Kentucky Medicaid Expansion

How many companies have agreed to provide insurance to the recently expanded Medicaid program enrollees?

Five. They are: Anthem, Coventry, Humana / CareSource, Passport, and Wellcare. A sixth company, Kentucky Spirit, terminated its contract for services as of July 6, 2013.

Beginning on Oct. 1, 2013, individuals in 104 Kentucky counties who are determined to be newly eligible for Medicaid will be able to choose Anthem, Humana or Passport as their healthcare provider for coverage effective Jan. 1, 2014. The three new MCOs are in addition to Coventry and WellCare, which are currently serving this area.

Do I qualify for their program?

There are several criteria in order to qualify for Medicaid Services. They include:

  • Must live in Kentucky
  • Must be a U.S. Citizen or national (or meet qualified alien status)
  • Cannot currently be in prison
  • Must provide proof of income (see below)

Does the company provide coverage where I live?

Kentucky is divided into 8 zones (see map) in which an insurance company may or may not provide coverage. There are five companies that may provide Medicaid insurance services in the following areas:

  • Anthem - Statewide, except Zone 3
  • Coventry - Statewide
  • Humana / CareSource - Statewide
  • Passport - Originally just Zone 3, now Statewide
  • Wellcare - Statewide

In Network / Out-of-Network, what does it mean to me?

Insurance companies typically have a list of care providers, such as doctors, hospitals, pharmacies) that agree to the terms of participation with insurance company. These providers are typically referred to as being part of the insurance company's in-network providers. At the same time, there are health care providers that may not agree with the terms of participation offered by the insurance company. These providers are typically referred to as Out-of-Network providers.

There are typically incentives that the insurance company will offer to you the subscriber in order to keep you using the in-network providers versus the out-of-network care givers.

These incentives may include:

  • Lower or no co-payments or deductibles when you receive care from the in-network caregivers;
  • Typically, you may have to obtain an in-network caregiver's approval prior to seeking treatment from an out-of network caregiver. You may be responsible for services provided by out-of-network caregivers by the insurance company without receiving prior approval.
  • Not all caregivers (including physicians, hospitals and pharmacies), are part of the insurance company's network of providers. For example, KDMC is not part of the Coventry company's network of hospitals, but it is part of Wellcare's network of hospitals. Be sure to check and see if your physician or hospital is part of an insurance company's in-network of providers prior to signing up for insurance coverage. The links below will take you to the company's website where you can search for this information.

In terms of benefits, what coverage does each company provide to me and my family?

Benefits / Services Covered? Anthem Coventry Humana/CareSource Passport Wellcare
Allergy Services (limited to children under 21) Yes Yes Yes Yes Yes
Ambulatory Surgical Centers Yes Yes Yes Yes Yes
Behavioral Health Services Yes Yes Yes Yes Yes
Chiropractic Care (restrictions may apply) Yes Yes Yes Yes Yes
Dental Services (services vary for children and adults) Yes Yes Yes Yes Yes
Doctor Office Services Yes Yes Yes Yes Yes
Durable medical Equipment Yes Yes Yes Yes Yes
Emergency Room Yes Yes Yes Yes Yes
Family Planning Yes Yes Yes Yes Yes
Hearing Aids (limited to children under 21 and cost restrictions may apply) Yes Yes Yes Yes Yes
Hearing Services (limited to children under 21, restrictions may apply) Yes Yes Yes Yes Yes
Home Health Services Yes Yes Yes Yes Yes
Hospice - Non-institutional Yes Yes Yes Yes Yes
Inpatient Hospital Services Yes Yes Yes Yes Yes
Outpatient Hospital Services Yes Yes Yes Yes Yes
Kidney Dialysis and Transplants Yes Yes Yes Yes Yes
Laboratory Diagnostic and Radiology services (By physician or lab) Yes Yes Yes Yes Yes
Maternity Care Yes Yes Yes Yes Yes
Out-patient Hospital Yes Yes Yes Yes Yes
Physical, Speech, Occupational Therapy(restrictions may apply) Yes Yes Yes Yes Yes
Podiatry Services Yes Yes Yes Yes Yes
Prescription Drugs (for Members who do NOT have Medicare)(restrictions may apply) Yes Yes Yes Yes Yes
Preventive Services (includes immunizations and certain disease screenings and wellness care) Yes Yes Yes Yes Yes
Prosthetic Devices Yes Yes Yes Yes Yes
Substance Abuse Yes Yes Yes Yes Yes
Tobacco Cessation Yes Yes Yes Yes Yes
Urgent Care Center Yes Yes Yes Yes Yes
Vision (restrictions may apply) Yes Yes Yes Yes Yes
No Cost Extra Benefits and Services Yes Yes Yes Yes Yes

I've been hearing about the health insurance described as different levels of coverage. What does that mean to me?

