Have the courage to learn

Nov 6, 2013


Take the fear out of the Affordable Care Act
My friend and colleague, the Rev. Herman Robinson says it best: “We have to help others to have the courage to learn about the Affordable Care Act (ACA)/ (“Obamacare”); otherwise, they will be overcome by fear and lack of understanding.” His point was that those who stand to be helped by the Affordable Care Act are likely to not opt for the health care insurance because they didn’t know better.

Whether you are for ACA/ Obamacare — or against it — isn’t what matters.

What matters is your level of understanding of it as it affects you. I’m the farthest thing from being an authority on the matter, but I did have the good fortune of hearing Josh Mesenburg, senior account executive with United Insurance Services, speak on two occasions about the ACA and how it works. I’ve also invested time reading and using the Healthcare.gov website.

Space limitations cause me to be brief.

Therefore, what I am about to share is not all-encompassing, it is simply some “nuts and bolts” information I hope will motivate you to find the courage to develop your working knowledge about the ACA as it pertains to you and your household. Then you will have a basis for opinion.

• Because of the ACA, your insurance company can no longer deny coverage of a pre-existing condition; nor can it jack up the price of the policy because of the existing illness/condition.

• If you do not have health insurance and you do not take advantage of the ACA, you will be fined $95 or 1 percent of your household income for 2014. That penalty fee increases in 2015 and again in 2016.

• Learn if you/your household is: A) earning between one and four times the federal poverty level; and B) if you have to pay more than 9.5 percent of your household income for your own coverage through the insurance offered by your employer. If the answer is yes to both, you do qualify for a subsidy (aka financial assistance) to buy insurance through the health exchange. (familiesusa.org)

• The Henry J. Kaiser Family Foundation has a calculator on its website. If you answer the questions, it can calculate what you would pay if you were to buy health insurance through the health exchange. The calculator is available at kff.org/interactive/subsidy-calculator/. Even if you don’t need health insurance, I encourage you to use the calculator, just so you can be better informed about the ACA subsidies and how they work.

• There are four types of plans to choose from. Platinum Plan: The insurance pays 90 percent of the bill, and you pay 10 percent. Gold Plan: The insurance pays 80 percent of the bill, and you pay 20 percent. Silver Plan: The insurance pays 70 percent of the bill, and you pay 30 percent. Bronze Plan: The insurance pays 60 percent of the bill, you pay 40 percent.

• The maximum out-of-pocket costs for any marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan. This is an important point to understand. For example, if you were in an awful car accident and your care costs $500,000, the maximum you would be responsible for paying — regardless of what type of plan you were on — would be $6,350 for an individual and 12,700 for a family.

Family Health Services of Erie County has hired a “Navigator,” someone who is trained to help people and organizations look through the plans — without any bias — and completing the necessary forms to help the consumer purchase the desired health insurance.

Their services are free.

For information, call Family Health Services of Erie County at 419-557-7072.

Help is also available by calling Jennifer Leonard, certified application counselor, at Community Health Services in Fremont at 419-208-5178.



Are you kidding me? Serving Our Seniors takes a pro stance on the law that takes BILLIONS away from the Senior program of Medicare (that they paid into all their lives) and potentially uses that money to cover people who are not seniors and have never paid so much as one dime in Medicare and/or Federal taxes???? Shame.


There is nothing in this article that suggests Serving Our Seniors leans one way or another as an organization in regards to the Affordable Care Act.

As the initial paragraphs state, becoming informed about the realities of the ACA for you as an individual and for those that have families is important no matter what your views are on the law overall.


Sue represents senior citizens which according to the state starts at age 60. The state department of aging sends out the golden buckeye cards when you are 60. You are not eligible for Medicare until age 65. And what makes you think that the people under that age who need insurance don't work and pay into medicare? We are fortunate to have someone like Sue Daugherty in our community.


It's my understanding that the maximum out-of-pocket ceiling doesn't exist for 2014. Apparently, that's yet another "delayed" part of the Obamacare monstrosity.


