Health Insurance

US health insurers raise rates to match increase in usage

SACRAMENTO, California (AP) — After putting off routine health care for much of the pandemic, Americans are now returning to doctors’ offices in big numbers — a trend that’s starting to show up in higher insurance rates across the country.

Health insurers in individual marketplaces across 13 states and Washington D.C. will raise rates an average of 10% next year, according to a review of rate filings by the Kaiser Family Foundation.

That’s a big increase after premiums remained virtually flat for several years during the pandemic as insurers seek to recoup costs for more people using their policies, combined with record-high inflation that is driving up prices for virtually everything, including health care.

The rates review included Georgia, Indiana, Iowa, Kentucky, Maryland, Michigan, Minnesota, New York, Oregon, Rhode Island, Texas, Vermont and Washington.

“We’re at a point in the pandemic where people are using health care that they may have put off before,” said Larry Levitt, executive vice president for health policy with the Kaiser Family Foundation. “We have a double whammy right now of people using more care and inflation throughout the economy.”

In California, state officials announced Tuesday that rates would increase an average of 6% next year for the 1.7 million people who purchase coverage through Covered California, the state-operated health insurance marketplace. That’s a big jump after years of record low increases, when rate increases averaged about 1% in the past three years.

Increased use of health plans was the biggest reason for the increase, accounting for four percentage points, according to Jessica Altman, executive director of Covered California.

“That is really the consistent message that other states are seeing as well, and even more so than California,” she said.

About 14.5 million people purchased individual health coverage through state marketplaces this year, according to the Kaiser Family Foundation.

That’s a small portion of the total number of insured Americans, as about 155 million people get their insurance through their employer-sponsored coverage. But Kaiser said the filings for the individual plans are more detailed and publicly available.

The annual open enrollment period for when customers can shop for and buy 2023 coverage starts this fall. That’s the main window each year when people on the individual market can buy coverage or change plans.

How much people will pay for coverage depends on a variety of factors, including where they live and what type of plans they choose.

The rate increases come as Congress debates whether to extend financial help for consumers through the American Rescue Plan — the $1.9 trillion economic aid package Congress passed last year to combat the economic impacts of the pandemic.

The American Rescue Plan included significant funding to keep health insurance premiums low for people who purchase coverage through state marketplaces.

California receives about $1.7 billion annually from that funding to make sure no one paid more than 8.5% of their household income on monthly premiums.

If that assistance expires at the end of this year, about 3 million Americans — including 220,000 Californians — would likely drop coverage because they will no longer be able to afford it, according to an analysis by Covered California.

Without guidance on whether Congress will extend the assistance next year, some insurers have reacted by proactively raising rates in anticipation of people dropping coverage. The uncertainty accounted for half a percentage point of California’s 6% increase, Altman said.

California officials have lobbied hard for Congress to extend the financial assistance through the American Rescue Plan. In general, the price of health insurance premiums depends on who is buying coverage. If its mostly sick people, the premiums are more expensive. If more healthy people buy them, the premiums cost less.

Altman said California has managed to keep its rate increases below the national average in part because more healthy people are buying coverage through Covered California than most other states.

She said that’s in part because of a California law that taxes people who refuse to purchase health coverage. But she said it’s also because of subsidies that keep premiums low so more people can afford them.

Altman said not extending the federal financial assistance would price some people out of coverage and “is the core outcome to be concerned about here.”

“That would be a big step backwards,” she said.

___

Associated Press health writer Tom Murphy in Indianapolis contributed to this report.

A Retirement Journey: Health Insurance Issues

Over the past two weeks, we’ve focused on the story of Bob, a recent retiree. We’ve gone over his pre-retirement experience and his journey through the processing of his retirement application. This week, we’ll look at his health insurance choices.

Bob has an ongoing dilemma when it comes to health insurance. He arguably doesn’t really need Federal Employees Health Benefits coverage or Medicare, because he is a veteran with a service-connected disability. That means all of his medical needs (service-connected and otherwise) are provided by the Veterans Health Administration, at no charge. VHA does bill private insurers (including those in FEHB) for the non-service connected care it provides.

Nevertheless, Bob enrolled in FEHB during his civilian service at the Federal Aviation Administration for a couple of reasons: in case he should need it for a future spouse, should he remarry, and in order to meet the requirement of being enrolled for the five years prior to retiring. Now that he’s retired, if he cancels his FEHB coverage, it’s a one-way ticket out. Bob isn’t eligible to suspend his FEHB, since having VA health benefits is not one of the reasons an enrollee can take this action. And he isn’t eligible for TRICARE because he isn’t retired from military service. 

