The Individual & Business Health Coverage Review

The Individual & Business Health Coverage Review

Fundamental changes to the nation’s healthcare system march along to completion, and proponents wave banners extolling the benefits to citizens. Assertions of widespread, fair coverage and goals being achieved are prolific. However, beyond denying, in some circles differing opinions have escalated to a full-on theoretical war. Sorry to say, conscientious consumers are often the casualties, left confused and wary.

If you find yourself doubting what you know about the Affordable Care Act (ACA), or your situation and needs have changed, you could feel at the end of your wits. Whether struggling to find dependable coverage for yourself and your family; or if as a business-owner, you are bogged down, deciding between private and public exchanges; you may be fresh out of answers. In light of the quagmire of opinions you may encounter, we present a compendium of facts; offering practical tips, touching on long-range considerations. So brew up a beverage, pull up a chair, and gear up for a clear, objective review.

Individual Health

Hard to reconcile, but over four years have passed since the Affordable Care Act was signed into law. And though we have been hearing about it ever since, a recent study conducted by health information corporation Healthline reveals that 25% of Americans—essentially 59 million people—rate their level of ACA knowledge as poor to none. It’s time to up the ante. With the ACA hitting its halfway point to full implementation in 2015, and this year’s open enrollment period already up and running, we need to get serious about involvement and understanding.

Deadlines in the Sand

First up: Deadlines. 2015 ACA Open Enrollment—the official, annual time frame set aside for selecting and/or switching healthcare plans—is in full swing, and the window of time is far narrower than a year ago. According to, here are four dates to know:

  • December 15, 2014: Last date to enroll for coverage to start January 1, 2015
  • December 31, 2014: Coverage ends for all 2014 Marketplace plans
  • January 1, 2015: 2015 coverage can begin
  • February 15, 2015: 2015 Open Enrollment ends

If you as of yet have not signed up for coverage under the ACA, your situation is taking on urgency. Deadlines could be missed, fines levied. Let’s say though, for discussion’s sake, that you did your due diligence last year, signing up for a Bronze, Silver, Gold or Platinum plan. Now, this policy has served you well, and allowing it to auto-renew—thus forgoing the rigmarole of a lost or forgotten login—is likely tempting. Beware, though: Big things have changed.

Don’t Forget What You Pay For

Several considerations come into play when determining your best plan. Cost is on everyone’s mind, and with subsidies making a noticeable shift this year, the possibility stands that your premiums could be higher. Buyers beware: “Cheaper” does not mean better. When choosing a plan, be sure to know what you’re getting into, as well as out of it. And remember: Any changes in household income can distinctly affect your most cost-effective option.

According to recent news stories, prices will fluctuate, insurance companies come and go. A resulting “25% more plans than last year” (via USA Today) will be up for grabs, spelling a wider array of choices. The logical step? A deeper attention to detail. So when examining your current policy and assessing existing and projected needs, aim for well-being and protection.

Some Key Factors

  • Subsidies—If yours have dropped (due to increased income, recalculation, etc.), premiums will hit your wallet harder (subsidies only available through public exchanges)
  • Deductible—Higher equals lower, premium that is; if you go this route, be sure to have reserves to cover the full deductible in case of a serious illness or injury
  • Out-of-pocket expenses—Whether coinsurance or copayments for covered services, it’s a good idea to be sure of what you will owe; also take time to understand which services are not covered
  • Single- vs. multi-state coverage—If you live near the state border, travel often, or visit family in other parts of the country, be sure your coverage journeys with you
  • Physician choice—Is your PCP or specialist within your plan’s network? Especially is this an issue when shifting from private to public marketplaces, or vice versa
  • Care provider—Is the local hospital within your plan of choice? Limitations can make seeking care—especially in an emergency—a bit on the tricky side

Life changes—think marriage, divorce, new baby or adoption, job change, relocation, etc.—are liable to prompt a change in coverage needs. And more often than not, major shifts in circumstances will not coincide with open enrollment schedules. Applying for a special open enrollment period is your answer.

Business Health

As a small business owner—50 employees or less—open enrollment deadlines can’t hold you down. Sign up for employee coverage anytime, and take advantage of possible tax credits via the SHOP Marketplace. Different story, however, if you own a larger business and are searching for a group plan. Public exchanges are just one option—There are seemingly infinite facets to consider.

Shifting Sands of Time

The insurance industry trends of tomorrow are fueled by broad societal changes in thinking. Experts have linked the current consumerist shift in private healthcare coverage—from defined benefits to defined contribution—to the steady swap out from yesterday’s pension plan to today’s 401k. The insurance scene is mirroring this shift in responsibility: From the parental to the collaborative, with the consumer at times even taking on a role of self-advocacy. Large employers are moving away from a ‘spoonfed’ version of healthcare, and are instead beginning to supply the basic ingredients; it may now rest on individuals to concoct the dish and ‘feed’ themselves.

In turn, the shift away from the federal- or state-run public exchanges to ‘private markets’ is gaining traction. Ever increasing in popularity with large employers, privately run health exchange markets allow employers to cap spending, setting aside a predetermined sum for employee health insurance. Workers then use the individually allocated funds to shop the private exchange, determining their best coverage for the cost. A word of caution: ‘Large group’ employers do well to review ACA guidelines when choosing a plan for employees—If minimum criteria, including wellness provisions, are not met by a plan in consideration, you could inadvertently be costing your company.

Options and Oysters

In efforts to control premium costs while improving quality and employee control, large employers may turn to consumer-directed health plans (CDHPs). Resulting in “high deductibles coupled with personal health spending accounts to increase consumer accountability for health care spending,” (via NCBI) CDHPs offer employees expanded choice. To a point, the world of healthcare options can be your oyster—Evaluate available funds, determine the best course. Gone could be the days of excluded providers, physicians and treatment; instead factors such as cost, quality, and convenience reign supreme.

Yet while a commercial approach to health insurance places more power in employees’ hands, a wider range of choices is always paired with increased personal responsibility. In essence telling employees, “Here’s a bunch of money, you go spend it,” the potentially huge impact to the individual is worrisome. The mere fact that not all providers and physicians crossover from public to private exchanges could be an oft-overlooked detail that can make plan selection tedious and confusing. Danger lies not only in a lack of sufficient education on the part of employers preparing staff for the switch, but also in employees’ impulsively making choices based solely on cost, while discounting their true needs.

Past the Cornucopia

Understandably so, consumers and business owners alike may find themselves stymied by the veritable cornucopia of change in the healthcare scene since establishment of the ACA. Indecision and lack of relevant data do not help the cause. And the weight of personal healthcare decisions is compounded when deciding which plan to offer employees.

Healthcare decisions are fundamental, and we trust you’re on the right track. Fortify your diligence with depth of knowledge, and you are well on your way. Time to give your undue health insurance fears the ole’ one-two. With experience and knowledge in your corner, there’s no need to worry.

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