5 facts about Medicare and the Health Insurance Marketplace
Georgia has one of the highest uninsured rates in the nation. And with Open Enrollment deadlines around the corner, time is running out to register for health insurance for 2019.
Since navigating coverage plans, subsidy applications and online forms can be tricky, The Telegraph has assembled a step-by-step guide to Open Enrollment.
What are the health insurance options in Georgia?
Open Enrollment insurance plans comprise just a portion of coverage options Georgia residents can choose from, depending on their employment status, age and other demographic factors.
Nearly 50 percent of Georgians are insured through their employer, according to the Kaiser Family Foundation. Those not covered through work can enroll in private insurance through the Health Insurance Marketplace or in government-run insurance through Medicare, Medicaid or the Children’s Health Insurance Program (CHIP).
Not everyone qualifies for government coverage.
Medicare enrollees must be 65 or older or have been diagnosed with a disability, ALS or End Stage Renal Failure. Medicaid and CHIP eligibility depend on income level and vary from state to state.
Georgia is one of 14 states that has not adopted the federal Medicaid expansion, and has one of the lowest eligibility income limits nationwide, the Kaiser Family Foundation reports. Parents with children under 18 qualify for Medicaid if they earn up to 35 percent of the federal poverty level. That’s less than $10,000 a year for a family of four.
Georgia youth not covered by Medicaid qualify for the state’s children’s health insurance program, PeachCare for Kids, if their household earns 247 percent of the federal poverty level or less.
Those ineligible for public insurance can choose between private coverage plans on the Health Insurance Marketplace, which took effect in Georgia in 2014, as part of the Affordable Care Act.
Four insurers offer plans for Georgia residents through the marketplace – Kaiser Permanente, Blue Cross Blue Shield of Georgia, Ambetter and Alliant – though most providers only cover one specific segment of the state.
Medicaid and PeachCare for Kids enrollment is open year-round, while Medicare and Health Insurance Marketplace enrollment is limited to a several-week span in late fall, with a few exceptions.
Those who miss the December deadlines will have to wait until next fall to apply for insurance coverage through Open Enrollment.
How does Open Enrollment work through the Health Insurance Marketplace?
Health insurance enrollment can take anywhere from 30 minutes to several weeks, said Sarah Sessoms, executive director of Insure Georgia, a nonprofit organization that helps Georgia residents access health care coverage.
Those who qualify for the federal health care exchange can create an account on healthcare.gov and compare coverage options once they enter the required personal information, including household size and estimated income for the coming year.
Marketplace enrollees with low enough incomes are eligible for subsidies, which may decrease the amount they pay in premiums or out-of-pocket costs.
Coverage plans on the Health Insurance Marketplace are broken up into four categories: bronze, silver, gold and platinum. Bronze plans require the consumer to pay the highest percentage of their health care costs out of pocket, covering just 60 percent of costs, while platinum plans put the smallest burden on the insured, covering 90 percent of costs.
Income is the biggest obstacle to enrollment on the Health Insurance Marketplace, Sessoms said.
Issues arise when people qualify to buy coverage through the Marketplace, but can’t afford the plans offered in their state, she said. When that happens, Sessoms refers clients to safety net health care providers that don’t require insurance, like First Choice Primary Care and Macon Volunteer Clinic.
Sessoms suggested that those worried about their ability to afford coverage apply sooner, rather than later. The subsidy application process can slow down the enrollment process, she said.
Her clients often struggle to accurately estimate their income for the following year, which can impact their ability to pay their premium or deductible down the line, depending on what subsidy they receive.
“If you’re worried at all about your income, find somebody to call that does this and can at least, you know, look over what you’ve done,” Sessoms said.
How does Open Enrollment work through Medicare?
Medicare offers both public and private health insurance plans, as well as prescription drug plans. When individuals first become eligible for Medicare, they can enroll at any point in the seven-month period around when they turn 65. Those who already meet age or health requirements can register during Open Enrollment through Friday.
On Medicare.gov, enrollees can browse through Medicare’s four types of health care plans in their area. Medicare Part A is typically premium-free, but only covers inpatient and hospital care. Medicare Part B covers doctors’ appointments, outpatient care and other preventive services based on an income-related premium that can range between about $130 and $460 per month.
Medicare Part C, also called Medicare Advantage, is an alternative to Parts A and B that offers both inpatient and outpatient coverage through contracts with private insurers, like Aetna and Humana. For prescription drug insurance, individuals can enroll in Medicare Part D.
Enrollment in Parts B, C and D are optional, though individuals are charged an annual penalty if they don’t enroll in Part B the first year they become eligible.
Eligible individuals shouldn’t wait to enroll in Medicare, said Dr. Lisa McAdams, regional administrator for the Centers for Medicare & Medicaid Services. Those still covered through an employer can enroll in Medicare as their secondary insurer, she said.
Those already enrolled in Medicare should still consider their options during Open Enrollment, McAdams said, because offerings can change from year to year, including which physicians are covered in their insurance plan.
If Medicare enrollees don’t log into their account during Open Enrollment, though, they’ll still be re-enrolled for the next year, McAdams said, as long as their coverage plan hasn’t been eliminated.
Where can I get help?
Enrolling in health insurance isn’t always straightforward, but there are resources to make the process a bit easier.
Insure Georgia, for example, has a team a patient navigators who help residents throughout the state apply for health insurance both remotely and in person. Those in need of assistance can call their toll free number (1-866-988-8246), email their questions to firstname.lastname@example.org or schedule an appointment for face-to-face help.
Insurance brokers help Georgia residents navigate the twists and turns of health insurance enrollment, as well. Heart of Georgia is one of the largest brokerage companies in the state, with over 1,000 agents serving clients throughout the state. Unlike most nonprofit organizations, though, insurance brokers typically charge a fee for enrollment assistance.
Medicare.gov offers assistance through a “Forms, help, & resources” page on its website, as well as its hotline (1-800-633-4227).
The wait time for phone help can add up, with so many calls coming in, Sessoms said. But she encourages her clients to stay on the line or leave a message.
“Usually, if you are already in line or if you’ve left your message or you’ve left a callback number, they will contact you even after the deadline has passed,” Sessoms said.
Samantha Max is a Report for America corps member and reports for The Telegraph with support from the News/CoLab at Arizona State University. Follow her on Facebook at https://www.facebook.com/smax1996 and on Twitter @samanthaellimax. You can also join her Facebook group. Learn more about Report for America at www.reportforamerica.org.