Untangling the Complexities of Vermont's New Health Insurance Exchange
The second floor of Winooski’s Vermont Student Assistance Corporation building was buzzing with activity on the first Thursday in September. In the sprawling, 1980s-style cubicle farm, about 75 employees of the Department of Vermont Health Access (DVHA) and an equal number of private contractors were racing against a major deadline. The state’s new health care exchange, known as Vermont Health Connect, goes live on October 1. By then, we’re all supposed to know how it works — or at least to start figuring it out.
It’s fitting that Vermont, the first state to be called for Barack Obama both times he’s run for president, also received one of the biggest chunks of money — $171 million — to implement the 2010 comprehensive health care reform law that informally bears his name: Obamacare. Officially known as the Patient Protection and Affordable Care Act, it aims to reduce health care costs by getting more people who qualify for government health programs to enroll in them. At the same time, the law makes it mandatory for everyone else to buy private health insurance. Vermont’s new insurance exchange that launches in less than two weeks is the first step toward that goal.
Ultimately, Vermont Health Connect intends to provide every Vermonter with health insurance regardless of their employment or health status or ability to pay. Though the state currently has one of the lowest rates of uninsured in the country — about 7 percent — DVHA Commissioner Mark Larson says he hopes the exchange will whittle that number closer to 2 percent.
Starting in 2014, Vermont Health Connect will be the only way to buy health insurance in Vermont for individuals, including those on government insurance programs such as Medicaid, Dr. Dynasaur, Catamount and the Vermont Health Access Plan (VHAP), as well as for employees of a business with fewer than 50 working full time. As of January 1, Catamount and VHAP, which serve low- and moderate-income Vermonters, will cease to exist; Dr. Dynasaur and Medicare will remain unchanged; and Medicaid will be greatly expanded to cover the many more Vermonters eligible for it under the new system.
Individuals and businesses with fewer than 100 employees will be required to participate in the exchange by January 1, 2016, though Vermont's largest employers, such as IBM and Green Mountain Power, will still be exempt. By January 2017, Vermont is expected to transition to a single-payer system, known as Green Mountain Care, in which employer-provided coverage would be eliminated and all Vermonters would be on a universal health-care system.
The Vermont Health Connect website — healthconnect.vermont.gov — enables people to compare the private insurance plans offered by two competing companies: Blue Cross Blue Shield of Vermont and MVP Health Care. These “apples-to-apples” comparisons spell out which services each plan covers and the cost in terms of premiums, deductibles and out-of-pocket maximums — that is, your total potential financial exposure per year.
The Affordable Care Act also mandates 10 essential services to be covered by every insurance plan, including emergency room visits, annual physicals, prescription drug benefits and mental health services. Patients can no longer be denied coverage for preexisting conditions or any other chronic health problems that might make them a bad insurance risk.
The “subsidy calculator” on the website is up and running; it invites individuals and families who are not getting health care through an employer to punch in their household income to determine whether they qualify for a free or low-cost public insurance plan, such as Medicaid or Dr. Dynasaur. The subsidy calculator also lets people know whether they qualify for subsidies to offset their insurance costs.
Those who don’t have internet access or who are intimidated by online research can call the state’s customer support center or meet with a “navigator.” As the term implies, navigators are there to help individuals, families and small businesses find their way through what can seem like a bewildering array of coverage options. The state has already contracted and educated 200 navigators; another 100 are currently being trained. Organizations such as the Lake Champlain Regional Chamber of Commerce, Planned Parenthood of Northern New England and the Association of Africans Living in Vermont all have navigators on staff to assist the public, free of charge.
In all, BCBS and MVP Health Care are offering 18 different plans. They’re grouped, from most costly to least, into four “metal” categories: platinum, gold, silver and bronze. Also included are several low-cost options available only to Vermonters under the age of 30. For as little as $213 a month, a twentysomething can insure him- or herself against a catastrophic medical event.
