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Idaho Health Insurance Exchange Opens Today

By Dr. David C. Pate, News and Community
September 29, 2013

The Affordable Care Act became law in March of 2010. It is the most significant healthcare reform law enacted since the Medicare Program in the mid-1960s and is arguably even more significant and far-reaching than that program.

A number of features of the law have already become effective, such as the ability of adults up to age 26 to be covered under their parents’ health insurance policy and the elimination of co-insurance for certain preventative care services.

But 2014 is the year for some of the most significant provisions of the ACA to be implemented – the individual mandate and the offering of insurance, along with subsidies or tax credits for those who qualify, through internet marketplaces called health insurance exchanges.

It was to be the year for even more extensive changes, but the employer mandate was delayed until 2015. And while it was contemplated under the law that all states would be expanding their Medicaid programs in 2014, the U.S. Supreme Court ruled that this provision was unconstitutional. States cannot be coerced into expanding their Medicaid programs but may do so voluntarily, and then may be eligible for additional federal funding.

About 7 million people are anticipated to buy insurance coverage through the health insurance exchanges next year across the country. In Idaho, nearly 200,000 of the estimated 255,479 uninsured are anticipated to enroll for coverage.

About 85 percent of those are expected to qualify for federal subsidies or tax credits, based in part upon their incomes and family size. Those who earn between 100 percent and 400 percent of the federal poverty level will qualify. The subsidies are only available for purchases of health insurance through the insurance exchanges.

In anticipation of Jan. 1, exchanges are to open enrollment and list plan offerings as of today, Oct. 1. Individuals will be required to have health insurance next year or pay a tax penalty when they file their taxes by April 15, 2015.

States had the option to adopt the federal exchange, create their own state-run exchange, or participate in a state-federal partnership. Idaho elected a state-based exchange and is using the federal information technology hub until it is able to operate the exchange on its own, targeted to be Oct. 1, 2014. The Idaho health insurance exchange has been named “Your Health Idaho,” and you can find it at www.yourhealthidaho.org.

Most people who have insurance through their employer are ineligible for subsidies under the health insurance exchange. The only exception is if the employer’s health plan does not cover at least 60 percent of medical costs or if the employee’s share of costs would exceed 9.5 percent of his or her income. Those on traditional Medicare do not need to go to the insurance exchange to continue coverage.

Health plans offered through the exchange are divided into four categories, based upon the portion of medical costs covered by the plan or the individual’s cost share responsibility. Offerings are, in general, less generous in their coverage than employer-sponsored insurance.

The categories are:

  • Bronze – plan covers 60 percent of costs
  • Silver – plan covers 70 percent of costs
  • Gold – plan covers 80 percent of costs
  • Platinum – plan covers 90 percent of costs
Average costs for a health plan offered through the exchange for Idahoans are among the lowest in the country, coming in at seventh-lowest for families not qualifying for a subsidy and eighth-lowest for individuals who do not qualify for a subsidy. Prices lock in officially today.

Here’s what to know:

  • It’s good to examine plans in the category you are selecting to determine deductibles, co-pays, covered services, choice of hospitals and physicians, and whether certain high-cost medications will be covered and, if so, to what extent under the particular plan. Avalere Health, a consulting firm, has found that patients will be responsible on average for 40 percent of high-cost medications.
  • While it may be tempting to purchase the lowest-cost, bronze plan, keep in mind that the reason it is lower cost is because you share more of the upfront costs and can be expected to be personally financially responsible for 40 percent of medical costs, subject to an annual out-of-pocket cap on expenses of $6,350 for individuals or $12,700 for families. Out-of-pocket expenses can be a significant issue, so if you are unlikely to be able to handle those additional payments and/or think you are likely to incur medical costs because you have a chronic illness or some other challenge, you should give consideration to a silver or gold plan, higher premiums for less out-of-pocket expenses.
  • If you qualify for a subsidy at the beginning of the year, but you are fortunate enough to increase your income during the year, you will be expected to refund the difference between what you received and what you were entitled to.
  • There may be premium increases in 2015 and 2016. No one knows what will happen, but there is speculation that insurance companies that are participating in the first-ever offerings on the exchange may offer premiums on the low side to gain many more participants. If the exchanges attract sicker or higher-risk patients and healthy, younger people don’t purchase insurance due to the relatively low penalty, higher-than-expected medical expenses also may cause premiums to rise before stabilizing.
For more information, go to the health insurance exchange website or contact the Consumer Help Center from 8 a.m. to 5 p.m. weekdays at 855-944-3246.


About The Author

David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.