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Health exchange marketplace is set to open; consumers told to walk not run to it

This article first appeared in the St. Louis Beacon: Business is good at the Pilates and Yoga Center in Ladue. But an issue that continues to interrupt the peace of owner Karen Prechtl is affordable health insurance for herself and her 10 employees.

"It’s insane," she says of her skyrocketing premiums. But she takes comfort in the possibility that, starting Tuesday, relief might come when a new insurance marketplace opens in Missouri and nationwide, promising affordable health insurance for individuals, families and some small businesses. It is expected to open with plenty of promise — and glitches as well.

GOP critics, such as Lt. Gov. Peter Kinder and House Speaker Tim Jones of Eureka, say the system is flawed and unclear. Supporters note that the marketplaces haven't even opened yet.

In an attempt to address some of the confusion and clear the air, executives from the Missouri Foundation for Health, Cover Missouri and groups such as Health Care For All have made intense efforts in recent weeks to explain the law, telling consumers what is known, what’s untrue and what’s still unclear. The message from MFH’s executives Ryan Barker and Tom McAuliffe is that there will be quirks as the plan takes flight but that it will eventually sail along as a good deal for uninsured and underinsured consumers.

That message sounds reassuring to consumers like Prechtl whose fitness business is at 9825 Clayton Rd. Just this year, she says, premiums for her office manager and the manager’s daughter rose to $980 from $770 a month. Prechtl, 60, adds that insurance for herself and a son has risen to $1,410 a month.

"It would have been $1,700 but we raised our deductible to a point where we can sort of afford it. I actually did ponder just not having insurance. It’s a whole house payment for me. I just can’t understand people who are against this legislation."

Confusion in the law

Some probably are against it because they don’t understand the law. Even some who have embraced health reform have questions.

One such person is Cynthia Bauer, 59 years old, a seasonal musician. She asks: “Will I need to read the entire Affordable Care Act to be qualified to determine the best available plan for me?” The answer is no more than she’ll have to read the entire Social Security Act to calculate her benefits when she retires in a few years.

A look at how the law will work

Such questions show that some consumers will need help wading through the system, says Barker, vice president for health policy at MFH. That help will come from trained and tested people called navigators, certified application counselors and from insurance brokers as well. When the marketplace opens tomorrow, consumers are expected to be able to tap in their ZIP code and get information on how to get assistance from someone within a 10-to-20 mile radius. Printed information is being translated into the seven most common nonEnglish languages in Missouri: Somali, Mandarin, Bosnian, Spanish, Russian, Arabic and Vietnamese.

During a community meeting last week in Kirkwood, Barker tried to simplify the law by urging consumers to think of the exchange as a farmers' market.

“You walk in and there are different stalls where farmers are selling produce,” Barker says. “You can compare produce, pricing and quality and choose what you like. Replace the farmers with insurance companies and substitute the produce with insurance plans. There will be different stalls and insurance companies selling different plans. You can easily compare what’s in each plan and what works better for you and your family.”

Then Barker repeated question he hears most often: “Is it going to be super simple? No. But it’s going to be a lot easier to shop for health insurance than it used to be.”

Two insurers, 20 different plans

On the plus side, he says, many of the uninsured or underinsured will for the first time use their collective buying power to get breaks on their premiums. The two companies selling insurance on the exchange in Missouri will be Anthem and Coventry Health Care. Together they will give area consumers a choice of 20 different plans.

The identities of hospitals and other providers in Anthem’s network haven't been announced.

On Friday, Coventry spokesperson Matt Wiggins said the company’s PPO provider network will include but won’t be limited to: BJC HealthCare, Mercy Health, SSM, St. Anthony’s Medical Center, and St. Luke’s Hospital. PPO stands for preferred provider organization, a health plan that contracts with a network of providers from which consumers can choose. Patients don’t need referrals to get services from other providers in the network but are charged higher premiums for getting services out of the network.

Another concern raised by Bauer, the musician, was whether adults with disabilities and older adults with limited computer skills will be able to get help in accessing the internet for health insurance? Consumers can apply online, by mail or in person for the marketplace. As for in-person help, consumers will have to go to sites where navigators are available.

Some Missourians have asked whether the law will require insurers in the exchange to give added recognition to mental health issues. Mental health and substance abuse services are among the required benefits for any plan offered through the exchange.

A basic package of other services include chronic disease management, emergency services, hospitalizations, lab services, maternity and newborn care, pediatric dental and vision care, prescription drugs, preventive and wellness services and rehabilitative care.

