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home : news : health care series   April 29, 2016

9/23/2013 8:00:00 AM
Health insurance: At what price? (first in a series)
Derek Schwartz restocks shelves at Sullivan’s Foods in Mendota. The part-time stocker/bagger at the popular Illinois grocery store is one of millions of Americans who will be impacted both positively and negatively by the Patient Protection and Affordable Care Act. Schwartz is young enough to be covered by his mother’s health insurance plan but the law’s impact on Sullivan’s will cause him to lose valuable work hours.  NewsTribune photo/Genna Ord
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Derek Schwartz restocks shelves at Sullivan’s Foods in Mendota. The part-time stocker/bagger at the popular Illinois grocery store is one of millions of Americans who will be impacted both positively and negatively by the Patient Protection and Affordable Care Act. Schwartz is young enough to be covered by his mother’s health insurance plan but the law’s impact on Sullivan’s will cause him to lose valuable work hours. 

NewsTribune photo/Genna Ord
Exchange dependent on income

Most Illinois Valley residents who choose to shop on the insurance exchange for a health plan will likely find their income qualifies them for discounts on their premiums.
People earning within 100 to 400 percent of the federal poverty level will pay premiums of about 2 percent of their income whereas individuals and families on the higher end will pay 9.5 percent for Bronze and Silver plans.
Gold and Platinum plans will have premium costs of no more than 12 percent. Although high-end plans may be subject to a 40 percent excise tax depending on cost.
No one will know actual plan costs until the exchange markets open Oct. 1.
The cost of plans are somewhat determined by what type of plan you want and your income level.
Under the exchange:
- Consumers earning an annual income of $11,505 to $46,021 can buy subsidized insurance in the federal exchange.
- Consumers who earn less than $15,302 may qualify for Medicaid.
-Consumers who earn between 100 to 400 percent of the federal poverty level — between $11,500 and $46,000 for an individual and $23,550 and $94,200 for a family of four — will be eligible for discounts on premiums.
-Consumers may qualify for extra subsidies to help with out-of-pocket costs or for government programs such as Medicare, Medicaid and the Children’s Health Insurance Plan.
All discounts — cash subsidies provided directly from the federal government — will automatically be included in the sticker price when consumers sign up.
As for deductibles and co-payments, federal officials in February lifted the price caps included in the law. Those caps meant deductibles and co-payments were never to exceed $6,350 for an individual and $12,700 for a family in out-of-pocket expenses in a calendar year.
Now, insurers have a one-year grace period lasting until Jan. 1, 2015 that allows them to set deductibles and co-payments higher or without limits depending on market conditions.
Official premium costs haven’t been released but federal officials claim there will be plans to fit just about every need and budget.
Some plans will have lower monthly premiums that may charge more out-of-pocket when the consumer needs care.
Some will be higher-premium plans that cover more of a consumer’s costs when he or she needs care and there will be others that will fall in between.

Did you know?
All health insurance plans must cover:
1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services,
including behavioral health treatment.
6. Prescription drugs
7. Rehabilitative and
 services and devices
8. Lab services
9. Preventative and wellness services and chronic disease management
10. Pediatric services,
including oral and vision care

Kevin Caufield
NewsTribune Reporter

Editor’s Note:
“A practical guide to the Patient Protection and Affordable Care Act” is a five-day series meant to remove emotionally-charged politics from the controversial law and present readers an opinion-free understanding of complicated and critical concepts.

