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Navigating the maze

For the poor and disabled — even for health care professionals — parsing Oklahoma’s new health insurance marketplace can get tricky.

Angela Chambers September 25th, 2013

Parking at the Oklahoma Foundation for the Disabled means finding a place in uneven, rigid red dirt. Inside the modest building, donations are piling up in the conference room, as there isn’t anyone available to organize.

Like many nonprofits, the foundation uses its limited funds not for outward appearance but for providing services to people in need.

In this case, it offers life skills training, socialization and therapy to central Oklahomans with developmental disabilities who may otherwise have few enriching activities during the day.

Available resources at nonprofits also create lower employee salaries and less access to affordable health care. But since OKFD began providing Insure Oklahoma, the state-based health insurance program for low-income residents, its employees now have better coverage.

“Before Insure Oklahoma, I had no insurance, and I couldn’t go to the doctor,” said Jessica Washington, OKFD floor supervisor. “If I did, it was straight to the emergency room to get a sky-high bill that I couldn’t pay.”

While IO provides primary care, the OKFD can no longer afford to offer supplemental coverage such as dental. It has been two years since Washington went to the dentist, when she had to receive treatment for a root canal. She also isn’t able to have eye exams.

Her coworker, Sheronda Davis, a certified nurse’s aide, said she has problems with her teeth but she is unable to go to the dentist because of the cost.

Gwen Williams, who works in human resources at OKFD, makes too much to qualify for IO, so she uses a more traditional health care plan.

Still, since she pays $400 each month for her insurance, she regularly thinks about dropping it to help pay for other expenses.

“The general consensus of all of us around here is it’s just almost unaffordable,” Williams said.

“We struggle with it.” Providing comprehensive, low-cost health care coverage is a continued debate at the state and federal levels. And the multiple options available are often confusing to consumers.

In Oklahoma, three key programs designed to help those with low incomes are Insure Oklahoma, the federal health insurance marketplace (offering enrollment from Oct. 1) and SoonerCare (the state’s Medicaid).

Health insurance programs of all varieties and employers must work in the coming months to follow new guidelines under the Affordable Care Act.

Insure Oklahoma
Most state health analysts agree Insure Oklahoma provides needed, affordable insurance and is a positive public-private partnership. However, they also believe gaps in coverage should be addressed by state leaders.

First authorized in 2004, IO covers about 30,000 Oklahomans with state tobacco tax revenue, federal funding and a percentage paid by employers and individuals to subsidized private health insurance. Washington and Davis pay about $50 per month in premiums for the program.

“I don’t notice it’s missing,” said Davis about the monthly cost.

In early September, the federal government gave IO a one-year extension through December 2014.

“In the coming year, Governor Fallin will encourage federal officials to review Insure Oklahoma’s many successes,” said Michael McNutt, Gov. Fallin’s spokesman, via email. “Her hope is that the Obama administration will announce its support for a permanent, ongoing program.”

The federal government was considering not giving the Medicaid waiver, which allows IO to operate, an extension because it didn’t meet certain ACA regulations. This includes concerns with the cap on enrollment (35,000), a measure that hasn’t changed.

With this extension, authorities did require Oklahoma to reduce IO copayments for medical services and prescriptions. Those receiving coverage through their employers may stay on the program. Individuals using the IO plan who are making above 100 percent of the federal poverty level (FPL) ($23,550 for a family of four) will have to transfer to health insurance through the marketplace. This equals around 8,000 people. The open places in IO will likely become available to other Oklahomans who make below 100 percent FPL.

Some fear their costs will increase when making the transfer. But since the marketplace rates are highly specific, it’s difficult to create a cost comparison with Insure Oklahoma, finds Carter Kimble, spokesman for the Oklahoma Health Care Authority.

“Somebody who is 57 and a smoker, their cost is going to be larger on the marketplace than someone who is 37 and a nonsmoker, so it’s hard to say blankly one is more expensive,” said Kimble.

Health insurance marketplace
Enrollment opens Oct. 1 and lasts six months for the health insurance marketplace created by the Affordable Care Act. Coverage begins in January.

Individuals and families making between 100 and 400 percent FPL who don’t have access to other affordable health insurance options are eligible for subsidies to help purchase the insurance plan.

In Oklahoma, three insurance companies offering services in the marketplace have released their rates: Blue Cross Blue Shield of Oklahoma, Coventry Health and Life Insurance and Aetna Life Insurance. Consumers may choose from companies competing in the marketplace.

Several organizations in the state are providing certified trainees to assist with questions.

“People should make sure the information they’re getting is accurate from someone who has official certification,” said Patricia Christensen, policy and program analyst for the Oklahoma Primary Care Association. “If you’re feeling overwhelmed, reach out for assistance because there are a lot of people to help.”

Professionals called navigators are there to help both small businesses and individuals, while certified application counselors give advice to individuals and families.

The monthly premium rates vary from less than $100 to around $1,000 before subsidies. Costs are determined by a number of factors, including age, tobacco use and the region in which a participant lives in the state. The young are offered lower rates than older participants, and tobacco users face additional costs, which differ in each plan from 10 to 20 percent.

Insurance companies must provide essential health benefits, which include, among others, maternity care, emergency room services, preventive measures and prescription coverage.

Children younger than 19 must have dental and vision care, but adults aren’t included in this condition.

Each company will provide different plan choices. A “catastrophic” plan, only minimal coverage, is available to participants younger than 30 and some with particularly low incomes. Other choices include a bronze (basic) coverage and continue with more services at the silver and gold levels.

With a bronze level, the monthly costs are low, but the deductibles and copayments are higher than other plans. Participants will pay 40 percent of medical fees in this plan.

If someone can afford insurance but chooses to stay uninsured, they will face a $95 per person penalty in 2014 and $695 by 2016. Those with higher salaries may have to pay a percentage of their incomes if this exceeds the flat fees.

When enrollment for the marketplace ends March 31, it won’t be possible to receive health coverage until the next enrollment period.

Anyone already covered by employer-sponsored insurance, Medicaid, Medicare or other qualifying health insurance plans also doesn’t face a penalty. Oklahomans who have incomes below 100 percent FPL and don’t qualify for traditional Medicaid aren’t required to have health insurance next year.

Statewide action
In the coming months, health care experts and state officials will help educate Oklahomans about these insurance options.

About 636,000 Oklahomans (17 percent) are uninsured according to the most recent results from the U.S. Census Current Population Survey.

Since Oklahoma has chosen not to expand its Medicaid program, an Urban Institute Health Policy Center estimated 172,000 low-income Oklahomans would be ineligible for either subsidies in the insurance marketplace or the current state Medicaid system.

Useful resources

Insure Oklahoma:

Enroll in the health insurance marketplace (Oct. 1 to March 31): or call 800-318-2596

Calculate your insurance marketplace subsidies:

Receive help with your health care questions:

Look for additional Oklahoma health care coverage in the coming weeks, including what state leaders say about the SoonerCare (Medicaid) program’s future, understanding who is ineligible for low-cost health insurance and how the Affordable Care Act affects employers.

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