What kind of advice should Vermonters expect? This week, Seven Days profiles five households that will soon be required by law to buy health insurance through Vermont Health Connect. Or, if they don’t, they will face penalties that will more than double every year, starting at $95 or 1 percent of their incomes, whichever is greater. None of the five is currently getting health insurance through an employer. One is a business that, like many other Vermont employers who have historically provided one-size-fits-all health insurance to their employees, is also negotiating the new pick-your-own system. It’s unclear yet whether it will cost her more — or less — to maintain the level of coverage she has been offering.
We asked navigators from different organizations how they would advise our five interviewees: a 33-year-old professional with a chronic health problem who just lost her job; a family of five headed by two self-employed parents; a retired couple exercising voluntary simplicity; a 48-year-old woman for whom moonlighting in Vermont doesn’t include health insurance; and a dentist struggling to stay in business. By law, navigators aren’t allowed to steer people into a specific insurance company or plan. Instead, their goal is simply to help people weigh their options based on their personal needs, wants and budgets.
Every case is different, and the navigators we consulted for this story didn’t always see eye to eye. One corrected a serious error made by another regarding who is eligible for “standard” plans versus a “nonstandard” one. By law, a Vermonter can choose any of the 18 plans.
Does it make more sense to buy a platinum plan with a high monthly premium but low annual deductible and out-of-pocket costs, a high-deductible bronze plan with a lower monthly cost, which keeps more money in your pocket — or something in between? The correct answer takes into consideration each person’s medical circumstances and financial means.
There’s handholding involved, too, given that a lot of Vermonters are choosing, and paying for, their own health care insurance for the first time.
“We’re in a situation where there are going to be a lot of people getting used to writing a check each month for what they may feel is a significant amount of money for health insurance,” notes Jon Bourgo, a navigator with the Community Health Centers of Burlington, who has already advised hundreds of Burlington residents. “So are they willing to cut back on their cable TV? Are they willing to change their cellphone plan? Are they willing to give more importance to paying for health insurance? We’ll see.”
All photos by Matthew Thorsen
Obamacare’s poster couple
Name: Jane Dwinell, 59, and Sky Yardley, 63
Professions: Retired “for now”
Annual household income: $25,000
Current health insurance: Catamount Health Plan
Current insurance cost: $289 per month
Jane Dwinell literally wrote the book on frugal living. Her 2010 self-help book, Freedom Through Frugality, offers practical advice for living a simpler, happier and debt-free existence. Many of her suggestions are ones Dwinell and her husband, Sky Yardley, have implemented in their own lives. That includes living in a 160-square-foot “tiny house” mounted on a flatbed trailer they can pull behind a pickup truck.
It’s not surprising that the retired couple, who have divided their time among Vermont, New Orleans and France, are equally frugal with their health care spending. The surprise is that Dwinell, a retired nurse, doesn’t really believe in preventative care, such as mammograms or annual physicals.
“I’m an RN, so I have enough knowledge to know what things can be treated at home and what needs attention by a professional,” she says. “I have not seen a doctor for a physical since I was pregnant with my son, who is almost 23.”
Until recently, the couple didn’t have any health insurance — though for years, both their kids were covered by Dr. Dynasaur, the state-sponsored health insurance plan for children in low- and moderate-income households. Dwinell says her family only accesses the health care system when emergencies arise.
That happened seven years ago when Yardley and their daughter, Dana, who was 19 at the time, were both injured in an accident. The family was building a house in Montpelier when the scaffolding on which father and daughter were working suddenly collapsed. Sky broke his hand. Dana broke both wrists and needed surgery to repair a torn tendon.
Since the family had no health insurance at the time, they paid cash for it all. According to Dwinell, the medical expenses totaled $15,000, including emergency room visits for both patients, MRI scans, Dana’s surgery and physical therapy. One might assume the family would have paid less if they’d had insurance.
Dwinell discovered otherwise.
“I looked into it,” she says. “Because we were self-employed at the time, if we’d gotten insurance through Blue Cross it would have cost us $16,000 that year.”
Nevertheless, Dwinell and Yardley decided last year it was time to enroll in health insurance, in part because they knew it would soon be mandatory. In November 2012, they signed up for Vermont’s Catamount Health Plan. It offers qualifying two-person households earning $46,536 per year — or a family of four making $70,656 — insurance for less than $300 a month.
