For one self-employed painter, the cost for health coverage left him seeing red.
When Paul Jackson, 49, shopped for insurance, he said, the price was more than $300 a month for him and as much as $1,300 per month for his wife, who has chronic health problems.
“It was too expensive,” he said.
So the Akron couple have been going without coverage and relying on AxessPointe Community Health Center, a sliding-scale health practice with an onsite pharmacy, to fill her prescriptions.
The Jacksons are among the estimated 1.5 million uninsured Ohio residents who must get health insurance starting Jan. 1 or potentially pay penalties when they file their tax returns for 2014.
The “individual mandate” is part of the sweeping federal health-care reform law called the Affordable Care Act, or Obamacare.
With the deadline looming, confusion still remains about the law and its requirements.
A recent national poll by the nonprofit health research group Kaiser Family Foundation found about half of Americans say they don’t know enough about the Affordable Care Act to understand how it will affect them. About one in four say they aren’t sure whether the politically controversial health-reform measure is even still in effect.
Tobbie Steele, 30, of Stow, said he knows he has to get insurance soon, though he doesn’t know many details about the federal health-care law.
“My mother said I have to,” he said with a laugh.
His temporary-to-hire job while he studies to become an electrician doesn’t offer health insurance or pay enough for him to afford to buy coverage on his own, he said.
Americans who don’t have health insurance they purchase on their own, obtain through their employer or get from the government (Medicare and Medicaid) will face a financial penalty if they don’t enroll in coverage by Jan. 1.
People with religious objections, members of Indian tribes and people who are incarcerated aren’t required to get insurance coverage, according to the U.S. Internal Revenue Service. Those who would have to pay more than 8 percent of their household income toward insurance premiums or low-wage earners who aren’t required to file a tax return also are exempt.
Otherwise, penalties beginning in 2014 will be $95 per adult — up to $285 per family — or 1 percent of annual income, whichever is greater, according to the Kaiser Family Foundation. Those penalties increase to $695 — up to $2,085 per family — or 2.5 percent of family income in 2016.
A requirement under the law that employers offer coverage to full-time workers or face penalties has been delayed until 2015. However, a Small Health Options Program, or SHOP marketplace, will be available through a government website to let businesses with 50 or fewer workers shop for health insurance and potentially earn a small-business, health-care tax credit worth as much as 50 percent of the premium costs.
Open enrollment starts Oct. 1 and continues through March 31 for the new Health Insurance Marketplace, a key part of the Affordable Care Act’s goal of expanding health coverage.
The marketplace, also known as an exchange, is a computerized system that’s being launched as a way for people to shop for health insurance and apply for federal subsidies to potentially lower their costs.
The federal government is approving in-person assisters, certified application counselors and “navigators” to help people find out information about their insurance coverage options and financial assistance that will be available in 2014. Insurance brokers also can be approved to enroll people in plans.
AxessPointe received a federal grant to hire additional staff to help its patients and other uninsured residents in the region apply for coverage and subsidies. About 40 percent of the practice’s patients are uninsured.
“We want there to be a community effort to help people get insurance,” said Dr. Kristine “Kris” Drummond, the organization’s chief executive.
The Congressional Budget Office estimates 7 million Americans will get coverage through the federal or state-run exchanges next year.
Ohio opted against starting a state-run insurance exchange, so residents who want to participate must shop for their coverage through the new federally operated marketplace.
A total of a dozen insurance companies have filed about 200 plans to sell to Ohio residents through the federal marketplace, but the list of approved, participating plans isn’t finalized yet.
Starting Jan. 1, all insurance plans in the marketplace must cover these “essential health benefits:” outpatient (ambulatory) care, emergency services, hospitalizations, maternity and newborn care, mental health and substance abuse services, prescription drugs, rehabilitation services, laboratory services and pediatric care, including dental and vision services for children.
The requirement also applies to plans that weren’t in existence before the federal law was enacted.
Federal health-care reform already requires many preventive care services to be covered without co-pays or deductibles.
Plans in the marketplace are divided into four categories, based on the estimated percentage of the cost for the required benefits they cover. Bronze plans will cover an estimated 60 percent; silver, 70 percent; gold, 80 percent; and platinum, 90 percent.
Under federal law, these plans won’t be able to deny coverage or charge people a higher premium because they’re sick or have a history of health problems. Other nongroup plans sold outside the marketplace must follow the rules, too, unless they are considered “grandfathered,” according to the Ohio Department of Insurance.
Insurers only will be able to consider family size, age, location and tobacco use when setting rates in the exchange.
Twenty-somethings in pristine health have been able to find cheap plans for $50 or $75 a month “that cover virtually nothing” and end up costing more if medical problems develop, said Karen Pollitz, a senior fellow at Kaiser Family Foundation, a national nonprofit health research agency. People with health problems have had much higher premiums, if they’ve been able to get coverage at all.
“All that is changing,” she said.
About 350,000 Ohio residents currently buy individual plans, according to the state insurance department.
The average cost for a plan in the individual market in Ohio will increase 41 percent from $236.29 per month this year to $332.58 next year through the exchanges, according to a recent report from the Ohio Department of Insurance. However, the analysis doesn’t include subsidies that might be available or consider differences between what the plans cover.
Tax credits may be available on a sliding scale to help purchase insurance through the exchanges for people with incomes up to 400 percent of the federal poverty level, or $45,960 for an individual and $94,200 for a family of four. Those earning 250 percent or less of poverty could also get help paying the out-of-pocket costs for care.
By the end of this month, all employers must provide their workers a notice about whether they are eligible for health coverage from the company and, if so, whether it would cost them more than 9.5 percent of their gross annual wages, according to Sam Fiorentino, professional development chair for the Ohio Association of Health Underwriters and an insurance agent in Hudson.
Workers who would pay more than 9.5 percent of their wages for coverage could qualify for subsidies to get coverage through the exchange, said Fiorentino, past president of the Northeast Ohio Association of Health Underwriters. Those with available coverage that costs less are not eligible for subsidies through the exchanges.
Steele, the uninsured Stow resident, could receive about $2,000 in federal subsidies to help pay the estimated $3,426 annual premium for a second-tier, “silver” plan, according to a subsidy calculator on Kaiser Family Foundation’s website, www.kff.org.
It remains to be seen whether Medicaid enrollment might be an option for low-income Ohio residents seeking coverage in 2014.
State legislators rejected a proposal to boost Medicaid eligibility next year to 138 percent of the federal poverty level ($15,415 for an individual). Supporters of expansion are trying to get the issue on a statewide ballot in November.
The federal government will pay 100 percent of the cost for three years for Medicaid patients newly eligible through the expansion in states that opt to raise the income limit to 138 percent of poverty. Federal funding then phases down to 90 percent.
The state estimates that 275,000 low-income residents would qualify for Medicaid through the expansion, which is still being discussed by lawmakers.
Cheryl Powell can be reached at 330-996-3902 or firstname.lastname@example.org. Follow Powell on Twitter at twitter.com/abjcherylpowell.