Dear Addy: Essential Health Benefits

Dear Addy Header_Updated
Dear Addy,
I am worried that my employer will stop offering health insurance to save money and send me to the Marketplace to get coverage. Is this true and, if so, should I be worried about finding good coverage?
Worried & Seeking Truth
Dear Worried,
The answer to your first question is maybe, but only if your employer has fewer than 50 employees. Under the Affordable Care Act (ACA) employers with fewer than 50 are not required to offer health insurance. On the other hand, ACA requires employer with 50 or more full-time equivalent (FTE) employees to offer “affordable” health insurance.* If you work for a small employer that chooses to no longer offer health insurance beginning next year, then the Marketplace is one option where you can turn to find an plan. You can start shopping for a plan beginning October 1, 2013. As to “good coverage” that depends on what you need. All Marketplace plans must offer essential health benefits so this is a good start to “good coverage.”
When you apply on the Marketplace, you can see all plan options available to you and enroll in the plan that works best. Compare plans based on what’s important to you. Choose the combination of price and coverage that fits your needs and budget. When making the comparison, some things to consider are:
• whether you can keep your doctor and/or receive care at an hemophilia treatment center(s);
• what are the out-of-pocket cost for copays or coinsurance for office visits, consider a year in which you might have a complication that requires lots of office visits;
• if and how your medications are covered, especially your clotting factor, and what are the out-of-pocket costs for factor, i.e., copays or coinsurance;
• what the annual limits for coverage is and is the limit based on a maximum dollar amount or on number of visits,
• what are the pharmacy provider options;
• what are the costs if you need to see a doctor outside of the coverage network; and
• what is the cost of you monthly premium verses your deductible cost if you have to have a major procedure.
For a helpful list of what to consider when comparing plans, see NHF’s Personal Health Insurance Toolkit. If you apply, you will find out if you can qualify for lower costs on your monthly premiums and lower out-of-pocket costs for private insurance plans and/or for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP). Information about plan prices and benefits will be written in simple language, so you will know how much you will pay for which benefits and protections before you enroll.
* The requirement for employers with over (50) full-time employees begins in 2015. “Affordable” health insurance is health insurance where the out-of-pocket premium for employee (single) coverage does not exceed 9.5% of family income or the plan pays 60% or more of the cost of covered services.

Have a question? Send us an email at: Your name will be changed in the response.

HFA frequently receives questions from the bleeding disorders community related to advocacy issues. The questions often impact the entire community. In an effort to reach the largest audience possible with our responses to these widely applicable questions, HFA developed “Dear Addy.” Questions submitted to this column are edited in order to protect privacy and should be considered educational only, not individual guidance.