WILMINGTON — Questions flew fast, and side conversations buzzed, at a presentation Oct. 9 at Memorial Hall on the state's new health care marketplace, the online Vermont Health Connect exchange.
Most of the questions came from small-business owners investigating whether to offer health insurance as an employee benefit - and if so, at what level of funding - or if they should turn their employees loose on the open market, where subsidized care is an option.
Emily Yahr, an education and outreach manager for the Department of Vermont Health Access, answered them all.
One woman at the front of the hall described herself as a small-business owner whose head was spinning with facts to do with health care options. She added that her seasonal business employed Vermonters and out-of-state commuters, and the options weren't clear to her.
Employers across the country likely would empathize. The controversial Patient Protection and Affordable Care Act, also known as Obamacare, went live Oct. 1, and coverage under Vermont's new health exchange kicks in Jan. 1, 2014. Time is definitely an element.
Yahr said that individuals buying insurance through the exchange should select their plan by Nov. 30 and enroll by Dec. 15, and that premium payments must be made by Dec. 31 to secure coverage heading into the New Year.
The payment date for employers is Dec. 21, with open enrollment ending March 31, 2014, Yahr explained.
At least 100,000 and perhaps as many as 250,000 Vermonters will be affected by the new rules, which require all but a few Americans to obtain health insurance starting Jan. 1.
Professionals such as state-trained “navigators” and independent insurance brokers can help individuals, families, and businesses choose health insurance through Vermont Heath Connect (VermontHealthConnect.gov).
The website allows people to compare insurance plans, enroll in a plan, and secure financial help to pay for health insurance.
To people who questioned what the state exchange is about, Yahr explained that the state is trying to fix, in her words, a broken health care system.
“The new Vermont Health Connect gives people more control over their health care decisions,” she said, adding that increased control also comes with changes.
Indeed, those are changes many in the Memorial Hall audience were still wrapping their heads around.
Under Obamacare, federal tax deductions will help eligible individuals and families pay their insurance premiums. The act has also set 10 standards for coverage, allows children to stay on their parents' insurance until age 26, and provides for co-pay-free preventative care.
Proponents are also quick to note that, under the act, those with pre-existing health conditions can no longer be denied coverage.
Vermont at the fore
Vermont has spent decades reforming health care with the goal of creating a single-payer system. The state has operated its own health insurance programs for low-income Vermonters - Vermont Health Access Plan, Catamount Health, and Dr. Dynasaur - in cooperation with the federal Medicaid program, and insurance carriers Blue Cross Blue Shield of Vermont (BCBSVT) and MVP Health Care.
In 2014, VHAP and Catamount will disappear. Those covered by those state programs will enter Vermont Health Connect to purchase their health plans. Other individuals, and businesses with fewer than 50 employees, will also have the option of purchasing insurance through the exchange.
Those who are eligible can still move into Medicare, which is not part of Vermont Health Connect.
Yahr said the state estimates about 100,000 people will receive insurance through the exchange.
Vermont has the second-lowest uninsured population in the country, about 44,000 people, said Yahr. But, the state wants all Vermonters to have health insurance.
To reach this goal, the state has expanded its Medicaid program and subsidies. The federal government will offer tax deductions to people up to 250 percent of the federal poverty level. Vermont has decided to offer additional subsidies to residents as high as 300 percent of the federal poverty level.
The health exchange breaks coverage into tiered plans of platinum, gold, silver and bronze. To receive these state subsidies, people must enroll in a silver plan, said Yahr.
At this time, coverage for people over 65 receiving coverage through Medicare or VPharm, or children on Dr. Dynasaur, will remain unchanged.
For many people, premiums and out-of-pocket expenses will decrease under Vermont Health Connect and the PPACA. But some low-income Vermonters may see their premiums increase.
The health care sea change represented by Vermont Health Connect led to questions Oct. 9 as audience members grappled with the newness of purchasing health insurance. But adding to the confusion is that Vermont effectively has Vermont's health coverage system in flux.
Vermonters are seeing two systems at play - what the federal government mandates under the PPACA and the additional protections the state has added to Vermont Health Connect. The state will roll out its expanded health care system in phases over four years as waivers and funding become available from the federal government.
According to Yahr, throughout 2013 and into 2017, the state aims to reduce health care costs and assure that all Vermonters have access to high-quality care and coverage. In 2017, the state hopes to move toward a single-payer system.
Vermont is one of 16 states to create a state-run market. It's the only state requiring individuals and small businesses to buy their insurance on the market.
The state decided to merge individuals and small business into the exchange to spread risk, said Yahr.
A helping hand
From her office in the basement of the Dunham Building at Brattleboro Memorial Hospital, Vermont Health Connect Navigator Joan Bowman clicks through the screens of the state's online enrollment program.
“People are surprised at the affordability, and their fears are allayed once we do the spreadsheets,” she said of sorting through the financial aspects of buying insurance through Vermont's new health insurance marketplace.
Bowman, a long-time health care advocate, who started as a Navigator last month, jokes that her two job challenges are time and unwavering optimism.
