Health Insurance Marketplaces play a critical role in health care reform

Oct. 05, 2013 @ 11:01 AM

The Health Insurance Marketplace in North Carolina is now open for business.

The Health Insurance Marketplace is a new mechanism for purchasing health insurance and a critical component of the Affordable Care Act’s plan to extend quality health insurance coverage to millions of Americans currently without it. 

The Marketplace operates primarily on line, somewhat like Travelocity and Expedia do for buying airline tickets.  Its goal is to create a more organized, competitive insurance market by providing information on different plans in plain language and by facilitating comparisons across plans. 

There are, in fact, two marketplaces, one for eligible individuals and one for small businesses with up to 50 full-time employees who want to buy insurance for their employees.  (Health insurance options for small businesses were described in a Herald Sun article Sept 22, and won’t be discussed here.)

Only U.S. citizens and legal immigrants who do not have access to affordable health insurance through their employer, Medicare, nor Medicaid, can purchase insurance on the Marketplace for individuals.   If you qualify, however, you can do a lot on the Marketplace:

-- You can see the various insurance plans available in our area and do side-by-side comparisons of different plans. 

-- You can find out whether you are eligible for federal assistance in purchasing insurance and, if so, how much.  This assistance includes subsidies to help pay your insurance premium (if your household income is between 100 percent and 400 percent of the federal poverty level) and lower out-of-pocket costs for deductibles, co-pays and co-insurance (if your income is between 100 percent and 250 percent of the federal poverty level).

--Based on what you learn, you can then complete an enrollment form for the plan that works best for you.  Plans purchased on the Marketplace by Dec. 15, will go into effect January 1, 2014.  Thanks to new regulations going into effect January 1, you cannot be denied coverage or charged a higher rate because of a pre-existing condition. 

-- You can also find out if you or your children qualify for Medicaid or the Children’s Health Insurance Program.

In some ways the plans offered through the Marketplace will be quite similar.  They must all provide “essential benefits” in at least the following 10 areas: 

-- Out-patient services

-- Emergency services

-- Hospitalization

-- Maternity and newborn care

-- Mental health benefits and substance use disorder services,

-- Prescription drugs

-- Rehabilitative services and devices

-- Laboratory services

-- Preventive and wellness services and chronic disease management

-- Pediatric services, including oral and vision care


In addition each plan must offer its benefits at four value levels: bronze, silver, gold and platinum, with each level distinguished by what the insurer pays.  At the bronze level the insurer pays an average of 60 percent  of the cost of plan benefits (and you pay 40 percent ), at the silver level it’s 70 percent , gold 80 percent and platinum 90 percent .  The premiums for bronze level plans are cheapest, and those for platinum plans are most expensive. 

The Marketplace will also offer catastrophic health insurance plans, but only to two groups: persons under age 30 and those people who are exempt from the ACA requirement to purchase health insurance because the premiums for all available plans exceed 8 percent  of their income.  The premiums on these catastrophic plans are considerably less expensive than even the bronze plans, but the deductibles will be substantially higher.

In North Carolina, the federal government is running the Health Insurance Marketplace so we will use the federal website to compare plans and enroll.  The enrollment period began Oct. 1 and runs through March 31 of next year.

This is a new system, it’s not that simple and there will probably be some glitches as it’s rolled out.  Fortunately, help is available.  Here in Durham, people needing assistance can look to Lincoln Community Health Center (LCHC), our federally qualified health center, for enrollment assistance.  LCHC has hired six certified application counselors (CACs).  Two CACs and the coordinator will be stationed at LCHC, while three CACs will be dispersed throughout the community with offices at El Centro Hispano Inc., Project Access of Durham County and Durham’s Department of Social Services. 

In addition to these facilities, individuals can also receive direct local assistance and information on the Marketplace from local insurance agents/brokers, Legal Aid of NC, MDC/The Benefit Bank and the Alcohol/Drug Council of NC.  Each of these organizations will have navigators and/or CACs who will be on staff and available to answer questions and provide one-on-one assistance with the enrollment application for the Marketplace.

David Jolly is with North Carolina Central University and Partnership for a Healthy Durham; Krystal Holman is with Project Access of Durham County and Partnership for a Healthy Durham