Short Takes On News & Events

Answering Consumer Questions About Obamacare Marketplaces

By KHN Editors

September 25th, 2013, 1:04 PM

As part of the Washington Post’s continuing series of online discussions about the health law’s new insurance marketplaces, KHN’s Phil Galewitz and the Post’s Sarah Kliff answered readers questions today.

A transcript of today’s discussion follows.

READER QUESTION:  Neither my husband nor I receive health insurance through an employer and have had an individual plan for years. His employer covers the cost of the plan. Will we still be eligible to buy our individual plan on the exchange? If we don’t/can’t buy on the exchange, will insurance companies still be allowed to deny coverage for pre-existing conditions or charge more for health reasons for individual plans not purchased on the exchange?

SARAH KLIFF:  Hi there – I’ll start with the last question, which is the easiest one to answer: No, insurance companies will not be allowed to deny coverage for a pre-existing condition, or charge more due to health conditions, beginning on Jan. 1, 2014.

As to your first question, yes, you should be eligible to buy health insurance on the new marketplace. Because it’s you and your husband buying health coverage – even though you’re using money from an employer – that should still mean that you can use the new marketplaces, which open for enrollment on October 1.

READER QUESTION:  If I lose my job (and with it my health plan) after the open enrollment period ends, will I be able to get a new plan right away in the exchanges? Or is there a coverage gap until the next open enrollment period begins?

SARAH KLIFF:  Yes, if you lose your job outside of open enrollment, you will be able to get a plan right away in the exchanges. While there is indeed an open enrollment period (this year, from October 1 to March 31), the health care law allows people who have certain life-changing events to sign up outside of that period. Losing a job, along with moving to a new state or having a baby, count as those life-changing events.

READER QUESTION:  Yesterday (September 24), Julie Appleby made the statement that people who are enrolled in Medicare don’t have to do anything differently this year. Why the qualification “this year”? Does this mean that we will have to do something differently in the coming years?

SARAH KLIFF:  No, there is nothing that Medicare enrollees will have to do differently in any years going forward, as a result of Obamacare. Julie, I think, was trying to clear up some confusion about how the health care law affects Medicare beneficiaries.

The bottom line: Medicare enrollment will work the same way as it did last year, in this upcoming year, and the years after that.

READER QUESTION:  Can Americans living abroad participate and where can we find options?

SARAH KLIFF:  Americans who live abroad are generally discouraged from purchasing a plan under Obamacare for two reasons. First, the health insurance you buy on the exchanges is unlikely to have coverage options outside the United States, so it won’t help much with seeing a doctor. Second, the individual mandate does not apply to Americans living abroad. For more on this issue, check out this story I wrote about it.

READER QUESTION:  Can I look at what’s available on the exchanges by giving only my date of birth and state of residence, or do I have to give my full name and address?

PHIL GALEWITZ:  Yes, the exchanges run by the state and federal government will allow people to shop for plans on the exchange without answering too many questions beyond, age and county of residence. But to determine whether you qualify for federal subsidies, you will have to include your income information or an estimate of your income in 2014.  Here’s a link to pricing information in about 26 states.

READER QUESTION:  What if you are on Medicaid, in a state that did not expand Medicaid?

PHIL GALEWITZ:  If you are in one of states not expanding Medicaid, you won’t have the benefit of the law which expanded coverage of program to everyone under 138% of poverty rate or about $15,800 for an individual. States can still expand in future years. You are not eligible for subsidies in the exchange until your income is at the federal poverty rate of $11,500.

READER QUESTION:  Is it true that the only way that the individual mandate penalty is collected is from any income tax refund the person otherwise would receive; i.e., no refund, no penalty? If so, why does all the commentary fail to point this out and instead claim everyone must be insured or pay a penalty?

SARAH KLIFF:  I would say this is half-true: For people who do not buy health insurance coverage, the federal government will deduct the tax penalty from a refund. If you don’t have a refund, the Internal Revenue Service will send you a bill for that same amount, much like they do for any other taxes you owe.

The thing that will be different about this fine, though, is there’s not much the federal government can do after sending you this bill. They cannot garnish your wages for example, or put a lien on your house. The tax penalty will, however, remain on your IRS bill in subsequent years. You can read more about the issue here.

