In LGBT communities, one in every three people (34 percent) does not have health insurance — that’s more than twice the national average! Oct. 1 marked the official launch of open access to the Health Insurance Marketplaces of the Patient Protection and Affordable Care Act, aka Obamacare, which will expand access to health care for millions of Americans who could not afford or access it before. There is a lot of information (and misinformation) floating around about Obamacare. While parts of this monumental legislation can be confusing, much of it is simple and straightforward.
At Mazzoni Center, we have been working with state and federal committees, programs and organizations for well over a year gearing up for the ACA’s launch. We’ve been training staff to help patients understand, apply for and navigate the new system. And we have witnessed some of the glitches involved with the healthcare.gov website, and the difficulties of completing an online application. Given the size and scale of this program, we anticipated some challenges (though perhaps not quite so many!) with the initial rollout. But as an organization that works to advance and protect the health of LGBT individuals and other underserved communities, we feel this legislation is a vital step forward that will positively impact the health and wellbeing of millions of Americans — so it’s well worth persevering through these early hiccups.
I’ll start with the big picture of what the newly implemented portions of the law mean, and close with specific information about local resources where you can learn more and get help with enrollment (online or otherwise).
In addition to the many changes that have already gone into effect since the law was enacted in 2010, two important additions go into effect Jan. 1. The first is that all Americans (with a few exceptions) are now mandated to have health insurance. If you don’t have insurance already, access to affordable insurance is available through special Marketplaces (formerly called Exchanges) at www.healthcare.gov or 800-318-2596. The second is that all public and private health-insurance plans are required to provide “10 essential health benefits”: outpatient medical care, emergency services, hospitalization, maternity and newborn care, mental-health and substance-use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic-disease management, and pediatric services.
First, for the vast majority of Americans, this law makes absolutely no changes to their insurance coverage or health-care access. If you already have health insurance that covers the required 10 essential health benefits through your employer (or your spouse’s or parents’ employer), you satisfy the mandate and don’t have to do anything further. Or, if you have Medicaid, Medicare or veterans coverage, you don’t have to do anything further.
For LGBT individuals who are legally married in states where it is recognized, the recent Supreme Court decision opens up many federal benefits, including those contained in the Affordable Care Act. More information specific to your situation can be found at: www.Out2Enroll.org.
If you are under 26, you should know that you are eligible for coverage through a parent’s plan (if that’s an option for you). For many people, particularly those who are recently graduated and not earning much income, or still looking for work, this will be the most cost-effective option.
Do I really need this?
Insurance is a strange category of consumer product, in that you are purchasing something you hope you won’t need (at least, not beyond the usual check-ups and preventive care). Unlike rent or groceries, it’s the kind of thing you can often get by without, assuming you are healthy and your luck holds. But, as we all know, luck can change in an instant. Something as “simple” as a broken arm might cost you $2,500 in the emergency room, and many thousands more if you need surgery. Three days in the hospital could cost $30,000. It’s the kind of thing that can set you (and your credit rating) back for a long time.
There are a lot of variables when it comes to pricing — depending on your age, location and whether or not you smoke cigarettes. But to give you an idea, a 26-year-old nonsmoker living in Center City could purchase coverage on a “Silver” plan for something in the neighborhood of $245 per month. That may seem like a lot to spend on something “intangible” like health insurance — particularly if you haven’t been paying for it so far. But we would encourage anyone to carefully consider the consequences of remaining uninsured and make an informed decision.
What’s more, if your income is between 100 percent and 400 percent of the Federal Poverty Level (roughly $11,500 through $46,000 for a single-person household), you will be eligible for tax credits/subsidies to purchase the “Silver” level plan. So for example, let’s say the 26-year-old earns $28,000 per year. He or she would qualify for government subsidies that cover about $60 per month of the insurance cost, bringing the monthly price down to $185.
The penalty for not obtaining insurance by the enrollment deadline of March 31 is $95, or 1 percent of your taxable income, for the first year (it will increase in future years). That doesn’t sound like much, but it’s the cost of having an accident or illness without insurance that will add up. Buying insurance doesn’t take care of all medical bills; you will still have a co-pay and deductible for certain medical treatments. But it does ward off financial ruin in the case of serious bad luck, and having insurance means easy access to care.
For those 30 and under, there are also “catastrophic plans” available. This plan has very low premiums and provides three primary-care visits per year, but the other plan benefits will not be available until a high out-of-pocket deductible is met. For that reason, this plan is only recommended for those in very good health.
Timeline and logistics
For those who plan to purchase health insurance through the Marketplace, the open-enrollment period runs through March 31. (For benefits to start on Jan. 1, you must enroll by Dec. 15). Uninsured Pennsylvanians can purchase affordable health insurance through the federally run Marketplace at www.healthcare.gov or 800-318-2596. (Other states may have their own Marketplace. If you start at www.healthcare.gov and enter the state where you live, it will direct you to the appropriate site.)
After creating an account and completing an application on this website, you will be directed to another site where you will be able to compare the health-insurance plans available to you. There are generally four levels of plans available: Bronze, Silver, Gold and Platinum. As you would expect, the lower the premium on the plan you select, the higher the deductibles and co-pays will be, and conversely the higher the premium, the lower the deductibles and co-pays. So you’ll want to consider how often you expect to visit the doctor to determine which option is the best deal.
As I mentioned above, there are three things that impact the cost of your premium: the state you live in, your age and whether or not you smoke (smoking can raise your premium by up to 50 percent). The great news from our perspective is that premiums are no longer impacted by things like gender, pre-existing conditions or high utilization (i.e., getting sick). Under the new law, you cannot be denied coverage, or charged more money, for pre-existing conditions, such as an HIV diagnosis.
As you can see, there’s a lot to consider in choosing the right health plan for you. Here are some general recommendations from Mazzoni Center:
Walk, don’t run! You don’t have to sign up this month, but you should aim to get it done by Dec. 15. Again, our advice is to take your time to learn all your options.
Do your homework! Find out what plans are available to you. See if you are eligible for tax credits. Find out what plans your current medical provider accepts. If you are taking any special medications, make sure they are covered by the plan you choose. Information specific for LGBT people is available at http://out2enroll.org.
Do the math! Look at what you are currently paying out of pocket for your health care. Review your budget to see how much you can afford. Based upon your current health situation, balance out premiums, deductibles and co-pays to see which plan is most affordable for you.
For trans-identified individuals: When completing an application on the Marketplace website, you should answer the question about gender based upon your gender marker on record with the Social Security Administration. Information submitted in the Marketplace is cross-referenced and verified with IRS data.
Ask for help, if necessary. Mazzoni Center is providing assistance with Marketplace applications for our uninsured clients and patients. Contact Stephanie Moran at [email protected] or 215-563-0658 ext. 332 for information or to schedule an appointment. For LGBTs, the Out2Enroll project is a collaborative effort from the Sellers Dorsey Foundation, the Center for American Progress and the Federal Agencies Project to educate the LGBT community about its options under the Affordable Care Act. Information and assistance at http://out2enroll.org.
In addition, the federal government has funded special Navigator sites to assist with health-insurance access. In Philadelphia, those sites are Resources for Human Development ([email protected] or 215-951-0300), Pennsylvania Association of Community Health Centers ( [email protected] or 866-944-CARE) and Mental Health Association of Southeastern Pennsylvania (215-751-1800 or 800-688-4226).
Ron Powers is director of programs at Mazzoni Center.