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NAVIGATING HEALTH CARE the post-dispatch guide

How to decipher the health law’s subsidies for insurance premiums INSIDE • Page R3

Illustration by Dan Martin •

Health insurance marketplaces offer new opportunities Individuals and families will face many choices to shape care, costs. By Jim Doyle • > 314-340-8372

Nathan Brown and Allyson Harper of south St. Louis embody the opportunity and uncertainties in the air as new health insurance marketplaces open for business. “I’ve got to get something,” said Brown, 23, who drives a truck for a local thrift center that does not provide health insurance to all employees. Starting on Tuesday, the Affordable Care Act’s open enrollment period begins across the United States for new state- and federal-run online marketplaces. The marketplaces, also known as exchanges, will present millions of consumers with various coverage options. The new law requires most adults to have health insurance beginning in 2014. Those without coverage will be penalized by the Internal Revenue Service. But the penalties — initially — will be small, and folks have until the end of March 2014 to obtain insurance. See INSURANCE • Page R2

What the Affordable Care Act means for businesses and employees INSIDE • Page R4

Most people can keep their favorite doctors, but questions remain INSIDE • Page R8

How the controversial individual mandate and penalties will work INSIDE • Page R10 Our website provides both consumers and providers with the latest news and analysis from a variety of authoritative sources. Follow @MoHealthReport on Twitter to get regular updates and breaking news alerts.


M 1 • Sunday • 09.29.2013

special report

navigating Health care

Committed to covering the Affordable Care Act By ROLAND KLOSE • Post-Dispatch Business Editor > > 314-340-8128

This special section, published just days before new health insurance marketplaces start open enrollment, represents just one part of the Post-Dispatch’s commitment to covering the Affordable Care Act. So far this year, we have: • Launched a yearlong series of reports on the new law. • Partnered with Kaiser Health News, a leading independent source of reporting on health-related issues, and several other news organizations to broaden and deepen our coverage. Others in the Kaiser consortium are the Miami Herald, the Seattle Times, the Philadelphia Inquirer, the Texas Tribune and the Chicago Tribune. • Created a new website,, to give both consumers and health providers the latest news and analysis from a variety of authoritative sources, and added @MoHealthReport on Twitter to provide regular updates and breaking news alerts. • Assembled an experienced and talented team of journalists to offer the best coverage of the Affordable Care Act in the St. Louis area. Our team includes:

Virginia Young Jefferson City bureau chief She is covering the politics of health care, including the new exchanges and Medicaid funding. Her blog, “Capitol Perspectives,” appears at To contact her • vyoung

Jim Doyle

Blythe Bernhard

Jim Gallagher

Walker Moskop

Tara Kulash

Health industry reporter

Medical and health reporter

Business reporter

Reporter and data specialist

Reporter and blogger for

His continuing series “Health Care: Changes and Choices” has investigated a wide range of issues, including the strength of rural hospitals, executive compensation, and health industry consolidation. The series also is available at To contact him • jdoyle

Her reporting examines, among other subjects, the quality of care. In 2011, she and investigative reporter Jeremy Kohler produced a series looking at dangerous doctors and the regulators who allow them to practice. To contact her •

His weekly personal finance columns frequently look at health care and insurance costs from the perspectives of consumers, employers and employees. To contact him • jgallagher@post-dispatch. com

He is making new data available and putting it into formats that will be easy to use for consumers. To contact him • wmoskop@post-dispatch. com

She was editor-in-chief of The Daily Egyptian, the newspaper of Southern Illinois University Carbondale, and was a summer intern for the Post-Dispatch health section. To contact her • tkulash@


• from R1

For the most part, individuals who are already covered under large group health plans will not be lured by policies sold on exchange Individuals and families are going to soon face numerous decisions that will shape the quality of health care they have access to in 2014 and beyond. Brown, like many young men, is in good health. But a recent spider bite hospitalized him for three days — reminding him that he’s not invincible and can suddenly be hit with huge medical bills. Harper, 22, is already covered by her mother’s health insurance policy — thanks to a provision in the Affordable Care Act that obligated large group health plans to maintain coverage for dependents up to age 26. Like many others, the young couple has a vague notion that something is about to happen that could affect Brown’s chances of obtaining affordable health insurance. But they know few specifics about the health policies or tax subsidies that will soon be available. But twenty-somethings aren’t the only individuals who may find opportunities on the new marketplaces in Missouri, Illinois and other states. Early retirees, who have not yet reached age 65 when the federal Medicare program will start paying for most health care costs, may also find affordable plans and possible tax subsidies on the exchange — or not, depending on their economic circumstances. Self-employed individuals, and those who work for small businesses that do not offer health insurance to their employees, may also find relief. Or, they may find better opportunities on the open market, depending on an exchange’s mix of insurers and products. Families with children who’ve had trouble finding an affordable health insurance plan may look to the exchange for help. Depending on their specific circumstances, they may or may not find better deals there. “There’s not going to be a bad policy. Everything’s covered,” said Vincent Blair, a Webster Groves-based health insurance broker. “Now’s the time you need to know: What is your financial risk? You really need to become educated on the out-of-pocket numbers: the deductibles, the co-insurance and the stop-loss (out-of-pocket limit) of your policy.”

UNCERTAINTY Still, many people at the bottom of the economic ladder may find themselves out of luck, at least on the western side of the Mississippi River. More specifically, some Missourians who are unemployed or have low-income, part-time jobs are currently caught in a gap. They are not enrolled in Medicaid, the joint federalstate health care program for

Associated Press FILE PHOTO

President Barack Obama signs the health care bill at the White House in March 2010. Since the Affordable Care Act was signed, some aspects of the complicated law have been implemented, while others have been set aside by the U.S. Supreme Court. Still, various provisions of the law remain murky or have been delayed by federal health officials.

the poor, yet they earn too little income to receive tax subsidies on Missouri’s federal-run health exchange. For the most part, individuals who are already covered under large group health plans will not be lured by policies sold on the exchange. But individuals who receive health benefits through their employer and who pay high monthly premiums for coverage of their spouse or children may look to the exchange for opportunities to reduce their costs. The new law was designed in part to help consumers find reasonably priced health insurance. But as the exchanges open, insurance brokers as well as consumers and government bureaucrats seem awash in uncertainty. The U.S. Department of Health and Human Services last week released preliminary estimates of some premium costs, making the case that rates will be affordable. But it gave few specifics about the plans that will be offered. For Missouri insurance professionals, the lack of information has been particularly vexing, given that details about rates and plans has been public for some time in states that chose to run their own exchanges. “I’m running a hundred miles an hour into what looks like a brick wall, but I guess it could be papier-mâché,” Blair, the health insurance broker, said recently. “The problem is that people don’t know their options yet,” said Paul Flotken, managing partner of Caravus, a St. Louis

“Now’s the time you need to know: What is your financial risk? You really need to become educated on the out-of-pocket numbers: the deductibles, the co-insurance and the stop-loss (out-of-pocket limit) of your policy.” Vincent Blair, a Webster Groves-based health insurance broker

group health benefit consulting firm. Since the Affordable Care Act was signed by President Barack Obama in 2010, some aspects of this complicated law have been implemented, while others have been set aside by the U.S. Supreme Court. Still, various provisions of the law remain murky or have been delayed by federal health officials. To be sure, the new law is not a panacea for the nation’s spiraling medical costs. And in the short term, experts say, it may actually raise the nation’s cost of health care. Some consumers, including many of those with chronic illnesses and a history of expensive health insurance policies, are

likely to end up paying a bit less for their medical care. But many others, including young adults, are expected to pay more in part to subsidize middle-age individuals, especially those with chronic or severe conditions.

MANDATES Another reason to expect increased costs for health coverage under the Affordable Care Act: Beginning on Jan. 1, 2014, the law mandates health insurers to offer comprehensive plans, including preventive care, as well as lower deductibles and copayments. On the exchange’s new website,, individuals — with or without the aid of a broker or agent — can compare the basic provisions of health plans offered by different insurers. Health policies will be rated in four basic categories, starting with “platinum” — policies with the most expensive, comprehensive benefits — followed by “gold,” “silver” and “bronze.” In addition, individuals under age 30 — and those who can prove hardship — will be able to purchase health policies that only cover “catastrophic” illness or accidents. Persons who meet specific financial eligibility requirements will receive a federal tax subsidy to help pay for their health coverage. But it is unclear whether those subsidies will be available only if a policy is purchased on the exchange. The federal government has proposed to amend

the rules to allow subsidies for policies purchased on the open market. Federal health officials have established specific criteria for tax subsidies. The income limits are about $46,000 for a single individual; about $62,000 for a couple; and about $94,000 for a family of four. Those with higher incomes will not be eligible for a subsidy. “The overwhelming majority of people going to the exchange product are those who are going to be getting subsidies,” said Flotken, the health benefits consultant, adding that others are likely to find better deals on the open market. “If you’re not getting a subsidy, you need to know all the products on the market,” said Blair, the health insurance broker. For those who don’t obtain health insurance, the federal tax penalties will start low — $95 in the first year, or 1 percent of taxable income, whichever is greater. The penalties will rise significantly in the next three years. For most people, it could be much cheaper to pay the penalty for 2014 than purchase a health plan. Still, if you’re uninsured, you run the risk of sudden medical bills and debt collectors. “You can get hurt,” said Brown, the young man whose current employer does not offer health insurance coverage. “In the past, it’s helped when I’ve had insurance.”

