Next Phase of Health Care Reform Act Coming Oct. 1


Regardless of where a person stands on the issue, the next phase of health care reform – open enrollment in Insurance Marketplace plans – is set to roll out October 1.

Kevin Kane, health care organizer for Citizen Action of Wisconsin, walked crowds in Price County through the basics of the at times divisive legislation recently in an event organized by the Price County Democrats.

“We’ve debated the worth of this law, the constitutionality of this law, all facets of it, and now we have to get to the process of understanding it,” Kane said.

Signed into law March 23, 2010, the two-part law known in long form as the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act has been rolling out in phases over the last three years.

Some parts of the law have already gone into effect, including a provision that allows young people to get coverage through their parents’ insurance plan up until age 26 and protections that in most cases keep children under the age of 19 from having benefits limited or denied based on preexisting conditions. In addition, since 2012 insurance providers have been required to cover a range of preventative screenings for women, from breast checks to pap smears, without charging coinsurance or a copayment.

The next phase, open enrollment for plans offered in the Health Insurance Marketplace, runs from Oct. 1, 2013-March 31, 2014. That’s when information on insurance plans and pricing options will be made available. Types of coverage are already explained, just not specific plans.

Insurance shoppers aren’t able to apply for a plan outside of the open enrollment period unless they experience something termed as a “qualifying life event,” which could mean a change in income, a move out of their home state or something that changes the size of their family.

Major points of the health care reform law are broken down on the government Web site, where those who’d like to search insurance options can also find the Marketplace for their state.

Since Wisconsin opted out of creating its own Marketplace, residents of the state will weigh their coverage options in a federally run exchange.

Once enrollment gets underway, people who’d like to shop Marketplace plans can do so at by setting up an online account, filling out an electronic application, comparing available options side-by-side and then enrolling online.

Those who aren’t able to complete the process online will have the option of enrolling through the mail or in-person.

Regardless of how someone moves forward with enrollment, they’ll want to work through budget figures to see how much they can afford to spend on a plan and gather the types of income information found on such documents as pay stubs, W-2s or tax returns.

Health insurance coverage won’t take effect until Jan. 1, 2014 or later depending on when a person enrolls and makes his or her first premium payment. Some other parts of the law kick in on the first of the new year, too, including the provision that prevents insurance companies from denying coverage or charging more on the basis of preexisting conditions. Different treatment for those with preexisting conditions may be grandfathered in when it comes to some individually purchased plans. However, as is explained on, holders of these plans have the option of seeking out other coverage options that don’t come with these restrictions in the Marketplace.

All Marketplace plans and a number of plans offered elsewhere will be required to cover various preventative services, from cholesterol screenings to flu shots, without charging coinsurance or a copayment. They must also cover any contraceptive services women receive in-network with no copayment, coinsurance, or deductible requirement, with the exception of plans offered by religious employers requesting to be exempt. Drugs that induce abortions in already established pregnancies and procedures related to men’s reproductive systems – vasectomies – aren’t required to be covered by Marketplace plans.

Insurance companies are already prevented from placing a lifetime limit when it comes to “essential health benefits” a customer may receive. Hospitalization, maternity and newborn care, emergency and ambulance assistance, lab work, and pediatric care are among the services falling under that essential health benefits umbrella.

Starting January 1, insurance providers will be prevented from imposing a yearly limit for these essential services except in the case of some individually held plans in which the limits were grandfathered in.

Depending on family size and income level, enrollees may qualify for reduced monthly premiums or out-of-pocket costs in terms of coinsurance, copayment and deductibles.

One aspect of health care reform that has stirred up more than a little controversy – the insurance mandate with financial penalties for non-compliance – is also set to go into effect January 1.

As of that date, those Americans who aren’t signed up for a plan representing “minimum essential coverage” will be charged a fee poised to go up over the next few years: $95 or 1-percent of income (whichever’s greater) per adult and half that rate per child in 2014. That rate is scheduled to climb to $695 per adult or 2.5-percent of income by 2016.

As of January 1, Medicaid expansion will take effect in the states that chose to do so.

Wisconsin elected against expanding Medicaid coverage.

Those lower income individuals who are excluded from BadgerCare and don’t qualify for lower premiums or out-of-pocket costs through the Marketplace will be exempt from the fee affecting others who qualify for and fail to seek out “minimum essential coverage.”

In order to qualify for BadgerCare in the year ahead, an individual would have to make 100-percent of the federal poverty level or less, with that income threshold set at about $11,500. That’s around $23,500 for a family of four.

The Legislative Fiscal Bureau, a nonpartisan body, estimated that the rejection of funds to expand Medicare coverage could cut 90,000 people out of the public assistance program, according to a Wisconsin Public Radio News update given by Maureen McCollum this June.

“But betting on money that the federal government can’t provide today would just be becoming a participant in an already failed project,” Walker said after the budget committee gave the go-ahead to declining expansion of Medicaid, as quoted in McCollum’s story.

The opening of the Health Insurance Marketplace won’t influence options or benefits available to Medicare recipients, as explained on the government Web site.Medicare supplement (Medigap) insurance and Part D drug plan options aren’t a part of the Marketplace.

On the business side of things, employers won’t be required to offer staff members insurance coverage, though companies with 50 or more employees need to begin making a “shared responsibility payment” once 2015 rolls around if at least one of their fulltime workers qualifies for a lower monthly premium rate in the Marketplace.

The Obama Administration recently proposed an arrangement in which the government would continue to share in the cost of coverage for Capitol Hill employees as long as they purchase plans through individual state exchanges, as touched upon in a Kaiser Health News update. Suggested guidelines leave it up tolawmakers, though, to decide which staffers move to exchanges for coverage and who will stay enrolled in the federal benefits program, according to that same story.

A live chat feature has been set up at to catch questions not answered by information on the Web site. Otherwise, members of the public can have their questions about the Insurance Marketplace answered by calling 1-800-318-2596.

The Kaiser Family Foundation offers a calculator to help people estimate the cost of coverage and potential savings before Marketplace features are fully implemented October 1.


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