Since Bob is over 65, he is enrolled in Medicare Part A. But he chose not to enroll in Part B (coverage for doctors and outpatient services). This won’t put him at great risk, because FEHB doesn’t require Medicare enrollment to maintain coverage. Bob has considered dropping FEHB, but he believes it’s possible Congress may not provide enough funding in future years for the VA to care for all veterans. Veterans who are in one of the lower priority groups could conceivably lose health care benefits in the future.

Bob could enroll in Part B later in a future general enrollment period. These are held each year from Jan. 1 to March 31, with coverage effective July 1. But he might be subject to  a late enrollment penalty for every 12-month period in which he could have been enrolled but chose not to. Currently, Bob has the opportunity to participate in a Part B special enrollment period,during which he can enroll without penalty. It will end eight months after his retirement last December. 

Here’s Bob on his insurance decisions: 

I enrolled in FEHB with the GEHA Standard Option FEHB plan when I onboarded in 2012, but switched to the GEHA High Deductible Health Plan about four years ago. My current premium is $136.95 per month. The HDHP includes a Health Reimbursement Arrangement, since I am not eligible to have a Health Savings Account. Having other health insurance, such as Medicare, disqualifies members from using the HSA, so GEHA establishes an HRA that does not earn interest and is not portable if I switch to another plan. But it does provide $900 annually to spend on co-pays for qualified medical expenses, as defined by the IRS.

The way I see it, having this extra $900 a year benefit effectively reduces my monthly premium. The way it works is when the VA sends the bill for my care to GEHA, GEHA pays the amount that would be covered by the plan. The remainder is covered by the VA, leaving me with $0 out of pocket expense for my care. I don’t have to worry about meeting the deductible or paying copayments since the VA covers my medical expenses.

Upon reaching my 65th birthday, I enrolled in Medicare Part A, since there is no premium for this coverage that helps cover the cost of in-patient hospitalization. Post-retirement, I am continuing my FEHB plan with GEHA but not Medicare Part B. Still, I question whether I really need it, when all of my medical care is free at the VHA. Veterans make up 30 percent of the federal workforce. And some of those veterans, like me, have service-connected disabilities and access to free medical care through the VHA. I also know retired veterans who thought that TRICARE for Life was free, until I told them that they had to enroll in Medicare Part B as well. With very few exceptions, all of my VHA visits are non-service-connected.

Bob’s Bottom Line

Bob’s top piece of retirement planning advice is not to be afraid to ask questions. He told me the people he spoke with at various federal agencies actually seemed to enjoy helping with whatever questions he had. Keep in mind that Bob communicates very clearly and takes his time. Customer service is a two-way street.

Of course, when it comes to retirement preparation, everyone needs to run the numbers. Make some rough financial projections, so you have a general idea of your income and expenses in retirement.

Bob has about half of his retirement income coming from his Social Security benefit, a little less than 20% from his federal retirement benefit, about 30% from a private sector pension that does not receive a cost of living adjustment, and roughly 3% coming from the VA. He doesn’t need to withdraw from his investments yet.

Overall, Bob is in very solid financial shape, due to his foresight, patience and planning.

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Health insurance giant Empire pulls out of NYC’s controversial Medicare plan for retired city workers

A major insurance company has pulled out of a deal to administer New York City’s new Medicare Advantage Plan — the latest setback in the city’s effort to shift roughly 250,000 retired municipal workers onto the controversial health coverage.

Empire BlueCross BlueShield, one of the country’s largest health insurance providers, notified Mayor Adams’ office that it’s not going to help roll out the Advantage plan after the city failed to provide a start date and benefit specifics as requested by July 15, the company said in a statement Tuesday.

“This timeline was important because delaying any further would not give retirees enough time to fully understand their options, benefits, and coverage in advance of open enrollment,” the statement read. “Given the level of uncertainty at this time, we informed the city that (Empire) is not able to participate.”

In light of Empire’s withdrawal, City Hall spokesman Jonah Allon said Adams’ administration is on the hunt for a new provider.

“We remain committed to moving forward with the program and are exploring alternative options,” Allon said.

Empire’s exit is the latest hiccup in the Adams administration’s push to implement the Advantage plan, which is supposed to save the city hundreds of millions of taxpayer dollars annually thanks to the partnership with a private insurance provider.