09.29.2013 • Sunday • M 1


special report

navigating Health care

Law has already reshaped how we get, pay for care Protections took effect immediately for families with very ill children. By Jim Doyle 314-340-8372

The new state- and federalrun health insurance marketplaces are only one small part of a far-reaching law that is slowly transforming the way American consumers receive and pay for health care. The Affordable Care Act already is beginning to shape the U.S. health care delivery system, not only for consumers who have had difficulty in the past obtaining coverage such as the chronically ill, but also for those individuals who pay for health insurance through their employer. “It’s an unbelievably complicated law, 380,000 words. It tries to reform the (health care) system in just one bill,” said Professor Sherry Glied of Columbia University, a leading U.S. health scholar and a former assistant secretary for planning and evaluation at the Department of Health and Human Services. “A pretty incoherent piece of legislation, and I’m a big fan.” Since President Barack Obama signed the health care law in 2010, a series of market reforms have been put into effect that are aimed at protecting consumers and reining in what some lawmakers view as excessive profiteering and abuses by the health care industry. In 2010, for example, temporary high-risk pools were created to insure those with chronic and severe conditions who were having difficulty obtaining affordable coverage. The law also immediately prohibited insurers from excluding children under 19 due to “pre-existing” medical conditions — a provision designed to protect very sick children and their families. In addition, a provision was enacted that enables young people to remain on their parents’ health insurance policies until age 26. Also in 2010, a one-time rebate of $250 was given to Medicare Part D beneficiaries who reached the “doughnut hole” — the coverage gap when consumers must pay the full cost of their drugs until Medicare’s catastrophic coverage begins. That coverage gap will be phased out during the next few years. And in that same year, a federal reinsurance program made funds available to employers who offer health coverage benefits to early retirees, ages 55 to 64. This subsidy was designed to offset the costs of early retirees’ comparatively more expensive medical bills and insurance claims. In 2011, federal officials implemented “medical loss ratios” to help deter insurers from spending a significant portion of consumers’ premium dollars on administrative costs, including executive salaries, overhead and advertising. Insurers are required to spend at least 80 percent of the premiums they collect on medical care. In the large-business market, insurers must spend 85 percent on health care. Insurers that fall short of the requirement must pay rebates to consumers. Starting in 2012, health insurers were mandated to begin providing a uniform, concise “summary of benefits of coverage” to make it easier for consumers to “comparison shop” for health coverage. This year, the health care law requires greater disclosure of the financial relationships and potential conflicts of interest between health entities, including physicians, hospitals, pharmaceutical companies, pharmacists, and the makers of medical supplies and devices.

Another windfall? The new health insurance marketplaces, also known as health exchanges, that open Tuesday are designed to help those who are having difficulty obtaining or purchasing affordable health insurance. Tax subsidies will be available to those who do not exceed federal income limits. Starting in 2014 • Health plans will be prohibited from excluding anyone based on pre-existing medical conditions, and most businesses with 50 or more full-time employees will be required to offer health insurance coverage with “essential benefits” to their employees, including preventive care without co-payments, prescription drugs, and mental health coverage. Most of these plans will not be permitted to impose lifetime or annual limits for benefits. Subject to fines • Firms that do not comply with these requirements will be subject to fines beginning in 2015. (Those fines, scheduled to take effect in 2014, were delayed due to industry pressure.) But some large companies in service industries such as fast-food restaurants, which have traditionally offered no health insurance or “mini-med plans” — extremely limited health benefits — to their employees, as well as placement firms that provide “temporary workers” (often in computer-related fields), may succeed at avoiding those requirements through federal waivers, reducing their full-time employees and other legal technicalities. Annual spending cap • Beginning in 2014, consumers who purchase coverage on a state- or federal-run health exchange will have an annual spending cap (in addition to monthly premiums) of $6,350 for individuals and $12,700 for a family. Those same limits will take effect in 2015 for most policies purchased on the open market. Electronic health records • The law requires health providers to convert to electronic health records, which should lead to less duplication of unnecessary medical tests, increased communication among health providers and better quality of care. These records will also make it easier for government bureaucrats to monitor a provider’s care and detect any deficiencies or fraud. Penalties and rewards • Federal health officials are taking a carrotand-stick approach to hospital systems and physician groups. Poorly performing health providers that fail to meet the government’s standards for quality of care will be penalized under the new law through fines and lower reimbursement rates. Newly formed “accountable care organizations” that successfully manage the health of a local or regional population will be rewarded with greater reimbursements and profit-sharing; the federal government is providing huge grants to innovative health programs and payment models to seed reforms to the health care delivery system. Who will profit • Potential winners under the new law include public relations firms such as St. Louisbased FleishmanHillard Inc., which has a marketing contract to help federal officials promote the new health exchanges; Anthem Blue Cross and Blue Shield in Missouri and its affiliates in other states, which plan to be highly active in the health exchanges; Medicaid contractors such as Clayton-based Centene Corp., which should benefit from serving millions of additional consumers in states that are expanding their Medicaid programs for the poor; high-tech firms that are converting the paper files of hospitals and doctors’ offices into electronic patient records; and pharmaceutical companies, whose drugs will be sold to tens of millions of additional lowincome patients receiving ongoing medical care. A healthier population • Lawmakers behind the Affordable Care Act pledged that the new law would lead to better health care at lower costs — and eventually a healthier U.S. population. But it is much too soon to determine if these ideals can be achieved — or whether the law, ultimately, will be viewed as just another windfall for the highly profitable health care industry.

Most people who shop on exchange will be eligible for subsidies Tax credits are available to people whose income meets criteria and who lack good employer coverage. By JULIE APPLEBY • Kaiser Health News

Tax credits to help low- and moderate-income Americans buy health insurance will become available in January, when for the first time, most people will be required to have coverage or pay a fine. The credits are available to people who don’t get what is considered affordable, comprehensive coverage through their jobs, and whose household income is less than 400 percent of the federal poverty level, which this year is about $46,000 for an individual, or about $78,000 for a family of three. Most of the 7 million people projected to shop for coverage in new online health insurance marketplaces, also called exchanges, will be eligible for the subsidies, expected to average $5,290 per enrollee. People who don’t have insurance coverage could face fines, which are $95 per adult and $47.50 per child the first year, or 1 percent of family income, whichever is greater. The fines will rise in later years. To help explain the process, we spoke with Cathy Livingston, a partner with Jones Day in Washington, who specializes in tax issues involving the federal health law.

THREE CUSTOMERS, THREE TAX BREAKS A look at how participants in the new state- and federal-run health insurance marketplaces may benefit from tax subsidies on their insurance premiums. Subsidies are tied to household income. Different plans will be available; premiums will be available Tuesday. To calculate your costs and subsidy, go to interactive/subsidy-calculator.


The law bases eligibility on household income. What does that include? The value of a house, stocks or bank accounts is not taken into consideration. Household income starts with adjusted gross income — a number people can find on their tax returns. Who determines eligibility? The exchange. It will have information from an applicant’s last filed tax return. The application also asks people to project their income for 2014. What happens once a person is deemed eligible for a subsidy? The exchange will tell applicants the maximum credit they are eligible for. Consumers can decide whether they want to take the maximum or some lesser amount. Those who think their income might increase beyond what they projected might consider taking less so they won’t have to pay the government back when the year ends. Once an eligible applicant determines how much he or she wants, the exchange will arrange for the amount to be paid every month directly to the insurance company offering the plan the applicant selects. For example, if the monthly premium is $600 and the individual is eligible for $400 (in a subsidy) and opts for that credit, every month the federal government will send $400 to the insurer. The consumer would be responsible for sending the remaining $200. How is the maximum premium subsidy amount determined? There is a complex formula that includes household income and the cost of a benchmark insurance plan, which the law has identified as the second-lowest-priced silver plan — one of four levels of plans — offered on that exchange. The law requires consumers to contribute a specific percentage of income to the premium. It’s a sliding scale based on the federal poverty level. For example, if your household income is at 150 percent of the federal poverty level, you are required to contribute 4 percent of income toward the premium. If your income is at 300 percent of poverty, then you’re required to contribute 9.5 percent. The subsidy then makes up the difference between that amount and the cost of the benchmark plan. The U.S. Department of Health and Human Services last week provided a glimpse of what typical rates may look like in the health insurance marketplaces. The estimated monthly premium for a family of four, with a household income of $50,000, was $798 a month in Missouri and $682 in Illinois. But subsidies reduced that amount to $282 in both states. Do people have to buy the silver plan? No, individuals can choose any plan they like. They might choose a bronze plan with a lower premium or a higher-cost gold or platinum plan. The credit is computed against the silver plan. If they choose a bronze plan with a lower premium, it’s possible the advance payment will cover the entire premium. But the credit cannot exceed the actual premium. Can I decide not to take the credit as an advance payment? Yes, but you would need to make sure you have the cash to pay the premiums. If you get past 90 days and the premium is not paid in full, the regulations direct the insurer to terminate coverage.

