Health Insurance Marketplace

THE HEALTH INSURANCE MARKETPLACE, A PRODUCT OF THE AFFORDABLE CARE ACT, ALLOWS INDIVIDUALS AND FAMILIES TO FIND COVERAGE THAT BEST FITS THEIR BUDGET AND NEEDS.

While St. John has been included in Marketplace networks in the past, insurance carriers have begun to limit their participation. As a result, St. John was not included as an in-network provider in any individual/family plans for 2017:

  • In 2016, UnitedHealthcare was the only health insurance carrier offering individual and family plans on the Marketplace that were in the St. John network. For 2017, UnitedHealthcare opted to exit the Marketplace.
  • Like last year, CommunityCare has opted to not offer individual or family plans in the Marketplace for 2017. St. John will continue to participate in all CommunityCare small business plans.
  • Blue Cross Blue Shield of Oklahoma (BCBS) has limited the plans offered to individuals and families on the Marketplace for 2017. St. John was not included as an in-network provider in the BCBS choices offered to individuals and families. Patients who are enrolled with BCBS through the Marketplace will have a higher coinsurance and deductible if care is received from a St. John provider. For questions about how the changes BCBS has made will affect you, please call BCBS at 1-855-798-2227.

St. John shares frustration with patients and loved ones that the health system will not be in network in 2017 for Marketplace plans. To voice concern on this matter, call the U.S. Centers for Medicare & Medicaid Services at 1-800-318-2596 or visit www.healthcare.gov/contact-us for more options.

Beyond the Marketplace, there are many health plan options for individuals and families that include St. John:

  • St. John (including our hospitals, physicians and urgent care centers) continues to participate with BCBS for health plans that include the BlueTraditional, BlueChoice and BlueOptions provider networks.
  • St. John also participates with CommunityCare, UnitedHealthcare, Aetna and many other insurance plans.

Before individuals seek or receive elective care from a St. John hospital or physician, they should check with their insurance provider to determine whether St. John is in network. For those whose policies do not cover St. John at the in-network level, care may still be obtained at St. John but may be subject to higher out-of-pocket costs (e.g., deductible and coinsurance).

Financial assistance may be available to some patients if they need care through St. John Health System but do not have insurance. Please contact a St. John financial counselor at 918-744-2451 for more information. Financial counseling will be provided at point-of-care (for example, emergency room visit).

How the Marketplace Works

The Marketplace offers side-by-side comparisons of local plans based on price, benefits and other features. The Marketplace application helps determine who is eligible for low-cost coverage based on income and family size, as well as who qualifies for free or low-cost coverage through Medicaid (Sooner Care). Most U.S. citizens and legal residents are now required by law (Affordable Care Act, 2010) to have qualifying health insurance coverage or pay a tax penalty.

Insurance plans in the Marketplace are offered by private companies. No plan can deny coverage or charge more because of a pre-existing illness or medical condition, and plans must cover treatments for those conditions. Health insurance plans help pay for routine health maintenance and serve to limit unexpected, high medical costs. Many preventive services are covered at no cost to the individual.

Individuals with the following are considered covered and do not need to make any changes:

  • Employer-sponsored coverage, including COBRA, retiree coverage and employer-sponsored coverage through a spouse/partner
  • Medicare
  • Medicaid (SoonerCare)
  • Individual coverage (outside the Health Insurance Marketplace)
  • TRICARE or certain types of VA coverage

Individuals eligible for employment-based health insurance have access to coverage that exceeds the standards required by the Affordable Care Act. In most circumstances, when an employer offers coverage, individuals are not eligible for tax credits or reduced costs through the Marketplace. However, if an individual’s employment-based plan is not affordable (e.g., the employee’s share of the annual premium for self-only coverage is greater than 8.05 percent of his/her annual household income), he or she may be eligible for tax credits or reduced costs through Marketplace.

Adult children can remain on their parents’ plans up to age 26, including those who are full-time students, disabled or not tax dependent.

Marketplace Coverage Options

Plans in the Marketplace have a similar set of core benefits, known as “essential health benefits,” but they differ on what providers are included and how the costs of the benefits are applied. To fit different needs and budgets, plans are presented in four categories: bronze, silver, gold and platinum. This allows for selection of a plan that best fits the needs of an individual or family. One plan may be a better fit than another, depending on health needs.

Bronze

  • 60 percent coverage
  • Lower monthly payments than other plans
  • Higher cost when you receive medical care

Silver

  • 70 percent coverage
  • Higher monthly payments than a Bronze plan
  • Lower cost than a Bronze plan when you receive medical care

Gold

  • 80 percent coverage
  • Higher monthly payments than a Silver plan
  • Lower cost than a Silver plan when you receive medical care

Platinum

  • 90 percent coverage
  • Higher monthly payments than other plans
  • Lower cost than other plans when you receive medical care

Open Enrollment

Open enrollment begins Nov. 1, 2016, and ends Jan. 31, 2017. Marketplace health insurance coverage for 2016 ends Dec. 31, and coverage for 2017 can begin as early as Jan. 1. Those who enrolled in Marketplace coverage for 2016 will need to update their information and re-enroll in a plan to continue coverage in 2017. Plans and benefits offered in the Marketplace change from one year to the next, making it essential to carefully review plans prior to re-enrolling in a plan or selecting a new plan.

Special Enrollment

Individuals and families with special cases, such as those with a qualifying life event, may be able to sign up outside the open enrollment period. Special circumstances are listed at www.healthcare.gov (www.cuidadodesalud.gov). Individuals and families who qualify for Medicaid (SoonerCare) may enroll at any time during the year. There is no enrollment period for Medicaid. Some individuals and families may also qualify for coverage through Insure Oklahoma.

Enrollment Preparation

To prepare for enrollment, you can sign up for emails and/or texts with news and reminders of important dates at www.healthcare.gov (www.cuidadodesalud.gov). Important steps include gathering income documents, finding out what you may qualify for and planning your budget.

How to Enroll

During open enrollment, there are several ways you can apply for coverage through the Marketplace:

  • Apply with a private insurance carrier.
  • Apply with one-on-one assistance from a certified application counselor (CAC) or navigator.
  • Apply on your own via www.healthcare.gov (www.cuidadodesalud.gov) or 1-800-318-2596.
  • Apply with an insurance broker.

Carefully review and select a Marketplace plan. Many different plans will be available in the Marketplace, so make sure your desired providers and benefits are included in the one you select.

Enrollment Assistance

Several local community agencies offer enrollment assistance through certified application counselors (CACs) and navigators. CACs and navigators help minimize confusion about Marketplace options and ensure desired providers and benefits are included in the selected plan. They can also assist with detailed questions about the Marketplace. Insurance brokers are also a great resource for help enrolling in health coverage through the Marketplace.

The 2-1-1 Oklahoma helpline can direct callers to additional information on the Marketplace, local enrollment assistance, and other resources, such as a list of community clinics that offer free or low-cost health care for individuals not eligible for health insurance coverage. Call 211 to reach the helpline.

Additional Information

Once you have health insurance, it is important to know what to expect. "From Coverage to Care: A Roadmap to Better Care and a Healthier You" ("De la Cobertura al Cuidado de Su Salud: Una Guía para Un Mejor Cuidado y Una Vida Más Saludable"), by the Centers for Medicare & Medicaid Services, provides key information on how health insurance coverage works and how to get the most of a health insurance plan’s benefits.

More information about St. John Health System physicians and services is available via the St. John PulseLine, 918-744-0123 or pulseline@sjmc.org.