Kearns and Sons RS Aesthetics

Hospital holds informational meeting on Obamacare

By Michael Howell

Implementation of the Affordable Care Act, often referred to as Obamacare, has already begun to slowly unfold across the country. It has weathered a 16-day federal government shutdown involving Republican demands that the implementation be suspended. It has also been slowed down due to technical difficulties related to the program’s federally sponsored internet website. But it is here and it is being implemented, according to Christina Goe, legal counsel for the Commissioner of Securities and Insurance (CSI) at the Montana State Auditor’s Office.

Goe came to Hamilton last week, along with representatives of the three insurance companies competing in Montana’s Marketplace, to address people’s concerns and answer some of their questions about the new law. She spoke to a crowd of over 300 people at a meeting hosted by Marcus Daly Memorial Hospital at the Bitterroot River Inn last Wednesday.

The law was passed in 2010 and, according to Goe, some reforms went into effect in September of that year, while others are being phased in. Many of the reforms are starting on January 1, 2014. The Exchange, the Marketplace where people can purchase insurance plans and get a tax credit subsidy to help make the payments, opened on October 1, 2013 and enrollment has begun. The three healthcare insurance providers who have been approved to sell their products on the federal Marketplace website in Montana are Blue Cross Blue Shield, Montana Health Co-Op and PacificSource.

She said that despite the glitches in the IT platform of the Marketplace website, “The law is the law. It has been determined to be constitutional by the Supreme Court. And it has to happen, one way or another.”

She said that the state has decided to call the Affordable Care Act “Obamacare” to avoid confusion. She said it was a popularly accepted name, used on the President’s website, and they decided to use it to avoid confusion over whether it was something different. She said they are exactly the same thing.

The law puts new requirements on health insurers. It also puts new requirements on citizens to have some sort of insurance, whether that is Medicaid or Medicare or private health insurance or insurance through your employer. There is requirement for employers to have an insurance plan if they have over 50 employees. There is no requirement on smaller businesses. There is a premium assistance tax credit for people who do not have insurance from their employers.

Goe said that some of the changes made by the act that are already in effect include no cost sharing for preventative and wellness care and no pre-existing condition exclusion for children under 19 and in January 2014 this will apply to adults as well. Lifetime limits were eliminated on insurance policies. Annual limits on essential health benefits were also eliminated. Coverage of children on a family policy was extended to age 26.

No insurer can refuse anybody for coverage no matter what health problems you have had and you cannot be rated up. Every company now has a single risk pool and cannot divide it up between sicker people and healthier people.

The plans sold on the federal Exchange, or Marketplace, are unique to the state and insurance plans cover the basic benefits such as doctor visits, hospitalization and surgery, prescription drugs, maternity, mental health, dental and vision care for children.

Since 2011, according to Goe, health insurers have been required to spend at least 80% of premiums on health claims or health care improvement expenses such as wellness programs. They can only put up to 20% towards administrative costs and profit. If they don’t meet this requirement they must provide a rebate to customers. For the largest insurers it is 85% and 15%.

Who is not affected at all? People on Medicaid don’t have to do anything, according to Goe. People on Medicare, VA Care or Tri-care, or HMK (CHIP) do nothing and are already covered. People on employer health plans probably have to do nothing unless their insurance doesn’t cover the basic benefits.

A qualified insurer’s exchange has been formed and the Exchange, dubbed the Marketplace, opened on the first of October. It offers information that enables a comparison of plans on an “apples to apples” basis where you can compare actuarial value, cost sharing, and the benefits. The essential benefit package must be a part of the plan. The plans have been reviewed by Montana’s CSI office.

Individuals who qualify for an individual tax credit for premiums must apply for insurance through the Marketplace from one of the three companies on the Exchange. If not, you won’t get the tax credit you might otherwise be entitled to. Health plans are being offered by insurers not on the Exchange and are required to offer plans with the same essential benefits as those on the Exchange, but you will not be eligible for any tax credits.

The open enrollment period started on October 1, 2013, and was set to end in December, but has been extended to March 31, 2013. This extension was due to the glitches in implementing the Marketplace website. After the first year the open enrollment period will be from October 15 to December 7.

She said the federal internet website,, was working, although slowly and erratically and leaving many people frustrated. She said those problems are being fixed and may be resolved by the end of November. If you wait until then, however, it doesn’t give you much time to purchase your product by December 15, the deadline for purchasing one of the qualifying policies for it to be in place by January 1, 2014. The final deadline for people to get health care insurance coverage that meets the law’s requirements is March 31, 2014. Small employers can buy from the SHOP on the Exchange any time of the year.

Since 2013, the Montana CSI has been given rate review authority and has lowered some rates significantly, said Goe. They reviewed and made recommendations as to what plans are offered on the Exchange in Montana. Maximum out of pocket expenses have been limited. She said the current rates look good both in and out of the Marketplace.

For details of how the tax credits are figured, which are based on income and other factors, you can check the state’s website at, and learn more about individual options. The median income for a household in Montana is $45,000, according to Goe, meaning about 80% of the population is eligible for some kind of a tax credit.

The law requires people to have health insurance that meets the minimum standards but there are exceptions to having to purchase a health plan. If your income is so low that you are not required to file a tax return you will not be penalized. If your insurance premium requires you to pay more than 8% of your Modified Adjusted Gross Income you can get an affordability waiver. There are also other religious related exemptions. Indians, Alaska Natives, non-citizens and people in prison are also exempted.

If you need help with the Exchange, in addition to certified Exchange insurance agents, there are “navigators” and “certified application counselors” operating in the Marketplace and not getting any commission. They are all on the state’s website list and using them does not cost you any more. The three navigator organizations in the state that have received grants to do outreach and education and assist people in enrollment are the Montana Primary Health Care Association, Planned Parenthood and Rural Health Development Montana Health Network. There are no certified navigators or application counselors working in Ravalli County, she said, the closest one is in Missoula.

Goe also cautioned people that fraud over the program is already rampant.

“Just like when we had Medicare Part D, the law changed, offering additional benefits and fraud just broke out all over. There were imposters. There were fake websites. There were people sending mail that looked like they were from the government but they were not,” she said, “and the same thing is happening now.” She said was the only legitimate website to purchase insurance and get tax credits.

The only certified application counselors are listed on the state’s website at No personal information has to be entered to use the state sponsored website. You cannot purchase a product on the site but it has all the information about what plans are available in our state and what the rates are. It contains other pertinent information and a calculator to help you figure out what your tax credits might be and choose the best plan. That way you can be prepared when you do get on the federal site to do your business.

There is a gap in coverage in Montana because the state legislature opted to not expand Medicaid. The original law contemplated that people up to 138% of the federal poverty level would be covered in the expansion of the Medicaid program. The Supreme Court ruled that it was a state option and could not be a federal mandate. The tax credits only go down to 100%, so if you are at 98% of the poverty level or less you will not get assistance. You won’t get a penalty but you won’t get insurance.  At least 50,000 people in Montana fall into this gap with no coverage options.

Hospitals are still required to provide charity care for the uninsured and it raises premiums for everyone else, said Goe. A lot of the government funds that went to help hospitals meet these costs is being phased out because no one was supposed to be left uncovered. Goe said Montana will lose economic benefits that would have accompanied this expansion. A University of Montana study of the health care market and the effect of this on the economy found that Montana will lose jobs and money amounting to about $6.5 billion over eight years.

Goe said that the federal website is working, it just takes patience and should improve soon. In the meantime, you can get on the state’s site to learn more about your options, though you can’t purchase. For more information help can also be found on the website, or call 1-800-332-6148.

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