Dwinell used it for the first time last week, when she fell and broke a bone in her foot. The ER docs at Porter Hospital fixed her up, and she just received the bill: She has a $500 deductible for the ER visit and diagnostics; her insurance covers 80 percent. She also has a $10 co-pay for doctors.
“So if one does not need catastrophic care,” Dwinell concludes, “it’s cheaper to pay as you go like we’ve always done, given that we put out $3600 this year to begin with.”
The only health care providers Dwinell and Yardley see on a regular basis are the dentist and optometrist, she explains. “Both my husband and I wear glasses, and he wears contacts, and we believe in taking care of our teeth on a regular basis.” Neither, she notes, is covered by Catamount.
Dwinell doesn’t know yet how her family will fare under Vermont Health Connect, but she says her priority will be to save money and perhaps offset some of their dental and vision expenses.
What the subsidy calculator says:
Of the 11,427 people on Catamount in 2012, the state estimates that most — 10,015 — will have to buy a private insurance plan through Vermont Health Connect; the rest, those with the lowest incomes, will likely qualify for Medicaid. Based on their income, Dwinell and Yardley should qualify for a subsidy of $734 per month. That alone would buy them a high-deductible bronze plan.
What the navigator suggests:
Yardley and Dwinell could be the Affordable Care Act’s poster couple. Ann Slattery, who works in Fletcher Allen’s community health improvement department, explains that one of the goals of the legislation is to get more people accessing preventative care, so they’re not using the emergency room for their primary care or accessing the system for “reactive” medicine only.
One benefit of this new system, she explains, is that all wellness visits, such as annual physicals, mammograms, Pap smears, prostate exams, diabetes screenings and flu shots, are free and require no co-pays.
“When we look at this family, we’d say, ‘You are healthy. You might choose to take the bronze because it is cheaper per month. But if you do become ill, it’s going to cost you more.’” Slattery says. “A lot of times we’ll encourage people to take the silver plan instead, because although the premiums are a little bit more, the deductibles are less. So in the long run, it might be cheaper. But that’s totally an individual preference.”
What if Dwinell and Yardley were 26 years younger and Dana was yet to be born? Slattery notes that all the plans cover maternity and newborn care. Moreover, everyone can change their enrollment during a specified time period each year, depending upon their life circumstances. So a couple with a bronze plan the first year may choose to upgrade to silver the next year if they plan to have a child. Ditto if they are having one; pregnancy was once considered a disqualifying preexisting condition.
“As you know, all insurance is a gamble,” Slattery says. “It can be great insurance — until you have to use it.”
Young, professional and ill
Name: Julielyn Gibbons, 33
Profession: Online political strategist
Annual Income: recently $65,000-$80,000
Current health insurance: None
When Julielyn Gibbons was offered a position two years ago as an online political strategist for Burlington-based Democracy for America, her make-or-break criterion for accepting it wasn’t the salary, the hours, the workload or the cost of relocating from Michigan to Vermont. It was what portion of her monthly medical expenses would be covered by her new employer’s health insurance.
That’s because Gibbons, 33, has a severe case of Crohn’s disease. Since she was diagnosed with the inflammatory bowel condition at age 14, she’s had more than 38 surgeries that have cost her a colon, rectum and kidney. Once, Gibbons contracted a MRSA staph infection and nearly lost an arm. These days, she sees doctors and specialists frequently and spends up to $500 a month on medical supplies.
DFA, the political advocacy group founded in 2004 by former Vermont governor and physician Howard Dean, provided Gibbons with a generous health care package through Blue Cross Blue Shield of Vermont. It paid all her premiums. Gibbons only had to contribute to a health savings account, from which she paid no more than $2500 a year in out-of-pocket expenses, including co-pays for the kidney specialist and primary care physician she sees every three months. Typically, she says, she would reach her deductible by mid-July.
