In 2010, Congress passed the Affordable Care Act (ACA). The ACA is also referred to as Obamacare. This law mandates that insurance companies can no longer deny insurance benefits to individuals who are seeking coverage. That remains the case even if those individuals have pre-existing health conditions that would’ve prevented them from purchasing insurance previously.
The ACA also put in place an individual mandate. This mandate requires that every person purchase insurance or obtain a waiver if they cannot purchase insurance. If you don’t buy insurance or receive a waiver, you will face a fine every year you don’t have insurance. The fine grows each year.
To help citizens purchase their insurance, states established health insurance marketplaces. Some of these marketplaces are state-run. In other words, the state maintains the exchange and helps citizens enroll and purchase health insurance. Other states, like West Virginia, use the federally run marketplace.
Each year, you can enroll in the exchange and purchase insurance through the marketplace. The period in which you can sign up is called open enrollment. If you fail to sign up during open enrollment, you may have to wait another year and pay fees. It’s in your best interests to begin the application process as soon as the open enrollment period opens.
You may be eligible to apply for insurance through a special enrollment period if circumstances in your life change. That includes changes to your employment or marriage status.
In 2015, only one insurance company in West Virginia provided health insurance plans in the marketplace. That company, Highmark West Virginia, is the largest insurance provider in the Mountain State. Before 2016 enrollment begins, other insurance companies could apply to be a part of the marketplace.
The ACA created 10 categories of care that all health insurance plans in the marketplace must cover. If a plan meets these standards, it’s known as a “Qualified Health Plan.” If it does not meet these standards, it cannot be offered in the marketplace.
These 10 categories of care include:
- trips to the emergency room
- outpatient care, or clinical services not requiring an overnight hospital stay
- inpatient care, or treatment in the hospital when you’re admitted
- maternity care, or care before and after delivering your baby
- pediatric services, including vision and dental care for infants and children
- mental health and substance abuse recovery care
- prescription drugs, although limited to a certain formulary
- rehabilitation services, including treatment if you’re injured or develop a disability and need different kinds of physical or psychiatric therapy
- lab tests and imaging tests
- preventative services, including annual check-ups and visits to help you manage a chronic disease or condition
The only plans that automatically include vision and dental insurance are children’s plans. If you’re an adult and want either of those additional types of insurance, you can purchase them through the exchange for an additional monthly cost.
Five basic health insurance plans are available in the marketplace. Each type has established guidelines for determining your out-of-pocket maximums, deductibles, and percentage of payments. Lower percentage plans have lower premiums. Unfortunately, that also means they typically have higher out-of-pocket deductibles and maximums.
The five basic health insurance plans include:
- Bronze: A bronze plan pays 60 percent of expenses (you pay 40 percent).
- Silver: A silver plan pays 70 percent of expenses (you pay 30 percent).
- Gold: A gold plan covers 80 percent of expenses (you pay 20 percent).
- Platinum: This top tier of plans covers 90 percent of expenses (you pay 10 percent). It will likely have the highest premium, but it will also have lower out-of-pocket costs and a lower deductible.
- Catastrophic: Only adults under the age of 30 can apply for and purchase this type of insurance. Catastrophic insurance is designed to be used only in the event of an emergency. The out-of-pocket costs are very high, while the monthly premiums are very low.
Health insurance premiums are determined by three factors. These factors include:
- Geography: Premium prices may be different depending on your zip code and region, even within the same state.
- Age: Older adults may pay higher premiums than younger adults.
- Tobacco use: People who smoke or use tobacco will likely pay higher premiums than people who don’t use tobacco products.
Final plan options are only viewable once you have enrolled in the exchange. Before you begin that process, however, you can get an estimate of your costs. West Virginia’s Marketplace page hosts the Kaiser Family Foundation’s Health Insurance Marketplace Calculator. You can enter a few basic details into the calculator and receive an estimate for your monthly premiums.
For example, the calculator estimates that a 30-year-old West Virginian who does not smoke and makes $40,000 a year can purchase a silver plan for $292 per month. This estimate does not include any financial assistance that may be available.
Depending on your income, you may be eligible for financial assistance. This assistance can help you offset the cost of purchasing health insurance. A few types of health insurance assistance exist. They include:
- Medicaid coverage: This type of health insurance is available to low-income individuals and families.
- Lower premiums: You will pay less for your insurance each month.
- Lower out-of-pocket maximums: The money you will pay for treatment will be reduced through either lower deductibles or lower out-of-pocket maximums.
The only way to know for certain if you’re eligible for any credits or subsidies is to apply for coverage in the marketplace.
The marketplace establishes income levels that are eligible for assistance. These levels are based on the federal poverty level. People with an annual income that falls within these ranges may qualify for lower premiums:
- $11,670 to $46,680 for 1 person
- $15,730 to $62,920 for 2 people
- $19,790 to $79,160 for 3 people
- $23,850 to $95,400 for 4 people
- $27,910 to $111,640 for 5 people
- $31,970 to $127,880 for 6 people
People with an annual income that falls within these ranges may qualify for lower premiums and lower out-of-pocket maximums:
- $11,670 to $29,175 for 1 person
- $15,730 to $39,325 for 2 people
- $19,790 to $49,475 for 3 people
- $23,850 to $59,625 for 4 people
- $27,910 to $69,775 for 5 people
- $31,970 to $79,925 for 6 people
To learn more about the exchange and how to purchase insurance through the marketplace, please visit http://bewv.wvinsurance.gov/.
You can also find local assistance in West Virginia in your county by visiting http://bewv.wvinsurance.gov/LocalHelp.aspx.
Once you’re ready to apply, visit Healthcare.gov and begin your application. If you need help during enrollment, Healthcare.gov can connect you with a local support person who can help you complete your application.
If you don’t currently have any health insurance, you should begin your application when open enrollment for 2016 starts, which is November 1, 2015. That way, you have time to gather and provide all the information you need, and you can begin receiving coverage as quickly as possible. Considering the financial risks involved with not being covered, buying health insurance just makes sense.