According to the Affordable Care Act (ACA), all insurance plans must fall within four levels of care with the lowest cost plan referred to as the bronze level and the highest cost plan referred to as the Platinum level (also called by some as “Cadillac plans”).

The table below summarizes the four insurance plan levels as offered by the Kentucky Health Cooperative in October 2013. Typically, the lower level programs such as the Bronze insurance plans, will have higher deductibles, higher out-of-pocket thresholds to meet before the insurance pays for your health care bills. These plans also have lower monthly premiums that you pay.

Will I qualify for lower monthly premiums? Do I qualify for an insurance subsidy?

If you apply for health insurance coverage through the Marketplace, you'll find out if you qualify for lower monthly premiums. Eligibility is based on your household income and size. (See chart.) You also may qualify to pay lower out-of-pocket costs for things like copayments, coinsurance and deductibles. Match your family size and income to the chart to see if you may qualify for savings.

Subsidy Calculator

This tool was developed by the Kaiser Family Foundation to illustrate health insurance on premiums and subsidies for people purchasing insurance on their own in new health insurance exchanges (or "Marketplaces") created by the Affordable Care Act (ACA). You can enter different incomes, ages, and family sizes to get an estimate of your eligibility for subsidies and how much you could spend on health insurance.

Click here to go to the subsidy calculator: http://kff.org/interactive/subsidy-calculator/

How about the tax penalties. What will that cost me if I decide not to purchase health insurance?

Starting with the 2014 tax year, any American citizen who does not have adequate health insurance will create a tax penalty for themselves or the taxpayer who claims them as a dependent. The penalties escalate through the year 2016. The penalties in 2016 are applied to all subsequent years.

The following table describes the tax penalties through the year 2016

Year Annual Penalty
2014 $95 per adult + $47.50 per child, up to $285 or 1% of income, whichever is greater.
2015 $325 per adult + $162.50 per child, up to $975 or 2% of income, whichever is greater.
2016 $695 per adult + $347.50 per child, up to $2,085 or 2.5% of income, whichever is greater

If you would like to see your possible tax penalty in 2014, visit the following website for a tax penalty calculator:

http://www.affordable-insurance.com/individual/penalty/obamacare-tax-calculator

Where are the websites so I can further investigate the different companies and/or sign up for insurance?

Ohio Medicaid Expansion

How many Insurance companies have agreed to provide Medicaid insurance patients?

Ohio has not yet decided whether or not it will expand its Medicaid program. Ohio Governor John Kasich wants to expand the program but the state legislature does not. A ballot initiative/petition is underway that would attempt to place this on the November 2013 ballot for a statewide vote.

At present there are five companies that provide insurance for Medicaid patients. They are:

  • Buckeye Community Health Plan
  • Humana / CareSource
  • Molina Health Plan of Ohio
  • Paramount Advantage
  • United Healthcare Community Plan of Ohio (formerly Unison Health Plan of Ohio)

Do I qualify for their program?

The following individuals may qualify for Medicaid coverage in Ohio:

Children and Families:

  • Children up to 19 years old
  • Families with children under 19 years old
  • Some 19 and 20 year olds

Women

  • Pregnant women
  • Some women with breast and/or cervical cancer

Older Adults and Individuals with Disabilities:

  • Adults aged 65 and older
  • People with disabilities, including blindness as determined under the Social Security rules

Refugees and Immigrants:

  • Some immigrants may be eligible for Medicaid
  • There are some programs to help immigrants who are not eligible for Medicaid.

To be eligible for coverage, you must:

  1. Be a United States Citizen or meet Medicaid citizenship requirements. The immigration rules are complex. Your local county Job and Family Services office specializes in getting you enrolled.
  2. Have or get a Social Security number.
  3. Be an Ohio resident.
  4. Meet certain financial requirements, which vary depending on the program. Some people who are blind or disabled may have too high an income to quality for Medicaid. In this case, you may have a spend down plan that allows you to qualify on a month-by-month basis.

The following link will take you to the State of Ohio Medicaid website: http://www.medicaid.ohio.gov/FOROHIOANS/GetCoverage.aspx

In Network / Out-of-Network, what does it mean to me?

Insurance companies typically have a list of care providers, such as doctors, hospitals, pharmacies) that agree to the terms of participation with insurance company. These providers are typically referred to as being part of the insurance company's in-network providers. At the same time, there are health care providers that may not agree with the terms of participation offered by the insurance company. These providers are typically referred to as Out-of-Network providers.