Gibbons’ situation changed in late August. She was one of about a half dozen staffers the progressive PAC laid off. As part of a severance package, she got a month of health insurance. Now she’s on unemployment, which doesn’t come close to covering the $600-plus per month it would cost to maintain the insurance she had through DFA. Gibbons has a live-in partner, but they’re not married and she says she can’t get on his plan. (Many Vermont companies cover domestic partners, but apparently not this one.)
“Like a diabetic needs insulin, I need my supplies,” Gibbons explains. “For me to go without insurance is not an option. I’ll be out on the street.”
Unlike many Vermonters who have not yet explored their insurance options through Vermont Health Connect, Gibbons has spent considerable time on the website. And, as a former patients’ advocate who’s worked with a lot of different insurance companies over the years, Gibbons has mostly positive things to say about Vermont’s new health care exchange.
On a recent weekend, for example, she emailed Vermont Health Connect some questions about competing plans. By 8:30 a.m. on Monday, the answers were in her inbox.
“Vermont, I’d have to say, probably has the best system in terms of the user’s experience,” Gibbons says. “But no matter how well versed you are in this stuff, health insurance is tricky and confusing.”
What plan is Gibbons considering? While she’d like a platinum or gold plan that requires a high monthly premium but covers nearly all of her out-of-pocket expenses, she says that her current unemployment may force her to sign up for Medicaid — the federal insurance plan for the poorest Vermonters. At least until she finds a new job.
“The reality is, I literally cannot live without health insurance,” Gibbons says, “so I have to suck up my pride and do what I’ve got to do.”
What the online subsidy calculator says:
Based on her unemployment status, Gibbons would likely qualify for Medicaid. Her previous earnings are not among the criteria for her eligibility.
What the navigator suggests:
Jon Bourgo at the Community Health Centers of Burlington agrees that Gibbons should qualify for Medicaid, which would cover nearly all of her medical visits and supplies. However, should she get a new full-time job in Vermont that provides health insurance, she’ll need to update Vermont Health Connect about her new status, then pick a new insurance plan.
Based on her ongoing medical needs, Bourgo says, Gibbons would likely want a plan with the lowest deductible and out-of-pocket expenses she can afford. “She’s the kind of person that, if she can afford something else, she definitely doesn’t want to buy a bronze plan.”
Bourgo points out that the platinum, gold and silver plans all have the same out-of-pocket limits on prescription costs — $1250 a year for an individual. The difference for Gibbons, he says, is how much she’d be expected to pay out of pocket for all her other medical expenses, such as her medical supplies. With a silver plan, it would be $5100 annually; with a platinum plan, $1250.
“So this becomes a very sophisticated calculation for someone in her situation,” Bourgo says. He suggests that Gibbons sit down with a navigator like himself, or a call-center operator, and do the math.
Fit family of five
Name: Katharine Montstream and Alan Dworshak, 51
Profession: co-owners, Montstream Studio
Annual household income: Declined to disclose
Current insurance: MVP Healthcare
Cost: $1305 per month, plus co-pays
Burlington artist and gallery owner Katharine Montstream admits she’s often fantasized about what she’d do with an extra $15,660, which is what her family currently spends on health insurance each year. Maybe they’d buy a new car or take a nice vacation.
“I can see where people would say, ‘Aw, screw it!’” Montstream says. “Health insurance is not like your vehicle, where if you don’t pay for it, they come and take it away.”
But Montstream is an artist, not a gambler, and she says she’s unwilling to let her family of five go uninsured for even one month. Because she and her husband, Alan Dworshak, have an active lifestyle and their kids run track and play soccer, someone is always spraining an ankle or injuring a knee.
Because Montstream and Dworshak are self-employed business owners — they sell paintings and greeting cards of Montstream’s artwork — they buy their insurance on the private market, which has traditionally charged some of the most expensive rates out there. Even at $1305 per month, their plan provides no coverage for vision, dental or prescription medications, Montstream says. Although there’s no annual deductible, and she reports having good experiences with MVP, the plan requires a $75 co-pay for every doctor visit. In a family of five, those add up.
“I’m not complaining, but we don’t have a regular paycheck,” Montstream says. “Certainly, if we could go to the eye doctor and get some of our dental covered, that’d be awesome, because stuff does come up.”