What the heck do Golden Buckeye cards have to do with Medicare? You said it yourself, they are not entitled to Medicare until they are 65. So stealing billions from the program to subsidize those who are not 65 is OK? Wonder how much SOS is being paid to offer these "information" sessions. More tax dollars out the door to promote a program that is so wonderful we will have millions signing up. LOL. With thought processes like those above no wonder we are in such trouble in this country.


I checked out the remark made by SAM ADAMS my contacting US COngress-woman Marcy Kaptur's Office. She referred to an article by the Kaiser:

Federal Rule Allows Higher Out-Of-Pocket Spending For One Year
JUN 11, 2013
Starting next year, the Affordable Care Act sets maximum limits on how much consumers can be required to pay out-of-pocket annually for their medical care. But some people with high drug costs may find the limits don't protect them yet.

That's because the federal government is giving some health plans extra time to comply with the rules.

Under the law, the maximum amount a consumer with single coverage will pay out-of-pocket in 2014 will generally be $6,350 while a family could pay up to $12,700. Those totals include copayments and deductibles, but not premiums, and they apply only to plans that are not grandfathered under the law.

Here's the catch. Although all non-grandfathered plans will have to cap the amount that consumers pay out-of-pocket for major medical expenses, if health plans use more than one company to administer their benefits—as many do for major medical and pharmacy benefits, for example—consumers may face separate caps next year, or no cap on their pharmacy spending at all.

According to guidance from the federal government issued in February, health plans with more than one benefits administrator don't have to combine their tallies of members’ out of pocket spending into one total until 2015. So a plan with a separate cap on pharmacy benefits can keep it as long as the limits don't exceed the new maximum. Plans with no drug spending limit—the norm, according to experts—don't have to cap members' out-of-pocket spending at all.

Drug costs can add up fast.
When Patrick Dee, 37, was diagnosed with brain cancer in 2009, doctors prescribed the oral chemotherapy drug Temador.
Dee, 37, worked as a pharmacist for a Knoxville, Tenn., hospital, and his health plan required that he pay 40 percent of the costs for the specialty drug , says Kate Dee, Patrick's wife. A single week's supply cost them just over $1,000 out of pocket, and doctors wanted Patrick to take the pills for a year.

"We rapidly depleted our savings," says Kate, 38.
Eventually, the hospital where Patrick was being treated agreed to absorb much of the drug's cost, and later Merck, the drug's manufacturer, covered the cost of the drug under its ACT Program, even though the family's income was higher than generally allowed in that program.

Dee finished his treatment and is no longer on chemotherapy. But Kate says the couple, who have two boys aged 8 and 6, worry how they will afford it if he needs treatment again.

"The out-of-pocket costs will be ridiculous," she says.
Next year, unless their health plan is grandfathered under the law, the family's out-of-pocket medical expenses, including drugs, will likely be capped at $12,700. The limit will kick in because their group health plan uses only one provider to administer its benefits.
For many other consumers whose health plans, contract with pharmacy benefit managers or other types of benefit administrators, however, nothing may change.

"No doubt there's a segment of patients who will benefit from the out-of-pocket maximum, and for that subset of patients they'll have to wait a year," says Mary Rosado, vice president of government affairs for Express Scripts, one of the country's largest pharmacy benefit managers, covering 100 million people in the United States.
(An exception to the new rule is for plans that use a separate provider to run their behavioral health benefits. Under the Mental Health Parity and Addiction Equity Act of 2008, health plans can't apply separate out-of-pocket maximum limits for those benefits.)
Some consumer advocates say their biggest concern is that consumers may not understand how their plan benefits work and what limits they’re subject to. However, they hope health care overhaul provisions that now require health plans to provide a summary of benefits and coverage that spells out plan details should make it clear, they say.

Beyond that, "the next year is really going to be about monitoring how this impacts patients and making sure this is truly a one-year moratorium," says Erin Reidy, associate director of policy at the American Cancer Society's Cancer Action Network.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.