First proposed by former Mayor Bill de Blasio, the plan was supposed to go into effect earlier this year with Adams’ blessing.

But Manhattan Supreme Court Justice Lyle Frank blocked the plan, ruling in March that it was illegal because it contained a provision that would slap a $191 monthly penalty on retirees who opted to keep their current traditional Medicare instead of getting automatically enrolled in the Advantage plan for free.

The Adams administration is appealing Frank’s ruling. City Hall confirmed Tuesday that the appeal is ongoing.

Frank’s decision was the result of a lawsuit filed by the NYC Organization of Public Service Retirees, which has argued the Advantage plan would water down health coverage for the city’s tens of thousands of retirees, including by instituting complicated pre-authorization requirements for certain medical procedures and treatments.

Marianne Pizzitola, the organization’s president, said she has for months asked City Hall for an opportunity to discuss the matter with Adams — and that she finally got a meeting scheduled with the mayor for this past Monday.

However, late Sunday, Pizzitola said she got word from City Hall that Adams could no longer meet after finding out the city remains in litigation with her group.

Pizzitola, a retired FDNY EMT, said she wishes Adams would take time to hear from her and the thousands of other former city workers who have pleaded with him to scrap the Advantage plan and let them stay on traditional Medicare.

“I really wish that he would just listen,” she said.

How to avoid a tax surprise from marketplace health coverage

Kateryna Onyshchuk | iStock | Getty Images

If your income is trending much higher this year than you anticipated, it's likely a welcome shift.

However, for anyone who gets their private health insurance through the public marketplace, that extra cash could mean an unexpected tax bill when they prepare their 2022 return next spring. A midyear income check could help avoid that.

Basically, if you receive premium subsidies (technically, advance tax credits) through the marketplace, having annual income that's higher than what you estimated when you enrolled could mean you're not entitled to as much aid as you're receiving. And any overage would need to be paid back at tax time.

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Report changes that may affect insurance subsidies

"You really should go into [your account] and take the steps to change your estimate so they can revise the subsidies as soon as possible," said Kristin Esposito, director for tax policy and advocacy with the American Institute of CPAs.

Esposito said a drop in income should also be reported — which could result in you getting bigger monthly subsidies. Make sure your account reflects other life changes, too, including marriage or a new member of your household, which also can impact the size of the aid.

"There are a lot of circumstances that can change and affect your insurance coverage," said Cynthia Cox, a vice president at the Kaiser Family Foundation and director of its Affordable Care Act program. 

Changing your information generally involves calling the exchange or going to your online account and updating your application (or calling the exchange). If you used an insurance agent or broker to sign up, or were assisted by a community organization, you should be able to get help from them, as well.

Income cap changes may reduce tax surprises

Roughly 89% (12.9 million) of the 14.5 million people enrolled in private health insurance through the public marketplace — which was authorized by the Affordable Care Act of 2010 — are receiving subsidies. Generally speaking, people who get coverage this way — either through healthcare.gov or their state's exchange — are those who can't get workplace insurance or who don't qualify for Medicaid or Medicare.

Subsidies through the exchange were expanded for 2021 and 2022 due to the American Rescue Plan Act of 2021. (Senate Democrats are trying to get the current expansion extended for two more years, although it's still uncertain whether it will happen.)

It's still important to report an income change to avoid any kind of surprise, but hopefully the worst kinds of surprises won't happen as much this year.

Cynthia Cox

Kaiser Family Foundation and director of its Affordable Care Act program

Prior to the temporary expansion, the aid was generally available to households with income from 100% to 400% of the federal poverty level.

The cap on income was eliminated for 2021 and 2022, and the amount that anyone pays in premiums is currently limited to 8.5% of their income as calculated by the exchange. 

The temporary removal of the income cap means there may not be as many cases of people having to repay all of their subsidies: Before, if someone estimated their income was at 399% of poverty but it ended up at 401%, they'd have to account for those subsidies on their tax return.

"It's still important to report an income change to avoid any kind of surprise, but hopefully the worst kinds of surprises won't happen as much this year," Cox said.

Review key tax forms next spring

When you start getting tax forms early in 2023 (for example, your W-2, or 1099 forms due to interest or dividend income), one of them generally will be a Form 1095-A from the insurance marketplace, which details how much you received each month in tax credits.