Age • 40 Household • Single, no children, nonsmoker Income • $28,725 (250 percent of the federal poverty level) Unsubsidized health insurance premium: $3,161 Estimated government tax credit subsidy • $849 Jim pays about $192 a month.


Age • 30 and 28 Household • Married, two children, nonsmokers Income • $50,000 (212 percent of the federal poverty level) Unsubsidized health insurance premium • $8,637 Estimated government tax credit subsidy • $5,272 John and Mary pay $280 a month.


Do consumers have to file information about the insurance subsidies on their tax returns? People getting subsidies in 2014 will report them on tax returns they file in April 2015. What kind of information will be reported to the IRS? The exchanges will report the level of coverage chosen by an individual, total premium and the amount of premium credit made to the insurance company. Is a worker who gets job-based insurance eligible for a premium subsidy? Only if the employer coverage is either not affordable or doesn’t provide minimum value. To be affordable, the employee’s share of the premium for a policy that covers just the individual (not a family policy) cannot exceed 9.5 percent of household income. And the plan has to cover at least 60 percent of expected medical costs. Does the administration’s decision to delay by a year the requirement that employers offer coverage or pay a fine affect the subsidies? It does not affect rules on eligibility. But it may mean that more people are eligible. Employers no longer have the incentive to offer policies or make plans affordable because they are no longer at risk of a penalty. What happens if I get advance payment, my income then goes up, and I no longer qualify for that amount? You will need to reconcile what was paid with the amount you were actually entitled to receive. If you get more than you were entitled to, you will owe it back in the form of additional federal taxes. There are some caps on the amount a person has to pay back, based on their income. If, for example, you are at 300 percent of the federal poverty level, the maximum amount you would have to pay back is $2,500. If you are under 200 percent, the maximum amount is $600.

Age • 55 Household • Single, no children, smoker Income • $40,215 (350 percent of the federal poverty level) Unsubsidized health insurance premium • $5,516 Estimated government tax credit subsidy • $1,695 Joyce pays $318 a month. Source: Kaiser Family Foundation


M 1 • Sunday • 09.29.2013

special report

navigating Health care

Businesses busy crunching the numbers Complying with law could mean companies pass some of the pain on to their employees. COVERING DEPENDENTS

By Jim Gallagher 314-340-8390

Most working people get their health insurance through their employer. If you’re one of them, here’s what the Affordable Care Act means for you in 2014: • If you work for a big company that offers a decent health plan, not much. • If you work for a small firm that offers coverage, maybe a significant change in premiums. • If your employer offers no coverage at all, or a lousy health plan, you’ll be able to get coverage on the new insurance exchanges, maybe with a subsidy from Uncle Sam. That’s the good news. The bad news: You may also see your work hours cut. Employees with health coverage from big employers have already seen the biggest changes under Obamacare — such as free preventive care, coverage of children to age 26 and the end of lifetime maximum limits on coverage. Next year brings an end to annual dollar limits on medical claims. An employee’s annual out-of-pocket expenses for medical care will be limited to $6,350 per individual and $12,700 per family. But most employers’ limits are already far below that, said Alan Loretta, partner at Mercer, the big employee benefits firm in St. Louis. There are new fees on employers and insurers, including $63 per year for each person an employer covers. Some of that will be passed on to workers. Premiums will also go up with the rising cost of medical claims, a trend that long preceded Obamacare. For workers at small firms, the change may be greater. The big shift will come with “community rating.â€? That means that insurers will no longer be able to look at a workforce’s health and medical claims when setting rates for groups of under 50 employees or for individuals. “That’s the crux of all issues for those with under 50 lives,â€? said Paul Flotken, of the Caravus group of

Employers who cover dependents can charge the worker the full cost of their coverage, with no company subsidy. Given all that, some low-wage workers with children might be better off if their employer offered no coverage at all, notes Gary Claxton, director of the Health Care Marketplace at the Kaiser Family Foundation. Take a worker making $30,000 a year with three kids. On the exchange, such a family might pay $600 a year for family coverage, according to Kaiser’s online subsidy calculator. Their subsidy would be $8,383. By contrast, an employer could charge that worker $2,800 for the worker’s coverage alone, with more charges for the children, and still comply with Obamacare. If the employer offers coverage, neither the worker nor the children would be eligible for federal subsidies on the exchange, Claxton said. However, the children might qualify for coverage under Medicaid. That government health program has looser income requirements for children than for adults. Associated Press

The short form for the new federal Affordable Care Act application. President Barack Obama issued a reprieve this summer for employers who offer no health coverage or bad plans. They now have until 2015 to decide if they’ll offer minimally decent employee coverage or pay a $2,000 per-employee tax.

Care Marketplace Project at the Kaiser Family Foundation, said he hasn’t heard of similar sharp increases, although it’s still early in the process. “It shouldn’t be that big on average,� he said. Employees will feel some of their boss’s joy or pain, because they typically pay a percentage of the premium.

benefits consultants in downtown St. Louis. In theory, the change will be good for, say, a manufacturer with several employees with heart problems. It will be bad for a health club staffed with veggie-eating fitness buffs. Right now in Missouri, the leastrisky employer pays 67 percent of the average rate for its industry class. A particularly sick group might pay 33 percent more than average. But Flotken suspects the ultimate result will be bad — very bad — for most of his firms’ small business clients. One major carrier has given his firm rates so far. Applying those rates, the average Caravus client would see a 28 percent increase. That means “major, major disruption� in the small business health insurance market, he said. Gary Claxton, director of the Health

TEMPORARY ESCAPE Insurers are offering select employers a temporary escape — early renewal of their existing policy, Flotken said. Policies renewed this year can be carried over for another 12 months. The issue means little to big companies, who tend to pay medical costs themselves, using insurance companies mainly for administration. President Barack Obama issued EMPLOYERS • CONTINUES ON R5

Limited-benefit policies • Some low-wage employers offer substandard plans, putting tight limits on claims the insurance will pay. Those are likely to disappear soon, said Alan Loretta, a partner at Mercer in St. Louis. In part, that’s because individuals next year must have coverage or pay a fine at income tax time. Such limited-benefit policies don’t qualify. Lots of individuals also bought such “mini-medâ€? policies — sometimes mistaking them for comprehensive health insurance. Those will now be gone too, predicts Vincent Blair, who sells individual policies at the Vincent K. Blair insurance agency. “The flimflam is off the street. Most of the rip-off stuff won’t be there any more,â€? he said. Help for small businesses • Obamacare throws some carrots to small employers to encourage health coverage. Companies of up to 50 workers next year can use the SHOP system, a health insurance shopping exchange for small businesses. Small businesses now pay on average 18 percent more than big businesses for health insurance. The idea behind SHOP is to combine small businesses’ buying power to leverage a better deal. Those that buy on the exchange can get tax credits ranging up to half their coverage costs. The most-generous tax goodies go to the smallest businesses.

Follow @MoHealthReport on Twitter to get regular updates and breaking news alerts

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a reprieve this summer for employers who offer no health coverage or bad plans. They now have until 2015 to decide if they’ll offer minimally decent employee coverage or pay a $2,000 peremployee tax. That requirement covers employers with 50 or more “full-time equivalent” workers. A full-timer is defined as someone working 30 hours a week or more. But businesses have to add part-timers’ hours together to see if they meet the cap. The Small Business Administration gives this example of how the math works. “Company X has 40 full-time workers working 40 hours per week, along with 20 part-time workers working 15 hours per week. The 20 parttime employees are counted as 10 full-time employees. Company X has 50 full-time employees.” Companies without coverage will pay the tax in 2015 based on the employee hour count in 2014. So employers anxious to slip under the limit will have to act next year. “We’re seeing maneuvering to get under 50,” Flotken said. The cost of coverage isn’t necessarily overwhelming. An employer might pay $9 an hour to a hotel maid working full time. Insuring her would equal a $2.85 an hour raise. That’s assuming a $250 monthly premium for minimum coverage. It also assumes the employer charges the maid the maximum share of the premium allowed under Obamacare. Employers who want to avoid that could cut the hours of part-timers. But there’s a cost to that as well. An employer might lose his best workers, who need more work. Finding and training new employees costs money. Lots of companies close to the limit will hesitate to go over it. Doug Simms, vice president at the Meyer Group of benefits consultants, has a maid service as a client. The company was thinking of expanding into a new area, but that would put them over the 50-worker limit. “They decided they’re not going to,” Simms said. Of course, that strategy can be self-defeating in the long run. It limits the company’s growth — and ultimately the owner’s profit. Lots of low-wage companies — chain stores, restaurant chains, janitorial services — are far over the limit. Will they offer Obamacare coverage — or opt to pay the fine and send their workers to the exchanges? There’s a good argument for covering the workers, said Loretta, the partner at Mercer. In plenty of cases, offering the minimum policy under Obamacare will be cheaper than the $2,000 per employee fine. Taxes are the reason. The fine isn’t tax-deductible, but employee health coverage is. So, at a 35 percent corporate tax rate, providing coverage is cheaper at costs up to about $3,000. An employee can be made to pay a chunk of the premium — up to 9.5 percent of the worker’s household income — and still comply with Obamacare. The lowest plan acceptable under Obamacare isn’t generous. It has to cover only 60 percent of expected medical expenses, allowing for fat co-pays and deductibles on the worker. Such a plan may actually cost the employer less than $3,000 a year per worker, notes Loretta. And if an employee rejects coverage, the employer pays nothing. “We don’t think it makes sense for an employer to drop coverage,” Loretta said. “You could set up a program and have it cost less, on a taxadvantaged basis, than paying the penalty.” That 60 percent coverage level compares to 80 to 85 percent in the more typical company health plan. Obviously, employers don’t know their workers’ household income, so they can’t calculate the 9.5 percent maximum employee contribution. However, the law provides a safe harbor of $90 to $95. So, many employers are offering a minimum plan that workers can get for $90 to $95 per month.


