Carolynn Cohrs of Gaston thinks of herself as an intelligent, well-informed person, but changes to next year's health insurance market have her feeling baffled and blindsided.
She recently received notice that the monthly premium for her, her husband and two kids could jump from $720 to $1,177 if they choose to stick with Regence BlueCross BlueShield. "This is middle America getting screwed again," she said.
But under the federal health law changes, her family may well qualify for income-based tax credits to reduce their premiums up front -- a fact not found in her insurer notice.
Because even families pulling down decent money -- as much as $94,000 for a household of four -- likely qualify for tax credits, credits that could result in paying less next year than they do now. The whole system under the Patient Protection and Affordable Care Act -- better known these days as Obamacare -- is based on income and the ability of individuals to pay.
When told this Cohrs' alarm subsided. But not her ire. "This is a government requirement," she said. "So why hasn't the government told us anything about it?"
The state has earmarked more than $20 million for outreach and advertising about the new federal health law. The most dramatic changes are slated for individuals and families who buy their own insurance -- Medicare is not affected -- and on small businesses and their employees, or more than 300,000 Oregonians in all. With some exceptions, Oregon's uninsured population of roughly 500,000 must get covered or pay a fine.
But as open enrollment begins Tuesday for the individual market, many Oregonians remain in the dark while new wrinkles and glitches keep surfacing.
Here are some of the less-well-known or late-breaking aspects of the law:
It's all about money
It's one of the least-understood aspects of the law: the listed premiums people see this year may be little more than a sticker price.
As Cohrs learned, consumers' household income determines what they actually pay for coverage. Using the new health insurance marketplace, Cover Oregon, income-qualified shoppers can apply a sliding scale of tax credits to premiums right off the bat.
Monthly bills will be lower immediately: no waiting until tax time. On the flip side, if consumers' estimate income for the coming year exceeds 400 percent of poverty level -- about $46,000 for an individual or $94,000 for a family of four -- they may pay a lot more for coverage.
That's why a lot of consumers are experiencing "rate shock." Qualification is determined by adding the household's estimated 2014 adjusted gross income to tax-exempt interest income. These are the numbers people enter on lines 37 and 8b of an IRS Form 1040.
Winners and losers
The new law creates winners and losers. The biggest winners may be people with chronic illness and medical bills to match.
That's because pre-existing conditions can no longer be used to deny coverage or set price. At a time when some new drugs for chronic illness cost $100,000 per year or more, the law institutes new caps on out-of pocket expenses of $6,350 for a single consumer, and a family could pay up to $12,700.
When costs exceed those caps, insurance companies pay the remainder. That means the cost of covering the sickest people will be divvied up among policy holders, resulting in higher prices.
Healthy people meanwhile, may pay more. Policies are now required to have a broad array of benefits, meaning lower cost policies are being phased out. But thanks to how the new plans are designed, the average copayment, deductible and co-insurance of new bronze-- and silver--rated plans are going up, according to a recent analysis from Avalere Health.
So many people will pay more out-of-pocket earlier than before -- even if they aren't big users of health care.
Bob Laszewski , a Virginia health consultant, has said people are facing not just rate shock, but "benefit shock" as they review the new plans.
Parents: be vigilant
Glitches are popping up. For instance, parents buying coverage are required to have pediatric dental for their dependents. And most health policies offer pediatric dental coverage as an embedded benefit.
While that sounds good, it may not be, says Lisa Lettenmaier, who owns health insurance brokerage Health Source NW in Tigard. Because of the way policies are designed, people with kids may be better off purchasing a health policy with pediatric dental stripped out, and buy a stand-alone pediatric dental policy or "rider."
Until the deductibles are reached, the new embedded policies will require parents to pay 100 percent of common dental visits, rather than including them for free as many policies do now, Lettenmaier says. So for healthy families that might not hit their deductible otherwise, it makes sense to buy their child a policy for $300 a year -- which could pay for itself in twice-yearly teeth-cleanings while better protecting against costs beyond that.
New health networks
Astute consumers are already noticing what agents have been saying for weeks: Many insurers are offering smaller provider networks or placing new restrictions to hold down costs.
Some have a two-tier provider network, some are offering narrower regional plans, and some require a primary care provider sign-off on specialty care. "There have definitely been some different strategies out there," says Damian Brayko, operations manager of Cover Oregon. "They all want market share and they all want the best risk of the market."
Healthy Kids expansion
Oregon has expanded eligibility for its Healthy Kids low-income government coverage, so kids under 19 who have parents who make 300 percent of poverty level or less qualify.
But that's created a dilemma for parents who aren't on government insurance.
Since the only way to tap tax credits is by going through the state's marketplace, Cover Oregon, parents who earn between 138 percent and 300 percent of the federal poverty level -- meaning about $32,500 to $70,650 for a family of four -- will face a difficult choice. Though they won't qualify for the Oregon Health Plan, the state has adopted rules that require their children to enroll in Healthy Kids.
Dan Neils, agent with Agape Insurance in Oregon City, has been spreading the word about this aspect of the law since July. He notes that it will mean lower costs for families in this income range, but their children may have less choice of doctor and face longer waits for appointments.
--Nick Budnick
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