READER QUESTION:  Why is there no discussion about improving health outcomes? Coverage without care is like having car insurance but no car. What will happen when people agree to pay for healthcare but do not get the medical, oral, rehab, or mental health services needed to be well?

PHIL GALEWITZ:  You’re right. Having health insurance plays an important role in health but its only one factor. Nutrition, exercise, stress, access to doctors also play an important role. The Affordable Care Act is spending billions of dollars to try to find new ways to improve the delivery of health care so doctors and hospitals work better together. CMS has set up an innovation center.

The law requires all health plans to include 10 essential health benefits which does include medical care, rehab and mental health services and dental care to children. But dental coverage for adults is not one of them.

READER QUESTION:  My son is 26 and working in California, no employer health coverage. We are Canadian and were horrified he might not have insurance so we have been paying for catastrophic insurance only thru Blue cross/Blue shield. He has been told by them that his access to services will be limited if he buys into the exchanges but he currently has no well care and he would under the other plan. How does he find out exactly how limited is options will become? Can he switch back at anytime?

SARAH KLIFF:  Hi there – the best place to research this will be California’s insurance marketplace, Covered California. It has published information on the different health plans that will be available in different parts of the state, which you can see here.

There are options that tend to have wider coverage, but they also come with higher premiums, so there’s a tradeoff you’ll have to think about between price and access.

The only time your son will be able to switch plans will be during the open enrollment process, which runs this year from October 1 through March 31.

READER QUESTION:  I’ve heard a rumor that even folks who work in DC and who currently have employer sponsored insurance will be required to participate in the exchange. Is this true? What will we have to do? (I am very happy with my insurance, have had it for a few years and don’t want anything to change!)

SARAH KLIFF:  For most people, this is not true: Residents of the District who get their insurance through a large employer right now, will continue to use that health insurance in 2014.

The one change that will happen next year effects small businesses. The District of Columbia has decided that beginning next year, all small businesses buying health insurance for the first time will need to use the health exchange. Companies that already have insurance can wait until 2015. You can read more about this issue in this article from my colleague, Lena Sun.

READER QUESTION:  I made little this year as I just graduated. I am 26. Can I buy on the exchange even though my income is 100 percent poverty or am I required to get Medicaid? My income will be more than 100 percent poverty for 2014. I live in California.

PHIL GALEWITZ:  If you fall under 138 percent federal poverty level (FPL) you will qualify for Medicaid, which generally is the best deal because has the least out of pocket costs. One caveat is you may have more trouble finding specialists compared to private coverage.

When you go to Covered California website you will be directed to a plan based on the income you list.

READER QUESTION:  I think I have needed to visit the doctor about five times in the past 10 years. With insurance premiums around $400/month or close to $5,000/year, I paid more than $50,000 in 10 years. That means each of those visits to the doctor cost $10,000. How is a 10 minute visit to the doctor to say, yes, you have a chest infection, bring this to the pharmacy possibly worth that much money? I can’t help but think I could have spent the money better myself instead of paying so much for insurance that I didn’t need or use.

PHIL GALEWITZ:  My rabbi did his sermon this year with the theme of you never know when you are going to die and which day is your last. Same goes for your health. You can be totally healthy one day and sick with pneumonia the next. Health care is incredibly expensive in this country. A one hour trip to the ER can cost $5,000 if you need surgery it could be $30,000 or more. You buy health insurance so you don’t go broke and bankrupt yourself and your family if that should occur. $50,000 over ten years is a lot of money —  but if you need bypass surgery, cancer, M.S. or host of other diseases you would have needed much more than that.  I would advise checking out the new insurance exchanges to see if you can find a better price.

READER QUESTION:  If my employer doesn’t offer affordable coverage – and I don’t get insurance in my state’s exchange – do I still have to pay the fine?

SARAH KLIFF:  Generally the answer is yes: If you don’t buy health insurance in 2014, you will likely face a tax penalty ($95 or 1 percent of your income, whichever is higher).

There is one exception to this: If you cannot find a health insurance plan that is affordable, the federal government will not require you to purchase a plan. The federal government defines “affordable” as something that costs less than 9.5 percent of your income.

