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Health Insurance Exchange Information for Physicians, Patients


Your patients may be asking about health insurance exchanges. Here's how to help direct them to the right information.

A primary mission of the Affordable Care Act is to provide universal health coverage through the creation of health insurance exchanges or marketplaces. The triad of employer-sponsored coverage, marketplace insurance exchanges, and expanded Medicaid coverage should cover most Americans under 65 years old, with some exceptions.

Unfortunately, there will be coverage gaps for low-income people who fall between certain income levels and live in states where the Medicaid expansion was rejected, according to Jennifer Tolbert, director of state health reform for the Kaiser Family Foundation.

Tolbert is charged with monitoring state implementation of the Affordable Care Act and the establishment of state insurance exchanges for Kaiser. She recently discussed in a webinar some consumer-based elements of the law that are also helpful for medical practices to understand and communicate with current or potential new patients.

Consumers will be able to shop and enroll in new insurance plans through the federal government's website (, or their own state's website if available, beginning Oct. 1, 2013. Open enrollment will continue through Mar. 31, 2014, with the option of enrolling after that date if a qualifying event occurs.

Coverage through the marketplaces and the expanded Medicaid program (where approved by individual states) will begin Jan. 1, 2014, when insurance market rules also go into effect. That is also when the individual mandate to have insurance coverage begins.

The exchanges will offer a choice between four plans (figures are for single coverage; family coverage would be double):

• Bronze – typical deductible $5,000 / typical coinsurance 30 percent

• Silver – typical deductible $2,000 / typical coinsurance 20 percent

• Gold – typical deductible $0 / typical coinsurance 20 percent

• Platinum – typical deductible $0 / typical coinsurance 10 percent

They will also offer a catastrophic plan for people up to age 30, with a typical deductible of $6,350 and no coinsurance. While these levels of cost sharing may seem prohibitive, most consumers will be eligible for federal subsidies and tax credits.

The cost of premiums will vary by state and locality; and also by age. Consumers who wish to get a ballpark estimate of the costs of different plans can use the Health Insurance Subsidy Calculator provided by Kaiser.

For example: A 40-year-old pre-school teacher making $30,750 - or 250 percent to 300 percent of the federal poverty level -  would be required to pay 8 percent to 9.5 percent of her income for healthcare premiums on the exchange. Her subsidized cost for the Silver Plan would be $2,633 annually. (The unsubsidized annual cost would be $3,857.)

All of the plans offered on the health insurance exchanges are mandated to offer "essential health benefits," said Karen Pollitz, a senior fellow on health reform and private insurance for Kaiser:

1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drugs

7. Rehabilitative and wellness services, and chronic disease management

8. Pediatric services, including oral and vision care

There are multiple health-reform resources available online through Kaiser and that would be helpful additions to your own medical practice website; even if your own patients don't need this information, most everyone has a family member who may benefit from knowing the facts, e.g. a young adult child who does not receive health insurance from her workplace, or perhaps a single professional who does freelance work or is self-employed.

As leaders in the health community, it is important for physicians to be knowledgeable about the coming changes in health insurance coverage. It also allows physicians to make informed choices about the types of new insurance they will participate in, and the numbers of new patients they take into their practices.


Kaiser Family Foundation - health reform

For Consumers: Understanding Health Reform

KFF Health Insurance Subsidy Calculator

Health Insurance Marketplace: 10 Things Providers Need to Know

What Does Marketplace Health Insurance Cover?

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