KHN’s Julie Appleby, the Washington Post’s Sarah Kliff and Consumers’ Checkbook’s Robert Krughoff answered readers questions today about enrollment in the health law’s new insurance marketplaces.
A transcript of the discussion follows.
READER QUESTION: My daughter earns $22,000 a year. Her employer offers insurance. Does she have to get insurance through her employer if it’s not more than 9.2 percent (or $40 a week) of her income? And so, is she not eligible to apply for affordable health care? She was told this by a navigator. She cannot afford insurance through her employer.
ROBERT KRUGHOFF: Under the Affordable Care Act employer insurance is not “affordable” if it costs more than 9.5% of annual household income. That income is calculated based on income tax concepts and is similar to the line for “adjusted gross income” (AGI) on form 1040. AGI is usually lower than gross pay. So first check to make sure that she really doesn’t have to pay more than 9.5% of that number based on your best estimate for 2014. Let’s assume that her “affordable” threshold is about $2,000. You appear to be saying she can’t afford to pay around $2,000 out of her $22,000 income (her take home pay will be less than her gross pay, so this is not a trivial amount to pay). She can still legally apply for exchange coverage, but almost certainly will face a higher premium for a plan with lesser benefits. So even though it may be tough to stick where she is, it is likely her best option. If, however, her share of the employer premium is more than the “affordable” level, then on the exchange she can get a tax subsidy and probably pay a lower premium. So do a bit more homework before making your decision.
READER QUESTION: We applied for Vita Health for my son. We received a letter that they will be on the exchanges. If he is approved for the Vita Medicaid program, what changes can we expect? We have not heard yet. He is a full time student. We will have a premium with Vita but will it increase if he is moved to the exchange?
ROBERT KRUGHOFF: We went online and it appears that Vita is a company that is offering full price policies but only if you sign up this month. If there is a premium it is not a Medicaid plan. The only way to find out if it is also on the exchange (with a different premium) and how it compares to other plans is to apply for exchange coverage and thereby get a price quote that includes any tax subsidies given through the exchange. You cannot get those credits directly from a private plan. So be cautious. There are five potential ways for your son to get insurance: through a family policy (if you have one) since those cover children up to age 26 at no extra cost; through a college plan if he is attending college; through an exchange plan offered under the Affordable Care Act on the federal exchange for the state of Florida, through a Medicaid or SCHIP policy (both free), and through a separately sold Vita or other policy. We suggest you call the federal exchange and share additional information with them (your own coverage, your son’s age, your income and your son’s income, etc.) to obtain advice. Depending on your situation you may also want to apply as a family or as individuals for coverage through the exchange.
READER QUESTION: I was told, as were all Americans, that we could keep our insurance if we liked it. However, our policies are not being renewed because our plan does not include coverages we neither need nor want, such as maternity or birth control, since we are no longer of child-bearing age. Our premiums are going up about $2,500 a year, with a larger deductible. Why is this good for us?
ROBERT KRUGHOFF: The claim that everyone could keep their insurance if they like it was a bit of an overpromise. But it sounds like you don’t like your current insurance, if for no other reason than its cost increase for the future.
Insurance always covers costs for many conditions that won’t, or are unlikely to, affect a particular family. The Affordable Care Act includes provisions that require all plan members to pick up a share of the cost of people with pre-existing conditions and also maternity coverage and other costs. That makes insurance more available and affordable for people who are likely to have such costs. The Act also creates incentives for people who might have such particular coverage needs in the future to get coverage, and share in the insurance pool’s costs now rather than waiting for the time that they have a personal need for such coverage. The idea is to spread risk. People who are not in child-bearing years may pick up a share of child-bearing costs but may actually benefit by the fact that younger people who are in child-bearing years but who also tend to have lower health care costs are incentivized to join the pool.
It sounds like you and your spouse are prime candidates for getting onto the online exchange for your state and finding out what coverage is available at what cost. You may be pleasantly surprised, as exchange plans are generally very good buys for older couples.
READER QUESTION: This year I was able to see exactly how much my employer spends on my health insurance on my W2. The amount is more than 11 percent of my annual income, and on top of that, I have a deductible that is more than half the annual cost of the premium. I make less than 400 percent of the poverty line for an individual. I am wondering if it would be a better move to opt out of the employer insurance and look for an individual plan through Obamacare.
My question is (and I’m not sure if this is something you can help me with or I just need to talk to my HR rep), if I opt out of the employer insurance, can I collect the money they would have spent on my insurance as income to apply toward an individual plan elsewhere? And will that money then be taxed like regular income?
I live on a very fixed budget and need to get the most out of every dollar, and since I am a relatively young and healthy person, it might be a better deal to choose a different plan. Any advice would be appreciated. Thank you!
