects heavy traffic in its retail centers.
“We feel like people are just going to want to have that interaction,” said Jon Urbanek, a Florida Blue senior vice president. “We’re going to have a lot of feet in the street.”
Questions about the enrollment process also can be answered by calling a toll-free hotline, 800-318-2596, or by logging on to a live, private chat at healthcare.gov/chat.
• You will pay a penalty if you don’t have health coverage.
Americans who choose not to carry health insurance will have to pay a penalty unless they meet one of a handful of exceptions, such as being a member of a federally recognized Native American tribe or have such a low income that they are not required to file an income tax return. Also, Floridians who would have qualified for Medicaid under the Affordable Care Act’s new income limits will not pay a penalty because the state refused to expand Medicaid coverage.
For the rest, the penalty next year for not having health insurance is 1 percent of a person’s annual income or $95 per person per year, whichever is higher. The penalty increases every year; in 2016 it will be 2.5 percent of income or $695 per person.
Children also must have coverage. The fee for uninsured children is $47.50 per child in 2014, up to $285.
• You may not have to use the online exchanges.
The exchanges are mainly for the uninsured and people who cannot get affordable coverage through their employer. The majority of Americans, about 85 percent, already have coverage through their jobs, and they likely will not buy policies on the exchanges.
Others who won’t need to shop for insurance on the exchanges include the roughly 12 percent of Americans covered through Medicaid and the Children’s Health Insurance Program. Also, people 65 or older on Medicare do not have to enroll. Undocumented immigrants are not eligible for coverage.
And others are exempt from enrollment, including members of Native American tribes, people whose premiums would cost more than 9.5 percent of their annual income, and those with incomes low enough that they don’t have to file income tax returns.
Those who likely will have to enroll or face penalties: the estimated 3.8 million Floridians younger than 65 who currently do not have health insurance.
Miami Herald staff writers Daniel Chang and Patricia Borns, and Tampa Bay Times reporter Jodie Tillman, contributed to this report. This story was produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.