Does your employer provide coverage?


Is your family income less than or equal to 138 percent of the Federal Poverty Level (FPL)*?

NO Has your state agreed to the ACA Medicaid expansion? Illinois





You’re eligible for coverage through Medicaid.


YES Do you pay more than 9.5 percent of your income for the premium in your company’s plan?

Is your family income between the FPL and four times the FPL*?



Does your employer plan to cover at least 60 percent of health expenses on average?



Has your state agreed to the ACA Medicaid expansion? Missouri


Is your family income less than or equal to 138 percent of the FPL*?






Is your family income between the FPL and four times the FPL*?


You can choose coverage in the company plan or buy unsubsidized insurance through an exchange or in the nongroup market.

YES Your family is eligible for coverage through Medicaid.

Your family is guaranteed insurance through an exchange and is eligible for a tax credit.

Your family can get access to unsubsidized insurance through an exchange or the nongroup market.**

You can choose coverage in your company’s plan or buy insurance through an exchange and be eligible for a tax credit.

* The Federal Poverty Level in 2013 is $11,490 for a single individual and $23,550 for a family of four. Using the current FPL, an individual who earned less than $15,856 a year would qualify for Medicaid, but only in states that agreed to expand Medicaid under the Affordable Care Act. Missouri is not among those states. Using the current FPL, an individual whose income is between $11,490 and $45,960 a year could qualify for a subsidy to buy insurance on the health insurance exchange. ** If your income is below the Federal Poverty Level, you can’t qualify for subsidies through the health exchange. In states such as Missouri that didn’t expand Medicaid, you may not be eligible for Medicaid, either. Poor children, however, may qualify for Medicaid or through the Children’s Health Insurance Program. SOURCE: Kaiser Family Foundation | Post-Dispatch

A consumer guide to the exchanges By MARY AGNES CAREY and JULIE APPLEBY • Kaiser Health News

The new health insurance marketplaces, also known as exchanges, are designed to allow consumers to comparison shop for health insurance, just like they can for airline tickets or hotel rooms. If done well, proponents say, the exchanges could make it easier to buy health insurance and possibly lead to lower prices because of increased competition. If designed or marketed poorly, the exchanges will not attract healthy people and will instead be left with a higher percentage of sicker people that will cause premiums to rise. Here are some answers to common questions about the exchanges: What is an exchange, as envisioned by the health law? It’s an online marketplace where individuals and small employers will be able to shop for insurance coverage. Enrollment begins Tuesday for policies that will go into effect on Jan. 1. The exchanges will also help people find out if they are eligible for federal subsidies to help cover the cost of coverage or if they are eligible for Medicaid, the federal-state health insurance program for the poor. Will all states have exchanges? Yes. The federal government is setting them up in 27 states, including Missouri. Twentythree other states, including Illinois, and the District of Columbia chose to either run their own exchanges or partner with the federal government. Will anyone be allowed to buy from the exchanges? Most people will be able to purchase coverage on the exchanges, but the marketplaces are geared for individuals who do not get insurance through work and who buy their own health care coverage. Immigrants who are in the country illegally will be barred from buying insurance on the

exchanges. Most states and the federal marketplace will allow businesses with 50 or fewer workers to purchase through the exchanges. Do I have to buy my health insurance on the exchange? No. If your employer offers health insurance, you can enroll through your job, just as you do now. People without workbased coverage can also shop for coverage on or off the exchange. However, if consumers purchase plans not being sold on the exchange, they will not be eligible for subsidies to help cover the cost of the insurance. If you are a young adult up to age 26, you may be able to get coverage through your parents’ health plan. Are exchanges the only place where I can get subsidized coverage? Not exactly. Under a littleknown rule proposed by the administration in June, consumers will be able to buy an exchange-approved plan — and receive a health law subsidy — from the insurance company itself rather than from the exchange.

I am on Medicare. Do I need to use the exchange? No. Medicare is not part of the health insurance exchanges. As a Medicare beneficiary, you can enroll in the program’s traditional fee-for-service program or in a Medicare Advantage plan, where Medicare enrollees get coverage through private health insurance plans. What about federal workers? Most federal workers will continue to get their health coverage through the Federal Employees Health Benefits Program and will not be required to purchase coverage through the health law’s marketplaces. What will the coverage sold on the exchanges look like? Plans will have to offer a set of “essential benefits” that include hospital, emergency, maternity and pediatric care as well as coverage for prescription drugs and lab services. Annual cost-sharing, or the amount consumers pay for out-of-pocket for care — but not premiums — will be capped at $6,350 for individual policies and $12,700 for family plans in 2014. What if I can’t afford the

premiums? The health law provides sliding scale subsidies to help pay premiums for people up to 400 percent of the poverty level, which is currently about $46,000 for an individual and about $94,000 for a family of four. There’s also some financial help with cost-sharing for individuals and families with incomes of up to 250 percent of the poverty level. Recipients must pay a portion of their household income — 2 percent to 9.5 percent — toward the cost of the premium. Does everyone on the exchange get a subsidy? No, subsidies will be limited to people who meet specific income requirements. In addition, individuals with access to insurance through their jobs but who decide to purchase insurance on the exchange instead are eligible for subsidies only if their employer’s plan does not cover at least 60 percent of estimated medical expenses or if it would cost the worker more than 9.5 percent of household income. Will all insurers have to offer policies through the exchange? No. Insurers are not required to sell through the exchanges.

Predictions of soaring claims provide fuel for critics By JAY HANCOCK • Kaiser Health News

It’s too early to know how much individual health insurance policies will cost once the online marketplaces created under the Affordable Care Act launch Jan. 1. But that hasn’t stopped experts and interest groups from making predictions. The latest analysis comes from the Society of Actuaries. It’s attracting attention because of the group’s expertise and nonpartisanship. What actuaries do for a living — predicting future expense based on multiple squishy factors — is at the core of figuring out what will happen under Obamacare. Thanks to subsidies and the requirement that everybody get insurance or pay penalties, the society forecasts that the number of people covered by individual policies will double to 25.6 million by 2017. Getting the headlines was the forecast that insurer costs — medical claims per policyholder — will soar, on average, 32 percent for the individual market in 2017, with wide variations among states. That’s not the same thing as saying prices consumers pay for policies will rise 32 percent. But if claims are higher, insurers generally charge more. Opponents of the health overhaul seized on the figure to suggest the law could really be called the Unaffordable Care Act. The Obama administration says the study leaves out factors that will restrain what plan members actually pay, including more competition among insurance companies. What’s predicted to drive up costs? Many of those seeking coverage in online marketplaces — known as exchanges — are expected to be older and sicker. They’ll have more incentive to buy policies, and they’ll tend to increase claims paid by insurers. On the other hand, “young and healthy people are less likely to be interested in insurance, because they’re less likely to find value,” said Kristi Bohn, a consultant for the Society of Actuaries who worked on the report. The penalty for not having insurance is likely to be far less than the cost of coverage. The fewer young or healthy people who sign up, the higher the costs per plan member. The authors also made assumptions about how many employers will cancel their plans. Companies with sicker

workforces are predicted to be more likely to end employerbased coverage and steer people toward exchanges. I get insurance at work. Were they talking about my insurance claim costs? No. This report was just about people who buy on the individual insurance market, currently under 10 percent of the country, though that’s expected to go up as the law kicks in. Most Americans get insurance through work or through government programs. Does the study predict health insurance premiums will go up 32 percent by 2017? No. First, it’s only forecasting the individual insurance market. That’s where millions of Americans newly covered under the ACA are expected to find

policies. The report says nothing about costs for employerbased health insurance. Equally important, the 32 percent forecast is for medical expenses paid by insurers, not what insurers will charge in premiums, and not what consumers will pay. But if medical claims go up, shouldn’t insurance prices also go up? How much difference could there be? In the individual market designed under the health law, quite a bit, say supporters. The ACA limits insurer profits and also gives government regulators oversight of rate increases, both of which could hold premiums down. Even if sticker prices rise, an important feature of the health law is subsidies for people to buy insurance, through tax credits for those with lower incomes. So what many newly

insured people actually end up paying won’t be the same as what the insurance company bills. Does it matter where I live? Yes. The report found huge variability, based on geography. While the estimated increase would be 62 percent for California by 2017, in New York state, the report estimates claim costs would drop by almost 14 percent. Will health plans offer the same coverage in 2017 that they do now? That’s another reason the 32 percent headline could be misleading. Thanks to ACA minimum coverage requirements, benefits will be more generous starting next year. So what insurers pay in claims can expected to be higher, too.


