Local experts explain insurance market changes, urge enrollment before Dec. 15 deadline

I #GOTCOVERED: Pisgah Legal Services client Fabiola, center, says she received lifesaving treatment after obtaining health insurance coverage under the Affordable Care Act. With Fabiola are, right, her daughter and, left, Pisgah Legal staff member Noele Aabye. Photo courtesy of Pisgah Legal Services

Shannon McAbee was teaching at her East Asheville preschool when she noticed she was not feeling well. Again.

“I just kept getting tired and having bronchitislike symptoms that were just getting worse,” McAbee, 41, recalls.

McAbee, who also works part time as a restaurant server, says despite growing concern for her health, the high cost of health insurance left her uninsured and unable to see a doctor for years.

Finally, after qualifying for health insurance subsidies through the Affordable Care Act, McAbee was shocked to discover that her shortness of breath and lethargy were caused by a serious heart condition, which stemmed from the lasting effects of having developed rheumatic fever at age 11.

“I didn’t think about the connection,” McAbee says. “I didn’t think that it was my heart going bad.”

Open enrollment for 2019 health insurance plans is underway through Saturday, Dec. 15. For millions of Americans who sign up for health coverage every year, this means wading through a deluge of dense information, rule changes and the seemingly endless number of circumstantial factors that influence price.

But for McAbee, who underwent heart surgery last fall, the headache of navigating the health care system proved to be a lifesaver.

“I’ll never make that mistake again,” McAbee says.

Law of the land

ACA UPDATE: Jaclyn Kiger, managing attorney for Pisgah Legal Services, wants consumers to know that the Affordable Care Act remains in effect and plans and subsidies are available for 2019. Photo courtesy of Pisgah Legal Services

Jaclyn Kiger, managing attorney for Pisgah Legal Services, a local nonprofit that provides legal aid to low-income residents in Buncombe and five other counties in Western North Carolina, says that while efforts by the Trump administration at the federal level have sought to repeal the 2010 health care law, the act remains in place and available for consumers in 2019.

“One common confusion that has been going on for a couple of years now is around whether the ACA is still the law,” Kiger says. “As new regulations come out, and there’s talk of different plans and different options, we do tend to come back to the point that the ACA is still the law: It has not been repealed or replaced. The financial assistance is still available, and many of the protections — including one of the most significant ones for some of the many people that we’ve helped, pre-existing conditions — are covered.”

Kiger emphasizes that the ACA Marketplace — the online sales and information platform where consumers ultimately purchase their insurance — requires that plans include coverage for pre-existing conditions, maternity care, mental health and substance abuse and preventive care.

“These are comprehensive plans that are meant to meet the needs of people so that they are able to get the coverage for services that they need when they need it,” Kiger says.

Going up

In an August press release, Blue Cross and Blue Shield of North Carolina announced that average premiums for 2019 individual plans will drop an average of just over 4 percent statewide. However, savings vary considerably among different regions within the state. Some areas, such as The Triangle, will see as much as a 21 percent decrease in monthly premium costs, while other locations across the state can expect higher prices for coverage.

The average individual premium for Buncombe County residents will rise nearly 10 percent this year. According to Austin Vevurka, spokesperson for BCBSNC, the lower costs in certain areas stem from competition among hospitals and insurance providers, a health care environment not found in WNC.

“The areas where we achieved decreases were the areas where there were multiple hospital systems, and we were able to have that competitive process,” Vevurka says. “That’s not available in Western North Carolina because there aren’t multiple hospital systems.”

Vevurka says other factors also influence the average price of premiums, including some actions from the federal government. Federal tax cuts and corporate income tax savings under the current administration were responsible for a considerable part of the statewide decrease. However, Vevurka explains, premiums could have dropped another 14 percent if a subsidy program, known as cost-sharing, had not been eliminated in 2017.

“There were some federal actions that benefited the rate and some that caused it to put some more upper pressure on it,” Vevurka says.

Mandatory coverage?

A key change to the health care law will take effect in 2019. Previously, the ACA required taxpayers to purchase health insurance or face a penalty. Those who remained uninsured during 2017 were required to pay $695 per adult or 2.5 percent of their of yearly household income when filing their taxes, according to the Centers for Medicare and Medicaid Services. But those who didn’t have coverage in 2018 won’t have to pay a penalty, thanks to the repeal of that part of the law in December 2017.

Geoffrey Ferland, president and owner of Hummingbird Insurance, says that while the penalty may have been one of the health care law’s least popular features, most taxpayers likely avoided having to actually pay due to factors like the price and availability of plans.

“We found that it’s really only subject to the top 1 percent of income earners. Ninety percent of people are subsidized through the ACA Marketplace and were not even affected by the penalty,” Ferland explains.

