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Making sense of the “Exchanges”

By Frank Lewis

October 1, 2013

Frank Lewis


PDT Staff Writer


If you have been reading the news, you have no doubt heard about it, and in some cases, you have been warned about it. It is the individual mandate portion of what has been tabbed “Obamacare,” and now, as of today, that mandate is a reality. “Exchanges,” or as they are now being called, “individual market exchanges,” are being established, which means many Scioto County residents as well as people all across the country are wondering what they have to do for their health care coverage.


Portsmouth Insurance Agency and Southern Ohio Medical Center are now Certified Application Counselors, which means they are the people with the answers to your questions concerning what you must do to comply with the mandate. The individual penalty, unlike the large employer penalty portion of the law, has not been delayed.


“Individual employees have a choice of buying health insurance,” Gary Duzan, of Portsmouth Insurance said. “They can buy it through their employer, they can buy it on the exchange or off the exchange. Or they can do nothing and pay a penalty for not buying insurance.”


Recent questions have arisen concerning the effect the new mandates will have on current insurance policies.


“The current rule says that if you work for an employer, and they offer essential benefits, meaning they cover at least 60 percent of your health care costs, and your cost for your individual health insurance premium, out of payroll deduction, is less that 9 1/2 percent of your personal income, then you do not qualify to go on an exchange to buy insurance,” Duzan said. “If your employer doesn’t offer the essential benefits, you’re paying more than 9 1/2 percent of your personal income for insurance, then you are eligible to go out to an exchange and apply or to see if you qualify for a subsidy.”


Duzan said people who fit the category can go to individual market exchanges or healthcare.gov to get information on how to buy insurance and what they need to apply. Portsmouth Insurance, an approved agency, has a website, insurancemarketplaceofohio.com.


“An individual can purchase insurance through a marketplace if they’re not incarcerated; if they’re a lawful citizen of the U.S. and they’re living in the marketplace where they are applying, they’re eligible to do that,” Duzan said. “They can go out to the marketplace; go through the application process to determine their eligibility. If they get to the point in the application process where they’re eligible for Medicaid, the application process stops, and they go to their local Job and Family Services to continue the process. Once they fill out the questionnaire, it will tell them if they qualify for a subsidy, and if so, how much they qualify for. Then the process continues where they will have an option of four different plans that they can choose from - anywhere from platinum to gold, silver and bronze - that’s anywhere from 90 percent down to 60 percent coverage.”


Duzan said those people will qualify with their subsidy for one of those plans. The higher the reimbursements, which is the platinum, which is 90 percent reimbursement, the higher the premium and the lower the out-of-pocket expense.


“Conversely, if you buy a 60 percent plan, the more you’re going to pay out of your pocket for the benefits, but your premium is going to be lower,” Duzan said. “And there’s a fifth plan that’s called “catastrophic” which is only available to folks under the age of 30, or folks over 30 with low incomes.”


Going online is the quickest way to find immediate answers.


“They can go on our website, complete the application, and it will guide them in terms of what they’re eligible for,” Duzan said. “They’re going to have a number of those people certified as well as social workers to assist people with answering questions for them and their families, helping them fill out forms to enroll. If they’ve got questions, they can call 740-356-3924 for assistance in handling the exchanges. They can go on line to our website healthcare.gov, or they can call our office at 740-353-4105, extension 22 or extension 30.”


Duzan said the Ohio Department of Insurance (ODI) has yet to approve the plans or the pricing for the exchanges in Ohio.


Frank Lewis may be reached at 740-353-3101, ext. 252, or at flewis@civitasmedia.com. For breaking news, follow Frank on Twitter @FrankLewisPDT.