M 1 • Sunday • 09.29.2013

special report

navigating Health care

Photos by Stephanie S. Cordle •

Chris Worth (left) of St. Louis participates in a Japanese fitness class led by Mitch Sasa (center) this month. Worth, 35, has cerebral palsy and takes the class for physical therapy.

More hurdles ahead for the disabled Missouri elected not to expand Medicaid, leaving many to wonder what services will be covered. By Tara Kulash • > 314-340-8114

Plans available on the new health insurance marketplaces won’t be able to turn away consumers, or charge them more, because of pre-existing medical conditions. For individuals with chronic illnesses or disabilities, that means they should be able to shop on the same playing field as healthy consumers. That was a key change in the Affordable Care Act, which barred insurance companies from denying coverage to individuals with pre-existing conditions. But the wording of the law is vague, and that could leave wiggle room for insurance companies, said Timothy McBride, a health economist and professor at Washington University. The new marketplaces, or exchanges, will offer four levels of insurance plans — bronze covers 60 percent of medical costs; silver covers 70; gold covers 80; and platinum covers 90. McBride said insurance companies could make those benefit packages less generous in the kinds of therapies and equipment they choose to cover, or they could raise premiums for everyone to make up for the expensive coverage. Differentiating between plans could be difficult for some consumers, but thanks to the Affordable Care Act, people with disabilities should not be as fearful about having to switch insurance carriers because of a job loss or change, said Sarah Durbin, director of public policy for Paraquad, the St. Louisbased nonprofit organization that advocates for people with disabilities. Still, in Missouri, the main concern for the many disabled people is Medicaid expansion, she said. Chris Worth, 35, who has

Home health care worker Tamara Kent helps Chris Worth dress in the morning and prepare for his day. She also does ironing and cleaning for him. Worth struggles to pay his in-home assistant $16 an hour out of pocket, on top of his college loans, rent and any repairs his motorized wheelchair might need.

cerebral palsy, struggles to pay his in-home assistant $16 an hour out of pocket, on top of his college loans, rent and any repairs his motorized wheelchair might need. Worth receives insurance from his full-time job at Paraquad but gets no coverage for attendant care, and he is not eligible for Medicaid. Disabled Missouri residents are eligible for Medicaid only if they make 85 percent or less of the federal poverty level. Under the Affordable Care Act, those who make at least 138 percent of the poverty level may be eligible for insurance subsidies in the

form of tax credits. The act also intended for those in between 85 and 138 percent to be added to Medicaid. But the Supreme Court ruled that Medicaid expansion should be left up to the states, and Missouri opted out of the expansion. Worth falls in the gap because he makes more than 85 percent of the poverty level and has to cover some of his most expensive medical costs out of pocket. He takes Japanese fitness classes for physical therapy, and replacement wheels for his motorized chair alone cost $800. “Honestly, without Medicaid expansion, (the Affordable Care

Act) really doesn’t mean much for us (people with disabilities),” he said. But it’s the in-home assistant who gets him physically ready for the day that hurts Worth’s budget the most. Durbin said Medicaid covers attendant care. But people who get Medicare because of a disability do not get coverage for attendant services. Much of Paraquad’s concern for its participants, she said, is that if Missouri does decide to expand Medicaid, legislators could decide not to include attendant care under its basic services.

Private insurance companies generally don’t cover attendant services either, she said, and it’s unclear whether that benefit will be offered by plans in the health insurance marketplace. “Unfortunately, we live in a world where the only way you can get your attendant care paid for is through the Medicaid process,” she said. Worth said paying for his attendant care without insurance coverage is very stressful and holds him back from taking on bigger projects advocating for the disabled. “You can’t take on the big social issue when your biggest issue is how am I going to eat, pay for this wheelchair part?” he said. Another concern if Missouri doesn’t expand Medicaid is the spend-down policy to become eligible for the program. Based on income levels, if an applicant makes more than 85 percent of the poverty level, he or she must spend down to 85 percent before applying for Medicaid. For example, if a resident makes 89 percent of the poverty level, he or she must spend 4 percent out of pocket on health costs and report it to the state before becoming eligible for Medicaid. “You’re asking folks that aren’t making any money anyway to spend down hundreds of dollars each month to get that coverage,” Durbin said. Plus, a single applicant may have no more than $1,000 in assets, and couples can have no more than $2,000. For Worth, his spend-down equals to around $1,900 a month. “If I paid that, I would be as poor as I was when I wasn’t working,” he said.

Answers to some questions about using health insurance marketplaces By MICHELLE ANDREWS Kaiser Health News

It sounds like people who buy coverage on the new health insurance marketplace will have to pay the full monthly premium for that insurance, and subsidies will be paid through tax credits that are received annually as a tax refund. How could any lowincome person who is living from paycheck to paycheck afford to do that? They won’t have to. When consumers apply for a plan on the health insurance marketplace, also called an exchange, they’ll be asked to provide income information to determine whether they’re eligible for a tax credit to help pay premiums. That subsidy will be available to people with incomes up to 400 percent of the federal poverty level ($45,960 for an individual in 2013, or $94,200

for a family of four). If they qualify, consumers can opt to receive the tax credits in advance, and the exchange will send the money directly to the insurer every month. This subsidy will reduce how much people owe upfront. Consumers can also choose to receive their credit when they file their taxes the following year. It’s important to estimate your income as accurately as possible and contact the exchange during the year if you find you’re making more or less than expected. That’s because when completing your 2014 taxes, your estimate will be reconciled with what you actually earned. If you’ve received more than you were due, you could have to repay those amounts. Likewise, if you earned less than expected, you’ll get money back.

My employer offers affordable health insurance for me for $136 per month, but adding my husband and 22-year-old daughter will push the premium up to about $2,050 a month. Will we be allowed to buy insurance on the exchange? We probably won’t qualify for a subsidy because our income will be between $85,000 and $120,000. I fear that in comparison to the marketplace, the individual plans sold by insurance agents will be inferior. Even if your employer offers health insurance, you can shop for coverage on the exchanges. However, because your income is more than 400 percent of the federal poverty level ($78,120 for a family of three in 2013), you won’t be eligible for a tax credit if you buy a plan there. Don’t dismiss plans sold outside the exchanges because you don’t think they’ll provide

good coverage. Starting next year, individual and small group plans, whether they’re sold through the online marketplaces or on the private market, all have to meet many of the same standards. The coverage is going to look very similar inside and outside the exchange if you’re not eligible for the exchange. Plans can’t turn people down or charge them more because they have pre-existing medical conditions, for one thing, and plans must cover 10 comprehensive “essential health benefits.” In addition, all plans must generally cap out-of-pocket spending at $6,350 for individuals and $12,700 for families, among other things. The only plans that are exempt from the new rules are those that are grandfathered under the law.

What happens when people don’t pay their premiums in a timely manner after they purchased insurance on the new exchange? If they are terminated from the policy, will they be able to reinstate? Consumers who are receiving tax credits for coverage on the exchange will get a 90-day grace period to catch up on late premiums. Other consumers not getting the subsidies might get more or less time, depending on the exchange rules or state law. Once the grace period has passed, consumers will generally have to wait until the next annual open enrollment period in the fall to re-enroll in coverage. If they’re uninsured for more than three months, they could be assessed a penalty for not having insurance coverage of up to $95, or 1 percent of income in 2014, whichever is greater.

09.29.2013 • Sunday • M 1


special report

navigating Health care

Giving you more tools to make good choices Under law’s requirements for greater transparency, consumers can directly compare costs, outcomes. By Jim Doyle 314-340-8372

Regardless of how you personally view the overall merits, regulatory strictures or societal costs of the Affordable Care Act, embedded in the new health care law are key elements that can help make you a more knowledgeable, independent and powerful health care consumer. Let’s face it, purchasing health care services can be among life’s most financially risky and frustrating endeavors. Often, consumers have no idea of the ultimate price they will pay for a particular medical test, procedure or course of therapy. Many hospitals and physicians’ groups are reluctant to provide written estimates of expected charges in part because every person’s body is different and an individual may need more medical attention than anticipated. Traditionally, it’s also been tough to assess a hospital’s quality of care. Most people rely heavily on a personal or familial sense of loyalty to one institution or another, or a community’s general word-of-mouth about these providers. And typically, the “This is not a bill” statements produced by health insurers are so complicated that they may cloud the true costs of medical services for the patient and his or her “payer,” whether that’s an employersponsored health plan, a policy purchased on the open market, or a government program such as Medicare. But among its myriad provisions, the health care law requires health providers to operate with far greater transparency than ever before. Hospitals must file periodic reports to the government on a variety of “objective measures,” from an institution’s mortality (death) rates to patient satisfaction surveys.

