Need help finding insurance? This primer may help

Posted: September 25, 2013

The Winchester Star

Laura Simmons (left) and Jackie Taff, group health insurance sales executives with Bankers Insurance, go over a policy at their Winchester office. (Photo by Ginger Perry/The Winchester Star)

Editor’s note: This is part of an occasional series on the Affordable Care Act, commonly called Obamacare.

WINCHESTER — Less than a week before the Oct. 1 opening of the health care marketplace, Laura Simmons still gets two or three emails a day outlining changes in the insurance coverage.

A broker who helps individuals and businesses select their health care plans, Simmons said it’s a challenge to keep up with the Affordable Care Act (ACA), often called Obamacare.

“It’s the most complex program we’ve ever come across in our 20-plus years,” said Simmons, who along with her colleague Jackie Taff staffs the local office of Bankers Insurance.

“It’s a full-time job keeping up with the Affordable Care Act,” Taff said. “There will be a lot of questions.”

Apply beginning Oct. 1

Beginning Oct. 1, Virginians can visit the online marketplace at to shop for insurance. Applications are accepted by mail or in person with the help of a navigator or other qualified helper.

Coverage begins Jan. 1, 2014, the date the law requires that most Americans have insurance or be fined.

Medicare recipients can keep their coverage. Workers who get health insurance through their jobs can keep their plans (they also can investigate the marketplace but they may not qualify for federal subsidies and their employer may not help pay for premiums).

Prisoners and illegal immigrants will not be able to purchase insurance on the exchanges. Religious objectors aren’t required to purchase insurance. In Virginia, anyone who doesn’t earn enough to purchase a policy yet and doesn’t qualify for Medicaid isn’t required to purchase insurance.

Virginians have choices

The insurance plans offered are divided into bronze, silver, gold and platinum levels. Bronze is the least comprehensive and the least expensive; platinum is the most expensive but offers the most comprehensive coverage.

Virginians will choose plans from nine companies (in contrast, West Virginia has just one participating insurer). All the plans must offer such essential benefits as maternity, mental health and prescription drug coverage.

Health insurance broker James DuBrueler, a co-owner of Creekside Insurance Advisors Inc. of Winchester, said he has seen the plans that will be offered in Virginia, but the premium costs are still not available.

In general, the plans have higher deductibles and co-insurance payments and higher out-of-pocket maximums than plans not on the exchange, he said.

Applicants will also find the exchange plans have “very narrow” provider networks, he said. A cancer patient won’t be able to go Johns Hopkins University for a second opinion. A frequent traveler for business wouldn’t be able to visit a doctor in a different city.

“We are going to see a lot of tightening up of costs in order to make this thing affordable,” he said.

Tax fines, tax credits

Two key provisions of the ACA — the penalties for not having insurance and the tax subsidies granted to help pay for it — will be itemized on tax forms.

“The penalty is relatively insignificant the first year,” said Brian Barto, franchise owner of Liberty Tax Service on Weems Lane. Fines range from $95 or 1 percent of income for an individual to $285 for a family of four in 2013.

But by 2016, the fine increases to $695 a year or 2.5 percent of income for an individual to $2,085 or 2.5 percent of income for a family of four.

“By the third year they’re just pounding you,” he said.

The subsidies to pay for the insurance are granted on a sliding scale for people making from 100 to 400 percent of the poverty level (400 percent is about $46,000 for an individual and $94,200 for a family of four).

Anyone who receives a subsidy will need to declare that money on their tax form. The money, however, will be sent directly to the insurer.

Depending on income, a family of four could receive tax help ranging from $3,000 to $10,000 a year, Bartow said.

Get paperwork ready

To fill out the online application on the marketplace, applicants will need:

Social Security numbers for everyone in the household who needs coverage.

Employer and income information for every member of the household who needs coverage (such as W-2s).

Policy numbers for any current health insurance plans.

If an applicant’s employer offers insurance but they don’t plan to participate, he or she will need the details of that plan.

Employers are supposed to notify workers before Oct. 1 that the exchanges are opening and provide details of the company’s plan.

Once applicants have entered such information as household size, where they live, their income and citizenship status, the computer system will verify the data in “near real time” with the Internal Revenue Service, Homeland Security and Equifax credit service, said Sara Koontz, a certified application counselor with Winchester Family Health Center, a satellite office of Shenandoah Community Health Center in Martinsburg, W.Va.

If applicants are eligible for Medicaid, they will be directed to the appropriate website to apply.

Applicants who don’t qualify for Medicaid will find out if they qualify for the subsidies. The exchange will then display a list of health plans with their premiums and out-of-pocket costs.

Once a plan is chosen, the applicant will be directed to the insurance company’s website to make the payment.

“It’s one-stop shopping,” Koontz said. “It’s supposed to be a seamless application process.”

Help is available

A computer-savvy person will be able to figure out the system, DuBrueler said.

“The problem is most people will want to bounce their decision off an expert,” he said.

Health insurance agents and brokers can guide anyone who needs help. They are paid by the insurance companies, so there is no charge to the applicant.

Also, the Blue Ridge Legal Services office in Harrisonburg has one navigator on site serving the counties of Highland, Augusta, Rockingham, Page, Warren, Clarke, Shenandoah and Frederick. Navigators, who must complete 20 hours of training, are expected to help about 20 people a week plus conduct community presentations.

“We are working hard to get ready by Oct. 1,” said navigator Andy Bolt, hired with government grant money by Enroll Virginia, a nonprofit group working to maximize the number of uninsured Americans who enroll in health coverage.

Enroll Virginia is setting up a toll-free help line and building a website, he said. Bolt plans to hold information sessions in the Winchester area during the enrollment period.

To set up an appointment with Bolt, call 540-433-7319.

Koontz, based in Martinsburg, W.Va., completed five to nine hours of training and passed an exam with a score of 80 or above to become a certified application counselor. Like the navigator, counselor jobs are also funded with government money.

The community health center is in the process of hiring two more counselors. One of them will most likely be assigned to the Winchester area. To set up an appointment, call 304-263-4999 or email at

The federal government has also set up a toll-free number to call 24 hours a day, seven days a week, if help is needed while filling out the online form: 800-318-2596. Help is available in Spanish and other languages.

— Contact Robyn Fontes Taylor at