Is there anything more confusing than figuring out the Affordable Care Act?
You are not alone!
Summit Medical Group is here to help.
Insurance expert Peter Saunders is SMG’s in-house expert on understanding and explaining health insurance.
Tune into SMG Radio to hear him explain the difference between Open Enrollment and Special Enrollment under the Affordable Care Act.
Selected Podcast
Open Enrollment/ Special Enrollment- ACA Explained!
Featured Speaker:
Peter Saunders
Peter Saunders is Summit Medical Group’s Director of Revenue Cycle and an expert in health insurance coverage. Transcription:
Open Enrollment/ Special Enrollment- ACA Explained!
Melanie Cole (Host): Trying to figure out the Affordable Care Act can be quite confusing and you’re not alone. My guest today is Peter Saunders. He’s Summit Medical Group’s Director of Revenue Cycle and an expert in health insurance coverage. Welcome to the show, Peter. Let’s start by explaining what the terms mean: “open enrollment” and “special enrollment.”
Peter Saunders (Guest): Okay. So, open enrollment is the period each year when all of us can sign up for health insurance. This is the time of year when our employers are providing us with new insurance information and it’s usually a very limited two week to three week period.
Melanie: Why is it so limited? Why is it not available all year?
Peter: Under the ACA, one of the big changes was the removal of the pre-existing conditions and what that did is that opened up insurance and allows people to get insurance on a much larger scale. With that, one of the concerns that payers had was that as people would start to enroll at all different times of the year, there would just be this massive “I only need insurance when I need it.” That’s really one of the driving factors of why we have open enrollment and special enrollment.
Melanie: Tell us, what is special enrollment?
Peter: Special enrollment is specific to an enrollment period that is usually due to what’s called a “qualifying event.” There are several types of things that come up as qualifying events. This would be outside of the open enrollment period. For example, you might be married, you might have a new child or an adopted child, you may also lose your job, there may be a death of a spouse who has insurance, your hours at work may be reduced which may result in the facts that you’re no longer be eligible for your employer insurance, so you would need to go to the exchange to look for insurance.
Melanie: If you’re covered under employer’s insurance, then do they go and do all of the work on the exchanges and can people still get insurance directly through Blue Cross or Humana?
Peter: They can still get insurance directly through the exchanges. That’s the first stop that they’re going to do. There’s always the option to get that through a broker or through the exchange.
Melanie: What about employers? Are they dealing with the exchange or directly with the insurance companies?
Peter: The employers, for the most part, are dealing directly with the insurance companies.
Melanie: If somebody wants to enroll in special enrollment and they go onto healthcare.gov, give them a little bit of what to look for when they’re looking for an insurance plan for themselves if they’ve never done this before.
Peter: When you go out to healthcare.gov, the important thing to do before you go is to really understand what your healthcare needs are. If you’re someone who is basically well, relatively young, does not need a lot of care from your physicians, you’re not someone who goes to the doctor on a regular basis, maybe once a year for a well visit, you’re going to want to shop with a plan with a higher deductible, limited benefits that’s not going to require you to pay a high premium. If you’re someone who is looking for something that is probably more comprehensive, you are probably going to want to go towards more of the silver type plans which offer more of a benefit. There are different cost-sharing structures and it really is going to depend on what you’re able to afford.
Melanie: If someone loses their job, how long do they have before they can get on the special enrollment? If they are really worried about health insurance and they go on special enrollment, is this something that they can do right away when they lose a job? Do they have to wait for COBRA?
Peter: COBRA should always be offered by your employer. That may not always be the option that you want to go with. It might be too expensive. Looking at what’s on the exchange is always the best option. There is a short enrollment period. The special enrollment period lasts for about 30 days. You have to be aware of that as well.
Melanie: What if you have trouble paying for health insurance, Peter? What do you do?
Peter: The marketplace has a nice calculator which when you’re going in and you’re registering, you’re going to put in your annual salary and if you’re someone who’s in a situation where your hours have been reduced by your employer and maybe you didn’t lose your job entirely but you have a reduced salary where you’re no longer having insurance benefits through your employer, you’re going to have to go through the marketplace. There are the subsidies that will help offset some of the cost sharing. So, depending on your salary, there are those additional subsidies that will help offset those costs.
Melanie: So, when employees at Summit Medical Group, for example, start to work there and get insurance, how does that process work? Do you send them a list of different plans or do they all kind of get one?
Peter: This year at Summit Medical Group, we have three options. That information is sent to us in advance by our Human Resources Department and we are actually having town hall meetings where we can go and meet with representatives from our HR Department and ask questions about all the different aspects of those three plans. Where we have an option of an EPO narrow network plan, a point of service plan with out-of-network benefits and a high deductible plan. Each one has those different options which will tailor to individual needs.
Melanie: This is for full-time employees, yes?
Peter: This is for anyone who is working over 30 hours, up to 30 hours or more a week.
Melanie: So then, do part-time employees, then, go through the exchange whether they’re individual or if they’re on a spouse’s insurance?
Peter: That’s correct.
Melanie: So, in just the last few minutes, Peter, give us your best advice--what do you tell people when they ask you about the Affordable Care Act? Explain it a little, to clear it up a little bit for them. Kind of give a little broad overview.
Peter: The first thing that I always tell people about the ACA is that it’s really meant to provide health care coverage to more Americans. As such, it doesn’t mean that everything is covered 100%. One of the things that we spend a lot of our time with our patients and fielding calls on “what should I do?” is what are your out-of-pocket costs and what are your needs? It’s really important to understand what your needs are going in to making any decisions about your insurance.
