Some Assembly Required

            We’ve all been to some sport match from another culture or time, or maybe a theater performance, even a new board game with friends. “What are they doing and why” immediately springs to mind as well as what is a “yellow card”, or “icing”, or a “contralto.” The one who owns the language owns the game. With the Patient Protection (yes, that’s part of it) and Affordable Care Act, we need to hop in as participants, some of us without ever having played the game.

 

            In central Ohio it is difficult, if not impossible, to hold a job without owning a vehicle (public transportation is not of the caliber that would permit anyone who relied on it the accuracy of appearing at work, on time, everyday). The state of Ohio requires insurance for the use of such a vehicle on the roads we all share in common. To pay for this “coverage”, the “policy” requires a “premium” to be paid (monthly, quarterly, half year, etc.). The premium is what the policy will cost the person insured (the rent). The policy is the contract that spells out what the buyer (policy holder, the insured) is obligated to, what the seller (the insurer, the provider) is obligated to, etc. Lots of fine print and more terms! All of which spell out the “coverage”, what is included and what is specifically not included. Health insurance differs from property insurance (car, boat, home). Although AFLAC may make it look simple with a cute duck, it can be quite convoluted because of the uniqueness of individuals and what it takes to make/keep them healthy (side effects may include, but are not limited to, death and dying). With health insurance, as with property insurance, there can be a deductible. This is the initial amount of the cost of any claim which the buyer (the insured) agrees to pay. A claim is when something that is covered by the policy occurs and the policy holder (the insured) “claims” that under the terms of the policy, the insurance provider now needs to do their part and pay the amount owed to cover the costs. If an operation costs a total of 10K, and everything involved with that 10K billing falls under the coverage that my policy provides for, then my claim will be for the entire 10K. If the policy I contracted has a 1K deductible. Then 9K would be paid. If the operation cost 1K or less, I could not file a claim because my policy stipulates that I have agreed to pay the first 1K of whatever occurs. The amount of the premium for a policy reflects the amount of deductible; the greater the deductible, the lower the cost (premium) of purchasing that policy (having that coverage). Confusion swirls around the term “co-payment”. Health insurance coverage is a business to earn a profit for the company. No different than Walmart or Home Depot, if the company can provide its own transportation, products or services through its subsidiaries, then it will. The subsidiaries contribute to the money making endeavor of the parent company. A co-pay is money the insured must pay per each doctor’s visit, therapy session, or pharmacy purchase, etc. Like a deductible, it is the upfront amount agreed to with whatever coverage is purchased. It differs from a deductible in that it is not part of an overall “claim” but rather it is ongoing care (akin to repair of a vehicle after an accident and the regular routine service required continuously). A health insurance company may have subsidiary health care providers, thereby allowing them to offer a lower premium but requiring that the insured utilize the services of those subsidiaries with a specified co-payment for each use. The Patient Protection and Affordable Care Act is centered on health insurance exchanges or markets. Like a farmer’s market, the various businesses which wish to offer coverage within the parameters of the ACA (Affordable Care Act)  list the policies they offer, what each policy covers, what the terms of the coverage are (what’s included, not included, deductibles, co pays, etc.) as well commitments (on the part of the insurer as well as the insured). The ACA has grouped coverage into 4 categories so that it is easier to compare like with like. The categories have been described as bronze, silver, gold and platinum (or catastrophic). Essentially, the bronze has the highest deductible with the catastrophic having none. The bronze should be at the lowest “cost”, with the catastrophic the most expensive. The premium amount of any policy with any of the categories depends on the coverage spelled out in the individual policies offered by the different insurers. A single insurer could offer several different policies within the silver category. One policy may involve using the insurer’s subsidiary health care provider, another may allow the insured to choose whatever source, etc. The premiums on these different products (the policies with their coverage differences) will likewise differ although they will qualify as havng the characteristics of all silver policies (in terms of deductibles, etc.). The enrollment period is the window of time in which a policy is purchased, modified or changed. As coverage is for only a year, during the enrollment period the insured as well as insurer can decide to renew or make a change. The final term which has been part of business but rarely indicated is “subsidy.” Several years ago it was brought to this writer’s attention that the Swiss government pays a subsidy to the inhabitants of the quaint little villages and farms in the high altitudes of the alps. Yodeling aside, having the cheese, mountain climbing, skiing, etc. associated with “Switzerland” is incredibly important to the Swiss identity, to tourism, maintaining the “quality” of Swiss products, etc. But no one really wants to live up there isolated and cut off with bad satellite reception and no Seven Elevens. And if they have kids, they likewise want them to go to college, be soccer stars, etc. It is hard to play soccer on the side of a mountain. So the government assists these folks with a “subsidy”, a payment that helps insure that the mountain lifestyle continues to benefit all Swiss. In the US this is part and parcel of our agriculture policy (since being able to eat is essential to national security). The bank bailout instituted at the end of the Bush presidency was described as a subsidy, as well as payments to schools, manufacturers of nationally vital products, energy producers, etc. (in fact most CIC’s can be described as subsidies since payment is made for the ultimate benefit of the community served).  It’s there, unseen, but essential in making sure that America has the benefits of these endeavors, at a cost the individual consumer can afford. The ACA likewise has a built in subsidy. This is the portion of the health insurance premium that the government will reimburse the provider. The amount of the subsidy varies with the income level of the insured. It is likewise paid either directly to the insurer providing the coverage or credited to the income tax of the insured. So the same policy offered to two different income level purchasers will involve a different cost for each.

 

            The ACA only, and exclusively, operates through an online exchange — meaning one has to have access to the internet to obtain health insurance. The Licking County library offers access to the internet on computers available to its card holders. According to the Newark computer desk librarian, no formal policy has yet been established with regard the ACA. The 9-8-13 Newark Advocate article (Exchange 101: The basics of the new health insurance marketplaces) discusses health insurance navigators, and likewise (as this blog has done) points out that the Ohio legislature has chosen to officially license and recognize a limited number. The librarians at the computer desk will assist with the operation of the computers, accessing the internet and interacting with any programs but they cannot assist with anything pertaining to the ACA. They are NOT health insurance navigators. The application to obtain a library card (in order to use the computers) requires personal identification such as a photo ID or two pieces of mail addressed to the applicant, etc. The card is issued immediately, along with a pin that grants access to the terminals. There is a 2 hour limit on each use. Notify the computer desk librarian if you are unfamiliar with the use of a computer and are applying for health insurance; this will allow for more time. This is all happening at healthcare.gov where we will meet next time.     

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