“Some of the other benefits in the plans are that there is no yearly or lifetime limit on benefits involving essential services and no cost-sharing for preventive care,” Barker noted. “So if you go to the doctor for your flu shot, for example, there is no co-pay. In addition, kids can stay on the family coverage for up to age 26, but that part of the law already has kicked in.”

Subsidies for buying insurance

One x factor in the Missouri exchange is the amount Anthem and Coventry will charge for their bronze, silver and gold plans. The insurance cost will depend in part on the size of subsidies for which individuals and families are eligible. The subsidies will be available to those earning between 100 percent of poverty, or $12,490 for a single individual, and 400 percent of poverty, or $45,960 for an individual.

The most recent report from the Department of Health and Human Services offered one example of costs: a 27-year-old Missouri resident earning $25,000 would pay $87 a month for the lowest cost bronze plan offered by the two insurers.

Barker offered another example: a family of four with income of $47,100, would pay 6.3 percent of its income – or $2,967 annually -- for the second lowest cost silver health plan. Whatever federal subsidy the family would get would be paid directly to the insurer. This family of four would pay $250 a month for insurance.

Myths and quirks

At an MFH meeting in Kirkwood to discuss the reform law last week, a questioner asked about  rumor that Muslims will get health care free. Barker says, “That is absolutely not true. There is a waiver if your faith doctrine says you can’t participate in health insurance. We have figured out that the Amish have that in their faith doctrine. There may be some smaller organizations that we don’t know about. But it’s not in the Muslim faith doctrine.”

Another myth is that it’s cheaper to pay the fine for not having health insurance under the law. “Yes and no,” Barker replies, noting that the fine is $95 for each adult in a household or 1 percent of the family’s income the first year, whichever is greater. But he says the fee jumps to $695 for each adult in the household or 2.5 percent of a family’s income by 2016.

What about the claim that people can be jailed for refusing to pay the fee or fine? Not true, Barker says. At most the IRS can send you a bill for the fine, but nothing in the law requires a special effort to collect it, he says.

Not all systems will be up and running by tomorrow. Training for navigators and others has been delayed somewhat because the federal system couldn’t accommodate a sudden influx of people seeking the training. Also, processing information in Missouri will be slower than expected because the state is still working on a computer system to communicate with the marketplace.

This glitch stems in part from initial delays by state lawmakers to accept $20 million in federal assistance that, among other things, was to be used to upgrade the COBOL computer system used by the Department of Social Services to process Medicaid claims.

Two years later, the state accepted the money, and Barker says he hears that Missouri officials “are really close to getting the system up and running, so it will work with the marketplace.”

If it’s not ready by tomorrow, there’s a backup plan under which federal workers will print out the applications and mail them to Missouri to provide updated information needed to certify individuals and families for the insurance program.

Another delay involves the Small Business Health Option Program. An online system for small employers, SHOP won’t begin taking applications tomorrow, federal officials announced recently, because of problems with the computer technology for running the system. They note that tomorrow is just the beginning of the program and that small business owners can enroll in SHOP throughout the year.

State and local officials note, however, that everyone must complete the process by Dec. 15 if they want their insurance to start on Jan. 1.

Perhaps the biggest quirk in the law, Barker says, is the fact that some families might not be able to take advantage of the exchange. The law says if an employer offers an employee-only plan that’s affordable and offers no family plan option, the rest of the family can seek insurance through the marketplace. But if the employer offers an employee and family plan, the coverage for the employee must be affordable, but there's no requirement that the employer coverage for the rest of the family be affordable. In that case, the family members are forbidden to buy insurance through the marketplace, based on the law.

Barker says such quirks would be easy to fix under normal circumstances, but not in the current climate of political gridlock.

Tim McBride, a health economist at Washington University, is among those who are stressing that Oct. 1 is not a deadline, but the opening date for eligible Missouri residents to begin the process of buying health insurance through the exchange.

He is encouraging consumers not to rush and make hasty decisions but to take the time to understand their options and decide which insurance plan best meets their needs.

Others have suggested that waiting might make sense because of kinks that are certain to need fixing in the internet-based marketplace system.

Similarly, Barker notes that the marketplace will be opened for six months, through March 31. If consumers want their coverage to start on Jan. 1, they have until Dec. 15th to sign up.

"There is not a need to rush to the exchange on Oct. 1," Barker says. “This is a marathon, not a sprint.”

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.