Health Care Reform: breaking it down with Wellpoint and sharing facts every parent needs to know!

It’s a fact : women (mothers) call the Shots and are currently responsible for more than 85% of all consumer purchasing decisions and 80% of healthcare decisions. And, as you may know, starting October 1st, all Americans will be able to sign up for healthcare coverage, as a result of the health care reform law.  Those who don’t plan to get health insurance from an employer, or through Medicare or Medicaid, will be able to comparison shop for health insurance through online marketplaces or “exchanges.”

 navigating the Affordable Care Act (ACA) with Wellpoint

If this confuses you ( for the record I was COMPLETELY confused as well) I had an opportunity to get some major clarification from Ellie Kay, WellPoint spokesperson and Patrick Blair, WellPoint expert two executives at WellPoint which does business in 14 states across the U.S. and is locally known as: Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Blue Cross Blue Shield of Georgia and Empire Blue Cross Blue Shield- both of whom provided some major clarification and the ins and outs for navigating the Affordable Care Act (ACA) and the health insurance exchanges in particular.

Keep reading for their  wonderful insight into Health Care Reform and facts every parents needs to know!

If you are still on the fence  about getting health insurance – the bottom line is this DON’T Gamble with your health and/or the future of your family:

  • Buying health insurance is an important way to protect you and your family in the event of injury or illness

  • It is also essential to protect your financial future, as injury and illnesses can be costly without insurance

    • Average cost of a 3-day hospital stay is $30,000

    • Without health insurance, a broken arm can cost $2,500 or more (without surgery!)

    • Over 10% of all Americans think they don’t need health insurance

    • Sources: WellPoint and Kaiser


Confusion around the Affordable Care Act (ACA) and the health insurance exchanges in particular:

  • 42% of Americans are unaware that the ACA is the law of the land

  • 45% know nothing at all about the health insurance exchanges

  • 75% of uninsured adults are unaware that they will have new insurance options

  • Sources: Kaiser Family Foundation and Enroll America

Four options to get health insurance for the next year:

  1. Continue purchasing insurance through your or your spouse’s employer

  2. Buy health insurance yourself – either through exchanges, direct for insurance companies or through traditional brokers

  3. Enroll in government programs like Medicare or Medicaid plans – if you are eligible

  4. Go without insurance – but pay a tax penalty

What are the Health Insurance Exchanges?

  • A health insurance “exchange” is just another word for “marketplace.”  Works similarly to Amazon, Expedia or Travelocity and lets you compare health insurance options. Public and private health insurance exchanges will operate in a similar way

  • Plans will be available for sale October 1, with coverage starting on January 1st of next year.  Each state will have its own exchange serving people who buy health insurance for just themselves and their families

  • The vast majority of people who are currently covered by their employers will not see a change or have to use the public exchange

  • When can you use the exchanges?

  • Enrollment begins: October 1, 2013

  • Enrollment ends: March 31, 2014

  • Coverage begins: January 1, 2014

  • NOTE:  For those who sign up before December 15th!

Exchanges 101

  • This is a transformative moment in the history of health care

  • It might seem complicated – but they’re here to make it easy

  • Health insurance in the exchanges will offer real benefits and quality coverage

Important things to remember

  • Affordable health care options will be available

  • You may qualify for financial help – and protect your whole family

  • You can get preventive health care at no cost

  • You can’t be denied based on pre-existing conditions

  • Help will be available for those people who make about $45,000 dollars a year and for families of four who make about $92,000 dollars a year

    • Financial help will be offered on a sliding scale, meaning the more money you make, the less financial help you will get

  • They are working with members and consumers to help them navigate through their options, including subsidies for qualified individuals and tax credits for small employers

  • Later this fall, Anthem will have a Subsidy Estimator available online to help individuals estimate how much of a subsidy they may receive

Choosing the right plan should be simple

  • Health insurance isn’t simple, but choosing the right plan should be

  • Later this fall, Anthem will have online tools available to help individuals choose the right health plan:

  • Family Checklist

  • They are providing consumers simple steps to help them select the right health plan

  • Subsidy Estimator

  • They are working with members and consumers to help them navigate through their options, including subsidies for qualified individuals and tax credits for small employers

Essential health benefits that all plans offer:

  • Emergency services

  • Maternity and newborn care

  • Mental health and substance use disorder services

  • Preventive and wellness services

  • Chronic disease management

  • Pediatric services, including oral and vision care

  • Women

    • Women won’t be charged more

    • Cannot be charged more or denied for a pre-existing condition

    • You’ll get preventative care for mammograms, well woman visits, contraception and much more

    • You can choose your own primary care, OB-GYN or pediatrician without referrals

Plans will come in levels or tiers

At Anthem, they are refining their networks, negotiating the best rates we can get for covered products and services and making more tools available to help members better manage health and out-of-pocket costs.

