Kim Avatar

Do a Little Homework and You'll Find Your Best Option

Posted 29 October 2013 12:00 AM by TCAuthor3

By Kim Barnas, senior vice president Appleton Medical Center and Theda Clark Medical Center

Wisconsinites have an opportunity to learn more about the health insurance options available to them through the Affordable Care Act (ACA). The ultimate goal of the act is to help more people buy the coverage they need.

But the health insurance companies have a great deal at stake, too. They need to have enough healthy people in the system to help offset the care of sicker patients. They must also keep their premiums low enough to be competitive, but high enough to be sustainable for the long-term.

Because the Wisconsin insurance exchanges opened on Oct. 1, we thought it might be helpful for you to see how people at different life stages assess the kind of coverage that’s best for them.

I’m young and healthy – what’s my best option?

Courtney is a healthy 25-year-old with her 26th birthday just around the corner. Translation? She needs to go off her parents’ plan. Her job offers health insurance, but she’s not sure if that coverage will be dropped. She’s paying off student loans and wonders if she’ll find a better deal on the exchange. She knows there is a penalty for not having coverage. 

What are her options? Well, first she should have a conversation with her employer. There may be a workplace wellness program or incentives like reimbursement for the cost of a gym, rewards for attending monthly health education seminars or completing a health risk assessment.

She should also research the Wisconsin health insurance exchange at There are four tiers of plans with different premium costs and coverage. Once she reviews the options, she can compare them against her employer’s insurance to assess the one that works best for her lifestyle.

I’m a healthy new mom – what’s the best choice for my family?

Melissa is a 29-year-old new mom of a healthy little boy. Her family receives health insurance through her husband’s employer and it’s a pretty good plan. Under the ACA, Melissa and her baby will see expanded insurance coverage for several benefits, including maternity and pediatric care, under the essential health benefits (EHBs) that must be covered by certain health insurance plans in 2014.

There are 26 total preventive services for children covered by the new EHB requirements. ThedaCare’s pediatricians want every two-year-old to be up-to-date on all appropriate vaccinations. Melissa’s current insurance only covers a few of the vaccinations to be fully immunized. Now, her baby’s shots will be covered. The ACA also covers oral and vision care for children, hearing screenings for all newborns, so for new moms, the ACA is a good thing.

I’m young, healthy and seasonally employed – what about me?

Rob’s a construction worker without employer-provided insurance. He relies on unemployment when he’s not working. Though his annual income is enough for him to provide the basic life necessities, for a single, 33-year-old man, health insurance is not one of them. He tries to take care of himself by avoiding junk food, taking vitamins and working out in a small weight room in his parents’ basement (where he’s living while seeking an associate’s degree).

Rob has looked at Wisconsin’s BadgerCare Plus Core Plan, but it’s full for childless adults. Since his income is above the $11,490 (Federal Poverty Level), he doesn’t quality for Wisconsin’s Medicaid program. He hoped to qualify for the catastrophic plan to cover an accident or serious illness on the exchange, but sadly the cut-off age for those plans is 30. Roy is keeping his fingers crossed that he will qualify for a subsidized plan on the exchange to reduce his monthly premium cost. Until then, he hopes he stays healthy.

I’m a self-employed, married guy with a chronic illness. Any hope for me?

Self-employed 42-year-old Josh is married with two kids – and he also has Type 2 diabetes. He has individual insurance, but to keep costs down, his family plan has a high deductible. Still, his premiums are expensive. His wife is a stay-at-home mom and the $1,200/month takes a chunk out of their living expenses. They’re hoping to find a family policy that’s less expensive on the exchange.

The ACA mandates coverage for all – even people with pre-existing conditions. Josh no longer has to worry whether he will get treatment for his diabetes. With ThedaCare’s help, he has managed his diabetes for 20 years. ThedaCare doctors are experts in diabetes care and have the highest rated diabetes care in Wisconsin.

He participates in ThedaCare’s Diabetes Self-Management Program.

Using the exchange, Josh can compare insurance plans and premiums and use an online calculator to get an idea of his potential subsidy. Subsidies are determined based on things like income, age, children’s ages and smoking status.

Hard-working laborer strains his back at work. Now what?

Miguel is 54 years old and recently strained his back lifting a crate where he works. He and his family do have health insurance through his employer, but since the company is self-insured, the employer doesn’t have to provide coverage for essential health benefits required by the ACA. The employer does sponsor a workplace wellness program with an onsite nurse from ThedaCare. He also gets a referral to ThedaCare Orthopedic Care to get a care plan with rehab exercises to strengthen his back.  While looking into the wellness program, he realizes it also includes support for smoking cessation and healthy eating – something he’s been meaning to do to live a healthier life.

I’m retired and recently diagnosed with breast cancer. Who’s looking out for me?

Paulette is a 66-year-old retired office worker who was recently diagnosed with breast cancer. She gets her health insurance through Medicare. The ACA actually strengthens Medicare to help seniors like Paulette take charge of their health.

Under the ACA, Medicare Part B covers some new preventive services including yearly wellness visits, flu shots, bone density, mammograms and prostate screenings. As part of Paulette’s ongoing care, her ThedaCare doctor noticed something suspicious on the image from her annual mammogram. She was immediately guided into a comprehensive plan of care. Because her cancer was caught early, her prognosis looks good and she’ll have many happy years watching her grandbabies grow.

She’ll also be happy to learn that the ACA includes benefits to make her Medicare prescription drug coverage (Part D) more affordable. It gradually closes the gap in drug coverage known as the “Donut Hole.”

Still got questions? Go to or  And you can always check with your friends at ThedaCare.