Melanie: That’s such important information and really great advice, Peter. Thank you so much. You’re listening to SMG Radio. For more information, you can go to SummitMedicalGroup.com. That’s SummitMedicalGroup.com. This is Melanie Cole. Thanks so much for listening.
Open Enrollment/ Special Enrollment- ACA Explained!
Melanie Cole (Host): Trying to figure out the Affordable Care Act can be quite confusing and you’re not alone. My guest today is Peter Saunders. He’s Summit Medical Group’s Director of Revenue Cycle and an expert in health insurance coverage. Welcome to the show, Peter. Let’s start by explaining what the terms mean: “open enrollment” and “special enrollment.”
Peter Saunders (Guest): Okay. So, open enrollment is the period each year when all of us can sign up for health insurance. This is the time of year when our employers are providing us with new insurance information and it’s usually a very limited two week to three week period.
Melanie: Why is it so limited? Why is it not available all year?
Peter: Under the ACA, one of the big changes was the removal of the pre-existing conditions and what that did is that opened up insurance and allows people to get insurance on a much larger scale. With that, one of the concerns that payers had was that as people would start to enroll at all different times of the year, there would just be this massive “I only need insurance when I need it.” That’s really one of the driving factors of why we have open enrollment and special enrollment.
Melanie: Tell us, what is special enrollment?
Peter: Special enrollment is specific to an enrollment period that is usually due to what’s called a “qualifying event.” There are several types of things that come up as qualifying events. This would be outside of the open enrollment period. For example, you might be married, you might have a new child or an adopted child, you may also lose your job, there may be a death of a spouse who has insurance, your hours at work may be reduced which may result in the facts that you’re no longer be eligible for your employer insurance, so you would need to go to the exchange to look for insurance.
Melanie: If you’re covered under employer’s insurance, then do they go and do all of the work on the exchanges and can people still get insurance directly through Blue Cross or Humana?
Peter: They can still get insurance directly through the exchanges. That’s the first stop that they’re going to do. There’s always the option to get that through a broker or through the exchange.
Melanie: What about employers? Are they dealing with the exchange or directly with the insurance companies?
Peter: The employers, for the most part, are dealing directly with the insurance companies.
Melanie: If somebody wants to enroll in special enrollment and they go onto healthcare.gov, give them a little bit of what to look for when they’re looking for an insurance plan for themselves if they’ve never done this before.
Peter: When you go out to healthcare.gov, the important thing to do before you go is to really understand what your healthcare needs are. If you’re someone who is basically well, relatively young, does not need a lot of care from your physicians, you’re not someone who goes to the doctor on a regular basis, maybe once a year for a well visit, you’re going to want to shop with a plan with a higher deductible, limited benefits that’s not going to require you to pay a high premium. If you’re someone who is looking for something that is probably more comprehensive, you are probably going to want to go towards more of the silver type plans which offer more of a benefit. There are different cost-sharing structures and it really is going to depend on what you’re able to afford.
Melanie: If someone loses their job, how long do they have before they can get on the special enrollment? If they are really worried about health insurance and they go on special enrollment, is this something that they can do right away when they lose a job? Do they have to wait for COBRA?
Peter: COBRA should always be offered by your employer. That may not always be the option that you want to go with. It might be too expensive. Looking at what’s on the exchange is always the best option. There is a short enrollment period. The special enrollment period lasts for about 30 days. You have to be aware of that as well.
Melanie: What if you have trouble paying for health insurance, Peter? What do you do?
Peter: The marketplace has a nice calculator which when you’re going in and you’re registering, you’re going to put in your annual salary and if you’re someone who’s in a situation where your hours have been reduced by your employer and maybe you didn’t lose your job entirely but you have a reduced salary where you’re no longer having insurance benefits through your employer, you’re going to have to go through the marketplace. There are the subsidies that will help offset some of the cost sharing. So, depending on your salary, there are those additional subsidies that will help offset those costs.
Melanie: So, when employees at Summit Medical Group, for example, start to work there and get insurance, how does that process work? Do you send them a list of different plans or do they all kind of get one?
Peter: This year at Summit Medical Group, we have three options. That information is sent to us in advance by our Human Resources Department and we are actually having town hall meetings where we can go and meet with representatives from our HR Department and ask questions about all the different aspects of those three plans. Where we have an option of an EPO narrow network plan, a point of service plan with out-of-network benefits and a high deductible plan. Each one has those different options which will tailor to individual needs.
Melanie: This is for full-time employees, yes?
Peter: This is for anyone who is working over 30 hours, up to 30 hours or more a week.
Melanie: So then, do part-time employees, then, go through the exchange whether they’re individual or if they’re on a spouse’s insurance?
Peter: That’s correct.
Melanie: So, in just the last few minutes, Peter, give us your best advice--what do you tell people when they ask you about the Affordable Care Act? Explain it a little, to clear it up a little bit for them. Kind of give a little broad overview.
Peter: The first thing that I always tell people about the ACA is that it’s really meant to provide health care coverage to more Americans. As such, it doesn’t mean that everything is covered 100%. One of the things that we spend a lot of our time with our patients and fielding calls on “what should I do?” is what are your out-of-pocket costs and what are your needs? It’s really important to understand what your needs are going in to making any decisions about your insurance.
Melanie: That’s such important information and really great advice, Peter. Thank you so much. You’re listening to SMG Radio. For more information, you can go to SummitMedicalGroup.com. That’s SummitMedicalGroup.com. This is Melanie Cole. Thanks so much for listening.