Wisdom teeth, for example. Over the summer, the dentist told Montstream’s 20-year-old son, who’s in college, that his back molars were going to “get wrecked” unless all four of his wisdom teeth were extracted.
“That was $3000 right out of my pocket. That sucks!” Montstream says. “And I got zero help on that one.”
Neither Montstream nor her husband has visited the state website to see how they’ll fare under the new health exchange. But she says she’s hoping they can find a plan that costs less each month than what the family is currently paying and “take my chances on our good health and save up a bit.”
“Mostly, I want to know what my bottom line is going to be, because of that huge chunk every month,” Montstream adds. “My concern is trying to pay for two kids in college and all our other expenses, such as taxes, utilities and other bills. If that were reduced, that’d be really exciting.”
What the online subsidy calculator says:
Based on the family’s annual household income range, which was provided on the condition it not be published, Montstream and Dworshak qualify for between $368 and $711 per month in subsidies. Upgrading to the silver plan would cost them between $460 and $803 additionally per month and lower costs for prescriptions and urgent care, say, if someone in the family has a sports injury and needs pain medicine. The top-of-the-line platinum plan — with the lowest out-of-pocket costs, no deductibles for drugs, ER visits, urgent care and office visits, would run them an extra $943 to $1285 on top of the subsidy. Additionally, the family’s 13-year-old daughter may qualify for Dr. Dynasaur until she’s 18 years old. If so, she’d get glasses and probably her wisdom teeth out for free.
What the navigator suggests:
Amelia Schlossberg, a navigator with the Community Health Centers of Burlington, suggests that if Montstream and Dworshak are looking to save money and get some of their family’s dental and optical care covered, they may want to choose a high-deductible silver or bronze plan with a health savings account. Annual eye exams would be covered and the family could put money in their HSA that could be used to buy glasses or contact lenses and dental visits.
With at least a $368 subsidy, Schlossberg adds, this family could buy a high-deductible bronze plan for about $700 a month, deposit another $300 per month in their HSA, and still be saving more than $300 over their current insurance costs.
Three jobs without insurance
Name: Krystal Woodward, 48
Profession: property manager; part-time office assistant, Johnson State College
Annual household income: $8640
Current health insurance: Vermont Health Access Plan
Cost: $33 per month
Krystal Woodward has experienced both ends of Vermont’s health insurance spectrum. For more than a decade, she enjoyed “top-of-the-line” coverage through her civil union partner, whose health insurance covered both of them through Johnson State College. That plan included many perks not included in other employee-provided insurance plans, such as dental and vision coverage and mental-health counseling.
Woodward lost all those benefits when her civil union was dissolved last December. Her own 20-hour-per-week job in JSC’s athletic department doesn’t qualify her for any benefits.
Today, Woodward, 48, cobbles together a living by doing three part-time jobs. In addition to her work at the college, she works in a cooperative barn where she stables her horses. She also manages 13 apartments in Johnson. The latter job provides her with rent-free living. “I have my hands full,” she says.
For about a month, Woodward went without any health insurance whatsoever, but she knew that wasn’t a wise long-term situation. One kick from a horse or a serious fall while working on an apartment, she says, and she could be facing tens of thousands of dollars in uninsured medical bills.
Woodward knows all too well how quickly one’s health status can change. About a decade ago, while constructing a second house on a property she and her former partner owned, Woodward fell through a staircase. She broke her wrist, collarbone and several ribs, and suffered a head injury that caused her to lose her vision for six months. She estimates her total medical bills from that one incident exceeded $100,000. Fortunately, her partner’s insurance plan covered nearly everything.
Today, such an accident would likely bankrupt her, Woodward says, were it not for VHAP — which covers qualifying Vermonters who make less than $21,264 a year. Because of her income, Woodward pays $33 per month and has small co-pays for her doctor visits — or would if she ever used the plan, which she hasn’t yet.
Woodward used to be “pretty faithful” about getting annual physicals and visiting the dentist regularly. Now “I don’t do any preventative care, and I haven’t been to the dentist. I don’t even know if dental is covered,” Woodward says. VHAP doesn’t pay for dental care.