  • Levels are based on the percentage the plan pays of the average overall cost of health benefits

  • Each level may have a few plans to choose from

  • Bronze plans have the lowest monthly premium, but will cover 60% of expected costs

  • Platinum plans have the highest monthly premium, but will cover 90% of expected costs

Photo courtesy of Oregon Insurance Division

Putting the ‘primary’ back in primary care

  • Doctors should spend more time with you

  • Doctors should coordinate all aspects of your medical care

  • A strong foundation in primary care lies at the heart of our networks and products.  Through their patient-centered primary care initiative, primary care physicians are offered incentives to spend more time with their patients, including focusing on preventive services

  • They encourage primary care physicians to actively coordinate specialty referrals and total care for their patient populations. 

Things to think about when choosing healthcare options:

  • Does it give you 24/7 access to health professionals?

  • Does it offer health and wellness initiatives?

  • What about comparison shopping tools for doctors and procedures?

  • Are the customer service reps speedy and responsive?

  • Do the products and prices match your needs? 

For more information:


  • has a section dedicated to ACA information for current members and are in the process of enhancing our online shopping experience and mobile capabilities to clearly discern between on exchange and off exchange options, as well as offer shopping guides and checklists to help people better understand what they need and when. Our goal is to help consumers and employers select a benefit plan that best fits their needs.

Where should I go to find the best healthcare for my family according to my state?

A great place to start when you’re shopping is at and They are great resources to learn from and share.

Who will be eligible to participate in the healthcare exchanges?

Practically everyone is eligible for marketplace coverage. Requirements are that individuals live in the U.S., must be a U.S. citizen or national and cannot be currently incarcerated.

What is the penalty tax if you don’t buy insurance?

The penalty tax is going to be 1% of your annual income, and that will go up every year. The exception to that is if you make $9,500 or less, then you won’t have to pay that penalty tax.

There will be a penalty for those who don’t purchase insurance.. in  other words WE all need to pay for insurance:

Yes, correct. The reality is that health insurance doesn’t work well if the only individuals that purchase it are people that have determined that they need it at a point in time. The idea of insurance is to have a balanced risk pool that is made up of both individuals who require care and individuals who do not require care. The mandate was put in place to make sure that the health insurance marketplace works as effectively as possible.

The penalty will either be 1% of taxable income or $95 per individual / $285 per family, depending on which one is greater. This will increase over the years with annual adjustments that will continue to 2017.

So if you want to look at 2015, fees will go up to $325 for uninsured person or 2% of taxable income. In 2016, the fee will go up to $695 for an insured person or 5% of taxable income.

The  open enrollment periods:

There are open enrollment periods:

  • Enrollment begins: October 1, 2013

  • Enrollment ends: March 31, 2014

  • Coverage begins: January 1, 2014

NOTE:  For those who sign up before December 15th!

If a job change resulted in loss of insurance would I be immediately eligible to sign up or would I have to wait?

For benefit years starting on or after January 1, 2015, the open enrollment period will run from October 15-December 7, but the law also allows for special enrollment period, which is a time outside the regular enrollment period. The special enrollments are typically allowed after a significant life event that involves a change in family status like having a baby or getting married or a job change. The ACA gives health insurers operating outside of the exchange the option of limiting open enrollment. So if a plan limits open enrollment the enrollment must fall into the regular enrollment period.

Does the new healthcare law only apply to those who don’t have other healthcare options through an employer?

Many of the changes in the law are related to the individuals who purchase on their own. There are a variety of changes in the coverage that is offered through employers. In particular, there will be a number of changes for smaller employers. As an example, they will be required to issue coverage to anyone who applies, and they cannot deny coverage to anyone with a pre-existing healthcare condition. It also makes sure that small employers are offering benefit plans that don’t have any lifetime limits on the dollar value of the essential health benefits.

