Answers to questions on Kentucky's Health Benefit Exchange

ctruman@herald-leader.comDecember 17, 2012 

The Herald-Leader posed some questions about Kentucky's Health Benefit Exchange to those working on the program.

Question: Do I have to have health insurance starting in 2014?

Answer: Beginning in January 2014, the uninsured and self-employed will be able to buy insurance through Kentucky's Health Benefit Exchange. Most Americans will be required to have insurance by this time or pay a penalty. For individuals who can afford insurance but decline to buy coverage, the annual penalty would start at $95, or up to 1 percent of income, whichever is greater, and rise to $695, or 2.5 percent of income, by 2016. The annual penalty for families is $2,085, or 2.5 percent of household income, whichever is greater. Individuals with income less than 100 percent of the federal poverty level are not required to have health insurance. Neither are those who are exempt due to religious or financial hardship reasons.

Q: What kind of insurance exchange will Kentucky have? How much will it cost for individuals and families? Which insurance plan will it resemble?

A: Beginning Jan. 1, 2014, individuals and small employers in Kentucky will be able to shop for insurance coverage through a state-operated, Web-based marketplace just as they would go online to buy airline tickets or book a hotel. The exchange will allow for easy comparison of available insurance plan options based on participating providers, price, benefits and services, and quality. In addition, individuals may use the exchange to find out if they are eligible for new affordability programs or subsidies to make insurance more affordable, such as premium tax credits or programs like Medicaid and the Children's Health Insurance Program.

The Affordable Care Act requires health insurance plans sold to individuals and small employers to provide a minimum package of services in 10 categories called essential health benefits. EHBs are the minimum standards to be applied to health plans both inside and outside the exchange. They include items and services within the following categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive/ wellness services/chronic disease management; and pediatric services, including oral and vision care. Kentucky has selected the Anthem small employer group PPO plan as Kentucky's essential health benefit plan.

Q: I'm pretty healthy. Am I going to be paying for other people's medical conditions, such as pregnancy and cancer?

A: By its very nature, insurance is the pooling of risk. Losses or medical claims (in the case of health insurance) are spread among all members of the risk pool. The premium charged reflects this pooling of risk. The Affordable Care Act allows insurers to take into consideration an individual's age, geographic location and smoking status. Health status, after 2014, is no longer a factor that may be considered in the rating of a policy.

Q: Can I still go to my doctor?

A: Private health insurance plans typically have provider networks made up of hospitals, doctors, specialists, pharmacies and other types of health care providers. Networks include health care providers that have a contract with an insurer to take care of the plan's members. When choosing a health plan on the exchange, individuals should review the list of providers that are included in the insurer's provider network. If staying with your current doctors is important to you, check to see whether they are included in the insurer's network.

Q: If I don't join and then get sick, can I join then?

A: Yes. Insurers no longer will be able to reject applicants or charge more based on their health status once the exchange is operating in 2014. The Affordable Care Act already prohibits health insurers from denying coverage to children younger than 19 based on a pre-existing condition. The exchange will have an initial open enrollment period from Oct. 1 to March 31, 2014. After the open enrollment period, individuals will be able to apply for coverage once a year during the annual open enrollment period.

Q: Can I still get Medicaid if I fall below the poverty line?

A: Currently, in most states, non-elderly adults without minor children do not qualify for Medicaid. Beginning in 2014, the federal government is offering to pay the cost of expanding Medicaid so that anyone with an income at or lower than 133 percent of the federal poverty level ($14,856 for an individual or $30,656 for a family of four, based on current guidelines) may be eligible for Medicaid. At this time, Kentucky has not decided whether to expand Medicaid coverage to individuals with income lower than 133 percent of the poverty level.

Individuals who make too much money for Medicaid but cannot afford to buy insurance might be eligible for government subsidies to help pay for private insurance sold in the exchange.

You can determine eligibility through the exchange. These premium subsidies will be available for individuals and families with incomes of 133 percent to 400 percent of the federal poverty level, or $14,856 to $44,680 for individuals and $30,656 to $92,200 for a family of four (based on current guidelines).

Q: If my employer provides health insurance, can I keep it? If I don't like my employer's health insurance, can I join the exchange?

A: Health plans in effect as of March 23, 2010, are grandfathered under the law and will be considered "qualified coverage," meeting the mandate to have health insurance beginning in January 2014. But, just as before the Affordable Care Act was enacted, employers offering health insurance still have the freedom to choose a health plan for their employees. If an employee does not elect to participate in the employer's health insurance plan, the employee may buy insurance on the exchange but will not qualify for premium subsidies unless the employer coverage is considered to be unaffordable for the employee.

Q: Will Kentucky have the technology to administer this program?

A: In October, the state signed a contract with an information technology vendor, Deloitte, to develop the exchange system, which will include a Web-based portal that will allow individuals and small employers in Kentucky to shop for insurance.

Q: How many Kentuckians are expected to take advantage of the new medical exchange?

A: The state Cabinet for Health and Family Services expects that more than 300,000 Kentuckians will use the exchange.

Source: Kentucky Cabinet for Health and Family Services

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