Benefit Shock at Obamacare Exchanges

If the Obamacare Marketplaces open on 10/1 as planned, the monthly price may be the easiest thing to understand.  Most people are not well versed in how health insurance benefits work, especially when reading it from a web site.

The rates that are being discussed in the news are generally for the lower cost plans, called Bronze or Silver.

Kaiser Health News describes the shock that consumers may feel when they discover what their money is actually buying.

Benefit Shock

Premium prices will be clear for shoppers in the marketplaces, but consumers won’t be able to assess the worth of these insurance policies until they grasp all the costs. Typical deductibles will be $2,000 or $5,000. In addition, patients will have to pay for part of their care even after they’ve satisfied their deductibles. For instance, Californians with a silver-level plan — a mid-level offering on the marketplace — will have to contribute $65 every time they see a specialist, $45 for a lab test, $65 for an X-ray and $250 if they go to the emergency room and 20 percent of the cost of hospitalization. Those co-payments continue until patients meet their maximum annual out-of-pocket amount, which generally will be $6,350 for individuals and $12,700 for families. The cheapest plans also may have the most limited groups of doctors and hospitals.

“The consumer is going to go to the exchange and find out for $2,500 a year they get a $2,000 deductible” for a policy they think they won’t really use, said Robert Laszewski, a former insurance company executive who is now a consultant. “The second thing they’ll find out is that their favorite doctor isn’t necessarily in the network, and to get a wide network it’ll be another $100 a month.


Agents Navigators Assisters in Ohio

Prior to Obamacare, only licensed insurance agents were able to sell or enroll people in health insurance products.

Starting 10/1/13, Navigators and Assisters will also be involved.

Here is a breakdown from the National Association of Health Underwriters that describes what each of these categories can do.

This is specific to Ohio:

Who can sell on the Exchange/Marketplace in Ohio?

  • Only licensed agents and brokers may sell, solicit, or negotiate a contract of health insurance.
  • Only licensed agents and brokers may recommend a particular product, or option, to a consumer.
  • Within the Exchange/Marketplace Agents and Brokers are required to provided unbiased information and comparisons of plans.

What is required to be an Agent in Ohoi?

  • Active State of Ohio Health Insurance License
  • Current appointment with all carriers they are writing
  • Complete Exchange training

What is a Navigator?

Under Ohio Law (H.B.3):

Navigator can: (1) conduct public education activities and raise awareness of  availability of Qualified Health Plans; (2) distribute fair and impartial general
information concerning enrollment in all QHPs and availability of premium tax credits and cost-sharing reductions; (3) Facilitate enrollment in QHPs, without
suggesting that an individual select a particular plan; (4) May provide information related to Medicaid eligibility.

Navigator cannot: (1) Sell, solicit or negotiate health insurance; (2) Provide advise concerning substantive benefits, terms or conditions of a plan or offer
advice about which plan is better or worse or suitable for a particular individual or entity; (3) Recommend a particular plan or advise consumers about which plan to
choose; (4) Provide any information or services related to plans or products not offered in an Exchange; (5) Engage in any unfair method of competition or any
fraudulent, deceptive, or dishonest act or practice.

5 Navigator Grants have been given in Ohio in 2013 totaling over $3 Million.  The grants went to:

  • Ohio Association of Food Banks
  • Children’s Hospital Medical Center (out)
  • Clermont Recovery Center, Inc
  • Helping Hands Community Outreach Center
  • Neighborhood Health Association

More about Navigators:

  •  Navigators do not receive commissions – their funding mechanism is via the Federal grants in 2014
  • Structured as a cooperative agreement – Performance period is up to 12 months from the date of the award and future awards funded by the exchange/marketplace
  • Navigators will be required to annually recertify
  • Navigator includes the organization receiving the grant and certification plus each person designated to perform navigator duties
  • Navigators DO NOT carry errors and omissions coverage

Certified Application Counselors:

  • On July 17, 2013 CMS issued a final rule at 45 CFR 155.225 introducing a separate class of Certified Application Counselors (CACs), such as community health centers, health care providers  and entities, and community-based organizations, to assist consumers with enrolling in coverage through the Marketplace.
  • Certified Application Counselors will be designated by the Marketplace to provide the same application assistance that is available from Navigators, but will not be funded through the Marketplace. However, the conflict of interest provisions that apply to navigators do not apply to CACs.
  • Certified Application Counselors must complete the CMS Exchange Training
    Certified Application Counselors do not receive commissions
  • Certified Application Counselors receive grants from states or other organizations
  • Certified Application Counselors will be required to annually recertify
  • Certified Application Counselors DO NOT carry errors and omissions coverage

Source: National Association of Health Underwriters

Don’t let your guard down – penalties still apply!

Lots of Peril for employer groups if they do not adhere to Obamacare rules.

TASC Provider News

As we close in on the deadline requirement to distribute the Healthcare Marketplace Notice, the Dept. of Labor (DOL) has issued guidance that an employer will not be fined or penalized for failing to provide such notice. The new guidance states that employers “should” distribute the notice.


  • A $110 per day fee can be awarded to employees when an employer fails to provide an ERISA SPD (as described in the Notice).
  • The Patient Protection & Affordable Care Act (PPACA) imposes a $100-a-day general non-compliance penalty. This general penalty requires employers to either (a) correct compliance failures within 30 days of discovery or (b) self-report on IRS Form 8928 a $100-a-day penalty for failing to comply for each day the employer filed to comply with a PPACA mandate.

What other things can result in $100-a-day penalties?

  • Violating the limits restrictions.
  • Failing to extend coverage to dependents through age 26.
  • Imposing…

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Health Premiums Tripple Under Obamacare for Kentucky Family

From Fox News:

Andy and Amy Mangione of Louisville, Ky. and their two boys are just the kind of people who should be helped by ObamaCare. But they recently got a nasty surprise in the mail.

“When I saw the letter when I came home from work,” Andy said, describing the large red wording on the envelope from his insurance carrier, “(it said) ‘your action required,benefit changes, act now.’ Of course I opened it immediately.”

It had stunning news. Insurance for the Mangiones and their two boys,which they bought on the individual market, was going to almost triple in 2014 — from $333 a month to $965.

Andy and Amy Mangione of Louisville, Ky. and their two boys are just the kind of people who should be helped by ObamaCare. But they recently got a nasty surprise in the mail….


Obamacare Scams Beginning

In a new report, the House Oversight and Government Reform Committee presented these shocking findings:

there are already numerous reports of scam artists posing as Navigators and Assisters to take advantage of people’s confusion about ObamaCare. According to recent news reports, scam artists are calling individuals and asking for information to sign them up for their “ObamaCare card,” are asking seniors for their personal information to verify their Medicare and Social Security status and are going door-to-door threatening people with prison time if they do not sign up on the spot. The Administration is keenly aware of these reports and concerns, but has thus far failed to take appropriate measures.

HT:  Heritage Foundation