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One of the major provisions of the ACA is the creation of health insurance marketplaces, the new way to compare and purchase health insurance coverage. People who are not covered by a health plan can sign up for a guaranteed issued (i.e., cannot be denied coverage due to pre-existing conditions) qualified health plan through these health marketplaces in each state. Some of these marketplaces, sometimes called “exchanges,” are run by the state and others are run by the federal government, if a state has chosen not to run its marketplace. The marketplaces have yearly open enrollment periods. Outside of the open enrollment periods, you can only enroll in the marketplace plans if you have a "qualifying life event," such as moving to a new state.

Each marketplace must offer several types of health insurance plans to individuals and families not otherwise covered by a plan. To qualify for sale in the marketplace, all plans must cover to one degree or another, essential health benefits, the basic categories of insurance benefits defined in law that all health plans in the individual and small group market must offer. There are 10 categories including emergency, mental health, prescription, pediatric and other services.

It may very well turn out that a Gold or Platinum plan which have higher premiums may be the better buy when out of pocket costs and premium subsidies are taken into account - especially for those families who have rare and chronic diseases and need on-going and expensive treatments.

A good place to start researching plan options is www.healthcare.gov. This website will allow individuals in states where the Marketplace is run by the federal government to compare plans and apply for coverage. It will also direct those who live in states with state-run Marketplaces to the appropriate navigator where they can do the same – compare plans and apply for coverage.

The plan categories are Bronze, Silver, Gold and Platinum with each of the metal levels representing a different patient cost sharing responsibility. For example, the Bronze plans will have the lowest premiums and the highest cost sharing responsibility for out of pocket expenses, while the Platinum plans will have the highest premiums and the lowest cost sharing responsibility for out of pocket (OOP) expenses. Out of pocket expenses include deductibles and copayments or co-insurance.

It is important for every buyer in the marketplace to understand how each of these plans work – especially if the buyer or a member of his/her family has a rare, chronic disease such as a primary immunodeficiency disease.

Maximum Out of Pocket (OOP) Cost Limits
It is essential that a person/family should know what their OOP costs are expected to be when choosing a plan. And, one must also know the maximum OOP costs the law allows for individuals and families. In 2015, the maximum OOP costs that a plan can charge patients for OOP costs will be $6,600 for an individual, while a family could pay up to $13,200. Those totals include copayments, co-insurance and deductibles, but not premiums. In 2015, OOP costs from prescription drug benefits must also apply to the total OOP limit. The OOP limit may increase slightly every year.

Premium Subsidies
The ACA provides premium and cost-sharing subsidies to help low- and moderate-income Americans afford health care coverage in the new marketplaces. Premium subsidies are available on a sliding-scale to individuals and families with incomes between 100-400 percent of the federal poverty level (FPL). For an individual the income range would approximately be between $11,500 and $46,000. For a family of four, the income range would approximately be between $23,500 and $ 94,000.

Plan Categories
The division of health plan versus patient costs is shown below for each category of health insurance plan. This does not necessarily mean that for each individual medical service the patient pays a given co-insurance percentage, but rather the percentage refers to the amount of overall medical and drug costs the patient will be responsible for through deductibles, co-payments and co-insurance.

Bronze Plan (60-40)

  • Characterized with less expensive premiums
  • While the premium may be low, OOP costs are high
  • Plan will pay for 60% of the medical and drug benefits and the buyer will pay 40% through deductibles, flat co-pays and/or co-insurance
  • Individuals must determine whether this cost structure will work for them – especially if they have a rare and chronic disease requiring on-going and long term treatment

Silver Plan (70-30)

  • One step up from the Bronze Plan.
  • Higher premiums than the Bronze Plan and more benefits
  • Plan will pay for 70% of the medical and drug benefits and the buyer will pay 30% through deductibles, flat co-pays and/or co-insurance
  • Individuals must determine whether this cost structure will work for them – especially if they have a rare and chronic disease requiring on-going and long term treatment