For a handy search tool for price shopping, the Post-Dispatch launched an online consumer database to review average hospital charges, as well as other tools for examining regional hospitals. The Joint Commission — an independent, nonprofit organization that accredits hospitals nationwide — has useful information about hospitals and their service lines on its website.

HOSPITAL EXPLORER A new online tool, available at the Post-Dispatch’s, offers readers a detailed look at hospitals across Missouri and in the Metro East. The tool includes information that helps consumers gauge the quality of care hospitals provide, such as average emergency room wait times and patient surveys. Information about hospitals’ average charges for many common treatments and procedures also is provided.

To help level the playing field, federal health officials are providing consumers with specific data that track the performance of health providers. The goal is for consumers to take greater responsibility for their health care and make more informed decisions. And the government also has begun sharing with the public information about the charges of various medical procedures at hospitals, whether it involves the cost of knee surgery or a pacemaker. Those charges are based on reimbursement claims filed by these hospitals for services

rendered in the federal Medicare program for individuals ages 66 and above. Hospitals may use these charges as a starting point in their negotiations with self-pay patients. Even the Medicare system is unlikely to pay the full rate. This publicly reported data is now available online. On the “Hospital Compare” website, consumers can compare the track records of hospitals and outpatient centers on a broad array of measures. The website — — is sponsored by the Centers for Medicare & Medicaid Services. The site began several years ago, but the new health care law has

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helped kick these transparency efforts into high gear. Using this consumer-oriented website, you can now look up all the hospitals in the St. Louis area by entering a ZIP code on Hospital Compare, and then choose the institutions you wish to directly compare. Or, you can simply look up specific hospitals. One quick measure of hospital performance is the patient satisfaction survey. These surveys — conducted by independent third parties and designed to assess how consumers perceive an institution — include everything from a hospital’s cleanliness to the loudness of hospital rooms

at night and the communication skills of doctors and nurses in explaining to patients their diagnosis and treatments. Another important point of comparison is the hospitals’ performance measures data for 30-day mortality rates for heart attack, heart failure and pneumonia. Generally, hospitals are rated by federal health officials on whether they meet, surpass or fall below state and national standards. Similarly, a hospital’s “readmission rate” for heart attack, heart failure and pneumonia is one measure of how well an institution fixes a patient’s medical problem. A hospital that has a comparatively high rate of readmitting patients within 30 days of discharge may indicate high rates of complications, a failure to provide adequate discharge instructions to patients or inadequate follow-up care for patients. Hospital Compare tracks hospitals’ rates of serious complications related to particular surgeries, including risky infections that can slow the healing process or cause serious bodily injury or death. The website also has information on hospital emergency rooms, including the average time it takes for a patient to be seen by a health professional. And it compares outpatient facilities’ use of medical imagery such as mammograms. Centers with unusually high rates of medical imaging for certain procedures may put their patients at risk of radiation damage. Earlier this year, federal health officials began making public the data they collected on hospital charges for various medical procedures. With that data, it’s possible for consumers to compare, for instance, charges for hip replacement surgery at hospitals across the state.

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M 1 • Sunday • 09.29.2013

special report

navigating Health care

Will you be allowed to keep your doctor? Plans on exchange might limit physicians covered — leaving promise of reform unfulfilled for some. By Blythe Bernhard 314-340-8129

Among the many questions posed by health care reform, the status of doctor-patient relationships could be the most personal. An initial promise of the Affordable Care Act was that people would be able to keep the same doctors and choose from a variety of hospitals. For the majority of Americans who get insurance through their employers, the doctors and hospitals already included on their policies are unlikely to change. But the new health insurance marketplaces — online exchanges designed for people who are not offered health insurance benefits through work — could include plans that reduce the number of doctors or hospitals covered under the network. The answer from the American Medical Association on whether people will need to get new doctors is: “That depends.� In a question-and-answer page on its website, the doctors’ lobbying group recommends that patients check out plans on the exchanges before buying to make sure their preferred doctors are included. Details have not been released about the insurance policies that will be available starting Tuesday on the exchanges in Missouri and Illinois. But insurers in other states have announced cuts to the number of doctors covered under the exchange plans compared to employer plans. Health Net, a large insurance company in California, has said its exchange plan will offer fewer than a third of the doctors compared to employer plans in that state. About half of the doctors

Hospital administrators said the combination of more people getting insurance and an existing shortage of primary care physicians could mean longer waits for appointments or more work for nurse practitioners. Others pointed out that people with pre-existing conditions, who may be eager to buy plans through the exchange after being previously denied coverage, could have a hard time getting in to see specialists.

in the Blue Shield of California network will be included under the exchange plan. Experts here didn’t expect Missouri or Illinois to necessarily mirror California. Until a few days ago, the possibility that insurers in the Missouri exchange would limit access to any of the large physician networks, such as BJC, SSM and Mercy, seemed small. “My sense about the St. Louis market is it tends to be more stable than other markets,� health economist Timothy McBride of Washington University told the Post-Dispatch this month. “Most of the big plans that are offered in the metro area like UnitedHealthcare and Blue Cross, they tend to offer most of the providers in the area. If one plan says you can’t go to BJC or SSM, that would be pretty bad.� That appears to be what has

happened in at least one case, however. Area insurance brokers told the Post-Dispatch last week that BJC likely would be excluded by Anthem Blue Cross and Blue Shield from some plans on the exchange. In the weeks leading to the opening of the health exchanges, insurance companies, such as Anthem, have been negotiating reimbursement rates with hospitals and physician groups, pushing for the best deals. “How fairly the doctors get paid will dictate what plans they participate in,� said Rex Budde, CEO of Southern Illinois Healthcare. Physician groups and hospital systems nationwide have continued to merge in a long-term trend aimed at improving their bargaining power with insurance companies. This month, Southern Illinois

announced it is joining the BJC Collaborative, which also includes the health systems Memorial of Springfield, Ill.; Saint Luke’s of Kansas City; CoxHealth of Springfield, Mo.; and Blessing Health System of Quincy, Ill. Budde and other hospital administrators said the combination of more people getting insurance and an existing shortage of primary care physicians could mean longer waits for appointments or more work for nurse practitioners. Others pointed out that people with pre-existing conditions, who may be eager to buy plans through the marketplace after being previously denied coverage, could have a hard time getting appointments with specialists. But access to more physicians and experienced specialists is one of the goals of

the partnership with BJC, Budde said, which should provide a smoother pipeline for patients in Southern Illinois to health care in St. Louis. People who have Medicare are unlikely to experience any changes in the doctors they can see, because the insurance for older Americans accounts for up to 50 percent of many doctors’ revenue. But people with Medicaid — the program for the poor that already suffers from a severe shortage of doctors because of lower reimbursement rates — could be stuck with even fewer who accept patients under the plan. Dr. William Peck, director of Washington University’s Center for Health Policy, said the exchanges are generally good business for insurers, and they’ll want to include as many doctors as possible to compete with the other plans on the market. “There are 1,100 health insurance companies (nationwide), so chances are that your physician will be on at least one or two of those insurers on the exchange,� Peck said. People who do find themselves buying a plan that does not cover their doctor need to work with new insurance navigators to avoid problems with continuity of care, said Tom Holloway, executive vice president of the Missouri State Medical Association. The association is working on a tool kit for its members to help their patients understand their options. But critics of the private insurance system said Americans already suffer from a lack of choice when it comes to health care. “If you had complete choice of physicians, you wouldn’t really need choice of insurance companies,� said Dr. Ed Weisbart, who leads the Missouri chapter of Physicians for a National Health Program. “It’s crazy that your employer picks your insurance, and then your insurance picks which doctor you can see.�

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09.29.2013 • Sunday • M 1


special report

navigating Health care Exchanges in Missouri, Illinois will do things a bit differently By Virginia Young •

Health insurance marketplaces begin open enrollment across the U.S. on Tuesday. But there are key differences among the states. This is how Missouri and Illinois compare. Who is running the exchanges? Missouri • The federal government. Illinois • The state is partnering with the federal government. Illinois is handling plan management and outreach and education. The federal government will run the website.

How many people are likely to participate?

Mark Harrison • MCT

An Army report recommended the use of alternatives to pain drugs, including chiropractic care, massage and acupuncture. Here, Dr. Frank Lawler gives Spc. David Ash chiropractic treatment in 2011 in Tacoma, Wash. Under the Affordable Care Act, alternative and complementary medicine could make more headway in the mainstream health care system because insurance companies are no longer allowed to discriminate against a licensed provider.