Woodward hasn’t ventured onto the Vermont Health Connect website yet, but not for lack of knowledge about the exchange. She knows it goes lives on October 1 but has yet to receive a notice from VHAP letting her know that the state program will not exist as of January 1. Moreover, she’s not sure whether she’ll qualify for a state subsidy or for Medicaid, the state’s public health coverage program for low-income Vermonters, as she still has some savings in the bank.
Does Woodward think she’ll fare better, worse or about the same under Vermont Health Connect?
“I am terrified to go find out,” she says, “but I’m willing to navigate it to find out what I come up with.”
What the online subsidy calculator says:
Because of her income and the fact that Woodward is ineligible for health benefits from any of her jobs, she will likely qualify for Medicaid, where she’ll have virtually no out-of-pocket medical expenses. Nearly all of her preventative care would be covered, including annual teeth cleanings and eye exams but not glasses or contact lenses. In fact, of the 38,602 people on VHAP in 2012, the state estimates that the majority — 28,587 — will qualify for Medicaid.
What the navigator suggests:
Tatum O’Malley, a navigator at the Champlain Valley Office of Economic Opportunity in Burlington, concurs, saying Woodward’s declared income should qualify her for Medicaid. However, O’Malley cannot guarantee that eligibility until Vermont Health Connect goes live and its computers are synched with the Internal Revenue Service database. She points out that the federal government considers both earned and unearned income when determining Medicaid eligibility.
If the IRS determines Woodward has too much money in the bank, O’Malley recommends a high-deductible bronze plan because of the low monthly premiums — as she does for most Vermonters of modest means.
She cautions that people should consider factors other than just cost. “We might ask people who think of themselves as ‘healthy’ about their lifestyle,” she says. “If someone is highly active and into taking risks — anything from backcountry snowboarding and less than 100 percent birth-control protection to regular alcohol or other drug use — they might want to think about the financial consequences of choosing a bronze plan if something did happen.”
Provider and employer
Name: Joyce Hottenstein, 51
Annual household income: less than $125,000
Current health insurance: Blue Cross Blue Shield of Vermont
Current insurance cost: $692 per month for a two-person plan
Joyce Hottenstein is the kind of customer that insurance companies love: She follows a healthy vegetarian diet; doesn’t drink much or smoke at all; is diligent about routine visits to her doctor and dentist; and tries to keep her stress levels low through yoga, meditation, regular exercise and twice-a-month massage therapy. As a result, she almost never goes to the doctor for anything but preventative care. As she puts it, “If you don’t have your health, what do you have?”
But Hottenstein’s stress levels have been steadily rising lately, especially as she anticipates Vermont’s new health care exchange, which she adamantly opposes. The 51-year-old dentist, who’s been practicing in Rutland for 13 years, launched a new solo practice about three years ago and is struggling to stay afloat. Despite Vermont’s reported dentist shortage, Hottenstein has had a hard time finding clients, and that’s made it difficult to pay off the loans on her new business.
“People don’t have jobs,” she explains. And if they don’t have jobs, they can’t pay me.”
Despite her financial woes, Hottenstein wants to do right by her six employees. She gets insurance for them — and herself — through the Vermont State Dental Society and pays their premiums in full. Two part-time employees get the cash equivalent.
“I don’t believe in this whole exchange system the way Vermont has set it up,” she says, pointing out that small Vermont employers like herself could face a double whammy. “As much as I like my employees, I’m not going to pay a penalty and then subsidize their insurance through my own higher taxes.”
Hottenstein pays $692 a month to insure herself and her 59-year-old pharmacist husband. Ironically, the plan doesn’t cover any of their dental expenses. She has no co-pays for regular office visits, but the couple has to pay a very high annual deductible before the coverage kicks in: $12,000. They’ve met it only once in the last five years, when her husband had elective surgery to fix a bone spur in his shoulder.