This was the last summer Haley Petre planned to spend working food prep at Trailheads in the Starved Rock State Park Visitors Center.
The Utica resident will graduate from Southern Illinois University in the spring with high hopes of transitioning from college life and summers serving hot pretzels to something more of the white collar variety — especially if that job offers health insurance benefits.
“I would like to have health insurance but I don’t see how I can afford it with the little income I make,” said Petre, who has been living without health insurance for at least three years.
The Patient Protection and Affordable Care Act — commonly known as Obamacare — promises affordable health insurance for all, lower prices through government-regulated insurance markets and improved quality.
But a study commissioned in March by the U.S. House Committee on Energy and Commerce tells a different story: Skyrocketing health insurance premium costs, new hardships for the young and old, and the creation of a new entitlement program governed by a board that will have the last say on who gets treatment.
Regardless of which side is proved correct, the Affordable Care Act is law and will continue trickling into existence causing many people to adjust their lives professionally and personally.
The most significant change happens Jan. 1. That’s when people without health insurance such as Petre must enroll in health insurance or risk being fined $95 or 1 percent of their income, whichever is more, payable when they file their 2015 income taxes. That same penalty is cut in half to $42.50 or ½-percent of income for each claimed person under 18 years old if they also are not covered.
These fines will steadily increase until 2016 where they stop at $695 or 2.5 percent of household income, whichever is more.
If people don’t pay, the Internal Revenue Service either will withhold any future income tax payouts until the fines are met or it could charge individuals with tax fraud.
The ACA requirement that every U.S. citizen be covered by health insurance or face penalties is called the “individual mandate” and it is just one of many ways the new law will impact individuals, businesses and communities.

In general, full-time employees who earn 1 to 4 times the federal poverty level ($11,505 to $46,021) in pre-tax annual income can shop on the federal health insurance exchange (see sidebar) or keep the insurance offered by their employer. This will be an option for most Illinois Valley residents given the local per capita income is $25,500 and the median income is $52,500, according to the U.S. Census.
Next is a matter of affordability.
Health insurance plans are considered “affordable” if they cost 8 percent or less of a household’s annual pre-tax income.
Individuals still may shop the exchange if they already have “affordable” insurance plans offered to them by their employer, but the employer will not be required to assist in paying any premiums.
But if the employer plan is considered “unaffordable,” those individuals can choose to find a plan on the exchange and the employer will then be required to continue paying a portion of their employees’ premiums. The government also may include subsidies to bring down the sticker price.
For example, the U.S. Census describes the average household as two adults with one child earning about $45,000.
The family’s household income is about 300 percent of the federal poverty line. Additionally, the family’s employer-provided health insurance costs about 10.5 percent of their pre-tax income annually. The family would not only qualify for the exchange, but their employer must contribute to their premiums or face fines.
If the family’s insurance plan was less expensive, they could still shop the exchange, but their employer wouldn’t be required to contribute to their premiums if they bought a plan on the exchange.
Once enrolled onto the exchange, the family could purchase a Bronze or Silver plan. But no one knows yet if that will be a less expensive option until the exchanges open Oct. 1. There is only the official promise from federal health officials who answer public questions at that “there will be plans to fit just about every need and budget.”
What is known is that all plans sold on any exchange in the U.S. must include 10 “essential” benefits such as emergency services, hospitalizations and prescription drugs. Also, anyone with a pre-existing condition cannot be turned down.

Part-timers and the unemployed
Unemployed people, or those who earn less than $$11,505 annually, will most likely be enrolled into Medicaid when they sign up on the exchange. Medicaid will cost them very little to nothing at all, but may result in price hikes for other plans on the exchange.
For part-timers, it’s more complicated.
Part-time employees who work more than 29 hours a week are considered full-time employees under the health law. And if an employer has more than 50 full-timers on its payroll, then that company must provide health benefits or face penalties. This mandate is dubbed the “employer mandate” and while it has been temporarily lifted, most experts agree it will be reinstated Jan. 1, 2015.
Temporarily lifting the mandate gives employers more time to weigh the economics of offering their employees health insurance or paying fines and sending their workers to the exchange.
However, most employers are opting instead to limit all of their part-timers to 29 hours per week or less, which allows them to avoid the mandate altogether.
For part-time workers such as Derek Schwartz, a bagger/stocker at Sullivan’s Foods in Mendota, halting the employer mandate means more time to work good hours and avoid what could become a double punch to his finances.
Sullivan’s officials already have said that once the employer mandate is reinstated it will cut part-time hours to no more than 28 per week because it cannot afford to follow the mandate and stay open. The limited hours are the first punch for workers like Schwartz.
The second punch strikes when workers are forced to purchase health insurance or pay an annual fine as a result of the individual mandate. Fortunately for Schwartz, he is 21 years old and is covered by his mother’s health insurance plan until he turns 26. After that, he will be forced to purchase health insurance.
“I have a graphic design degree so I’m trying to find a job in that area or get full-time here,” Schwartz said. “If that doesn’t work, I’ll just have to get a second job.”
 And for part-timers such as Haley Petre who work less than 29 hours a week and are without health insurance, the options aren’t any better: find a good job in a troubled economy and hope they offer health benefits, pay the fine until she gets really sick or injured and sign up on the exchange at that time, or leave the workforce and go on Medicaid.
“I’ll just pay the fine out-of-pocket and hope for a job,” she said.

