What happens to the uninsured?

A hypothetical walk through the many options and hurdles

By ANNEMARIE SCHUETZ
Posted 5/5/20

Meet Jane. She had a job and, like 30 million+ other U.S. residents, she lost it. Today, she woke up with a dry cough and a slight fever. She has no insurance. What happens if she gets really …

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What happens to the uninsured?

A hypothetical walk through the many options and hurdles

Posted

Meet Jane. She had a job and, like 30 million+ other U.S. residents, she lost it. Today, she woke up with a dry cough and a slight fever. She has no insurance. What happens if she gets really sick?

We decided to find out.

Jane had a job with insurance: Lucky Jane! She can choose between COBRA (she should consult with her job’s human resources department) or can qualify for the ACA, because, no matter what, losing your job-based insurance is a special event and you can apply. Great, that version of Jane is good to go, assuming she can afford her ACA insurance (but that’s a different story).

What if Jane didn’t have job-based insurance?

Jane 2.0 didn’t have insurance at work and she didn’t buy ACA insurance on the exchange at the end of 2019. She didn’t buy an association plan or anything else. If Jane is eligible, there’s Medicare. But let’s assume she’s too young.

So what does she do now?

If Jane lives in New York state, she can still get insurance on the exchanges until Friday, May 15, as of this writing. Check the Health Department website to see if that has been extended; NY runs its own exchange, so it can do that. There are people to contact that will walk her through the process. If she works it out on her own, Jane needs to keep various things in mind (see the Community Service Society in a list of contacts below). Expanded Medicaid is another option, if Jane’s got little income. There are also association plans if Jane belongs to some kind of organization (discussed in more detail through middle-income Jane).

Those are New York Jane’s options.

Pennsylvania Jane must deal with the federal exchange. This is the last year PA will use the federal exchange; next year it’ll run its own, like NY. But because this year is this year, if PA Jane didn’t have insurance on her job, she will not be able to qualify for ACA insurance, because the Trump administration chose not to open the federal exchanges to new applicants in a special enrollment period. (Expect to hear a lot about that as we get closer to November.) Now, just in case you are wondering, PA Jane can get ACA insurance if she had job-based insurance. But she can’t (in PA or any of the other 38 states that use the federal exchange) if she didn’t.

Still with me?

So, she can’t get ACA insurance. She can call Wayne Memorial’s Outreach and Enrollment Coordinators (see the contact box below) for a walk-through of her other options. If she doesn’t have much money, she can qualify for expanded Medicaid, and the Trump Administration has expedited the enrollment process for that. That takes care of low-income Jane.

Middle-income Jane doesn’t qualify for Medicaid; she should ask the Wayne Memorial Outreach Coordinator about what she qualifies for. There are sliding fee scales for office visits, for instance.

There might be an association health plan. If she is in a group like the Freelancers Union, Rotary or AARP, she should ask if they have insurance options. (If so, they’ve probably sent her many letters about it she might’ve thrown out in more normal, healthier days.) If she belongs to a religious faith, they might offer one.

These plans do not have to comply with the ACA, so read the information over very carefully. Make sure it covers your doctors, medications and local hospital. Check for pre-existing condition exclusions, like the fever and cough Jane has which is getting worse.

The worst-case scenario is that Jane gets really sick and ends up in the hospital, recovers and goes home. (Okay, that’s great for her—we’re talking worst case for finances.) She still doesn’t have insurance. She doesn’t have the assets to pay all her hospital bills. However, the massive CARES Act includes funding to reimburse providers for uncompensated care, which would include Worst-Case Jane... if her hospital qualifies. (You can find out more at the Kaiser Family Foundation, www.kff.org.)

Why does all that matter for Worst-Case Jane? Well, it means that her care may or may not be reimbursed by the federal government. If it is, then great! (Probably. She needs to find out what, if anything, she is on the hook for.)

If not, Worst-Case Jane has a big problem. Good luck, Worst-Case Jane. You need it.

Contacts

For help with insurance in New York, the Community Service Society is staffed with health counselors and financial coaches who will guide you through the system. Visit their website at www.cssny.org or call their Navigator Network at 888/614-5400. Assistance is free. (They provide many services, so their site is worth checking out.)

For Pennsylvania residents, Wayne Memorial Community Health Centers’ Outreach and Enrollment Coordinators for their free assistance in navigating the marketplace, getting medical assistance, or learning more about the system’s sliding fee scale.

For the Wayne Memorial Community Outreach and Enrollment, call 570/-251-6569 or 570/251-6554. Office is located at 630 Park St., Honesdale, PA.

Learn more about cost-sharing

This is in the fine print of your health insurance packet. It’s important, especially if you’re about to consume a whole lot of healthcare.

Deductible size: Most ACA plans come with deductibles and some are huge. (See info from KFF below.) You have to pay off your deductible before your medical expenses are paid for. The deductible renews each year.

Copays: A fee you pay each time you use medical care.

Coinsurance: Your share of a given cost once you’ve paid off your deductible. Ten percent of costs, 20 percent of costs—I’ve even seen 40 percent. Make sure you know how much you have to pay in coinsurance for what kind of treatment or hospital stays.

Maximum Out of Pocket: The most you can pay of covered costs. Some costs don’t come under this, like medication, providers, and treatment the insurance doesn’t cover.

Silver plans are heavily subsidized, and all those costs above might be subsidized too. An applicant needs to check on that.

More cost-sharing info from the Kaiser Family Foundation:

“Increasingly, cost-sharing is becoming unaffordable for many private health plan enrollees. Half of the adults covered under job-based plans report foregoing or delaying needed care in the past year due to cost. Among adults who do skip or delay needed care due to cost, 13 percent report their health condition worsened as a result.

“Among covered workers in job-based plans with a deductible for self-only coverage in 2019, the average deductible was $1,655. Employer-sponsored health plan deductibles have increased six times faster than average wages over the past decade.

“Under non-group plans, deductibles are even higher—on average more than $4,500 for self-only coverage in silver plans this year—although half of marketplace enrollees qualify for subsidies to significantly reduce deductibles and other cost-sharing.”

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