READER QUESTION:  I currently have insurance through COBRA, which will expire on Jan. 31, 2014. How and when do I shop for insurance? I am single, living in Virginia, working as a contractor and not eligible for subsidy.

Am I better off in the marketplace or private insurance? How do I answer the standard question regarding my current insurance situation (I don’t have private insurance and I don’t have insurance through my employer)?

SARAH KLIFF:  You could start shopping for health insurance right now, if you want, in the individual market. Beginning October 1 though, you’ll also be able to shop for coverage on the new exchanges. You can access Virginia’s health exchange at www.healthcare.gov.

When that website goes live on October 1, you will be able to see what health insurance costs for you (the federal government did give us a bit of a preview in a new report today). Then it’ll be your decision whether you’d rather buy inside the marketplace or outside of it.

READER QUESTION:  The fine/tax is MUCH less than the cost of minimal health insurance so why would I want to participate?

PHIL GALEWITZ:  Talk to a parent or a friend who has been sick or in an accident and asked them how much it cost to get health care. While on the surface it may appear paying a $95 fine in the first year is the better deal— if you get hit by a car or develop a health problem, you’ll be regretting your decision. Check out some of the low prices on the exchange, particularly the catastrophic option which would be the lowest monthly premium–these are designed for people who are in their 20s and don’t expect any health issues but want to be covered in case the unexpected happens.

READER QUESTION:  I am a federal employee and my son is on my policy. He will turn 26 in May and be released from my policy, which is after the open enrollment season. Should he get his own policy during open season or can he wait until he goes off my policy?

SARAH KLIFF:  Federal rules allow for certain people an exemption from the open enrollment period, if they have a life-changing event. Losing one’s health insurance coverage counts as one of those special events, which means that your son would be able to enroll in coverage outside of the normal enrollment period.

READER QUESTION:  Is HHS trying to stop state obstruction of navigators? I have an idea on how to stop it. Who should I contact?

SARAH KLIFF:  Health and Human Services has taken some steps to protect the navigator program, which is currently under investigation in the House of Representatives. It sent a letter to House Republicans, on behalf of the navigator organizations, so they wouldn’t have to each respond individually. Still, a few have decided to drop out of the program. You can read more on where things are on this issue here.

READER QUESTION:  I know that there’s no chance that you will bother to respond to this comment, but I would like to ask Phil Galewitz what the CHANCES are that young man whose five doctors’ visits cost $10,000 each will get a terminal disease like cancer or MS or need emergency surgery that would possibly bankrupt him?

The fact is that they are quite low, and it DOES make sense to allow reasonably healthy young people to save their money rather than force them to buy policies that are very likely not to need. Any statistician will tell you have to take into account the likelihood that a bad event will occur before you know its true cost. ACA simply ignores that reality.

PHIL GALEWITZ:  The reality is no one is guaranteed health forever. And reality is most people need to see health providers to stay healthy or at least monitor their health. That’s why we buy insurance. We all wish we could avoid buy property insurance until after the hurricane or storm hits but that’s not how insurance works.

READER QUESTION:  Can a U.S. citizen sign up his whole family (spouse and dependent children (citizens)) if one of those members (spouse) is here undocumented?

PHIL GALEWITZ:  Undocumented citizens are barred from Medicaid and from buying coverage on the exchange. But that should not preclude the rest of the household from participating. The National Immigration Law Center is a great resource on immigration questions

READER QUESTION:  My organization is working on “navigating” folks through the system. One thing we have been hearing is that it will be cheaper for businesses to just pay the penalty/fine and not insure folks…how can I address this notion? This seems unethical to me, but some insurance folks and others are advising the small businesses to do this.

SARAH KLIFF:  This is generally true: Since the tax penalty for not purchasing coverage is $95, it will typically be cheaper to pay the fine than purchase a health insurance policy. For this reason, some people are worried that the individual mandate is not strong enough to convince people to sign up.

On the flip side, if someone does not purchase health insurance during the open enrollment period, they will have to foot the bill for any health care costs, big or small, they incur in the next year. I think the decision that a lot of people will need to make is whether they see value in purchasing a health insurance policy. When they pay the individual mandate fine, they don’t get anything – but when they purchase coverage, they actually get something in return.

