Understanding health insurance and the Affordable Care Act

There are two types of financial assistance available to marketplace enrollees. The first, called the premium tax credit, works to reduce your monthly payments for insurance coverage. The second, referred to as cost-sharing reductions, is designed to reduce your out-of-pocket costs when utilizing care. In order to receive either type of financial assistance, qualifying individuals and families must enroll in a plan offered through the health insurance Marketplace.

Eligibility:

• Premium tax credit: Have a household income from one to four times the Federal Poverty Level (FPL)
• Cost-sharing reduction: Have a household income from one to 2.5 times the Federal Poverty Level (FPL) & choose a Silver level plan
• Do not have access to affordable coverage through an employer (including a family member’s employer)
• Not eligible for coverage through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or other forms of public assistance
• Have U.S. citizenship or proof of legal residency (Lawfully present immigrants whose household income is below 100 percent FPL and are not otherwise eligible for Medicaid are eligible for tax subsidies through the Marketplace if they meet all other eligibility requirements.)
• If married, must file taxes jointly in order to qualify

When choosing a plan, it’s a good idea to think about your total healthcare costs, not just the monthly premium you pay every month. Other amounts, sometimes called “out-of-pocket” costs, have an impact on your total spending on healthcare.

• Deductible: How much you have to spend for covered health services before your insurance company pays anything (except free preventive services)
• Copayments and coinsurance: Payments you make each time you get a medical service after reaching your deductible
• Out-of-pocket maximum: The most you have to spend for covered services in a year. After you reach this amount, the insurance company pays 100 percent for covered services.

Consider additional benefits, such as the embedded savings with Spira Care plans, as your policy may provide low to zero dollar services included with the cost of your monthly premium. These features can be an important savings throughout the course of the year.

When you compare plans in the Marketplace, the plans appear in 4 “metal” categories: Bronze, Silver, Gold, and Platinum. The categories are based on how you and your plan share the total costs of your care.

Note: Plans in all categories provide free preventive care, and some offer selected free or discounted services before you meet your deductible.

Generally speaking, categories with higher premiums (Gold, Platinum) pay more of your total costs of healthcare. Categories with lower premiums (Bronze, Silver) pay less of your total costs. If you qualify for cost-sharing reductions (CSRs), Silver plans may offer a better value. If you qualify, your deductible will be lower and you’ll pay less each time you get care.

If you don’t expect to use regular medical services or take regular prescriptions, you may want a Bronze plan. These plans can have very low monthly premiums but have high deductibles and pay less when you need care.

If you qualify for cost-sharing reductions (CSRs), then Silver plans may be a better value. If you qualify, your deductible may be lower, which means you pay less when you get care. You get these extra savings only if you enroll in Silver. If you don’t qualify for CSRs, compare premiums and out-of-pocket costs of Silver and Gold policies to find your right plan.

If you expect frequent doctor visits or need regular prescriptions you may want a Gold plan. These plans usually have higher premiums but pay more of your costs when you need care.

All Marketplace plans must cover treatment for pre-existing medical conditions. Once you are enrolled in an ACA health plan, no Marketplace insurer can reject you, refuse to pay for essential health benefits, or charge you more for any condition you had before your effective date. Also, the insurer cannot raise your rates, deny you coverage, or cancel your policy based only on your health. Insurers can only adjust rates at renewal time for all enrollees and not just based on your individual health.

While none of our plans require the selection of a primary care physician (PCP), there are benefits in doing so. PCPs often maintain long-term relationships with patients and can advise and treat you on a range of health-related issues. They may also coordinate your care with specialists.

If you need to find out if your doctor or other healthcare providers are covered by your plan, or if you need to find a covered provider if you don’t have one yet:

1. Find in-network doctors, hospitals, behavioral health providers, and other healthcare professionals based on your plan. View our network now.
2. Once you’re enrolled in a Blue KC policy, you should review the specific list for your policy on MyBlueKC.com to find customized doctors and hospitals directories.
3. Call your doctor’s office. They can tell you if they accept your health plan.

When in doubt, call Blue KC or your provider to verify your provider is in-network. This is especially true with Exclusive Provider Networks (EPOs), as these have a restricted network and won’t pay for the care you receive outside of the network unless it is an emergency.

The Prescription Drug List is a list of prescription medications that have been reviewed and recommended by Blue KC’s Medical and Pharmacy Management Committee. Feel good knowing that each medication has been reviewed for safety, effectiveness, clinical outcomes and cost. View prescription drug list here.

Yes. The Affordable Care Act provides mental health and substance use disorder coverage. This means that most individual insurance plans, including all plans offered through the Health Insurance Marketplace, cover mental health and substance use disorder services. This law also requires coverage for rehabilitative and habilitative services that support people with behavioral health conditions.

Consider additional benefits not required by the Affordable Care Act when looking at your plan options, as these will add value to your premium dollar. Blue KC offers a variety of additional benefits, such as Telehealth/Virtual Care, Mindful (behavioral health), Blue365 (health and wellness discounts and offers), Healthy Companion (chronic condition support), Smartshopper, & Rx Savings Solutions (prescription savings).

You can shop for and enroll in an ACA health plan during the annual Open Enrollment Period which runs from November 1, 2024 to December 15, 2024. For health coverage needs outside of the Open Enrollment Period, you may still sign up for an ACA health plan for you and your family if you qualify for a Special Enrollment Period. To qualify, you must experience a qualifying life event such as having or adopting a baby, getting married or divorced, moving, or losing your health coverage to name a few.

Please contact our sales team at 844-655-0355, Monday – Friday 8am – 5pm or enroll online where we can provide a stream-lined enrollment experience that includes:

• Shop and enroll in an on-exchange policy in one experience
• Submit required documentation to the marketplace, such as proof of income and citizenship status
• Report life changes and update your information
• Easily renew your coverage during open enrollment

Or contact your local agent to assist you with your enrollment.