More to consider than just premium when shopping ACA plans

Andrew Gold was surprised to learn that he'll pay more for his health plan next year, even though insurance premiums are going down and he expects to earn less in 2019.

Gold, 55, of Center City, buys insurance through the Affordable Care Act marketplace healthcare.gov, and he receives an income-based tax subsidy that this year reduced his monthly premium to zero.

Next year, Gold's tax subsidy will be smaller and won't cover as much of the premium. He'll owe more than $100 a month to keep his plan.

It's a sizable difference, but going without insurance or choosing a cheaper plan with less coverage weren't options that Gold was willing to consider — even if buying the better plan means cutting back elsewhere in his budget.

"I wanted to pick a plan that would cover me, worst-case scenario," said Gold, who works as an independent personal-finance consultant. "It's not going to bankrupt me, but it's confusing, for sure."

Open enrollment for the ACA marketplaces is in full swing and will run through Dec. 15. For the first time in years, premium prices are declining and new insurers are entering the market or expanding their offerings — signs that once-volatile marketplaces are stabilizing.

But those who plan to buy or renew ACA marketplace plans still need to shop carefully. In Philadelphia's Pennsylvania suburbs, premium cuts and new competition mean lower tax subsidies, leaving people to pay more next year if they want to keep their plans.

Enrollment specialists are concerned that lower subsidies could push people out of the ACA marketplace, where they will be vulnerable to subpar insurance plans that have become more accessible under the Trump administration.

"Folks are really going to have to be savvy shoppers this year and look at the details," said Antoinette Kraus, director of Pennsylvania Health Access Network, a Philadelphia organization that helps people enroll in coverage.

In other words, consider more than the premium, she said. Focus on the total cost of the health plan by looking at its deductible, its out-of-pocket maximum, how your medications are covered, and whether the doctors you see are in-network.

That's what Lois Weaver plans to do when she signs up for coverage.

The 53-year-old Philadelphia resident has breast cancer, so she needs any new plan to cover her current doctors.

And with two college-age children covered under the plan in 2019, Weaver wants to make sure the deductible on whatever plan she chooses is reasonable.

ACA marketplace shoppers in Philadelphia, Bucks and Montgomery Counties also will need to look closely at their tax subsidies.

After years of having only one insurer to choose — Independence Blue Cross — consumers in these counties will have new options from St. Louis-based Centene.

But Centene's new, lower-cost plans will also mean smaller tax subsidies.

Tax subsidies vary depending on your income level and are based off a benchmark premium — the second-lowest-cost silver plan. If the cost of the benchmark plan goes down, tax subsidies go down, too.

Where other plans fall in relation to the benchmark premium can affect how far your subsidy goes in reducing your premium costs.

In 2018, the second-lowest-cost silver plan was Independence's Personal Choice Silver Reserve. Next year, that plan will, instead, be the second-most-expensive silver plan — even though the premium is going down slightly.

Centene's much cheaper Ambetter Balanced Care 11 will be the new second-lowest-cost silver plan and serve as the benchmark for tax subsidies.

The result is that people who want to keep the plans they had last year will pay more, since their subsidies won't cover as much of the premium.

"Pricing and plan options change every year. Even if you enrolled last year in the lowest-cost silver plan, it may not still be the lowest," said Megan Foster Friedman, a senior health-care analyst at the University of Michigan's Center for Health and Research Transformation.

People who receive small subsidies may find that they can get better deals by buying similar plans outside the ACA marketplace.

Pennsylvania Insurance Commissioner Jessica Altman urged consumers to consider all their options, but to be cautious when shopping outside healthcare.gov because plans sold outside the ACA marketplace aren't required to meet the law's coverage standards.

Altman said she is concerned that a consumer looking for a better deal on full coverage could unwittingly buy a short-term plan that doesn't meet his or her expectations. That's  because these plans are more readily available and, often, are marketed as an option for comprehensive coverage.

Short-term health plans have cheaper premiums because they do not have to cover certain benefits, such as prescription drugs, maternity, and mental health. They can deny coverage to people with pre-existing conditions or decline to cover certain conditions, and in most cases, there's no limit to the amount members pay out of pocket.

Under the ACA, short-term plans were limited to three months. Now, you can be covered by one for 364 days.

"The narrative [is] that these are an alternative to comprehensive major medical insurance, talking about them not in the way they should be, what they've always been intended to be — filling short-term gaps — but something you may want to choose instead of what I would call real insurance," Altman said.

Consumers also need to be on the lookout for health-insurance scams, reaching a fever pitch with an estimated 409 million calls in August, a four-fold increase since the beginning of the year, according to YouMail, a company that tracks robocalls and sells software to block them.

Health-insurance shoppers are prime targets for identity thieves because people expect to give up personal information when enrolling and scammers are catching people at a time of year when they know they need to take action to sign up or renew their plans, said Alex Quilici, YouMail's CEO.

"It's lucrative and it works," Quilici said.

Philadelphia-area residents who want to be sure they're buying health plans that meet ACA's coverage requirements should look for plans sold by Independence Blue Cross or Centene, Altman said. The two insurers, which sell plans on the ACA marketplace, are required to offer near-identical plans outside the marketplace, too.

Through a partnership with Consumers' Checkbook, Pennsylvania's Insurance Department offers a tool where you can compare plans both on- and off-market and that shows only plans that meet ACA requirements, she said. Access the tool through the Insurance Department's website, www.insurance.pa.gov.

In New Jersey, state leaders are optimistic that a 9.3 percent average decline in individual premiums will drive up enrollment this year.

Although Pennsylvania residents will no longer face a tax penalty if they don't buy insurance, New Jersey residents aren't off the hook. The state was one of the few to establish its own tax penalty for being uninsured.

Marlene Caride, commissioner of New Jersey's Department of Banking and Insurance, encouraged people to not procrastinate signing up and to seek help from an enrollment specialist if they feel overwhelmed. The state's new enrollment campaign, Get Covered New Jersey, has more resources online at www.getcovered.nj.gov.

When Rosemary Clark, a 63-year-old Lindenwold resident, needed help choosing a plan during a special enrollment period last month, she turned to Center for Family Services in Camden.

Clark receives partial Social Security benefits and works part time, so her budget is tight. But she said she's committed to making sure she sets aside enough to pay her $191 health-insurance premium every month.

"It's tight, but I have to do it. I have to have medical care," she said. "It's not an option to be without health insurance."