Law boosts status of alternative medicine — at least on paper In reality, each state is still free to set its own definition of ‘essential’ care. By Tara Kulash 314-340-8114

Complementary and alternative medicine — a term that encompasses meditation, acupuncture, chiropractic care and homeopathic treatment, among other things — has become increasingly popular. About four in 10 adults — and one in nine children — in the U.S. are using some form of alternative medicine, according to the National Institutes of Health. And with the Affordable Care Act, the field could make even more headway in the mainstream health care system. That is, unless the fine print — in state legislation and insurance plans — falls short because of unclear wording and insufficient oversight. One clause of the health law in particular — Section 2706 — is widely discussed among providers of alternative medicine because it requires that insurance companies “shall not discriminate” against any health provider with a state-recognized license. That means a licensed chiropractor treating a patient for back pain, for instance, must be reimbursed the same as a medical doctor. In addition, nods to alternative medicine are threaded through other parts of the law in sections on wellness, prevention and research. But because under the health care law each state defines its essential benefits plan — what is covered by insurance — somewhat differently, the wording concerning alternative medicine has to be very specific in terms of who gets paid and for what kinds of treatment, said Deborah Senn, the former insurance commissioner in Washington and an advocate for coverage of alternative medicine. For example, naturopathic care would not fall under the nondiscriminatory list in Missouri because

the state does not recognize it as a licensed practice. And even if a practice is licensed, that doesn’t mean it will receive coverage, said Afua Bromley, a licensed acupuncturist at the Acupuncture St. Louis and Wellness Center. “Some people have the misconception that the (Affordable Care Act) means that acupuncture coverage will be mandated, and that’s not the case,” she said. Insurance companies can still decide not to include acupuncture in their plans, so Bromley cannot bill an agency for acupuncture care if coverage isn’t provided. However, because she’s licensed, Bromley will be able to bill insurance companies for office visits, just like a medical doctor can bill separately for an office visit, nutritional counseling, exams and more. Also, if an insurance company reimburses an M.D. for practicing acupuncture on a patient, that company is then required to reimburse licensed acupuncturists as well. For a practice such as chiropractic care, the benefits are a bit more recognizable in Missouri. Margaret Freihaut, insurance committee chairwoman for the Missouri State Chiropractors Association, said the state already has a law in place where fully insured plans — employers pay premiums to insurance companies — must provide coverage for chiropractic care. Self-funded companies in which the employer has a separate pool of money to pay for employees’ claims — often state workers — are not required to cover chiropractic care. Many of them do anyway, but they don’t cover as many visits as the law requires. “But now with this anti-discrimination, unless they’re limiting (everyone), they can’t just limit one profession,” Freihaut said. This could affect global fees, too.

Some insurance companies pay one set fee to chiropractors even if the services amount to more. This, just like Bromley’s acupuncture, differs from the itemized billing at a medical doctor’s office, where many services are billed separately. “We don’t know how (insurance companies) are going to handle it,” Freihaut said, but “I would assume they can’t keep doing that because they would be paying for the same service at a different fee.” In the long run, Freihaut and Bromley say including their practices in health care coverage is actually cheaper for insurance agencies, because their care can prevent surgery and expensive drugs. Proving that alternative medicine has real, measurable benefits has been key to increasing its role in the system, said John Weeks, editor of the Integrator Blog, an online publication for the alternative medicine community. The Patient-Centered Outcomes Research Institute, created by the health law, is funding studies on alternative treatments to determine their effectiveness. Weeks said both lawmakers and the general public will soon have access to that research, including the amount of money saved by integrating other forms of medicine into the current health system. Freihaut said she’s excited about what this means for consumers. “It’s a very positive thing,” she said. “It’s going to level the playing field so that people can make their own health care choices.” But Bromley said because acupuncture care receives little to no insurance benefits in Missouri, it’s not likely she will be affected by the Affordable Care Act until the state embraces her practice. “In theory, it’s great,” she said. “In reality, I continue taking my cash patients.” Ankita Rao of Kaiser Health News contributed to this report.

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Missouri • The federal Centers for Medicare & Medicaid Services, which is overseeing the federal exchanges, said it has no state-by-state projections but expects 7 million people nationally to enroll next year. The Missouri Foundation for Health, a St. Louis-based nonprofit agency, estimates that 350,000 Missourians will be eligible for subsidies through the exchange. Illinois • Estimates that 486,000 people will enroll through the exchange next year.

How are the exchanges being marketed? Missouri • The state is not doing any marketing because Missouri has a federally run exchange. The private Foundation for Health is spending $1.8 million on a public relations campaign, which will be unveiled this fall. CMS, the federal agency in charge of the exchange, plans “targeted ads” in states such as Missouri and is “finalizing the creative elements and placement.” The agency would not say how much it will spend here. Illinois • In July, the state awarded a $33 million contract to St. Louis-based FleishmanHillard to design an advertising and grass-roots campaign promoting the marketplace.

How much is being spent on consumer assistance? Missouri • Federal money is paying for community organizations and health centers to hire insurance counselors in both states, but Missouri’s share of the grants is smaller because it has a federally run exchange. Twentytwo community health centers got $2,947,351 to hire 59 counselors. An additional $1,795,624 went to two agencies — Primaris Healthcare Business Solutions and the Missouri Alliance of Area Agencies on Aging — to hire “navigators,” another name for counselors. In addition, the Missouri Foundation for Health gave 17 organizations $5 million in private funds to hire counselors. That makes the total available in Missouri $9,742,875. Illinois • Illinois has nearly four times that much money available for consumer assistance. Forty-two health centers got $6,161,944 to hire 132 counselors. Eleven agencies got $3,060,471 to hire navigators. On top of that, Gov. Pat Quinn awarded $27 million in federal funds to 44 community organizations to “reach out to every corner of the state and make sure that no one is left out of this historic opportunity to obtain quality health coverage and the peace of mind that comes with it.” That brought Illinois’ total to $36,222,415.

How many people will be added to the Medicaid rolls? Missouri • The state Legislature rejected the Medicaid expansion proposed by the Affordable Care Act. It would have covered adults earning up to 138 percent of the federal poverty level, or about $32,500 for a family of four. However, Missouri already covers children in families earning up to 300 percent of poverty, and many currently eligible children are not enrolled. So the state estimates that 24,617 additional children will enroll next year when their parents use the exchange. Illinois • The state expanded Medicaid to cover adults with annual incomes of up to 138 percent of poverty. Next year, that is expected to add 199,000 people to the rolls. The full cost of the new participants will be borne by the federal government for the first three years, with the state picking up a share after that. Also, 97,446 currently eligible people are expected to sign up for Medicaid, for total growth of 296,446 next year.

How many people are on Medicaid now? Missouri • 866,383. Illinois • 3,052,664.

How many people will fall into the coverage gap? Missouri • Congress assumed the states would expand Medicaid, but the U.S. Supreme Court made the expansion optional. Because Missouri rejected the expansion, about 226,525 working-age adults — those under age 65 and below the poverty line of $11,490 for an individual and $15,510 for a couple — will fall in a gap. They do not qualify for Medicaid — which doesn’t cover childless adults unless they are elderly or disabled. But they make too little to be eligible for federal subsidies on the exchange. The subsidies will go to those making between 100 percent and 400 percent of poverty. Illinois • The state expanded Medicaid and so will have no coverage gap.


M 1 • Sunday • 09.29.2013

special report

navigating Health care

Understanding the individual mandate By ALVIN TRAN • Kaiser Health News

Among the federal health law’s most controversial provisions is the individual mandate, which goes into effect on Jan. 1. The mandate, which requires most people to obtain health insurance or pay a tax penalty, survived a constitutional challenge last year in the Supreme Court but remains under attack by conservatives and libertarians in Congress. Despite all that attention, many Americans still aren’t aware of the requirement. Here are some basic questions and answers about mandate. What is the individual mandate? The individual mandate is a provision of the federal health law that requires you, your children and anyone else that you claim as a dependent on your taxes to have health insurance in 2014 or pay a penalty. That coverage can be supplied through your job, public programs such as Medicare or Medicaid, or an individual policy that you purchase. The health law is setting up online health insurance marketplaces, also known as exchanges, to help you shop for plans. Who is affected by the mandate? The mandate is aimed at the 57 million people younger than 65 who now do not have insurance. The Congressional Budget Office estimates that in 2014 nearly three out of five Americans will have coverage through an employer-provided plan and 12 percent through Medicaid and the Children’s Health Insurance Program, federalstate programs that provide insurance to lower income Americans. If you have insurance in either of those ways, you are not affected. If you are on Medicare, you also meet the requirement. Are there any exceptions to the mandate? Yes, the government has identified exemptions. Individuals who cannot afford coverage because the cost of premiums exceeds 8 percent of their household income or those whose household incomes are below the minimum threshold for filing a tax return are exempt. People experiencing certain hardships, including those who would have been eligible for Medicaid under the health law’s new rules but whose states chose not to expand their programs, also are exempt. Other exempt groups include prisoners, Native Americans eligible for care through the Indian Health Care service, immigrants who are in the country illegally, people whose religion objects to having insurance coverage, members of a health care sharing ministry and individuals who experience a short coverage gap of less than three consecutive months. The CBO estimates that in 2016, after the major provisions of the health law are implemented, 24 million people will be exempted from the mandate’s penalties. Why is there a mandate? The health law was designed to extend insurance to nearly all people, including those who have medical conditions that require expensive care and have often been denied coverage. But to pay for the care of those beneficiaries, insurance companies need to have a large enrollment of consumers, especially young and healthy people who use fewer services. The mandate was adopted to guarantee a broad base. How do I satisfy the mandate? Health coverage provided through a job-based plan (including COBRA or a