JULIE APPLEBY: If the amount taken out of your pay that goes toward your share of the cost of employee-only coverage through your job exceeds 9.5 percent of your household income, you may qualify for a subsidy through the new marketplace. If your share of the cost is less than 9.5 percent, you could still shop in the market to see if you can get a better premium, but you would not get a subsidy. I suspect your employer would not cut you a check for what they are not spending on you, however, if you opt out.
READER QUESTION: Washington is a region, like New York City, Philadelphia and some other parts of the country, where people routinely move across state lines without changing jobs. If you have group health insurance from an employer, moving doesn’t usually affect your coverage. How does moving affect you if you buy an individual policy on an exchange? If I buy insurance while I’m living in D.C. and I move to Maryland or Virginia, or to D.C. from somewhere else, or really from any state to any other, do I lose my coverage and have to get new insurance in the new state? If so, is there an overlap? Does the old policy continue long enough to cover me while I sign up for new insurance? Suppose I move between open enrollment seasons? What happens if I’m in some kind of ongoing treatment when I move?
JULIE APPLEBY: Consumer advocates say you should generally buy coverage in the state in which you live. Depending on the plan you purchase, it may have a broad enough network that if you move nearby, say from Northern Virginia to DC, that you may not need to change plans. But, if it doesn’t, moving is considered a “qualifying event.” That means you could shop again on your new state’s marketplace and enroll in new coverage, even if it wasn’t open enrollment season.
READER QUESTION: Why is it that no one seems to be talking about the high-cost deductibles of the ACA? Everyone appears to be focusing on the monthly premium, but the high cost of the deductibles seems to be completely ignored. Paying $9,000+ for insurance for year plus a $11,000+ deductible is definitely not affordable. Why is this topic largely ignored?
SARAH KLIFF: Definitely a fair point. A lot of the time when we talk about affordabiltiy under the health care law, we use monthly premiums as the measuring stick. But other cost-sharing provisions, such as deductibles and co-payments, are important too.
One reason they haven’t come up as much is that data on deductibles hasn’t been as easily accessible as premium information, which health plans file with state insurance offices. It requires combing through a lot of the plans that we’re seeing for the first time on the marketplace. I’d expect going forward we’ll see a fuller discussion of deductibles and other cost-sharing, now that we have more information that’s available.
READER QUESTION: My in-laws (57 and 59) live with us. We cover their day-to-day expenses, but they have no income and no health insurance (they don’t want it anyway). Last year, we claimed them as dependents. Are we responsible for providing health insurance for them in 2014? They both smoke, so I expect the premiums for them to be outrageous. I already dislike that they smoke, but I expect I’ll get extremely resentful if we have to pay for their continued bad choices for several more years, considering that smokers must (rightfully) pay a higher premium than nonsmokers.
ROBERT KRUGHOFF: Your in-laws may qualify as your dependents on your tax return so long as they do not have more than a few thousand dollars of annual income and you provide a majority of their support and are the only ones claiming them. That is a question to confirm with a tax professional. But we are not aware of their being eligible to qualify as your dependents for insurance coverage under the Affordable Care Act. We suggest you get advice from your exchange.
Assuming they do not qualify to be covered under your policy and that they will be responsible for their own insurance, they might be able to qualify for Medicaid depending on your state’s program’s rules. Again, check with your exchange.
As to a premium adjustment for tobacco use, if plans in your state make such an adjustment, such adjustments do not apply to Medicaid.
READER QUESTION: I have a hard time finding enough information to determine the cost of the care to the individual or family. Is there a chart or schedule to compare your own income to the cost of health care? Like the government’s price scale.
ROBERT KRUGHOFF: You need to think about plan costs in two groups. One part is the premium cost. That will differ in a major way from plan to plan. But depending on your income, you may get a tax credit subsidy, which you can subtract from each plan’s premium to get the net premium cost. Calculating the subsidy levels is complicated. Some of the marketplaces (exchanges) have calculators you can use, by putting in information on your income, family size, etc. The most accurate way to find out the subsidy amount in the exchanges is to fill out the application form for your state. You will then be able to see what the premium prices for each plan are after reducing the premium by the amount of the subsidy.
An entirely different issue is what you are likely to pay out of pocket in the different plans. You will see information on things like deductibles, copayments, and coinsurance. Very important is the maximum amount you can pay before the plan pays all the rest. You will need to compare plan cost-sharing yourself, perhaps by looking at two or three plans side-by-side. Unfortunately, this is complicated: is a plan with a $200 deductible and a $10,000 out-of-pocket maximum better for you than a plan with a $1,000 deductible and a $3,000 out-of-pocket maximum, etc., etc.? All this information can be boiled down into a single dollar-amount estimate for your family for each plan so that plans can be compared side-by-side. But very few state exchanges give you simple summary estimates like this (exceptions are Colorado, Massachusetts later this fall, and a partial calculation in California).