READER QUESTION:  What is the role of the Equifax Workforce Solutions specialty consumer reporting agency in obtaining subsidized health insurance coverage from a federally-operated exchange?

Page 3 of the basic application released by HHS says “We need [your income] information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.”

Should I request a copy of my Equifax Workforce Solutions report prior to applying for subsidized insurance coverage?

PHIL GALEWITZ:  No need to get your credit report for obtaining coverage. But the federal government is paying Equifax to collect annual income information on consumers so they have another resource to check people’s eligibility for subsidies. This may be helpful for people who don’t pay taxes and thus the IRS does not have their most recent income information.  The subsidies are based on your estimated income for 2014 not your current income, but if your estimate if way off compared to your latest data the federal government database, the exchange will likely ask you for more information to back up your claim. Remember, if your income estimate later turns out to be too low (and you get a bigger subsidy than you should have been entitled) you will have to pay money back.

READER QUESTION:  Love your replies, but could you revisit as to what people on COBRA must or can do? Do they have to wait until the end of their COBRA or can they end it at any time and go to an exchange policy?

SARAH KLIFF:  Sure thing – this article from Michelle Andrews at Kaiser Health News has a good take on the COBRA issue, as does this one from Jay Hancock. In general, people who don’t have an affordable offer of health insurance (anything that costs more than 9.5 percent of their income) are welcome to shop on the exchange. So if COBRA premiums are above that price, then you would not need to wait until your COBRA runs out to shop on the marketplace.

READER QUESTION:  If I drop my individual health plan and go barebacked for three months at end of year will this affect my choices in marketplace? I could save almost $3000!

SARAH KLIFF:  No, dropping coverage will not effect your plan choice in future open enrollment periods. Insurance plans are only allowed to use a few factors to determine your premium, such as your age and where you live. Whether you’ve had continuous coverage is not among them.

READER QUESTION:  I live in a state that is not expanding Medicaid. My sister who has no income helps take care of my mother. Knowing that she won’t qualify for any subsidies, can she still purchase a plan from the exchanges or open market by paying the full premium? Family is willing to help with this cost.

SARAH KLIFF:  Yes, as long as she is a legal resident of the United States, she should be able to purchase coverage on the marketplace. As you mention though, without the Medicaid expansion, she will need to pay the full price of the premium without any subsidy.

READER QUESTION:  1. In the wake of the DC shootings, many have argued for better mental health care…doesn’t the ACA provide for the largest expansion of mental health care that we have had in decades? 2. Many are complaining that the rates now revealed for ACA actually increase their rates. But, won’t many qualify for subsidies?

PHIL GALEWITZ:  Yes, the ACA requires individually  sold policies to include mental health services including many services not covered today. Some mental health preventive services like depression screening now must be offered for free. Read more here from National Alliance on Mental Illness and The White House.

READER QUESTION:  If my state decides to expand Medicaid later in 2014, and I qualify (eg, I earn less than 138 percent of the federal policy level (FPL)), will I have to give up the private, subsidized plan I enrolled in and switch to Medicaid?

PHIL GALEWITZ:  If you have private coverage, you are never required to sign up for Medicaid. But you may find Medicaid a better deal, depending on how much your employer makes you pay for coverage at work.

READER QUESTION:  My retiree contract has retiree heath insurance for my son who is 23 until he is 26. Both my husband and I are covered under this plan until I am Medicare age. Can my son stay on my retiree health plan as before? At 26, when he comes off my plan, what does he need to do? Is there a specific time of the year that he needs to get insurance at 26?

SARAH KLIFF:  When your son ages off your plan, he will need to purchase health insurance coverage, either on his own or through an employer, or pay a tax penalty to the federal government.

He can do this whenever his coverage under your plan ends. While there are certain open enrollment periods, people who lose their insurance coverage get an exemption: They can purchase a new plan whenever their old insurance coverage expires.

READER QUESTION:  Our small town Pennsylvania government is currently looking at health plans for our staff of less than 50 employees. Are the exchanges available for enrollment of our employees? If yes, is that a viable option that we should consider in addition to private insurers?

