'Obamacare' arrives soon: A look at what is known so far

Editor's note: This is the first of several stories in an ongoing series about the Affordable Care Act.

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On Tuesday, the first major domino will drop in the Affordable Care Act, also known as "Obamacare," yet in Missouri few details are known about what the uninsured will have to pay for their insurance or even what insurance companies will be offering their services.

On Monday, Missourians should be getting some long-awaited answers.

The sweeping health-care law will fundamentally change the health-care system in the U.S. A primary component of the legislation is the individual mandate, meaning every person will now be required to obtain health insurance or face financial penalties.

The mechanism by which uninsured people will choose their insurance plans is through online insurance exchange sites, set up in each state. Insurance companies -- which can no longer turn away people for pre-existing conditions -- that want to compete for new and previously uninsured customers will put forth their plans on these exchanges.

It's not known how many insurance companies will participate, exactly how many plans will be offered or the range of costs for premiums and deductibles.

According to The Associated Press, officials have said details on consumer costs and plans will be released Monday, the day before the exchanges open to the public.

The AP also reported earlier this week Missourians will have an average of 17 qualified health plans from which to choose, much fewer than the national average of 53.

Other states, including Illinois, have a clearer picture of what to expect Tuesday.

The Chicago Tribune reported Illinois residents will pay slightly less than the national average for health insurance offered under President Barack Obama's health-care law, according to rates released Tuesday by state and federal officials.

The average consumer in Illinois will be able to choose from 58 health plans from as many as five insurance companies, the Tribune said. Eight insurers will offer plans in the state, though not all will offer coverage in each region.

The Affordable Care Act has been debated in state capitals and by federal lawmakers since it was signed into law by Obama more than three years ago.

Those without access to insurance from their employers or who are ineligible for Medicare or Medicaid will have to enroll in a plan using online health-insurance exchanges. Those who already have insurance through an employer do not have to use the exchanges.

Individuals or families who do not have health insurance by 2014 must pay a fee of 1 percent of their yearly income or $95 per person for the year, whichever is higher. The fee increases every year; by 2016, the fee will be 2.5 percent of a person's income or $695 a person, whichever is higher.

The exchanges open Tuesday and close March 31. After open enrollment ends, individuals won't be able to get health coverage through an exchange until the next annual enrollment period or a qualifying life event.

Health insurance policies must cover 10 "essential health benefits": outpatient care; emergency services; hospitalization; maternity and newborn care; mental health and substance-use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including dental and vision care, according to healthcare.gov, a website that provides information on the law and health-insurance exchanges.

As long as health insurance plans covering individuals remain in effect before Tuesday, there will be no penalty if the plans do not cover all 10 essential health benefits, said Dave Dillon, vice president of media relations for the Missouri Hospital Association.

Beginning Jan. 1, insurers no longer will be able to exclude people with pre-existing conditions, and legal non-U.S. citizens will be eligible to qualify.

The U.S. Supreme Court ruled that Obama's Medicaid expansion for the Affordable Care Act was optional for states. Missouri's Legislature declared it would not expand Medicaid, though Gov. Jay Nixon favored it.

Because Missouri chose not to expand Medicaid, the state lost three years of full federal funding beginning in 2014 that other states that voted to raise adult eligibility to 138 percent of the federal poverty level will receive.

The online health-insurance exchanges will compare costs and benefits of certified health insurance plans and help consumers enroll.

The exchanges will display four categories of coverage: bronze, silver, gold and platinum, according to healthcare.gov. Each category represents a different premium cost each month and what portion one pays for things such as hospital visits or prescription medications, the website says. The platinum plan will have the highest monthly premiums but fewer out-of-pocket costs and lower deductibles. The bronze plan will have the cheapest premiums, but require higher out-of-pocket costs and deductibles.

The Department of Health and Human Services estimates a family of four with a $50,000 income could face average monthly premiums of $798 for a benchmark policy known as the "second-lowest-cost silver plan," the AP reported. That cost could decline to $282 a month after federal subsidies.

A similar plan for a 27-year-old individual earning $25,000 could carry an average monthly premium of $220, which could be reduced to $145 with subsidies, the AP reported. A subsidy calculator is at kff.org/interactive/subsidy-calculator.

States could choose to create a state-based health insurance exchange, a state-federal partnership exchange or default to a federally facilitated exchange.

Missouri defaulted to a federal exchange. The Department of Health and Human Services will establish and operate a federal exchange in any state that is not able or willing to establish a state-based exchange. In a federal exchange, the HHS will perform all exchange functions.

Dillon said the government has to authorize insurance companies that wish to be included in the marketplace of the health-insurance exchanges.

"There would be an assumption that that is done," though there has not been an official announcement by the federal government confirming certain insurance companies will be in the marketplace, he said. Some companies are starting to announce their place in the exchange. Blue Cross and Blue Shield of Kansas City, Mo., on Sept. 12 announced it would participate in the health insurance marketplace, according to its website.

Dillon said there will be at least two or three well-known insurance companies selling policies on the Missouri exchange.

The AP said the federal Department of Health and Human Services said Missouri residents will have an average of 17 qualified health plans on the exchange from which to choose; the national average is 53 options.

Dillon does not foresee more insurance plans in the marketplace until a year or two down the road, and does not encourage people to pick a plan on the first day of open enrollment. He sees the opening of the exchange as a chance for people to explore options, figure out the coverage they need and what they can afford.

Individuals can visit healthcare.gov to set up an account and find information on how an exchange will work in a state, steps to prepare for enrollment, the enrollment process, important dates and how to sign up for updates and alerts.

The insurance policies do not go into effect until Jan. 1, which gives the public three months to enroll in a policy that works best for them.

"Everyone would love a little more certainty" about the exchanges, Dillon said, but the mechanics of the system are in place regardless of the lack of information. He said even though only a small percentage of Missourians who know the happenings of the health-insurance exchange, the number of those informed grows daily.

Navigators will serve as in-person resources for those who need assistance in shopping and enrolling in health policies via the exchange.

Jeremy Milarsky is the navigator program manager at Primaris in Columbia, Mo., a federal health services contractor that was one of two groups in Missouri that received a navigator grant in federally facilitated and state partnership marketplaces.

Milarsky said those who enroll in a health-insurance plan on or before Dec. 15 will have their plan take effect Jan. 1 and will be immune from a tax penalty. A person who enrolls on Dec. 16, for example, will have their plan take effect Feb. 1 and will be charged a penalty of one-twelfth of the fee of 1 percent of the person's yearly income or $95 a person for the year, whichever is higher.

The late penalty is a fraction of what the penalty will be for someone who does not enroll in a health-insurance plan at all, even if he or she enrolls on the last day of enrollment March 31, he said. The health-insurance exchange enrollment is a "better late than never situation," Milarsky said.

The six-month enrollment period will provide many opportunities for individuals to enroll, he said, even if preparations are not finished on opening day.

"I can't say that every single navigator we proposed in proposal will be up and ready," Milarsky said. " ... This is a marathon, not a sprint. It is a start date, not a day the sky falls."

adowning@semissourian.com

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