That document is then used to complete Form 8962, which shows whether you received the correct amount in subsidies — and if not, what the excess or shortfall is, Esposito said.

Any amount you weren't eligible for would reduce your refund or increase the amount of tax you owe. Likewise, if you are entitled to more than you received, the difference will either increase your refund or lower the amount of tax you owe.

Retiree health insurance to end for new administrators in Buffalo schools | Education

Lifetime health insurance is about to become a thing of the past for administrators in the Buffalo Public Schools.

Administrators hired after July 2023 will not be eligible for health insurance paid for by the district after they retire, under the terms of a new contract approved this week by the School Board. 

“It is significant. It’s something the district had pursued for at least the last two collective bargaining agreements,” said Robert Boreanaz, the attorney for the Buffalo Council of Supervisors and Administrators.

Over the years, Boreanaz said, Buffalo had become one of the few districts in New York State still providing retirees with health insurance.

Administrators hired prior to July 2023 will remain eligible for retiree health insurance.

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Those hired after July 2023 will have the option of selling back to the district up to 120 unused sick days to be used toward the cost of their health insurance premiums after they retire.

Teachers in Buffalo still receive retiree health insurance. The Buffalo Teachers Federation is currently in negotiations with the district for a new contract. Union President Phil Rumore said the district is hoping to negotiate an end to retiree health insurance for teachers.

“Every union has the right to do what they think is best for their members,” Rumore said. “But I believe it’s against everything that unions stand for, to sacrifice newer members for existing members.”

The administrators union represents about 200 principals, assistant principals and Central Office administrators.

"This contract benefits both parties by eliminating the discrepancy in pay between elementary and high school principals, makes changes to health care benefits, in addition to raises and a signing bonus," said School Board President Lou Petrucci.

Until now, elementary principals had been paid less than high school principals.

“Many years ago, the elementary schools were much smaller than the high schools, and had less students. That’s not the case anymore,” Boreanaz said.

The contract brings nominal increases in the amount that administrators have to contribute toward their health insurance premiums. Veteran administrators will now pay 10% of their premium, and new administrators will pay 16%.

The contract also brings pay increases.

This summer, administrators will receive a 10% raise, plus step increases. Then, for each of the following three years, they will receive a 3% raise, plus step increases.

Boreanaz pointed out that the administrators union’s previous contract, which was reached in 2017, expired nearly two years ago.

Administrators also will each receive a one-time bonus equal to 7% of their annual salary as a result of ratifying the new contract. 

The administrators union met with district officials 13 times over 16 months to hash out the terms of the new contract, he said. The majority of the progress toward reaching the contract was achieved under the past few months under Superintendent Tonja Williams, Boreanaz said.

“Unequivocally, the principals and administrators of the Buffalo School District are really looking forward to a new chapter and working with and supporting the new superintendent,” he said.

Now that the administrators contract has been settled, Petrucci said, the board can focus on settling the teachers contract.

"Contracts are about more than just dollars; new contracts help the district to address changes in working conditions and benefits," he said.

N.J. public workers face big increase in health insurance rates in coming year

Hundreds of thousands of public workers, early retireesm and school employees in New Jersey are facing potential rate increases of as much as 24% for health benefits under proposals being considered by the State Health Benefits Commission.

Rate increases being considered include a 24% increase for medical and a 3.7% increase for pharmacy benefits for active public workers, as well as a 15.6% increase in medical and a 26.1% increase in pharmacy benefits for public workers who retired before the age of 65, according to an email sent to county administrators from New Jersey Association of Counties Executive Director John Donnadio.

Donnadio said in the email that the figures, which haven’t been made public, were shared by an insurance and benefits broker.

StateTreasury spokeswoman Jennifer Sciortino acknowledged rate increases were being considered and added that rates for active members and early retirees would likely increase between 12-20% across the various plans for the upcoming year.

A vote to approve the rate increases was scheduled for Monday, but the state health benefits board and the Division of Pension and Benefits postponed the vote after acknowledging during a public meeting on July 13 that more time would be needed to address questions and concerns, Sciortino said.

“As has been the official process for many years now, the presentation materials provided to the State Health Benefits Program and School Employees Health Benefits Program Commissions last week are confidential until the rates are finalized,” Sciortino said.

The New Jersey League of Municipalities on Wednesday sent an email urging members to contact their representatives and the governor’s office, prompting a public outcry from state and local governments, as well as Democratic and Republican state lawmakers.

