Monday, November 30, 2015

Insurance Exchanges 101

If you are still unsure what Insurance exchanges will actually do, you are not alone. Polls show that most Americans are confused about how the health reform law works. Here, in three easy steps, are the most important elements of using an exchange.

Insurance Exchanges 101


 The Field Clinic welcomes Katheryne Lawrence, a third year law student concentrating in health law at the Earle Mack School of Law at Drexel University as a regular contributor over the next several months. This is her inaugural post.

If you have been following this blog, you have seen a lot of discussion about insurance exchanges. They are at the heart of Obamacare, and they will begin operating in just four months - on October 1. But if you are still unsure what they will actually do, you are not alone. Polls show that most Americans are confused about how the health reform law works.

The first thing to keep in mind is that if you presently get insurance through an employer or receive Medicare or Medicaid, the exchanges won’t matter to you. In fact, you won’t even be allowed to use them. You will continue to receive insurance as you have in the past.

Exchanges are for people who purchase coverage directly from an insurance company or who would like to but have been turned down because they have a preexisting medical condition. If that describes you, then you need to know how the exchanges will work. If you don’t, you could end up uninsured, which could subject you to a financial penalty starting in 2014.

More coverage
Are doctors in it for the money?
You’re about to find out what health insurance really costs
Doctors die differently than their patients
We’re a lot sicker than we realize
U.S. healthcare costs: It’s time to get worried
Your Health Flexible Spending Account just got a little less flexible

Here, in three easy steps, are the most important elements of using an exchange:

First, visit the exchange for your state. Beginning October 1, there will be an exchange in every state. They will function as one-stop shops for purchasing coverage.

How will you find your exchange? The easiest way will be online. Each will have a website and a toll-free telephone hotline for assistance. Depending on your state, your exchange will be run either by the federal government, by your state, or by a partnership between the two. In Pennsylvania, the exchange will be run by the federal government. To learn more about the status of your state's health insurance exchange click here.

Second, consider the coverage options and pick the one that best fits your needs. That will require some decisions, like balancing the cost and the amount of coverage.

In each exchange, the available health plans will be grouped into four levels according to how much they cover. These will be named after precious metals - platinum will be the best, followed by gold, silver and bronze. All of them will cover the same essential benefits that are required of all plans under the health reform law. The main difference will be in the amount of those benefits they pay for. Platinum plans will cover 90% of your expected expenses, gold will cover 80%, silver 70%, and bronze 60%. In addition, some plans will offer additional benefits above those required by the law. 

This will translate into differences in the amount you will have to pay out-of-pocket for care. Under bronze plans, you will have to contribute the most and under platinum plans, the least. You can find more information on metal levels and what they mean for your wallet here.

Third, see if you qualify for financial assistance. The key question on many people’s minds is, how much is all this going to cost me? That answer depends on the health plan you choose and your income. If your income is low enough (less than 400% of the federal poverty level), you may qualify for a subsidy that will help reduce premiums and out-of-pocket expenses. You may also qualify for Medicaid, depending on the eligibility requirements of your state.

Before you select your plan, you should have your financial documentation ready. The exchange will tell you once it verifies your income and determines if you qualify for a subsidy. To calculate in advance if you will receive assistance and how much it will be, click here

Finally, start using your new insurance after next January 1, when exchange-based policies will become effective. The most important point to remember of all is that under health reform, you will be able to get one, regardless of your medical condition. Access to coverage will be guaranteed.

From Obamacare to Medicare to managed care, read more of The Field Clinic here >>

We encourage respectful comments but reserve the right to delete anything that doesn't contribute to an engaging dialogue.
Help us moderate this thread by flagging comments that violate our guidelines.

Comment policy: comments are intended to be civil, friendly conversations. Please treat other participants with respect and in a way that you would want to be treated. You are responsible for what you say. And please, stay on topic. If you see an objectionable post, please report it to us using the "Report Abuse" option.

Please note that comments are monitored by staff. We reserve the right at all times to remove any information or materials that are unlawful, threatening, abusive, libelous, defamatory, obscene, vulgar, pornographic, profane, indecent or otherwise objectionable. Personal attacks, especially on other participants, are not permitted. We reserve the right to permanently block any user who violates these terms and conditions.

Additionally comments that are long, have multiple paragraph breaks, include code, or include hyperlinks may not be posted.

Read 0 comments
comments powered by Disqus
About this blog

Do you have a large bill from a provider you didn’t expect? A claim that was denied without explanation? A change in your insurance plan you don’t understand? Do you need help sorting through data on the quality of your doctor or hospital or figuring out what your care will cost?

“Health Cents” will point you toward answers, while also offering insights on government health policy and political debates. Read more about our panel of bloggers here.

This blog is produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health-policy research and communication organization not affiliated with Kaiser Permanente. Portions of this blog may also be found on and in the Inquirer's Sunday Health Section.

Robert I. Field, Ph.D., J.D., M.P.H. Professor, Drexel University Kline School of Law & Dornsife School of Public Health
Jeffrey Brenner, MD Founder of the Camden Coalition of Healthcare Providers, Medical Director of the Urban Health Institute at Cooper University Healthcare
Andy Carter President & CEO, The Hospital & Healthsystem Assoc. of Pa.
Robert B. Doherty Senior Vice President of Governmental Affairs & Public Policy American College of Physicians
David Grande, MD, MPA Assistant Professor of Medicine at the University of Pennsylvania
Tine Hansen-Turton Chief Strategy Officer of Public Health Management Corporation
Drew A. Harris, DPM, MPH Director of Health Policy Program at the Jefferson College of Population Health
Antoinette Kraus Director of the Pennsylvania Health Access Network
Laval Miller-Wilson Executive Director of the Pennsylvania Health Law Project
David B. Nash, MD, MBA Founding Dean of the Jefferson College of Population Health
Mark V. Pauly, Ph.D. Professor of Health Care Management, Business Economics and Public Policy at The Wharton School
Howard J. Peterson, MHA Managing Partner of TRG Healthcare, a national healthcare consulting firm
Paula L. Stillman, MD, MBA Healthcare consultant with special expertise in population health and disease management
Elizabeth A. W. Williams Senior Vice President & Chief Communications Officer for Independence Blue Cross
Latest Health Videos
Also on
letter icon Newsletter