VICKI SMITH, Associated Press
MORGANTOWN, WV (AP) — West Virginia is ready to launch a health insurance marketplace born of the Affordable Care Act, but a state official overseeing it says enrolling the average uninsured person will be a challenge because the federal government has failed to adequately explain what's happening.
While the technical systems should function as designed, "low public understanding" could hinder signups, said Jeremiah Samples, assistant secretary for the state Department of Health and Human Resources.
"This is a federal law, and it is the responsibility of the feds to fulfill this mission," he wrote in an email to The Associated Press, "and for the most part, this effort has been a failure."
Private and nonprofit organizations are ramping up outreach efforts, and Samples said that should help increase awareness during the open enrollment period, which starts Tuesday.
West Virginians who have no health insurance can sign up for coverage under a state and federal partnership called a health care exchange.
Some 245,000 people are currently uninsured, by federal estimates, and the administration of Gov. Earl Ray Tomblin expects 37,000 to 60,000 people eventually will seek coverage through the new online marketplace.
Benefits begin Jan. 1, and the U.S. Department of Health and Human Services predicts that six in 10 people will be able to find at least some level of coverage for $100 or less per month, after tax credits.
Under the Affordable Care Act, no one can be denied health insurance because of a pre-existing medical condition. That's good news for a state consistently ranked among the nation's worst for obesity, diabetes and other health problems.
And the U.S. Department of Health and Human Services says average premiums in West Virginia are lower than originally projected.
On average, the monthly premiums for a midrange benchmark plan will cost $331 per person, compared with $328 nationally. That's before the tax credits.
In West Virginia, Highmark Blue Cross Blue Shield also will offer a lower-cost plan for an average of $280 per person.
Averages can be misleading, though: People can have dramatically different costs based on their circumstances.
Tax credits are based on income, age, location, benefit plan and family size. Tobacco use affects the bottom line, too, and West Virginia has the nation's highest smoking rate: Nearly 29 percent of adults smoke, according to the U.S. Centers for Disease Control and Prevention.
Navigators, independent counselors paid under federal grants, will help people determine which plan best suits their needs. Assistance is available at hospitals and other health care facilities, at county DHHR offices, and at a variety of private and nonprofit organizations.
People can choose from four levels of coverage — bronze, silver, gold and platinum.
All provide the same benefits, and all cap annual out-of-pocket expenses at $6,350 for an individual, or $12,700 for families. The big difference is cost sharing. Bronze covers 60 percent of expected costs; silver, 70 percent; on up to platinum at 90 percent.
Bronze plans have the lowest premiums; platinum have the highest.
But low premiums have a trade-off: They could lead to big out-of-pocket expenses later when medical bills exceed what's "expected," or the amount insurers consider reasonable.
Any difference between the out-of-pocket cap and the bill falls on the consumer.
All plans must offer 10 essential health benefits, including doctor visits, hospitalization, emergency room care, prescriptions and mental health services.
In theory, that will benefit West Virginia hospitals. Currently, many uninsured people rely on the most expensive place in the health care system — a hospital emergency department — for all health care needs. When patients lack insurance, hospitals have to absorb that cost.
But Bruce McClymonds, president and chief executive officer of WVU Hospitals, said that while he expects the number of uninsured patients to drop by 70 percent next year, the federal government's payments to hospitals also will decline.
Hospitals get lump-sum payments based on the percentage of patients who are uninsured or on Medicare. As more are insured, that payment drops.
At the same time, WVUH would ordinarily expect a 2.5 percent increase in Medicare reimbursements next year. Instead, McClymonds said, that increase will be 0.7 percent.
"If you add it all up," he said, "our best guess is we're going to get paid about $1.5 million less next year than we did this year."
By 2020, WVUH projects it will bring in $20 million less. That's small compared with an $800 million annual budget, but could eventually mean some programs will be cut.
"Most all hospitals will have the same kind of negative impact," McClymonds said. "This is not a financial windfall."
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