“This is a staggering increase that will saddle taxpayers, public sector workers and educators with higher costs at a time when we are all contending with inflationary pressures and a possible recession,” state Senate President Nicholas Scutari, D-Union; Senate Majority Leader Teresa Ruiz, D-Essex and Senate Budget Chairman Paul Sarlo, D-Bergen, said in a joint statement.

The Democratic state senators urged the board to reject the proposal and called on New Jersey Treasurer Elizabeth Muoio to use her authority to block the planned approval “and make sure a full accounting of the finances of the two health benefits’ plans is made public and fully discussed.”

Republican leadership in the state Legislature on Thursday called for the creation of a special legislative committee to investigate Democratic Gov. Phil Murphy’s administration for a “failure to control health care costs for public employees, retirees and taxpayers.”

“The 24% premium increase proposed for most active employees will take thousands more out of their paychecks annually and lead to huge costs for local governments that will translate into higher property tax bills for struggling families,” state Senate Republican Leader Steven Oroho, R-Sussex, said in a statement. “We must investigate the failures that led to these catastrophic premium increases to develop an effective plan going forward.”

The proposed rate increases shine a new spotlight on allegations that the Murphy administration squashed an attempt to recover $34 million the state paid to Horizon for a cost savings program that outside consultants found “yielded no apparent savings,” according to a report from Bloomberg.

Horizon administers health care plans for state and local government employees and retirees in New Jersey.

“It’s absolutely scandalous that high-level administration officials would intercede to prevent Horizon from being held accountable as premiums are set to skyrocket,” Senate Republican Budget Officer Declan O’Scanlon, R-Monmouth, said in a statement. “Employees, retirees, and taxpayers deserve to know why.”

Sciortino said several “extraordinary factors” are affecting rates for the coming year, including higher utilization of medical services during the COVID-19 pandemic and a return to normal services and procedures that had been previously postponed.

Those factors are being compounded by rising prices amid historic inflationary pressures that have increased health care costs nationwide.

“While there is significant volatility in health care trends, the rate increases for the State plans are in line with rate increases that our consultants’ other clients are experiencing and are also being reported nationwide,” Sciortino said. “We believe that these circumstances are an anomaly, rather than the norm, and we believe that it is more likely than not that utilization and costs will normalize.”

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Derek Hall may be reached at [email protected]. Follow him on Twitter @dereknhall.

Californians brace for increased healthcare premiums if federal subsidies expire

For the last two years, Syd Winlock has had a major burden lifted from his surgically repaired shoulder.

Federal subsidies passed as part of a temporary pandemic relief package have drastically cut how much he pays in healthcare premiums, allowing the Sacramento-area small-business owner to purchase an insurance plan during the last two years that provided better coverage for his shoulder and knee replacements.

Those federal subsidies, however, will expire at the end of this year if Congress does not extend the program. His “very manageable” price — about $700 a month for him and his wife — will increase to $2,300, Winlock said.

“Even if we went to a lesser-type policy, it would still be about $1,800 a month,” Winlock, 63, said. “I mean, that’s more than my mortgage.”

Roughly 150,000 lower- and middle-income Californians would be similarly priced out of coverage by the rising premiums if the federal subsidies are not extended, a Covered California analysis recently estimated.

The federal subsidies were passed in early 2021 as part of the Biden administration’s American Rescue Plan Act, which temporarily provided help to Americans to recover from the economic and health effects of the COVID-19 pandemic.

Under the act, health insurance premiums were capped at 8.5% of a household’s income. That significantly dropped monthly payments and led to more consumers signing up through Covered California, the insurance marketplace created by the 2010 Affordable Care Act for working-age people who aren’t covered by a health plan at their job.

Enrollment in the state’s exchange has hit a record-high 1.8 million, of which Covered California reported that 92% received some form of subsidy.

“These enhanced subsidies have fundamentally delivered affordability and delivered on the promise of the Affordable Care Act in the way that it was intended,” said Jessica Altman, executive director of Covered California.

“There were a lot of people who said things like, ‘Oh, my gosh, you know, for the first time I can afford my health insurance and my child care....’ This is particularly important given the inflationary environment we are in now.”

More than 1 million lower-income earners — individuals making between $17,775 and $32,200 and families of four with income between $36,570 and $66,250 — would see their premiums more than double if Congress doesn’t extend the program, according to the Covered California analysis. Monthly premiums for middle-income earners would increase, on average, by $272 per member next year.