“This [new system] is good for you,” she tells enrollees.
In Bowman's view, Vermonters are fortunate because the state is united in its focus to provide health care for everyone.
“[Health care] really matters here,” she said.
Over the past month, Bowman has met and discussed Vermont Health Connect with individuals, families, small businesses, nonprofits, and associations. So far, she said, everyone has found a plan and budget to fit the given situation.
There's been no exceptions to the rules, Bowman said. “But I'm still new.”
Bowman said there's no time limit on how long she works with people and employers as they choose insurance plans.
Remember, she said, people are only making insurance decisions for 2014. They can make new decisions for the following year.
People panic themselves by going straight to the insurance plans and subsidy calculator, Bowman observed. She offers a different approach for choosing insurance through Vermont Health Connect:
First, she offers guidelines. If a person works for a company with more than 50 employees, they will receive insurance through their employer.
Also, people 65 or older will automatically receive Medicare, a federal program, that remains unchanged for now, said Bowman. Because Medicare remains unchanged, people purchasing supplemental insurance, say from an organization such as AARP, will continue to do so.
People earning up to 133 percent of the federal poverty level automatically filter into the Medicaid program, Bowman continued.
The individuals or employees of businesses with fewer than 50 employees will go through Vermont Health Connect, she said.
Bowman recommends that anyone weighing insurance under the new rules make looking at plans in the exchange their final step in the process.
She explained that choosing health insurance is as much about people's lifestyles as it is about their budgets.
First, people should check to see which insurance company, BCBSVT or MVP, accepts their health care provider, or if they don't have a provider, which plan covers the doctors and hospitals in their area.
Next, Bowman suggests people evaluate their lifestyle to see which insurance company is the better fit. For example, MVP is an HMO-style plan that only covers New York, Vermont, and New Hampshire. BCBS operates nationwide and in about 200 countries. If a person travels a lot, BCBS might be the better option.
Understand your needs
Under the PPACA, all health plans must offer, at a minimum, the same 10 benefits: ambulatory patient services, emergency services, prescription drugs, rehabilitation services and chronic disease management, hospitalization, maternity and newborn care, mental health and substance use treatment, laboratory services, preventative care, and wellness, and pediatric services.
Where insurance plans will differ the most is in premium costs and deductibles, she said.
People also need to assess their “self-care regimen,” said Bowman. How often do they tend to visit the doctor? Once a year? With each sniffle? Do they have ailments such as diabetes or cancer that require expensive medications or surgeries? How much can they budget for health care? Do they tend to have more out-of-pocket expenses and need a lower deductible?
Once people have determined how health care fits in their lives, Bowman advised, then they should look at what federal tax deductions and state subsidies they're eligible for.
The Vermont Health Connect website has a calculator for estimating eligibility for different programs like Medicaid or income-based tax deductions. Also, as people start the enrollment process, the website will inform them of program eligibility based on household information, said Bowman.
Finally, people can consider tiers of care within individual plans and see what fits their budget and lifestyle the best.
Bowman characterized insurance navigators as people who “take a snapshot of your life” in helping individuals, couples, and families craft health insurance decisions.
“What's affordable is really a case-by-case basis,” she said.
When determining modified adjusted gross income, said Bowman, people should refer to their 2012 tax returns. If people filed a 1040 tax form, then refer to line 37 for their modified adjusted gross income. If they filed a 1040A form, refer to line 21.
People receiving Social Security benefits and earning income should remember to add these two totals together, she said.
Bowman advises small business owners with under 50 employees consult a tax professional. Whether these businesses offer health insurance or other benefits, such as health savings accounts, will have tax implications for the business and employees.
Employers that don't offer insurance will have to pay a per-employee penalty of $119.12 quarterly or $476.48 annually. Still, for many companies, the penalty costs less than offering insurance, she said.
Employees choose their own insurance plan through Vermont Health Connect exchange, said Bowman. Their employer will give them a code number, business' EIN number, and tell employees the amount of the company's contribution. The employees then choose a plan.
Vermont Health Connect, acting as the intermediary between enrollees and insurance companies, will generate an aggregate bill for the business.
If a company offers health insurance, employees are required to take it, but there are a few exceptions, said Bowman. For example, if the cost of insurance through their workplace is 9.5 percent or more of the employee's total household income, then they can leave the employer's insurance and purchase insurance within Vermont Health Connect independently.
Bowman said people can save and exit their account at Vermont Health Connect any time during enrollment. They can phone the call center, a navigator, or insurance broker with questions and return to their application.
But, warns Bowman, don't try to use the back button on the website. People will lose their work. Use the save button instead.
To prevent identity theft, said Bowman, Vermont Health Connect runs account data against the IRS database and generates questions such as, “You lived in Hartford in 1989. Which state?”
In addition to English language speakers, the state's call center has interpreters who speak the top 10 languages spoken in Vermont: Arabic, Bosnian, Burmese, French, Kirundi, Nepali, Somali, Spanish, Swahili, and Vietnamese.
A toolbar at the top of the Vermont Health Connect homepage lists the call center's number, a button for language services, and a place to find live help.