Gold Plan (80-20)

  • Closer to the “average” plan that is currently offered by employers
  • Premiums are higher than the Silver Plan and the medical and drug benefits are more generous
  • Plan will pay for 80% of the medical and drug benefits and the buyer will pay 20% through deductibles, flat co-pays and/or co-insurance

Platinum Plan (90-10)

  • Most generous of all plan offerings
  • Premiums are higher than the Gold Plan and medical and drug benefits are more comprehensive
  • Plan will pay for 90% of the medical and drug benefits and the buyer will pay 10% through deductibles, flat co-pays and/or co-insurance
  • Many platinum plans will have an OOP limit that is lower than bronze, silver, and gold plans. If you anticipate high OOP costs, it is likely that overall health costs, which include premiums and OOP spending, may be lower in such a platinum plan.

There will likely be a variety of plans available that fall under each of the above categories. State and the federal government determine which insurance products qualify to be sold through the Marketplace. All companies participating in the Marketplace must offer at least one silver-level plan and one gold-level plan. The number of choices available for each individual depends both on the state and federal government and on the insurance companies.

What a Person with PI Needs to Know
If one is a patient with a primary immunodeficiency disease who requires Immunoglobulin (Ig) Replacement Therapy through Intravenous Immunoglobulin (IVIG) or Subcutaneous Immunoglobulin (SCIG), it is extremely important to calculate which plan is best for you. It is not always about the premium to be paid. The out of pocket (OOP) costs for a patient with PI can dwarf the premiums in some plans. Keep in mind that, in general, the lower the premium is the higher the OOP costs will be when a patient needs care. It is necessary for patients to calculate the costs for their current Ig treatment, number of trips to doctors’ offices, emergency room visits, treatments for other conditions and any other costs including drug costs. Once calculated, one needs to investigate how each plan will pay or not pay for those services and Ig products that a patient will need.

If one’s expected OOP costs are greater than the premium for any particular plan, that plan is probably not the right plan. It may very well turn out that a Gold or Platinum plan which have higher premiums may be the better buy when OOP costs and premium subsidies are taken into account - especially for those families who have rare and chronic diseases and need on-going and expensive treatments.

The IDF Health Insurance Toolkit is designed to help patients through the process.

As one goes through the Marketplace process of finding a suitable and appropriate health plan, please keep in mind that the answers to one’s questions may not be readily available. The summary description of benefits is usually not specific enough to learn what and how treatments will be handled. Questions can be submitted through navigators and certified application counselors. If these sources are not able to fully answer questions about coverage or direct patients to sources that can do so, it is perfectly acceptable to directly contact the insurance companies that are offering qualified plans in the Marketplace to ask them, online or by phone, the questions regarding coverage of the specific treatments a patient may need as well as the projected OOP costs. With that information one should be able to make an informed choice of the plan that will best suit their individual healthcare needs.

Important Definitions
Co-insurance: A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid. Once any deductible amount and coinsurance are paid, the insurer is responsible for the rest of the reimbursement for covered benefits up to allowed charges: the individual could also be responsible for any charges in excess of what the insurer determines to be ‘usual, customary and reasonable. Example: Your IVIG infusion may cost $5,000 per month. If your co-insurance percentage responsibility is 30%, you would be expected to pay $1500 for each infusion.

Co-payment: A flat dollar amount you must pay for a covered program. Example: you may have to pay a $15 copayment for each covered visit to a primary care doctor.

Deductible: The amount you must pay for covered care before your health insurance begins to pay. Insurers apply and structure deductibles differently. Example: under one plan, a comprehensive deductible might apply to all services while another plan might have separate deductibles for benefits such as prescription drug coverage. Some plans may also cover some services before the deductible is met, such annual exams.

Out of Pocket (OOP) Costs: Costs you must pay including deductibles, co-pays, and co-insurance but not premiums