Associated press file photo

Amy Brighton of Medina, Ohio, holds a sign in front of the Supreme Court in March 2012 in Washington during a rally over the Affordable Care Act. The law’s individual mandate survived a constitutional challenge last year but remains under attack by some in Congress.

retirement plan); policies that you bought for yourself or your family; Medicare (and Medicare Advantage); Medicaid; CHIP; some Veterans Administration health programs; or TRICARE coverage for members of the military and their dependents will satisfy the mandate. If you are uninsured or thinking about switching plans, you can shop for coverage through the online marketplaces, starting Tuesday. These marketplaces will operate in every state and the District of Columbia and will alert people with lower incomes if they are eligible for Medicaid. The marketplaces will also offer tax subsidies to help reduce the cost of premiums. Although the mandate takes effect Jan. 1, the initial enrollment period continues through March 31. Because people are exempted for a short coverage gap — less than three months — individuals that obtain coverage before the end of March will be exempt from the payment for that period. How do I report my coverage or exemptions to the government? You will not have to report your coverage or exemptions until you file your 2014 income tax return, which won’t be due until April 15, 2015. Insurance providers will also be required to help their clients report their health coverage. The Internal Revenue Service says it will put out details later about how the reporting will work. If your income is so low that you do not file

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a tax return, you are exempt from paying the penalty. What happens if I don’t get coverage? If you do not have the minimum level of coverage and do not qualify for an exemption, you must pay a penalty to the IRS at the end of the tax year. The penalty for the first year is $95 per adult and $47.50 per child, or 1 percent of family income, whichever is greater. The fine, however, increases over time and in 2016 will be $695 per adult and $347 per child (up to $2,085 for a family) or 2.5 percent of family income, whichever is greater. The amount you owe will be prorated to reflect the number of months you were without coverage. The CBO estimates that 6 million people, about 2 percent of the population, will be assessed a penalty in 2016. How do I apply for an exemption? If you are seeking an exemption for incarceration, membership in an Indian tribe or health care sharing ministry, you can apply through the health insurance exchanges or make a claim when you file taxes, according to final rule issued by the U.S. Department of Health and Human Services. If you are claiming economic hardship or a religious exemption, you must get an exemption certificate from the online insurance exchange. If you are claiming

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Where did the idea of the mandate originate? The origins of the individual mandate have been controversial. Many Democrats who support the law suggest it was originally a conservative idea developed in 1989 by the Heritage Foundation’s Stuart Butler to counter liberals’ efforts to establish a single payer system and impose a mandate on employers to provide insurance. Several years afterward, Republicans used the individual mandate in a bill they offered as an alternative to Bill Clinton’s proposal to overhaul health insurance. The mandate also was incorporated as part of the Massachusetts overhaul of health insurance in 2006 under then Gov. Mitt Romney. Democrats later adapted the concept and pushed it as part of the congressional debate over the Affordable Care Act, despite President Barack Obama’s initial reluctance to embrace it. Whatever their prior views, most conservatives opposed the health law’s version of the mandate, and Butler made a spirited argument that the current mandate is not what he was endorsing years ago.


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What To Do When Decibels Get Dangerous xxxxx, xx —If you think hearing loss Sept. 29, 2013 How Loud is is just an inevitable part of aging, think again. One in five Americans—that’s Too Loud? more than 48 million people—have

Noise levels are measured in decibels (dB). The higher the decibel level, the louder the sound. Both the level of noise and the length of time you are exposed can contribute to hearing damage. Your hearing can be injured not only by sudden, extremely loud sounds, but by exposure to noise over time.

trouble hearing in one or both ears. But, age and genetics are only partly to blame.

Leading Cause of Hearing Loss? Noise, Not Age We live in a noisy world, and every year it seems to get noisier. The seeds of hearing loss in older age may have been planted in our younger years by exposure to excessive noise. From lawnmowers and vacuum cleaners to factory machines and rock concerts— we’re repeatedly exposed to loud noises—the cumulative effect of which can show up in midlife as hearing loss.

Damage from a lifetime of noise is a major cause of hearing loss.

‘Turn It Down!’ and Do Your Ears a Favor To understand how hearing loss occurs, we need to know how we hear. Sound waves enter the ear and travel through the ear canal to hair cells located in your inner ear. These highly sensitive cells convert sound energy into electrical signals that are sent to the brain. But, when the volume is too loud, the hair cells get damaged. And once damaged, they don’t regenerate, causing permanent hearing loss. Since age-related hearing loss is often the accumulated damage from a lifetime of noise, the impact of noise exposure may not show up for many years.

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Sound level


140 -165 dB

Fireworks Jet engine

120 dB

Ambulance siren, Thunderclap

110 dB

Jackhammer, Rock concert

Regular exposure of more than 1 minute at or above 110 dB risks permanent hearing loss

MP3 players at maximum volume

105 dB

No more than 15 minutes of unprotected exposure at or above 100 dB is recommended

95 dB

Subway train

85 dB

Heavy city traffic

Prolonged exposure at or above 85 dB can cause gradual hearing loss

Make a Sound Decision— Get Your Hearing Tested As we get older—and the years of excessive noise take their toll—there’s a good chance most of us will deal with hearing loss. That’s why experts urge anyone over 50 to make annual hearing screenings a routine part of their medical care. Luckily, hearing technology and testing have never been better. And, many hearing care providers make it easy by offering comprehensive hearing screenings on a complimentary basis.

140 dB

75 dB


70 dB

Hair dryer, vacuum

60 dB

normal conversation

40 dB

Refrigerator hum

30 dB


Did You Kn K ow? The ear has a defense mechanism. Tiny muscles in the ear automatically tighten to resist loud sounds. But sudden, high-decibel noises, like a firecracker, can get in before the ear can defend itself. r Have you ever left a concert or sport r ing event and heard ringing in your ears? That is noiseinduced hearing loss. Although normal hearing is generally restored, constant exposure to excessive noise causes permanent hearing loss and may be the leading reason so many older people have trouble trouble hearing. hearing

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Excessive noise is hard to avoid. Here are some tips to protect yourself: • Wear protective earplugs if exposed to excessive noise at work • Turn down the volume when listening to music through earphones • Get a baseline hearing exam… experts say it’s a must if you’re over 50.

RemembeR: Catching hearing canit Catching hearing loss loss early early can slow slow or it even down or the even stop it. down stop progression.

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mind, though, delays and glitches may accompany the launch of this massive information-gathering system. To apply for coverage at the site, you’ll need to provide key information: Social Security numbers, employer and income information, and current insurance policy numbers for all household members seeking coverage. If members of your household already have employerbased health insurance, you’ll also have to complete something called the “employer coverage tool.” A number of governmentapproved nonprofit health centers have received grants to provide free outreach and assistance with enrollment. To identify times and locations, check their websites or call.

In the St. Louis area, they include: Betty Jean Kerr-People’s Health Centers Online • Phone • 314-367-7848 Grace Hill Health Center Inc. Online • Phone • 314-898-1700 Myrtle Hilliard David Comprehensive Health Centers Inc. Online • Phone • 314-367-5820 Crider Health Center Inc. Online • www.cridercenter. org Phone • 636-332-6000 Southern Illinois Health Care Foundation Inc. Online • Phone • 618-332-0694 You can learn more about the Affordable Care Act or insurance from these government sources: • Illinois Department of Insurance, Office of Consumer Health Insurance. 1-877-527-9431 (toll-free in Illinois) • Missouri Department of Insurance, Consumer Assistance Program. 1-800-726-7390 • Centers for Medicare & Medicaid Services

Is exchange a better choice for students? By MICHELLE ANDREWS Kaiser Health News

My son is a college student, and I know the Affordable Care Act has made him eligible to remain on my employer’s insurance until age 26. However, if it’s cheaper for him to get subsidized coverage through the health marketplace, can he do so? It depends. Almost anyone can shop for coverage on the marketplace. But your son will be eligible for subsidies to reduce the cost of coverage only under certain circumstances. If you don’t claim him as a dependent on your tax return and his own income is between 100 and 400 percent of the federal poverty level ($11,490 and $45,960 in 2013), he could be eligible for tax credits on the exchange. But if you do claim him as a dependent, his eligibility for subsidies will be based on your family’s income, not just his own. It’s also worth looking into Medicaid eligibility. Roughly half of states have decided to expand Medicaid coverage to adults with incomes up to 138 percent of the federal poverty level ($15,856 for an individual in 2013). Medicaid would be even less expensive than a private plan on an exchange. But if you claim your son as a dependent, your family’s income would have to be no more than 138 percent of poverty in order for him to qualify.

Navigating health care: the Post-Dispatch guide  

Individuals and families are going to soon face numerous decisions that will shape the quality of health care they have access to in 2014 an...