John Baackes, the chief executive of L.A. Care, a health insurance plan serving Los Angeles County’s poorest and most vulnerable residents, said that although the enhanced subsidies don’t expire until the end of the year, the window for Congress to act is growing smaller because of its monthlong August recess. At that point, legislation typically slows down in an election year.

Baackes said health plans will need time to send renewal notices to consumers of anticipated rates for the 2023 coverage year, which are mailed in October.

“So we’re very concerned about it,” Baackes said. “The American Rescue Plan provided increased subsidies that are really a wonderful thing. And many of our members benefited from it.”

With open enrollment beginning one week before the Nov. 8 midterm elections, Democrats on Capitol Hill are increasingly eager to prevent consumers from receiving notices about huge increases in insurance premiums before voters go to the polls. But the debate about whether to extend the subsidies or — as some have pushed — make them permanent has been hamstrung by wrangling over the price tag and the effect on skyrocketing inflation.

Keeping the subsidies an additional three years would cost $74 billion, while the price tag for making them permanent is $220 billion over the first 10 years, according to the Congressional Budget Office.

Gov. Gavin Newsom and state lawmakers proposed spending $304 million in separate state healthcare subsidies to lessen the burden if the federal program is not extended. That money, which is included in a state budget that is expected to be finalized this month, would offset premium increases for more than 700,000 residents.

However, those state-funded subsidies will cover only a fraction of the federal premium discount currently available under the American Rescue Plan, which provided $1.7 billion to California in each of the last two years to help with healthcare costs.

“Nearly half of the folks in Covered California are paying less than $10 a month,” said Anthony Wright, the executive director of Health Access California, a consumer group that is pushing Congress to make the increased federal subsidies permanent. “We live in a high-cost-of-living state, so people will have to make decisions about how much healthcare they can afford.”

That worries Tuan Nguyen, a caregiver in the Silicon Valley city of Milpitas. Having been diagnosed six years ago with a rare and painful disorder called glossopharyngeal neuropathy, Nguyen said he has to buy more costly insurance coverage that allows him to see particular specialists.

“I need the healthcare plan,” said Nguyen, 44. “I need to see my doctor. I need my treatment. These are things that are a necessary part of my life, and they’re all very expensive and getting much harder to afford.”

Reducing the number of uninsured residents in the state has been a top priority for Newsom and legislative leaders, who in 2019 approved legislation creating a fee for anyone who does not have insurance. The individual mandate was intended to induce younger and healthier individuals to buy coverage through Covered California to widen the pool and lower rates overall as Democratic leaders move California closer to universal coverage.

As part of that effort, California has incrementally expanded eligibility for Medi-Cal, the state’s healthcare program for the poor, to certain age groups of low-income people regardless of immigration status. California’s pending budget would offer Medi-Cal to the final remaining age group in 2024, opening the healthcare program to residents 26 to 49 years old regardless of immigration status. Newsom said the move will make California “the first state in the country to achieve universal access to health coverage.”

Miranda Dietz, a research and policy associate at UC Berkeley Labor Center, said the significant increase in the number of Californians with health insurance over the last two years would be in jeopardy without the federal subsidies. Dietz co-wrote a study in partnership with the UCLA Center for Health Policy Research that projects that as many as 1 million people will forgo insurance in California next year if federal subsidies expire.

“It makes it so it’s very disheartening to take away these extra subsidies that have been really crucial in improving affordability for folks,” Dietz said. “It’s a real blow towards that goal of universal coverage and more affordable coverage.”

The added cost of premiums “will be a real struggle for folks who are deciding between rent and groceries,” Dietz said.

For Winlock, the small-business owner, the added cost if federal subsidies are not extended would be temporary. Next year, Winlock and his wife turn 65 and will qualify for Medicare. In the meantime, he would probably look for the cheapest plan possible and hope for the best.

“We probably would look at some alternative ways to get healthcare,” Winlock said. “We certainly wouldn’t be able to afford mainstream healthcare. It is just out of our budget.”

Times staff writer Jennifer Haberkorn in Washington contributed to this report.

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Supreme Court Roe v. Wade decision could affect health insurance coverage

Abortion rights demonstrators protest outside the United States Supreme Court as the court rules in the Dobbs v Women's Health Organization abortion case, overturning the landmark Roe v Wade abortion decision in Washington, U.S., June 24, 2022. 

