The health insurance system can be daunting, even for those who have used it their entire adult lives.
Plans change constantly. Costs change constantly. And then there's the mind-glazing jargon regularly tossed at consumers -- words like "deductible" and "cost-sharing."
"It's a whole different language," said Robin Lamott Sparks, senior director of policy and research for the Bridgeport Child Advocacy Coalition.
For those who have never used insurance before, or who haven't been covered in years, it could be even more daunting.
And, in a couple of weeks, both insurance newbies and veterans could get their minds blown when the state opens its health insurance exchange, Access Health CT. Come January, millions of the nation's uninsured are expected to be covered via plans sold on these exchanges, established through the Affordable Care Act. The exchange opens for enrollment on Oct. 1, but many of those who will be covered through the new health plans likely still don't know how they will work.
"There are still a number of people in our state who have no clue what's coming," said Patricia Baker, president and chief executive officer of the nonprofit Connecticut Health Foundation.
Experts said questions range from the complex, such as whether certain doctors or prescription drugs are covered under the exchange plans, to the basic.
"Someone who's never had insurance before might not even know what a co-pay is," Sparks said.
While some answers might be hard to come by (turns out, even those affiliated with the state exchange aren't sure which doctors will be covered), others are more readily available.
What the plans cover
Under the Affordable Care Act, essential health benefits like maternity and newborn care, emergency care and basic doctors' office visits must be covered.
"The point of having these essential health benefits is to offer as comprehensive coverage as possible," said Kevin Counihan, president and chief executive officer of Access Health CT, the state's health exchange.
How much consumers actually pay for these services varies on the kinds of plan they buy. Each of the three insurance carriersoffered through the state's exchange -- ConnectiCare Benefits, Anthem and HealthyCT -- has a Gold plan, a Silver plan and a Bronze plan. The Gold plans have higher premiums, but cover more of the costs for care -- 80 percent, compared with 70 percent for Silver and 60 percent for Bronze.
Regardless of what plan you buy, there are some services that won't be covered, at least not automatically. Though children's vision and dental care will be offered through all the plans, adults seeking coverage for eye or teeth issues will have a tougher time finding it.
Adult vision care is not available through the exchange at all, while dental plans are available for separate purchase. These won't be sold directly through the Access Health site, but the site will link consumers to the two carriers providing these plans -- Anthem, which will sell plans for individuals and small businesses, and MetLife, which will sell plans for small businesses.
However, consumers can't get tax credits or other subsidies for the dental plans, the way they can for the overall health plans sold through the exchange, said Chad Brooker, legislative and policy analyst for Access Health CT.
Baker said it's disappointing that dental and vision care aren't automatically covered.
"Frankly, both oral health and vision are key parts of a healthy individual," she said. A lack of access to dental health care in particular has long been a problem for the low-income population. "It is regrettable that they didn't include adult dental coverage as part of the essential health benefits," Baker said.
What about my doctor?
Those who are used to seeing a particular doctor or getting certain prescription drugs will likely wonder if they'll still have access to the same care under the exchange plans. That's a complicated question. Brooker said negotiations with many health care providers are ongoing and the carriers haven't provided lists yet of which doctors they plan to cover. Those matters likely won't be settled until the exchanges open for enrollment, but he remains optimistic that people will have access to their current physicians.
"The likelihood that people's current doctors would be covered, if things work out the way they're supposed to, is high," Brooker said.
As for prescription medications, that's another complicated area. Prescriptions are one of the essential health benefits all the plans have to cover, and carriers must cover at least one drug in every major category. The insurers can decide how much of the prescription cost to cover, but have to adhere to certain guidelines, said Connecticut Insurance Department spokeswoman Donna Tommelleo. For instance, she said, the maximum co-pay the department will allow for prescription drugs is $40 for a 30-day supply. Also, the department won't allow a carrier to have a "generic only" prescription provision.
"Carriers must cover non-generic drugs if they are medically necessary," Tommelleo said.
Entering the system
Though many buying insurance through the exchange will have had coverage before, some will be new to the system. Sparks said that unfamiliarity could make this already complicated system even more confusing.
"I think there's definitely a learning curve," she said.
For instance, some people who don't currently have coverage might be used to seeking treatment through hospital emergency rooms -- even if what they're suffering from isn't an emergency.
"There will have to be a statewide push out there to let people know that the emergency room is not the place to go (for non-emergencies)," Sparks said.
Baker agreed the public will need to be continually educated about the coverage and suggested the navigators and assisters, who are being trained to teach consumers how to enroll, as possible providers of this education. The state has six navigator organizations, dispersed throughout the state, who will oversee the 300 assisters -- mainly staff of area hospitals, health departments, and other organizations. The Bridgeport Child Advocacy Coalition, where Sparks works, is an assister organization, as is AmeriCares Free Clinics, with sites in Bridgeport, Norwalk and Danbury and a new mobile site in Stamford.
Though these organizations are primarily focused on teaching people how to get into the new insurance system, but they might also be useful in teaching people how to use their coverage once they have it, Baker said.
Despite her concerns that some might need some hand-holding to adapt to the new system, Sparks anticipates that plenty of people will be ready and able to use their insurance coverage once they have it.
"Even those who go to the emergency room know that they'd rather have a doctor," she said.
acuda@ctpost.com; 203-330-6290; twitter.com/AmandaCuda; http://blog.ctnews.com/whatthehealth/
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