Regardless, Ferland says, the elimination of the individual mandate may push some consumers to seek options outside of the ACA requirements.

“The penalty going down to zero dollars on paper, and everybody being more and more aware of that, I think will make people that pay that full price that don’t really need the full coverage more interested in other marketplace options.”

Alternate route

The Trump administration has also loosened regulations to offer less expensive but less comprehensive plans. Known as short-term plans, these options will now provide a full year of coverage to consumers and may reduce costs significantly for some people whose incomes are too high to qualify for ACA subsidies.

However, the short-term plans do not meet the strict requirements for coverage that all ACA plans must meet, including coverage for pre-existing conditions, substance abuse, mental health services and pregnancy.

Mike Peterson, director of the health and life department at Hummingbird Insurance, says that while the plans offer insurance at a cheaper monthly rate, it’s important for consumers to find a plan that covers all of their needs.

“Really, it’s important [to note] that if you do qualify for subsidies, the Affordable Care Act is the best place to be, but there is a percentage of the population that makes too much money, and it makes the ACA really unaffordable,” says Peterson. “It strips a lot of coverages down, but as long as people don’t have any problems with those, they get a much cheaper option.”

Fifty-eight-year-old Asheville resident Colleen Troy, who owns a fitness cycling company for people 50 and older, says she switched to a short-term plan for 2018 when her small-business income exceeded what would qualify for subsidies under the Affordable Care Act. Without the subsidies, the costs of the plans rose out of reach.

“The first two years, we were with the ACA, and so that worked out OK,” Troy says. “But this year, when I started looking at the plans back in December [2017], the Blue Cross Blue Shield plans that we had been with, the premiums were skyrocketing. We went from paying a couple hundred dollars a month in insurance to over $1,000.”

Troy says that she and her husband, Mark, maintain active and healthy lifestyles, which allows them to feel confident in choosing plans that don’t include comprehensive coverage.

“We’re both thankfully in very good health. We don’t have pre-existing conditions — that’s the biggest thing,” Troy says. “I’m glad to have the option.”

Glitchy

Insurance agent Ferland says the short-term plans may also be a viable solution for those caught by what’s known as the “family glitch.”

According to Ferland, the family glitch occurs when a person is offered an affordable employer-sponsored plan, which makes them ineligible for ACA subsidies. These plans, however, do not take into consideration the costs of covering other family members when calculating affordability. Once family members are factored in, the overall rates tend to exceed what families can afford to pay, leaving many families unable to qualify for ACA subsidies or sponsored plans.

Short-term plans may bridge that gap for some consumers.

“Hopefully, they’ll fix it with the new Congress coming in, but in the meantime, every employee, every spouse and every other kid or family member of them, is shut off from assistance that they should receive otherwise,” Ferland says.

Still, Kiger of Pisgah Legal, warns that while short-term plans may sound like a less expensive option, consumers of every income level should review the plans carefully before making a decision.

“There is a possibility that these plans may create some confusion or may sound good, but we are really emphasizing to the community to make sure that you know what you’re getting with your health insurance coverage,” Kiger says.

Free-for-all

According to a report from the Kaiser Family Foundation, a nonprofit organization that focuses on national health issues, funding for health care Navigator programs, which supply trained instructors and insurance professionals to provide consumers with enrollment assistance, has been slashed by 85 percent in North Carolina since 2016.

“I would be lost without referring to somebody. I mean, it wasn’t this way years ago. I’m 58, I’ve been in the workplace forever, and now it’s changing and shifting so much, and I really want a professional that I can trust to sort through the options,” Troy says.

Both Pisgah Legal and Hummingbird Insurance will provide free and confidential guidance throughout the enrollment period.

“We’ll give you an honest opinion. We deal with this stuff all day and we want you to be happy,” Ferland says. “There’s not very many other things where you can get free help from someone who is educated and professionally licensed.”

In addition to making an appointment by phone or online, Pisgah Legal will also provide walk-in services every Saturday during open enrollment.

“In Asheville, people can walk into our office on Saturdays without an appointment, and we can assist them,” Kiger says. “We are here to be a resource to the community. We are glad to meet with people and we are not going to pressure someone to enroll.”

Pisgah Legal, in partnership with Mission Health, will also host a last-chance enrollment event 9 a.m.-4 p.m. Saturday, Dec. 15, at the Mission Health/A-B Tech Conference Center, 16 Fernihurst Drive.  

“That will just be a communitywide, come on in, you don’t need to have an appointment. We want to help you meet the deadline and get enrolled on that very last day,” Kiger says. “Walking through all of this, especially if you haven’t done it before, having someone by your side to help you understand why those questions are being asked and why this information is needed, can be really helpful.”

 

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