We want to maintain good insurance coverage for our staff, but increasing costs are eating away at available tax dollars. As I understand it, Pennsylvania has not set up its own exchanges.

SARAH KLIFF:  Yes, the health law’s small business marketplace is open to businesses businesses with 50 or fewer employees. So that would be one option that you could begin researching on October 1, when the new marketplaces open for enrollment.

You’re right that Pennsylvania has not set up its own exchanges. That means the federal government has stepped in, and will run the marketplace in your state. Beginning October 1, you’ll be able to see the rates you would pay for insurance coverage at www.healthcare.gov.

READER QUESTION:  Are there any resources out there that rate the quality of various health plans or can help me see differences and compare plans?

PHIL GALEWITZ:  Good question. The nonprofit National Committee for Quality Assurance has ranked health plans for many years…so does Consumers Reports.

Your state insurance department website may also publish information ranking health plans.

READER QUESTION:  I am a retiree and eligible for social security retirement but I am not eligible to be covered by Medicare yet. I am currently covered under the retired employee healthcare coverage with my last employer and the premium is so expensive. Can I enroll the ACA health exchange on Oct 1st and be covered immediately for both me and my spouse?

SARAH KLIFF:  This is an important question: While enrollment on the health law’s marketplaces does begin on October 1, coverage will not start until January 1. This is true whether you buy a plan on October 1, November 1 or even December: None of the coverage starts until January. So no, the plan will not take effect immediately, but rather three months after you purchase coverage.

PHIL GALEWITZ:  Yes, if you are under 65 and not on Medicare you can get coverage through the exchange. Word of caution: As you may expect, rates for people in their 50s and 60s are more expensive than younger adults but if your income is below 400 percent of poverty level. ( $62K for a couple) you will be eligible for a subsidy to lower the price.

READER QUESTION:  Do you know how the premiums under the federal multi-state ACA exchange compare to the total premiums under the Federal Employee Health Benefits Plan? Shouldn’t OPM be able to get about the same results for both the multi-state exchange and FEHB?

SARAH KLIFF:  The best information we have on the premiums under the health care law is probably in a report that Health and Human Services put out today.

In general, it might be hard to draw a comparison between FEHB and ACA premiums. That’s because you don’t have OPM negotiating the rates for the ACA exchanges, as it does with FEHB. Instead, its state regulators who are overseeing and approving insurance rates in the case of ACA offerings.

READER QUESTION:  My husband currently has health insurance coverage through his employer and I am covered as a family member. The price is affordable and the coverage is relatively good. Will I have to obtain my own policy or can I continue on under his plan?

PHIL GALEWITZ:  If you are happy with your employer based coverage, you don’t have to do anything. But be grateful.

READER QUESTION:  My daughter is on Medicaid but my wife and myself pay for insurance. Will we have to purchase insurance for my daughter? Will she lose her Medicaid beginning in October?

PHIL GALEWITZ:  No. If you daughter is on Medicaid, nothing will change.  The health law expanded Medicaid eligibility because in most states only children, pregnant women and parents were eligible,–so called childless working adults were shut out. What’s changing is now everyone under 138% of poverty level (about $15,800 for an individual) can qualify for Medicaid regardless of their age. But this part of the law was made optional by the Supreme Court so only about half the states are expanding in January.

READER QUESTION:  I’m in sales and my annual income fluctuates do to variable compensation/commission. I do have a base income but in determining eligibility for subsidies I’m unsure of what amount to enter in the calculators. Do I use my guaranteed base income or make an educated guess that includes commission amounts?

SARAH KLIFF:  That’s a good question. The federal government generally will ask you to estimate what income you will make in the forthcoming year, which is tough for someone in a commission-driven industry.

One thing to know is that your initial estimate doesn’t have to be the final say. The federal government actually asks that, if your income ends up being higher or lower than what you expected, that you go back and let them know, so they can adjust your premium subsidies appropriately. This is important because, if you don’t do that, the federal government will likely recoup any excess subsidies in your tax return the next year.

READER QUESTION:  I have an adult daughter who has been unemployed for in excess of a year. We do not desire for her to enroll in Medicaid, but rather we are willing to purchase a policy under Affordable Health Care Act. I have read if you are in this position you can acquire the Gold plan “deductibles, etc.” for the Silver plan price. Can you explain how I might accomplish this?