Jim Bourg | Reuters

Even when Roe v. Wade was in effect and women had the legal right to an abortion no matter where they lived in the U.S., health insurance coverage of the procedure was limited.

Many states restrict what plans can cover, and a decadeslong national law bans the use of federal funds for abortions, meaning that women on Medicaid and Medicare were often not covered when it came to pregnancy terminations.

With abortion now expected to be prohibited in at least half the states after the landmark decision protecting women's right to an abortion was overturned by the Supreme Court last week, coverage will only become rarer, experts say.

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"State-regulated insurers in states where abortion is banned will have to drop coverage of abortions to stay in compliance with state criminal law," said Caitlin Donovan, a spokeswoman for the National Patient Advocate Foundation.

Still, women seeking coverage for abortion may have options available to them. Although the landscape is quickly changing, here's what we know as of now.

How much does an abortion cost?

How did coverage of abortions work before?

Prior to the Supreme Court's decision last week, abortion coverage was still highly dependent on where you lived and what type of plan you had, Donovan said. "Most states impose restrictions on coverage in varying degrees."

Eleven states limit the coverage of abortion in all private health insurance plans written in the state, according to The Guttmacher Institute, a pro-abortion rights research organization. They are Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, Nebraska, North Dakota, Oklahoma, Texas and Utah.

Meanwhile, just six states — California, Illinois, Maine, New York, Oregon and Washington — require abortion coverage, with some stipulations, on private plans.

The Hyde Amendment, passed in 1976, blocked federal funding for services such as Medicaid from being used for abortions, except in limited cases including rape and incest. States can choose to use their own budgets to supplement their Medicaid coverage and extend their abortion policies, but more than 30 states have not done so, Donovan said.

As a result, "in many states, hundreds of thousands of women seeking abortion services annually are left without coverage options," according to a 2019 report by the Kaiser Family Foundation.

How will coverage now change?

It will just get more limited, experts say.

If you live in a state such as Louisiana or South Dakota, where abortion is now banned, "you probably don't have any insurance coverage for it at all except in the case of rape, incest or a threat to the mother's life," Donovan said.

"Some states may not even allow those exceptions," Donovan added.

However, employers that self-fund for their health insurance policy, meaning they take on most of the costs of benefit claims, may be able to maintain their abortion coverage, said Joelle Abramowitz, an assistant research scientist at the University of Michigan. Such plans tend to be subject to less regulation, giving the company more flexibility on benefits offered.

Donovan recommends calling your plan provider and asking about its abortion coverage. Of course, if abortions are banned in your state, even if you're covered, you'll likely have to travel to another state to get one.

Some companies are also covering travel expenses for employees who need to leave the state for an abortion.

What about leaving my state for an abortion?

If you have abortion coverage, you may need to go "out of network" on your health insurance plan to see a doctor in another state, experts say.

Out-of-network coverage is typically less robust, and some health plans, including HMO plans, don't offer it at all. Abramowitz suggests calling your insurance plan and asking whether you have out-of-network benefits and how they work.

In some cases, people may find it's cheaper to pay a provider out of pocket than to go through their out-of-network insurance option, Abramowitz said. Many abortion providers work on a sliding scale, she added.

It's also worth asking your insurance plan if there are any in-network abortion providers in another state. There could be one right over the state line, for example, Abramowitz said.

You also may be able to see a provider in another state virtually through a telehealth visit to get a medication abortion. In these cases, your medication can be mailed to you or you'll be asked to pick it up somewhere.

However, 19 states have already made it illegal to receive medication prescribed during a telehealth visit.

How can I get financial help?

Half million Floridians could lose health insurance in 2023, study says

TAMPA, Fla. (WFLA) — If the federal Premium Tax Credits expire due to legislative inaction in U.S. Congress, over half a million Floridians will lose their health insurance. The PTCs were set up through the American Rescue Plan Act of 2021, which temporarily expanded eligibility to pay for health insurance through 2022.

So far, U.S. Congress efforts in the House and Senate have failed to finalize a plan to extend the PTC credits, putting over 3 million people at risk of losing their health care coverage, purchased through the market set up by the Affordable Care Act of 2010.

Of the 3.12 million across the U.S., based on estimates by the Robert Wood Johnson Foundation and Urban Institute, 513,000 of those who would lose their insurance are Florida residents. That’s 16% of Americans at risk of losing their health care coverage.

