Explainer: Open Enrollment for State Insurance, Medicare, Obamacare

Lilo H. Stainton | October 18, 2016 | Explainer
Policy holders have chance to examine new options, take advantage of subsidies under Affordable Care Act

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Selecting a health insurance plan is never easy, yet each fall millions of New Jersey residents are faced with that very decision. Factors include cost, coverage, and healthcare needs, and a wrong choice could leave customers without protection in a medical crisis.

“Open enrollment period” refers to the timeframe in which most insurance customers must sign up for a new plan, or are eligible to switch coverage, without being penalized. There are some exceptions for those who lose their jobs or have other status changes.

While customers may not be required to take action, experts encourage customers to review their options; given the evolving marketplace, they may find lower-cost policies or better coverage than in the past. A recent federal analysis found as many as 44,000 New Jersey residents are paying full price for health insurance when they are actually entitled to subsidized care under the 2014 Affordable Care Act.

For those who receive insurance through a non-government organization, the open enrollment period is established by the employer. But for public workers, some Medicaid recipients, and senior citizens covered by Medicare, decision time is looming.

A breakdown of these open enrollment periods is below; changes would take effect in 2017, as part of a new policy year.

State Health Benefits Plan: Open enrollment ongoing through October 31

For the more than 700,000 public workers in state, county and local government, there are just two weeks left to sign up or make a switch. The State Health Benefits Plan covers these individuals and their families, as well as retired workers. Open enrollment began on October 3 and closes at the end of the month.

Information on the plans and the process can be found through the Department of Treasury website, including charts that allow customers to compare the benefits of each plan. Medical plans are available from Horizon Blue Cross Blue Shield and Aetna; Express Scrips offers pharmacy benefits; and a half-dozen carriers provide dental coverage.

This year the offerings include two tiered health plans, Horizon Blue Cross Blue Shield’s OMNIA and the Liberty Plan, by Aetna. Tiered plans offer consumer savings in exchange for using a select group of providers, a top tier within the larger network.

Medicare: Open enrollment ongoing through December 7

For the nearly 1.4 million Medicare beneficiaries in New Jersey, this decision-making process began a few days ago and runs through December 7. The Medicare website has detailed information about coverage and the enrollment process, including a search page that enables users to narrow down the choices. The federal insurance plan, sometimes considered the gold standard in coverage, protects more than 16 percent of Americans.

Medicare includes Part A, which covers hospital and inpatient services and related costs, and Part B, which covers visits to the doctor and other outpatient care. Medicare Part D is an optional prescription benefit plan; it is sold through private insurance companies. Other policies, generally known as Medicare Health Plans, are also sold on the private market and cover a mix of benefits. Many seniors also purchase a “Medigap” private plan to protect them against charges that may not be paid by the government.

Affordable Care Act/Obamacare marketplace: November 1 through January 31, 2017

The ACA marketplace, a public-private hybrid, was created as part of the 2010 federal insurance reform law to help cover a greater percentage of the working poor. The law included an expansion of Medicaid, which enabled even more families to be protected by the jointly operated federal-state program, and also called on states to coordinate a “marketplace” or “exchange” to sell lower-cost private insurance policies.

Those who earn up to 133 percent of the federal poverty level, or just over $32,200 for a family of four, can now qualify for traditional Medicaid. Those who earn between 133 percent and 400 percent, or $97,000 for that four-person family, are eligible to shop on the marketplace. Most of these shoppers will be automatically eligible for tax credits that keep monthly premium costs under $100. Nationwide, some 6.9 million eligible Americans have yet to take advantage of these benefits, a recent report showed, and federal officials continue to spend millions of dollars to enhance outreach efforts.

Nearly 300,000 New Jersey residents have purchased insurance on the exchange since it opened two years ago, but the system has suffered some instability. Some 35,000 policy holders will be forced to search for a new plan next month, since the state declared Health Republic Insurance insolvent late last month. The story is the same for the 24,000 individuals now covered by Oscar Insurance Corp. and the 12,000 insured through Oxford Health Plans; both programs won’t be in business in the Garden State next year.

For 2017, consumers must choose among the handful of plans offered by Horizon Blue Cross Blue Shield, which now ensures a total of 149,000 people, and AmeriHealth, which currently covers 56,000 individuals. Both companies also insure customers who don’t purchase plans through the exchange.

While the state Department of Banking and Insurance maintains some information on the exchange, consumers are encouraged to go through the federal ACA website, healthcare.gov, to calculate their eligibility and potential benefits.

For those who don’t qualify for Medicaid or the exchange, the DOBI also posts “buyers guides” regarding policies directly available to individuals and small businesses. The open enrollment period for these also begins November 1. Updated information on these offerings will be posted when the process beings next month, at the following sites: one for individuals and another for small businesses.