PROVINCETOWN — Massachusetts had universal health care before it was cool. Even before Obamacare, local residents were able to get insurance regardless of their work situation, income level, or pre-existing conditions. Some people still haven’t signed up, though. And others might be paying more than they need to. The Independent talked to health care access specialists at Outer Cape Health Services to discover some common and uncommon knowledge about finding a plan that works best for you.
First, a few terms. MassHealth covers lower-income people — it’s either free or close to it. Nationally, the program is called Medicaid.
Health Safety Net is a related program that covers people new to the state for up to 90 days. It’s also free, or close to free, and designed to keep you covered while you establish residency and obtain health insurance.
ConnectorCare is the Obamacare part of the system. It’s a series of plans that are tightly regulated and offer a comprehensive range of benefits. “There are private plans outside of ConnectorCare that are also quite good,” said Sheila Lyons, the access specialist at the Provincetown branch of Outer Cape Health. “The thing about the plans inside ConnectorCare is you know what’s being offered definitely meets these strong criteria. It makes choosing a plan easier, because you know that what you’re looking at is a solid choice.”
ConnectorCare offers plans from a variety of health networks, or carriers. Some are nonprofit, some are for-profit, but within ConnectorCare they offer an essentially identical product, whether it’s the silver plan from BMC Health or a silver plan from Tufts or Neighborhood Health or Blue Cross Blue Shield. Silver plans from various carriers differ in only a few ways. First, they feature different networks of doctors and clinics. Second, the prescription drug list might be different. Lastly, there’s the cost. It’s strange to realize that nearly identical plans can have a significantly different price. But it’s true, and it means that shopping during open enrollment can save you money even if you’re already insured. As long as you get to keep your same doctors.
The reason prices are so different is that insurers are basically playing a game of The Price Is Right. Each year they have to guess what it will cost them to insure all their customers. If they bid too high, no one will enroll in the plan. If they bid too low, they lose their shirts. That’s also why prices for the same plan from the same carrier might change from year to year.
With those terms established, it’s time to see what plans are out there.
The Mass. Health Connector — at mahealthconnector.org — is the place to sign up. The first half of the process is an application. The application includes questions about your income for the year, which helps determine whether you’re eligible for MassHealth, a ConnectorCare plan that’s government subsidized, or a ConnectorCare plan that you pay for entirely by yourself.
Some people think they make too much money to buy health care this way. They’re wrong, Lyons said. “Absolutely anyone can apply through the Health Connector,” she said. “That’s kind of the whole point. You might not get a subsidy, but you will still see a whole raft of well-regulated plans you can buy.”
The subsidies are for people who might have trouble paying full-priced premiums. “They start to really kick in below three times the poverty line, or $37,000 a year for a single person,” Lyons said. “Below that income, premiums start to be more and more subsidized, until you might be paying $50 a month for your premiums instead of $350 a month.”
The application also asks whether you are offered health care through your employer — and never fear, that’s not a problem. Just because your employer offers a plan doesn’t mean you’re obligated to take it, Lyons said. ConnectorCare plans are frequently cheaper than the plans small businesses can buy, although a business might offer an ultra-premium plan that’s worth the extra money up front.
After finishing the application and learning whether you get a subsidy, you’ll have to choose which plan to sign up for, and the choices can be dizzying — Gold, Silver, Bronze, Silver II. What does it all mean?
“They’re basically different ways of arranging your costs,” Lyons said. “A gold plan will have a much higher monthly premium, and much lower costs for doctor visits and prescriptions. A bronze plan will have the lowest monthly premium, and the highest doctor and prescription cost. If you think you’re not going to need much care, you might go with a bronze plan. If you know you see the doctor often, it might be easier to have a predictable high monthly premium, and not worry about budgeting money for visits and scripts.”
The bottom line is that all these plans have the same protections built in for serious medical events, such as an annual out-of-pocket maximum — the ceiling over which you will never be called to pay. In 2020, that number is $8,150 for an individual, for a year. That means the total of your premiums, co-pays, prescriptions — everything, as long as it’s from an in-network provider — cannot exceed that number. The out-of-pocket max is the same for a bronze plan and a gold one.
“A bronze plan may sound worse, but it really isn’t — it’s just a different bet on what you’re going to need in the year,” Lyons continued. “It could work out better for you.” Or it could mean that you might have to cough up a larger chunk of change mid-year, in exchange for having paid those lower premiums.
When choosing a plan, knowing what providers are covered in its network is key. Fortunately, the Health Connector (mahealthconnector.org) has a feature that filters out networks that don’t work with your doctors, clinics, and prescriptions. Especially on the Outer Cape, this makes a big difference. “BMC HealthNet and Tufts seem to usually be the cheapest plans that include Outer Cape Health personnel in their network,” said Lyons. “At least lately. The prices change a lot.”
You can do the application and pick a plan yourself. When the Independent went through the whole process yesterday, it took just under an hour. But you can always get help.
“There are health care access specialists at each of the Outer Cape Health locations —Provincetown, Wellfleet, and Harwich,” Lyons said. “We work full-time, just on signing people up for care.” It’s a drop-in system — no appointments are necessary. “These positions were originally funded by a national grant, and when that expired, we realized the system was still too complicated, and people needed help to get them through it.”
And don’t forget: open enrollment is a limited window. Otherwise, people could wait until they were sick to sign up for insurance. In most of America, that window ends Dec. 15, but in Massachusetts, it lasts until Jan. 23. If something changes dramatically in your life — loss of a job, a marriage or divorce, moving out of state, the birth of a child — you can probably change your coverage outside of the open enrollment window. But for everyone else in a normal year, the next seven weeks are the only time to sign up for health insurance until Nov. 1, 2020.