Hottenstein pays for almost all of her medical and dental expenses out of her health savings account, into which her company makes pre-tax contributions. But she complains that the federal government limits those contributions to a total of $6450 per year, rather than allowing the couple to contribute up to the full amount of their deductible.
Planning what she’ll do when Vermont Health Connect goes live has been difficult and confusing, Hottenstein says. As a provider, she still doesn’t know what plan she’ll buy for her employees or herself, largely because she’s not sure what her income will be next year. One employee will be out on maternity leave. And she still doesn’t know what the insurance companies will pay in reimbursements for her services. The Green Mountain Care Board recently told Blue Cross Blue Shield and MVP to lower the proposed charges for some procedures.
“How am I supposed to make business decisions when, in less than five months, they’re going to be changing what they pay me?” Hottenstein asks. “This is a subject that I’m getting bashed with on both sides of my head.”
Hottenstein has considered moving her practice to another state. “I would leave in a heartbeat,” she admits, “but I’m underwater in my business right now.”
What the subsidy calculator says:
Because of their household income, Hottenstein and her husband do not qualify for any federal subsidies. A high-deductible silver plan would cost them $841 per month. A “nonstandard” gold plan through Blue Cross Blue Shield would cost $920.74.
Hottenstein has yet to verify this with a navigator. “I’m not giving them any of my information. I don’t trust them,” she says. “It’s none of their damn business!”
She does have one question for the navigators: “What if I offer insurance and nobody takes it? Will I still be penalized?”
What the navigator says:
Peter Sterling is a navigator with the Vermont Campaign for Health Care Security in Montpelier. He says that Hottenstein must first decide whether to continue offering insurance to her employees — or drop it altogether.
If she chooses the latter option, her employees would go on the exchange and buy their insurance as individuals. Depending on their income, they may or may not qualify for federal subsidies. Remember: Vermonters insured through their employers won’t get any financial assistance from the government, no matter how little money they make. Sterling says it’s worth doing the math to ascertain which route would yield the greatest health care insurance savings.
Under that scenario, there’d be no federal penalty on Hottenstein because she has fewer than 50 full-time employees — the federal cutoff. But the state of Vermont will be imposing its own penalty, or “assessment,” on businesses that choose not to provide health insurance. The question is how the total sum of those penalties compares with the new cost of insuring employees through the exchange.
Hottenstein is in luck here. Sterling notes Vermont’s “assessment” only kicks in at five employees. Because she has only four full-time employees, she would not pay any federal or state penalty. And, if she offered insurance and none of her employees accepted it, there’d be no penalty, either.
If Hottenstein wants to keep offering her employees health insurance, her next step is deciding how much to contribute to their premiums. For example, if she offered everyone $400 per month, she’d call Vermont Health Connect and supply that information. When each of her employees then goes to the website to select an individual plan — based on needs and budget — he or she will see Hottenstein’s contribution factored into the price calculation. If it’s a $600 plan, each month Hottenstein would pay $400 toward that premium and $200 would be taken out of the employee’s paycheck. Both contributions, as well as any made to an HSA, are pre-tax.
“The benefits package for all the plans is exactly the same,” Sterling emphasizes. “So the only thing her employees will go shopping for is the cost-sharing mechanism.”
As for Hottenstein and her husband, Sterling says that if they want to continue with a high-deductible, low-premium plan with an HSA, they can pick a standard bronze plan for $672.26 per month. Preventative care is 100 percent covered and the medical deductible is $7000. Their out-of-pocket maximum would be $12,500.
Also, because Hottenstein is diligent about her preventative care, she may want to explore some nonstandard plans. Unlike the standard plans, which were created by the state, these products were designed by the insurance companies. Although the benefits are identical to those of standard plans, the nonstandard ones have somewhat different cost-sharing options, such as lower co-pays and certain wellness incentives.
Still have questions about Vermont’s new health care exchange? Tune in to a discussion with a panel of Vermont Health Connect navigators on Thursday, October 3, from 6:30-7:30 p.m. on Burlington’s Channel 17 Town Meeting Television. Seven Days will be streaming this live, call-in show at sevendaysvt.com.
The original print version of this article was headlined "Patients and Understanding"