For Florida, the number of uninsured residents would grow by 24.8% according to the estimates in the study. It would also mean a more than $5 million drop in total spending on health care for nonelderly residents in the Sunshine State.

“States with the largest losses include non-expansion states such as Florida, Georgia, and Texas, which saw large enrollment growth in 2022 with the enhanced PTCs,” the analysis reported. By non-expansion state, the analysis refers to states which have not expanded access to Medicaid or Medicare.

Residents at highest risk for loss of coverage due to PTC expiration are those living below the federal poverty line. Americans who are currently eligible for free coverage on silver plans, the ones who live at 150% or below on the FPL, meaning individuals earning less than $20,385 per year, or a family of four with a household income of $41,625, would be required to pay premiums “an average of $457 per person per year.”

FamiliesUSA, a healthcare advocacy organization, said that should the PTC credits expire, premiums for American consumers will go up 53%. The average cost per person for premiums is currently $960, according to FamiliesUSA. They said if ARPA’s health provisions are not extended, Floridians could see their go up as much as 61%.

The Centers for Medicare & Medicaid Services reported 2.7 million Floridians currently get their health insurance from healthcare.gov, the insurance market created by the ACA, a 28% increase over 2021.

For Florida residents, FamiliesUSA said the cost for health insurance would increase by more than $1.6 billion in 2023.

When Does Health Insurance Cover Abortions?

Following the Supreme Court's overturning of Roe v. Wade last week, Americans who live in areas that ban abortion now must travel out-of-state in order to receive the medical care they're seeking.

On top of the financial burden created by travel alone, abortions can cost anywhere from $350 to over $1,500. But depending on the state you live in and your insurance provider, health insurance can cover some or all of the bill. 

Insider spoke with two health policy experts about which insurance plans cover abortion, and questions to ask your provider in the post-Roe era. 

Which types of insurance plans cover abortion? 

State policies on abortion health insurance coverage.



State policies on abortion health insurance coverage.


KFF



After the fall of Roe v. Wade, many companies across the US announced they would cover travel costs for employees seeking out-of-state medical care. 

Employer health insurance falls into two categories: fully-insured plans and self-insured plans. A fully-insured plan is when an employer purchases health coverage from a state-regulated insurance company.

By comparison, companies with self-insured plans pay for employees' medical bills directly. Approximately 64% of US workers were covered by self-funded health insurance plans in 2021, according to Statista.

State laws — including those that outlaw insurance providers from covering abortions — can only regulate fully-insured plans. Companies with self-insured plans are "free to make whatever coverage decisions they want," Sara Rosenbaum J.D., a professor and founding chair of health law and policy at George Washington University's school of public health, told Insider.

"The woman may have to travel and [the provider] would have to make clear that that they'll let you go out of network for the care," she said. "But they could certainly cover it."

Currently, only eleven US states have laws that prohibit abortion coverage from being included in fully-funded private insurance policies, according to health policy nonprofit KFF. 

"So there are some states that will ban abortion, but that have not banned coverage," Laurie Sobel, the Associate Director for Women's Health Policy at KFF, told Insider, adding that it's "probably a matter of time" before those states ban insurance coverage as well. 

When it comes to federally-funded health insurance, coverage is only offered in very specific cases. Due to the Hyde amendment, federal funds can't be used to pay for abortions. That means Medicaid is unable to cover abortions unless the pregnancy is life-threatening or resulted from rape or incest. 

Questions to ask your employer or insurance provider in the post-Roe era

While employers have largely focused on travel costs in their corporate responses to the fall of Roe v Wade, there are other logistical hurdles companies need to consider in order to ensure their employees have access to out-of-state care, Sobel told Insider. 

"It's important to look at the structure of the plan. So what is the deductible? What is the copay? What is the network?" she said. "If abortion is now illegal in the state that you reside in, then there needs to be some contract with the clinic out of state."

If the out-of-state abortion provider is not in-network, the deductible could be more expensive than the procedure itself, she explained.

"Even employers who have the best of intentions and are trying to cover this, it will be challenging just to make it actually work in a way that the person doesn't have to pay out of pocket," Sobel added. "For many workers, paying out of pocket won't be financially feasible."

Here are five questions Sobel recommends asking your employer or insurance provider in order to determine the extent of your plan's abortion coverage: 

1. Is abortion covered?

2. Are there any restrictions?

3. Does the deductible apply?

4. Is there cost sharing?

5. Are there out-of-state abortion providers in network?