Health reform rollout in Durham

Sep. 10, 2013 @ 11:45 AM

It has been a long wait since major health reform – the Patient Protection and Affordable Care Act (ACA) or Obamacare – was signed into law in March 2010. Some of the law’s provisions are already in place and more are quickly approaching.

Most Americans already have – and will keep – their health insurance through Medicare, Medicaid or their employer. However, 16 percent do not have health insurance. These citizens and legal residents will need to obtain coverage by January 2014 or pay a penalty, which will grow over time. Millions of individuals and families will qualify for help with insurance costs.

The ACA expands coverage to more Americans by:

-- Creating marketplaces (exchanges) where individuals and small businesses can buy coverage with federal subsidies or tax credits.

-- Regulating insurers so they can’t deny coverage or charge more because of medical problems.

-- Providing significant federal support to states to expand Medicaid to individuals with incomes up to 138 percent of the federal poverty level (FPL). The law also realigns the delivery and payment for health care services in significant ways to slow rising medical costs and focus on improved quality.

Healthcare marketplaces

Many new consumer protections will apply to current health insurance policies and those obtained through the new marketplaces. The major expansion of health care coverage to those under 65 is achieved by broadening Medicaid eligibility for individuals with the most limited incomes and setting up standardized health care marketplaces for others. There will be one statewide marketplace for individuals and families and another one for small businesses. Elected officials in North Carolina chose to have the federal government set up our two statewide marketplaces and they are being finalized now.

In the individual/family market, three insurance companies will offer plans in North Carolina, depending on county of residence. In Durham, there will likely be two insurers – Coventry and Blue Cross Blue Shield NC (BCBSNC) – offering a range of coverage options. These plans must be standardized as bronze (covering 60 percent of overall medical costs), silver (70 percent), gold (80 percent), or platinum (90 percent). Each tier will cover comprehensive “essential health benefits” and free preventive services. The same tier across plans will offer the same average value of benefits. The actual costs of the plans (premiums, deductibles, co-pays or co-insurances) and their list of contracting providers and institutions (networks) will not be available until October. Policies will begin in January.

Tax credit subsidies are only available for plans sold on the marketplace. They are based on a sliding scale for those with incomes between 100-400 percent FPL (see accompanying box for actual income levels). The government will pay the credit each month to the insurance company, lowering the premium; those with incomes below 250 percent FPL may qualify for other help with co-pays and deductibles.

Individuals younger than 30 can purchase a standard plan or high-deductible policy that offers protection for catastrophic events, plus some primary care and preventive visits with no co-payment. Also, the ACA allows those younger than 26 to be included on their parents’ policies. Many younger adults will qualify for subsidies to help purchase coverage because of their incomes. 

For small businesses (fewer than 50 full-time-equivalent employees), the online marketplace is called the SHOP: Small Business Health Options Program. Employers can review their options and make decisions on their own or use agents. Some businesses will be eligible for significant tax credits when purchasing coverage through the SHOP. Only BCBSNC will be selling plans on the SHOP in NC for 2014, and there will be nine options. Businesses of any size can also purchase coverage for employees outside of the SHOP.

Medicaid expansion

In states like North Carolina that are not expanding Medicaid for 2014, individuals with incomes below 100 percent FPL are not eligible for subsidies. This is because they were supposed to be covered by expanded Medicaid. In Durham, this means that roughly 30,000 of our poorest citizens will continue to be without coverage.

This is happening as federally qualified health centers, like Lincoln Community Health Center, are scheduled for dramatic reductions in federal support in 2016. Many hospitals will also see steep declines in their partial reimbursement for uncompensated care from the government.

What help will be available in Durham to review options

These insurance options are complex. Project Access of Durham County and the Partnership for a Healthy Durham are convening agencies and other interested parties to ensure that people get reliable information. Throughout our state, agencies are collaborating to ensure that residents have access to the information they need.  Several types of help will be available: trained navigators (federally supported to conduct outreach and enrollment), insurance agents and company representatives will assist individuals; hospitals, clinics and other health agencies throughout Durham  will have “certified application counselors” (CACs) to advise shoppers; and  a national group – Enroll America – will be conducting grassroots outreach to engage individuals who need to make decisions.

With expanded access to health insurance, the City of Medicine inches closer to the Community of Health. While insurance doesn’t guarantee good health, access to medical care makes an important difference.

Gina Upchurch is executive director of Senior PharmAssist and a member of the Partnership for a Healthy Durham




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Percentage of Federal Poverty Level (FPL) in 2013

(will change for 2014 and allow adjustments; based on Modified Adjusted Gross Income)

Single annual income

Family of 4 annual income














What to know when choosing a plan:

  • Consider all potential costs when making a decision: premiums, co-payments, deductibles, co-insurances and what the annual maximum out-of-pocket costs might be.
  • Make sure that the providers you want to see are “in network” with the plan you choose.
  • Check to ensure your medications are covered by your plan.
  • Make sure that you are getting unbiased facts from the individual who might be helping you make a decision.

Timeline and Contact Information:

One-on-one assistance in Durham for individuals/families less than 65:

  • NC marketplace/exchange – enrollment begins October 1, 2013 and runs through March 31, 2014
  • Use website: or call – 800-318-2596 available 24 hrs/7 days per week; paper applications will also be available
  • Local help: several agencies and institutions will have “navigators” or “certified application counselors” to help people review their coverage options. They include Lincoln Community Health Center, Project Access of Durham County, Legal Aide, El Centro Hispano, the Alcohol and Drug Council of North Carolina, and MDC/The Benefit Bank.

National small business call center or SHOP

  • NC marketplace/exchange – enrollment begins October 1, 2013 and runs through March 31, 2014
  • Use website: or call – 800-706-7893. Hours: Monday through Friday, 9 a.m. to 5 p.m. EST.

Medicare coverage options are not on the marketplaces but continue as usual.

  • Medicare’s annual election period is from October 15 – December 7 every year 
  • Use website: or call 1-800-Medicare; 1-800-633-4223 or call the state Seniors’ Health Insurance Information Program (SHIIP) at 1-800-443-9354
  • Local help: Senior PharmAssist – the SHIIP coordinating site for Durham at 919-688 -4772 or for Lincoln CHC patients, ask the pharmacy staff for assistance

If you have problems with your health coverage (not Medicare) now and in the future:

  • Fortunately in North Carolina, we have Smart NC, which was set up by the NC Department of Insurance to help consumers understand their rights and responsibilities and they can help file complaints and appeals and request external reviews if a health insurance claims are denied. SMART NC - 877-885-0231

Understanding medical coverage options now available in Durham:

  • The Partnership for a Healthy Durham created a brochure that explains free and reduced healthcare services available in Durham for 2013;