via Wall Street Journal
The self-employed are finding it easier to buy health insurance on their own because of the Affordable Care Act, as are workers looking to leave corporate life. But as the 2015 enrollment season ramps up, many of them must weigh new trade-offs between cost and coverage.
Plans opened for enrollment last month and the deadline is Feb. 15. Those who bought plans last year will be automatically renewed in those plans on Monday if they don’t opt for a new plan.
Beth Moore, a 32-year-old independent behavioral therapist in Louisville, Ky., credits the 2010 law with making it possible for her to leave her job at a not-for-profit agency in January to counsel children with autism—in part because it meant she could afford and qualify for health insurance on her own for the first time this year.
She plans to wed her fiancé this summer, and she says the couple hopes to begin a family shortly thereafter.
Yet some doctors don’t participate in her current plan’s network, including her obstetrician. As she looks at the plans available for 2015, Ms. Moore’s biggest concern is whether her doctors accept the policies, which she says is tricky to determine without calling individual physicians’ offices.
In addition, Ms. Moore says she doesn’t qualify for government subsidies, and her monthly cost is rising to $220 from $192, a price she says she can handle as long as it doesn’t go much higher in coming years.
The new law isn’t universally popular with independent workers, says Katie Vlietstra, vice president for government relations at the National Association for the Self-Employed. For some, the requirement to have health insurance adds costs and means a loss of flexibility, she says.
Some shoppers could face higher prices and a constrained choice of doctors, while others—especially those who qualify for government assistance or have pre-existing health-care conditions that made it difficult to obtain coverage before the law—are reaping the benefits, says Sabrina Corlette, project director of Georgetown University’s Center on Health Insurance Reforms.
Here are health-care experts’ top tips for self-employed workers trying to navigate the marketplace this season.
Consider the coverage.
HealthCare.gov is the main federal marketplace, and the site also will direct shoppers to state-based exchanges in those locations that run their own programs.
People in business for themselves who have no employees can shop the federal and state individual exchanges, while those with employees should look to separate small-business portals, says John Arensmeyer, chief executive of the Small Business Majority, a national group that advocates for small businesses.
The plans come in five general tiers. Four of them—platinum, gold, silver and bronze—correspond to how much in medical expenses they cover. Bronze plans, for example, pick up an average 60% of expenses, while platinum plans cover 90% on average. Consumers who choose the fifth option, catastrophic plans, cover costs up to a specified limit. Such plans are available only to people under 30 or those with hardship exemptions.
Most plans now are required to pay for certain essential health benefits, such as emergency services and maternity care, and there are typically limits on out-of-pocket spending: for 2015, $6,600 for an individual plan and $13,200 for a family plan, according to HealthCare.gov.
Costs are likely to vary depending on where consumers live, how old they are and whether they smoke, among other factors, experts say. For 2015, the average lowest-cost monthly premium for bronze-level plans is $265, before any government subsidies, and up to $439 for platinum-level plans, according to the Department of Health and Human Services.
Look into lowering costs.
Applicants should check to see if they qualify for financial help, says Christine Barber, senior policy analyst at Community Catalyst, a consumer advocacy group based in Boston.
Some 80% of current enrollees in the marketplace plans could get 2015 coverage for $100 a month or less, after taking into account tax credits available to people who qualify, says the Department of Health and Human Services.
Professionals might be surprised to find that they qualify for some support even with relatively high incomes. According to HealthCare.gov, a family of four making less than $95,400 can qualify for help. When an applicant’s household income is lower than $29,175 for a single person or $59,625 for a family of four, premiums as well as copayments are subsidized on the marketplaces.
One problem for entrepreneurs is that their income can vary sharply from year to year, Georgetown’s Ms. Corlette says. This presents a problem when calculating the tax credits for which people might be eligible. She advises taking less help than you might be eligible for to pay for monthly premiums up front, in case your income rises later in the year, as consumers will be repaid at tax time if they were eligible for more support.
Evaluate the network.
For people used to employer-provided coverage—which can pick up close to 90% of medical expenses—it is important to evaluate marketplace plans for the adequacy of their network of doctors and their out-of-pocket costs, says Caroline Pearson, vice president of Avalere, a health-care data firm based in Washington.
Experts say one way some plans keep prices down is to limit the doctors in their networks, so check with your doctors to make sure they take the policy before signing on.
The law requires health insurers that sell plans through the exchanges to meet certain network adequacy requirements, says Aaron Albright, spokesman for the Centers for Medicare and Medicaid Services, which runs the HealthCare.gov marketplace. People also can review plan details on that site to see which providers or facilities are in a network, he says.
The exchange contains on average 25% more issuers than last year, according to the Department of Health and Human Services.
Ms. Moore, the behavioral therapist, says she is unlikely to change medical plans. She is grateful for the coverage she got this year, which helped pay for an emergency appendectomy and a hospitalization for pneumonia. Plus, the plan accepted her even though she had a pre-existing thyroid condition.
“I’d rather spend a little more and be confident in the benefits,” she says.