Health exchanges open next week

The linchpin of the Patient Protection and Affordable Care Act is the health insurance exchange.
A health insurance exchange is an online marketplace where individuals or small businesses without insurance can buy insurance plans much the same as they might buy a book on Amazon.
Individuals and families that are covered by federal government-approved health care plans are not required to sign up on the exchange. Everyone else must sign up unless they choose to purchase health insurance privately.
Federal health officials hope insurers competing in government-regulated exchanges will offer consumers cheaper health plans.
Illinois residents will use the federal exchange at until state lawmakers create a statewide exchange. Open enrollment begins Oct. 1 to March 31, 2014 in the first year. Thereafter, enrollment periods will be from Oct. 15 to Dec. 7.
For those who cannot afford to purchase a health plan on the exchange, the federal government will offer tax credits to help lower the monthly cost.
Additionally, low- and middle-income consumers will be able to apply for premium tax credits and for Medicaid and Children’s Health Insurance Program through the exchanges, if needed.
All exchanges offer four basic tiers of plans named: Bronze, Silver, Gold and Platinum. Bronze will be the cheapest and offer the fewest benefits whereas Platinum will have high premiums and offer many benefits. Others fall in between.

Tomorrow: Health care professionals speak out; Malpractice and choice

Kevin Caufield can be reached at (815) 220-6932 or

Related Stories:
• Many seeking health care benefits (last in a series)
• Seniors Worry: Will Medicare become unaffordable? (third in a series)
• Employers: Difficulty doing business under health care act (fourth in series)
• Hospital execs weigh in on Affordable Care (second in a series)

Reader Comments

Posted: Monday, September 23, 2013
Article comment by: METALWORKER

Here's the thing.
Lets say the people I work provide health ins. and they employ 500 people.
Lets say the coverage they give covers families also. at the same price as single people. Married , same price. add a child, same price. Ten kids, same price to the insured. Pretty much free.
Fair? No!
Should you be required to income tax on the amt. that ins would cost you on the open mkt.
I think so. If I have to purchase my own insurance, I pay taxes on that money, why is yours free.
There are all sorts of inequities with the present system.
Some ins. co. reguire one to see people in network. Will pay one fee for out of network and another for in network.
Some demand precertification for care given.
If you, now do not have insurance and have no money treatment cannot be refused you and there may never be any payment extracted from you, but if I have insurance a part of your fee will be tacked onto my part of my bill not covered by my insurance.
What's fair? Ron Paul said that you should not be treated. Period, end of story. Maybe, but what of your young child? Should that child be treated for free? Or should that child too, not be treated. What's fair.
So, the bottom line for most of you will be only I matter and the hell with you.
Me, personally, I think that no co or org. should provide health ins. for anyone. If a co wants to provide group buying power. OK, but you pay for it. One price for you twice as much for a man and wife and if you have children, there yours and you should pay for them. Fair/ May be. At least fairer than me paying for them or their coverage being free.
Much fair than now
You call yourselves Christians and yet you do not want to do for Christ. Remember, He said what you do for the leas, you do unto ME. His words, not just mine.
What a bunch of hypocrites you cry babies are.
Heaven, indeed will be quite empty I fear. Christ will be very lonely. Ya think?

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