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Some help in dealing with health act startup

The number of Western New Yorkers expected to sign up for health insurance under the Affordable Care Act this year could fill all the seats in Ralph Wilson Stadium, plus Kleinhans Music Hall and Shea’s – perhaps more than 90,000 people – according to the best guesses of state officials and insurance providers.

But they all acknowledge that the numbers are only an actuarial guess. The Affordable Care Act is taking health insurers and state benefit agencies into uncharted territory, and they really are not sure what to expect.

The same holds true for tens of thousands of uninsured in our region as they face the prospect of signing up for “Obamacare” when open enrollment begins online Tuesday.

On the plus side, the uninsured do not have to figure it out alone.

The new law provides for health care “navigators” – real, live people who can explain how to sign up, point out the differences in the health insurance plans available, and guide small-business owners in setting up coverage for their employees.

Obamacare opponents have tried to restrict access to in-person help in some parts of the country, but that has not been the case in New York, which is one of 17 states that created their own insurance “marketplaces.”

In the Buffalo area, Kaleida Health, Niagara Falls Memorial Medical Center and Chautauqua Opportunities are among the groups and agencies training their staff to help with enrollment. The sign-up will be done almost exclusively through the New York State of Health website. New York State of Health is the official health plan marketplace, or exchange, for the state.

“This is a natural add-on for us, because Kaleida has been a facilitated enrollment site since the 1990s,” explained Simmone Washington, who is in charge of the program at Kaleida Health. “It’s the navigator’s role to explain the different premiums and the different plans, so the customer can decide what’s the best option for them.”

Kaleida will have navigators in its hospitals – Buffalo General Medical Center, DeGraff Memorial Hospital and Women & Children’s Hospital – and in a stand-alone center on Main Street.

Neighborhood Legal Services is also providing navigator assistance in Buffalo.

In Niagara County, applicants have several locations to find in-person help, according to Patrick Bradley, director of marketing and public relations at one of those sites, Niagara Falls Medical Center. Besides the hospital, navigators will have hours at Lewiston Red Brick School, Niagara Community Action and the Dale Association in Lockport, the YWCA in North Tonawanda, Wheatfield Community Center, United Way in Sanborn, and the Doris W. Jones Family Resource Center in the Falls.

Most sites require appointments.

No paper forms

The sign-up will have one key difference from most government-based registration processes: There isn’t much paperwork.

“This is all going to be done through a Web portal,” Washington said. “Before, to apply for benefits, people had to bring in all kinds of ID.”

The enrollment process can be compared to filing an electronic tax return, which also does not involve any physical forms, said Donna Frescatore, executive director of New York State of Health.

“The application is a ‘question set,’ ” Frescatore said. “The program directs you to the next questions based on your answers.”

For instance, it will ask who is in the household, income figures, and details about what you are looking for in health insurance. Like the online tax programs, the application plugs into Social Security and Internal Revenue Service databases to determine eligibility for tax credits that, for most applicants, will offset some of the cost of premiums.

“Just make sure you have the Social Security numbers for yourself and your kids,” Washington said. “The system does all the verification. If for some reason it can’t, or if there is a discrepancy, then you might have to provide the documents.”

Based on the applicant’s income and family situation, it will direct the person to either a selection of health insurance plans or to a Medicaid application. Under the new law, low-income people who were not previously eligible for Medicaid – especially single, working adults – may now qualify.

Choose a color

Health insurance companies will offer plans in four “metal” categories, based on the amount of the monthly premium. Plans with lower premiums will have higher deductibles – out-of-pocket expenses that must be paid before the insurance coverage begins. (This does not include the free preventive care services).

In Western New York, the marketplace will offer plans from six insurance groups: Univera Healthcare, BlueCross BlueShield of Western New York, Independent Health and Fidelis Care, plus American Progressive Life & Health Insurance Company of New York and Freelancers Co-op, also known as Health Republic.

Monthly premiums for individuals start at $218 for the lowest-cost “bronze” plan, $275 for “silver,” $312 for “gold” and $367 for “platinum.” Those number do not reflect any discount for tax credits.

For small-business plans, the premiums are slightly higher but, Frescatore said, many employers are expected to pay a portion of the premiums. Payment can be arranged online at the end of the application process.

Not much change

Most Western New Yorkers already have health insurance coverage, through their employers, Medicare or Medicaid, and may have received notification from their employers that their insurance meets the standards of Obamacare.

Some may also receive a notice from their insurer that their plans will be changing in some way, if they did not offer the “10 Essential Benefits” required by the law.

“For those in plans that offered less, participants are being notified,” said Art Wingerter, Univera Healthcare president. “We’ve eliminated those plans and we will be ‘rounding up’ to include those essential benefits.

“Generally,” he pointed out, “in states that were ‘highly evolved’ in health care like New York, you won’t see much change.”

A bigger change, he said, is the addition of insurance plans with much lower premiums but much higher deductibles – some in the thousands of dollars.

“We’re hoping the new insurers don’t get all the ‘young and healthy’ applicants because of the premium price, and we get the older and sicker people because they know and trust our products,” he said. “If there isn’t a balance, the law is not going to work.”

Wingerter anticipates it will take two or three years for the dynamics of the new system to play out.

At Independent Health, chief marketing officer Nora McGuire agrees.

“We think 2014 will be a learning year,” McGuire said. “Things may go in a different direction in 2015.”

For now, her company is offering 18 benefit and cost combinations in the four “metal” tiers, she said, with different premiums and deductibles. “People will have to look at more than the basic price,” she said. “Is their doctor in the plan? How much is the deductible? How many prescriptions do they have? There is a lot to consider.”

Coverage under the Obamacare programs begins Jan. 1, 2014; enrollment starts Tuesday and is open until March 31, 2014.