Meet the experts

The hospital lobbyist

Rozalynn Goodwin

Director of Policy Research

S.C. Hospital Association

Columbia

www.scha.org

The insurance executive

Adrian Grimes

Director of Communications

Consumers’ Choice Health Plan

North Charleston

www.cchpsc.org

The benefits consultant

Colin Smoak

Principal

McLaughlin Smoak & Clarke

Mount Pleasant

www.mclaughlin smoak.com

Go back 13 years, back to the turn of the century.

To learn more

Federal Health Insurance Marketplace

www.healthcare.gov

800-318-2596

Medicare (health insurance plans for those over 65 and/or permanently disabled)

www.medicare.gov

800-633-4227

Medicaid (health insurance plans for low-income adults and children)

www.scdhhs.gov

888-549-0820

Tricare (health plans for military families and veterans)

www.tricare.mil

800-444-5445

S.C. Department of Insurance

www.doi.sc.gov

803-737-6160

Remember Y2K? The uncertainty?

The fear? The confusion?

Well, this Oct. 1 is kind of like health care’s Y2K.

That’s when the federal government opens health insurance enrollment through its new insurance marketplace.

This online portal — kind of like Travelocity for health insurance, as one expert describes it — is a fundamental underpinning of the Patient Protection and Affordable Care Act.

There’s uncertainty about whether this new framework can support the millions of people who need to sign up for a policy.

There’s fear — some say unfounded — that the federal government is trying to socialize health care in this country.

There’s widespread confusion about what the law actually says.

So The Post and Courier recruited Adrian Grimes, a local health insurance executive, Rozalynn Goodwin, a Columbia-based hospital lobbyist, and Colin Smoak, a Charleston benefits consultant, to answer a few basic questions about health care reform.

As much as anyone understands this controversial law, these three South Carolina experts do.

Officials from the S.C. Department of Insurance and the S.C. Department of Health and Human Services declined to participate.

Some of the following answers have been edited for length.

How will the Patient Protection and Affordable Care Act affect me?

Goodwin: “The Affordable Care Act (ACA) has four broad goals: increasing coverage, payment reform, delivery system reform and insurance reform.

While payment and delivery system reform measures in the act aim to improve the care you receive from health care providers, the measures to increase coverage and reform insurance will impact decisions you make in the coming months.

“Increased health insurance coverage is intended to be achieved through the Health Insurance Marketplace and the expansion of Medicaid. If you are uninsured and make between $11,490 and $45,960 a year ($23,550 to $94,200 for a family of four), you will likely be eligible for premium assistance and/or subsidies to help you purchase private insurance in the Health Insurance Marketplace, which starts open enrollment on Oct. 1.

“But if you are one of more than 200,000 uninsured South Carolinians making below $11,490 a year, you will be left out of any coverage or coverage assistance through the ACA because South Carolina, to date, has rejected extending coverage through Medicaid Expansion.

“Insurance reforms in the ACA are expected to increase access to health insurance. If you have a pre-existing condition, you can no longer be denied coverage.

“Your coverage can no longer be canceled because you get sick. Higher premiums based on gender or medical history, and annual or lifetime limits on coverage are no longer permitted.

“If you are a young adult, you can now stay on your parent’s health insurance policy until you are 26 years old.”

What is the health insurance marketplace?

Goodwin: “The Health Insurance Marketplace is an online shopping mall like Orbitz or Travelocity for health insurance. Consumers can shop for and compare the coverage of various health plans in the Marketplace by visiting Healthcare.gov after Oct. 1 or calling 800-318-2596.”

Where do I buy insurance?

Smoak: “This is a great question as there are numerous ways to purchase health insurance. For those working through a broker/agent, they will be able to continue that relationship — either off the Marketplace or on it. The prices for coverage either way will be the same. Individuals and later, small employers (50 or fewer employees), will have access to the Marketplace to enroll in coverage from Oct. 1, 2013 through March 31, 2014.

“People that currently access coverage through their employer will continue to do so going forward.”

I heard there won’t be a health insurance marketplace in S.C. Is that correct?

Grimes: “No, it is incorrect. There will be a health insurance marketplace for South Carolina but it will be the federally managed marketplace. S.C. declined the option to set up its own marketplace.”

