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The Health Insurance Maze

Let MDIS help navigate the multitude of options

This is the first in a series of articles written by the MDIS team from their area of expertise. The articles are meant to enlighten or remind members about aspects of that particular line of insurance. The following is from Christy Diehl, MDIS Employee Benefits Manager, who works with health insurance products.


ue to the passage of the Patient Protection and Affordable Care Act (PPACA/ObamaCare), health care and the marketplace have

endured many changes in recent years— which include the right of chronically ill patients to purchase health insurance and the ability of lower income earners to afford to purchase coverage. Premiums have drasti- cally increased as a result of many provisions, like these, required by the law.

With 2016 comes premium increases across all markets. These increases are forcing many older “grandfathered” insureds into ACA compliant plans. ACA plans carry a higher out of pocket maximum compared to older style plans. If feasible, and depending on the situation, I recommend keeping a grandfa- thered plan over an ACA-compliant plan.


We have seen an unprecedented shift in in- surers, such as Assurant, Celtic and American Community exiting the individual market- place. The competition also has decreased in recent years, with Aetna acquiring Coventry and Humana, and Anthem acquiring Cigna. These consolidations leave three national

26 focus | NOV/DEC 2015 | ISSUE 6

marketplace carriers in control of premiums and limits to network providers. United- Healthcare continues to be the largest single health insurer in the nation; however, on November 19, the company warned that it may leave the ObamaCare exchanges within two years—casting doubt on its ability to carry plans on the healthcare law’s exchanges beyond 2016 and offering a grimmer financial outlook than it had previously expected.


Lower income exchange insureds are experiencing similar premium increases, with additional decreases in the amount of subsidy they receive. For example, a recent client had a decrease in subsidy from $527/ month in 2015 to $458/month in 2016, with no apparent change in income or eligibility. Her portion of her premium also increased more than $100 per month, forcing her into a lower tier plan. Subsequently, her deductible increased by $2,300 for 2016, with additional increases in coinsurance and out-of-pocket expenses.

For 2016, an individual earning $15,655– $47,080 annually may receive a premium tax credit or subsidy. The subsidies are on a sliding scale; the lower the income, the higher the subsidy. Missouri did not expand Medicaid, and as a result, individuals earning $11,770–$15,654 annually are not eligible for subsidies or Medicaid. Silver plans have addi- tional cost-sharing benefits with a reduction in out-of-pocket expenses. If an individual does not qualify for a subsidy through the

exchange, there is no incentive to purchase a policy through the exchange and be limited on plans, carriers and networks.


Off exchange plans for higher income wage earners have greater access to carriers and plans with broader networks. Plan designs in the exchange are sometimes much different than plans outside of the exchange. Many times, exchange plans have a more limited network, with the exclusion of expensive hospital systems such as Barnes-Jewish and Washington University hospitals.


Group health insurance plans have not seen the drastic network changes and continue to have broader networks than individual health plans. Group health insurance plans have richer benefits as well. Employers can offer split options with many carriers, such as offering many different plan designs within one employer group. The employer is respon- sible for at least 50 percent of the employee- only premium. Any full-time employee work- ing an average of 30 or more hours per week is eligible to join the group health insurance plan. If an employee has an individual plan or spousal coverage, he or she can waive the group plan. Blue Cross Blue Shield of Kansas City does not have participation or contribu- tion requirements.


Important benefits to look for when choos- ing an individual or group health insurance

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