The ACA, Private Exchanges and Public Thoughts

By Rick Bell

Feb. 18, 2015

The Affordable Care Act is on the minds of lots of people this week, but what I am walking away with after several conversations is that there are still way more questions than answers.

Take my taxman, for example. I did my taxes over the long holiday weekend, and the conversation eventually rolled around to health care reform and what he’s dealing with.

“It’s a mess,” he said bluntly, peering over his spectacles and stacks of manila folders that lined the edge of his desk.

I asked him if he had to take seminars to prep for the ACA. He nodded. “I got different answers at each one,” he said, casting his eyes upward and shaking his head. “No one knows what’s going on.”

My son didn’t really have any questions this past weekend regarding the ACA. He was just unaware the deadline to sign up for the public exchange was Feb. 15, which was extended by a week because, well, few people were able to solve the mystery of properly filling out the online forms, and those who couldn’t were unable to get the answers from the help desk because they were either overwhelmed with calls or didn’t have the answers. If that is a confusing sentence, well, this is a confusing topic.  OK, my son did have one ACA-related question: “There’s a deadline?”

I was relieved to discover that my son and taxman — both bright, well-read, astute guys —  aren’t the only ones with questions about the ACA. HR consultancy Towers Watson just released a survey regarding the top 10 employee questions on private exchange enrollment. Unlike my son, tax guy and the hundreds of thousands of people who couldn’t sign up on the public exchange by the Feb. 15 deadline, I’m hoping that employees whose companies are on private exchanges — like Towers Watson’s — have better luck getting answers from their employers.

Here are the Top 10 questions followed by commentary from Towers Watson:

1. Which plan has the lowest cost?
Using premium cost as the most important criterion for making health plan choices could be a mistake, because the least-expensive plan is not always the best one for a given individual. Other factors that should be taken into consideration include employees’ health status, the doctors and hospitals they use, and the prescription medications they take.

2.      What are the copays for the medical plans being offered?
Historically, employees have gravitated toward the predictability of preferred provider organization health plans with copays, but they may not understand that these plans may cost more out of pocket and may not be the best plan choice for them. Some employees may be surprised to learn their employer doesn’t offer any copay plans. In these situations, it’s important to explain that there may be plans of similar value even if they have different coverage features.

3.      Why do my health plan options have high deductibles?
As employers seek ways to keep health care costs down, many are offering only account-based health plans, which are consumer-driven plans that have high deductibles and are connected to accounts for funding or saving for health costs, such as health reimbursement arrangements, or HRAs, or health savings accounts, HSAs. Employees need tools to help them understand how these plans may actually be the better choice for them. Employees also need help understanding how accounts work and the tax advantages of HSAs. Some employers enhance this transition by jump-starting the balance with a cash contribution, or “seeding the account.”

4.      What's the difference between gold, silver, bronze and safety net plans?
The metal tiers mandated by the Affordable Care Act for public exchanges (and adopted by many private exchanges) are designed to make it easier for people to compare plans. However, employees should delve deeper into the details beyond the metal hierarchy. Coverage, premiums and out-of-pocket costs vary by plan and insurer within the metal plans. Employees should make decisions based on a thorough comparison of plan details, and they often need the help of decision support tools and live, personalized advice from an expert to do that.

5.      What do I need to do to earn my wellness dollars?
Over 50 percent of enrollees say they will engage in wellness activities and have many questions on how to earn wellness dollars, when they’ll have the money in their account and what they can spend it on. This is good news for employers, which in the past have struggled to engage employees in wellness programs.

6.      How do I know if my doctors are part of the plan I choose?
Being able to continue seeing their current medical providers is top of mind for employees when evaluating new health plans. However, answering this question can be a moving target as contracts between doctors, hospitals and insurance companies can change from year to year. Exchange providers can make this complicated task easier by integrating doctor and facility lookup tools into the exchange enrollment experience. Many physicians are part of multiple plans, giving employees the choice of carriers and price points while still keeping their family physician.

7.      What’s the difference between an HRA, HSA and FSA?
Health insurance is a complex topic with confusing jargon and acronyms. HRA, HSA and FSA — flexible spending account — refer to the options employers have for funding health benefits through accounts that offer tax advantages to employees and employers for offsetting health care costs. These types of accounts have been available for some time, but are increasing in popularity as employers seek new ways to fund health benefits and encourage employees to save for health expenses.

8.      What does the prescription drug plan cover?
Employees are confused by the array of pharmacy provisions, copayments, coinsurance minimums and maximums, formularies and more. They want specific information on what their drugs will cost for each of the plan and insurer options they have to choose from. In addition to using the decision support tools available, many employees want to talk to an informed service center representative about their particular circumstances.

9.      What are the differences between insurers?
Confronted with different price points from different insurers for similar plan designs, employees want to know what added value they might be getting from a higher-cost insurer. While most insurers believe they do a good job of marketing and differentiating themselves from the competition, the prevalence of this question suggests there is more work to be done.

10.   If I want to keep the same plan I had last year, do I need to do anything?
Historically, plans have had default rules that place employees in a predetermined safe plan choice if they don’t take action during open enrollment. In an exchange offering, some employers want to encourage an active enrollment choice each year so employees get to know the available options through a shopping experience. As employers offer more voluntary and ancillary benefits, employees should evaluate annually which of these to keep or change, as well.


Does that help? At this point it seems like any information regarding health care reform can’t hurt.

Rick Bell is Workforce’s editorial director. For comments or questions email

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