PHIL GALEWITZ:  You can cut the cost of your coverage through the federal subsidies that are based on your household income. But you get the most “bang for your buck” on the  silver plans, I’m told, though silver may have a little higher deductible than gold. Its best to check ou the plans when they come out on tuesday at www.healthcare.gov..If you want to get an idea how much subsidy you will be entitled to, see here.

READER QUESTION:  My sister lives in Michigan and is currently on Medicaid. She is also on SSI and has no other income. Will her Medicaid be impacted at all by Obamacare? (I see Michigan is currently one of the states expanding Medicaid).

SARAH KLIFF:  Most likely not: People who currently have Medicaid shouldn’t see much of a change to their coverage under Obamacare. The  only possible change could be to access: With lots of people joining Michigan’s Medicaid program, some people worry that it will become harder to see doctors next year.

READER QUESTION:  This program doesn’t look anything like the bill of goods we were sold at election time. Who has the time and the savvy to work through this bureaucratic labyrinth of plans graded as metals and prices that can change anytime? It is an unmitigated mess and the only people who will benefit are the insurers and their high priced executives and the lawyers who will have to be called in to make some sense of it.

PHIL GALEWITZ:  Don’t get scared off by all the naysayers. Seniors were frightened in 2005 when the Medicare prescription drug program launched and many were overwhelmed by their choices. Today, seniors are grateful for the coverage and a simple software program helps them figure out which plan is right for them….The same will likely be true with the new exchanges. There will be choices but you will be able to determine what price point you are shopping for. And as for prices changing anytime — that’s inaccurate. Insurers can only change their prices once a year. That’s why it pays to check your coverage each year to make sure you are in the best plan.

READER QUESTION:  Is it true that the patient has a 90-day grace period to pay the monthly premium?

PHIL GALEWITZ:  You should check with your state exchange on the rules they have set up. Generally to have coverage on Jan 1, 2014, you need to have paid your coverage by Dec. 15. States have set up rules so people aren’t kicked off policies if they are a few days late paying premium.

READER QUESTION:  Is Obamacare available for a senior citizen working via green card?

PHIL GALEWITZ:  If you are in the country legally and don’t have coverage, you are eligible to enroll in the exchange.

READER QUESTION:  I am interested in knowing whether doctors and other health care providers will be required to accept Obamacare patients who sign up for, let’s say, an Aetna plan if the doctors accept other Aetna plans? In other words, can doctors decline to accept Obama reimbursement, thus making doctor availability a continued problem for patients?

PHIL GALEWITZ:  Doctors have no new oligations under Obamacare. They negotiate with private insurers on which plans they will participate in. As occurs today, not all doctors accept patients in all health plans. Doctor availability varies widely around the country and will continue to.

READER QUESTION:  I become eligible for Medicare in April of 2014. Must I buy health insurance for the first quarter in order to escape paying a fine?

PHIL GALEWITZ:  Yes, to avoid a fine you must buy coverage before the close of open enrollment on March 31 BUT millions are exempt from the mandate.  The mandate’s exemptions cover a variety of people, including: members of certain religious groups and Native American tribes; undocumented immigrants (who are not eligible for health insurance subsidies under the law); incarcerated individuals; people whose incomes are so low they don’t have to file taxes (currently $9,500 for individuals and $19,000 for married couples); and people for whom health insurance is considered unaffordable (where insurance premiums after employer contributions and federal subsidies exceed 8% of family income). More details here.

2 Responses to “Answering Consumer Questions About Obamacare Marketplaces”

  1. Kent says:

    I am currently offered “affordable” insurance for myself through my employer; however, they do not subsidize family coverage for my wife and child, making my family coverage astronomically expensive. My wife is a stay at home mom, so from what I have read, I don’t qualify for subsidies since my employer offers “affordable” coverage for me; thus, disqualifying my wife. My question is, can I move my wife and child on to the public marketplace through ACA, even without subsidies?

    Seems like I just fell into the Obamacare donut hole!

  2. Sherry says:

    Yes.

    Also if your employer stops offering coverage for spouses and dependents, then they may be eligible for subsidies depending on income.

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