There are typically incentives that the insurance company will offer to you the subscriber in order to keep you using the in-network providers versus the out-of-network care givers.

These incentives may include:

  • Lower or no co-payments or deductibles when you receive care from the in-network caregivers;
  • Typically, you may have to obtain an in-network caregiver's approval prior to seeking treatment from an out-of network caregiver. You may be responsible for services provided by out-of-network caregivers by the insurance company without receiving prior approval.
  • Not all caregivers (including physicians, hospitals and pharmacies), are part of the insurance company's network of providers. For example, KDMC is not part of the Coventry company's network of hospitals, but it is part of Wellcare's network of hospitals. Be sure to check and see if your physician or hospital is part of an insurance company's in-network of providers prior to signing up for insurance coverage. The links below will take you to the company's website where you can search for this information.

I've been hearing about the health insurance described as different levels of coverage. What does that mean to me?

According to the Affordable Care Act (ACA), all insurance plans must fall within four levels of care with the lowest cost plan referred to as the bronze level and the highest cost plan referred to as the Platinum level (also called by some as “Cadillac plans”).

The charges that you will be responsible for is dependent upon the coverage level that you choose.

  • A bronze plan will provide a 60% level of coverage;
  • A silver plan will provide a 70% level of coverage;
  • A gold plan will provide an 80% level of coverage, and;
  • A platinum plan will provide a 90% level of coverage.

All of the plans must contain 10 essential health benefits in order to be a qualified health plan. The ten essential benefits are:

  1. Hospitalization - A stay in the hospital, including inpatient surgery and recovery.
  2. Emergency services - Visits to the emergency room, including ambulance services or treatment at an urgent care center.
  3. Ambulatory services - Doctor visits when you're sick or injured, or outpatient clinic visits.
  4. Prescription drugs - Medicine your doctor orders.
  5. Laboratory services - X-rays, MRIs, blood tests, etc.
  6. Maternity and newborn care - For women who need prenatal care or help with pregnancy, complications and delivery.
  7. Pediatric services, including oral and vision care - Dentist check-ups, routine eye doctor visits, eyeglasses, immunizations and more.
  8. Preventive and wellness services, including chronic disease management - Screening tests for things like osteoporosis and mammograms, and help living with long-term illnesses like diabetes.
  9. Mental health and substance use disorder services, including behavioral health.
  10. Rehabilitative and habilitative services and devices - Physical therapy, speech therapy, artificial limbs and other medical equipment.

Will I qualify for lower monthly premiums? Do I qualify for an insurance subsidy?

If you apply for health insurance coverage through the Marketplace, you'll find out if you qualify for lower monthly premiums. Eligibility is based on your household income and size. (See chart.)

You also may qualify to pay lower out-of-pocket costs for things like copayments, coinsurance and deductibles.

Match your family size and income to the chart to see if you may qualify for savings.

Incomes are based on 2013 numbers and could be higher in 2014.

Subsidy Calculator

This tool was developed by the Kaiser Family Foundation to illustrate health insurance on premiums and subsidies for people purchasing insurance on their own in new health insurance exchanges (or "Marketplaces") created by the Affordable Care Act (ACA). You can enter different incomes, ages, and family sizes to get an estimate of your eligibility for subsidies and how much you could spend on health insurance.

Click here to go to the subsidy calculator: http://kff.org/interactive/subsidy-calculator/

For more information on methodology and to read answers to frequently asked questions, click here.

How about the tax penalties. What will that cost me if I decide not to purchase health insurance?

Starting with the 2014 tax year, any American citizen who does not have adequate health insurance will create a tax penalty for themselves or the taxpayer who claims them as a dependent. The penalties is escalate through the year 2016. The penalties in 2016 are applied to all subsequent years.

The following table describes the tax penalties through the year 2016

Year Annual Penalty
2014 $95 per adult + $47.50 per child, up to $285 or 1% of income, whichever is greater.
2015 $325 per adult + $162.50 per child, up to $975 or 2% of income, whichever is greater.
2016 $695 per adult + $347.50 per child, up to $2,085 or 2.5% of income, whichever is greater

If you would like to see your possible tax penalty in 2014, visit the following website for a tax penalty calculator:

http://www.affordable-insurance.com/individual/penalty/obamacare-tax-calculator

Where are the websites so I can further investigate the different companies and/or sign up for insurance?

To sign up for insurance in Ohio, visit: https://www.healthcare.gov/