How many insurance choices will I have?

Smoak: “Overall, there will be a similar amount of choices as offered now. The Marketplace itself will have coverage offered from four different insurance companies; Blue Cross Blue Shield of South Carolina, Blue Choice Health Plan of S.C., Coventry, and Consumers’ Choice Health Plan. Off the Marketplace will likely be even more choice.”

What if I have a pre-existing condition?

Grimes: “The Affordable Care Act law removed penalties and coverage exclusion due to pre-existing conditions.”

What if I don’t sign up for a plan?

Smoak: “Effective Jan. 1, 2014, having health insurance is mandated for everyone. If the coverage is not elected, there are financial penalties imposed by the federal government.

The penalties are subject to coverage tier (individual, family, etc.) and income.

Penalty increases will be annual, with increases in subsequent years of no coverage.”

(Editor’s Note: In 2014, the annual penalty for uninsured adults in $95. For uninsured children, the penalty is $47.50.)

If I already have insurance, can I keep my current plan?

Grimes: “Probably so. As long as the coverage is considered ‘minimum essential coverage,’ people will be able to keep their current health plan.”

If I already have insurance, should I expect the price of it to go up?

Grimes: “Not necessarily. Health insurance plans need to be compared as apples to apples to get an appropriate price comparison.

“For example, a consumer would want to line up similar plans based on variables such as those with the same deductible amounts, same out of pocket.”

Goodwin: “It is difficult to predict how premiums will be impacted before the Marketplace opens for enrollment in October and before a number of ACA elements are implemented in 2014.

“The future price of your current plan will depend on a number of factors — whether it is a grandfathered, individual market, or employer-sponsored plan, and whether you or your employer will be eligible for financial assistance for future purchases, to name a few.

“For every study predicting premiums will increase, there is another predicting premiums will remain unchanged.”

If I’m already enrolled in Medicare or Medicaid, what will happen to that coverage?

Goodwin: “Those enrolled in Medicare will see additional benefits like free preventive screenings, annual well visits, and prescription drug rebates until the ‘doughnut hole’ is closed in 2020.

“If you are enrolled in Medicaid, that coverage will remain as long as you continue to meet the program’s eligibility requirements.”

Q: Is the government going to tell me which doctor I must see or which hospital I must go to?

Grimes: “As with most health insurance issuers, there are health care provider networks available to lower the costs of medical services. Members can choose to use any doctor they want to, but the level of payment from the issuer may be affected.”

Goodwin: “Insurance plans have designated provider networks today, and that is not determined by the government, but by negotiations between insurance companies and health care providers. That won’t change as the ACA is implemented.”

How do I enroll my children in a health insurance plan?

Smoak: “If your children need health coverage, they may be eligible for the Children’s Health Insurance Program (CHIP). If they qualify, you won’t need to buy a Marketplace plan to cover them. CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In addition, coverage choices will be available on the Marketplace. For those that qualify, based on family income, Medicaid may be another choice. If either parent has coverage through an employer-sponsored health plan, a child(ren) can be added/remain on the plan until the child’s 26th birthday, regardless of college student status.”

How long do I have before I need to make a decision about which health insurance plan to purchase?

Goodwin: “Open enrollment for the Marketplace will take place Oct. 1, 2013 through March 31, 2014.”

When will the coverage kick in?

Smoak: “If you enroll in a private health insurance plan in the Marketplace any time between Oct. 1, 2013 and Dec. 15, 2013 and make your first premium payment, your new health coverage starts Jan. 1, 2014.

During the rest of open enrollment, if you enroll between the first and 15th day of the month and pay your premium, your coverage begins the first day of the next month. So if you enroll on February 10, 2014, your coverage begins March 1, 2014.

If you enroll between the 16th and the last day of the month and pay your premium, your effective date of coverage will be the first day of the second following month. So if you enroll on Feb. 16, 2014, your coverage starts on April 1, 2014.

After March 31, 2014, you can get new private health insurance for 2014 only through a special enrollment period if you have a qualifying life event like a job loss, birth or divorce.”

Reach Lauren Sausser at 937-5598.