One last element is that the ACA requires that dependent coverage for children until they turn 26 years old. So children are eligible to receive coverage regardless if they are in college, a tax dependent or are married.

Employers vs. individual health plans:

There is a concept of “grandfathered” health plans. Any health plan that was in force by March 23, 2010, is eligible to be grandfathered forward. These would be plans that meet many requirements of the new healthcare reform. However, if a small employer group – for example – does not have a grandfathered plan, then they would have to offer the metallic tiers within their benefit plan.

What about large employer groups? Businesses that have 50 or more full-time employees are considered a “large business” under the health care law. Beginning in 2015, large employers that do not offer affordable health insurance that provides minimum value to their full-time employees (and dependents) may be required to pay an assessment if at least one of their full-time employees is certified to receive a premium tax credit in the Marketplace. (A full-time employee is one who is employed an average of at least 30 hours per week). This is called The Employer Shared Responsibility Payment.

Family plans or only individual plans:

There are both available. As you go to shop, you’ll be asked to enter family information and you will be exposed to those plans that are specifically designed for family coverage.

Does the new law apply only to health care or does it also covers dental and vision? Will this also give people more options for eye, and dental coverage?

As of January 4, the medical plans all have to be compliant with the 10 essential health benefits (listed above). But only pediatric dental and vision benefits are a part of those essential healthcare packages. The law does not expand dental and vision coverage for adults. But they are available for individuals to purchase on a stand-alone basis. So you will have plenty of options for both dental and vision coverage as you shop for your family’s coverage.

How the new law affects people on Medicaid?

Medicaid is a program for individuals that meet both an income and categorical requirement, for instance a senior with a disability or a child with special needs. The new law was established so that the exchanges can create a new pathway into state Medicaid programs. They want the exchange to be a single integrated application in the process to determine the consumer’s eligibility that will direct individuals to the program that best fits their need.

The ACA actually expanded the eligibility for Medicaid to a larger group of low income Americans. While the Supreme Court has made it optional for states to participate in Medicaid expansion, the threshold for eligibility has changed. If their income is up to 133% of the federal poverty level, they are now eligible for Medicaid. By increasing the federal poverty level, new eligible adults will be covered by Medicaid.   

With the increase in population that is now going to be insured do you have a plan to increase staffing to handle the influx?

As an organization, they have hired thousands of people to support the surge in enrollment and the care needs that will come with the enrollment. They have individuals who are being trained and are standing by to make sure you have a live representative to speak with on the phone. They are not just focused to make sure they have the right customer service capacity, but they have invested in their information technology and all of their systems that will be used to process claims and premiums, pay physicians and more. They have spent tremendous time and effort identifying the highest quality providers to take on the increase of population. They are also contacting community leaders to make sure that people are aware of our readiness to serve.

The cost options and how moms can make it work:

The challenge is that so many things will impact the cost: family, geography, income, and subsidies that you may or may not be eligible for. All of these factors make costs very hard to predict.

What they’ve generally seen is that the changes that are being made will make healthcare more affordable. The more young, healthy individuals they can include in the insurance pools, the more affordable rates are for everyone. The older individuals will likely see their rates go down, while younger healthy individuals might see an increase in their rates. But really, it’s too soon to be able to predict what costs will be like. The design of this system will hopefully have a wonderful uptake, and if that happens, they will see the best possible outcome as it relates to cost.

For many, health care reform will mean access to care for the first time in their lives and for others it means access to expanded care.  Expanded benefits will include doctors’ visits and outpatient services, emergency care, maternity and newborn care, and prescription drugs. Screenings, shots and exams will be included for free, and plans with lower deductibles will be offered as well as subsidies for people who need them.  Not only will benefits be more expansive, but under the new law more people will be covered and that is a good thing.  

But along with expanded benefits come higher costs – and health insurers are faced with a choice; either pass those costs on to their members – or figure out ways to manage those costs so that health insurance remains affordable.  For those who have trouble paying for their coverage, government subsidies will be available to them making the products affordable.

Here are some websites you can visit to learn more:

The Kaiser Family Foundation at‎

This post is part of a sponsored conversation with The Motherhood, but as is always the case all opinions are my own.

Leave a Reply

Your email address will not be published. Required fields are marked *