Be aware that the plans with the lowest premiums might be much more expensive than plans with higher premiums once you take into account that the low-premium plans may leave you paying much more for your share of the cost of care from doctors and hospitals, drug costs, and other costs.
READER QUESTION: I have two daughters in college and both of them are headed for careers in the entertainment industry. While I hope for their success, it’s more likely that they will be struggling artists for a while. The ACA will be a critical and much needed service for them as they build their lives. And one of my daughters had cancer when she was 14, she is fine now with no expectation that her particular type of caner will come back. However, she now has the dreaded pre-existing condition. My question: Aside from all the talk about repealing the ACA, it’s law now and being implemented. Should a future administration (in 2016?) be elected that decides they want to repeal it altogether, can they?
JULIE APPLEBY: Yes, if one party has the White House and both chambers, the law could be repealed. But polls show the pre-existing conditions provision is very popular, so Congress would be hard-pressed to come up with some kind of replacement. High-risk pools have been suggested, but those have met with mixed results in the past.
READER QUESTION: What is the state of getting the public educated about what the ACA does? I am still flabbergasted at what I hear–like yesterday at a public health clinic when a woman, who uses veteran’s benefits was there with her grandchild who was being seen under Medicaid, told me that Obamacare would be the ruin of the country. Is there any plan to offer some concise education, particularly in states like mine that have opted not to participate in the exchanges?
ROBERT KRUGHOFF: The ACA has many provisions related to insurance an many other parts of the health care system. Understanding them all would be an enormous challenge. Hopefully, on the insurance front, people who use the exchanges will be able over time to judge for themselves how well it is working for them.
READER QUESTION: It looks like the exchanges require registering with personal information before you can obtain information about plans and prices, and that the registration process is what’s causing delays and hanging up the system. Why wasn’t the site designed so that basic information would be available without registering? You can shop on Amazon and Ebay without registering until you’re ready to buy something, and you can get general information about benefits and procedures at the Social Security and Medicare web sites without actually signing up. Why is the exchange web site so cumbersome?
ROBERT KRUGHOFF: The ability to browse options is different from exchange to exchange. Some exchanges may have concluded that it would be confusing for consumers to see options and get an indication of cost if that indication would later prove to be inaccurate when the consumer actually tried to sign up for a plan using all the personal information officially required. But it is clear that many consumers would like quickly to browse and exchanges may move to make that easier. It is important to note that even if you do register and put in all the required information, your subsidy amount might vary over time as your income changes; so requiring you to register does not eliminate uncertainty.
READER QUESTION: What will the average cost be for a family of three making about $110,000 a year? And if we opt out, and choose our current insurance, do we have to pay any additional charges?
ROBERT KRUGHOFF: At your income level you would pay “sticker price” for any exchange plan, without any tax subsidies for your premiums. Since we don’t know what kind of insurance you have now, we cannot answer the question. Assuming you have insurance from the individual market, your company may allow you to renew it for 2014 and continue to pay for it (this is not the case for most existing policies in many states, so double-check). Whether it is a better buy than exchange insurance will likely depend not only on the rates you are now being charged, but also on your ages and other factors. You should certainly check out the exchange options before making your decision. For example, there will be benefits on the exchange plans (free preventive care, no “maximums” or “gotchas”) that may well make even a slightly higher premium a very good decision for your family. And the exchange premium may be lower.
READER QUESTION: Been trying for a week to get an account started. I’ve seen changes in the glitches, each time is different. Probably the most frustrating now is the return: Unable to create user account. Username is taken. I’m familiar with the world of usernames, but the names I’m submitting are so obscure that I know that this is just another glitch. As a believer, I am not going to give up. The ACA will save my family $6,000 in the first year, with no government subsidy! Our esteemed Gov. Jindal prevented a state exchange, so we’re going “national” here in Louisiana. Just a more competitive market, I think.
ROBERT KRUGHOFF: The federal government’s web site, which covers most states including Louisiana, and many state web sites, have had lots of start-up glitches, especially in creating user accounts. To save a lot of time and frustration you might want to wait a week or two before applying. It doesn’t matter when you apply this fall, as long as you apply by December 15, because your new coverage will not start before January first.
READER QUESTION: Those who oppose the Affordable Care Act often cite the mandate or the costs to small businesses as the reason for their opposition. However, having read a summary of the Act, I believe that political opposition mostly has to do with the “caps” on insurance company profits and administrative costs in 2014 and beyond and on the provisions for preventable tests and care for all. I would be interested in seeing lawmakers’ campaign contributions from major insurers to ascertain if this is, in fact, their real opposition.
ROBERT KRUGHOFF: Opponents to ACA have various reasons. Actually, the insurance companies are generally on record as favoring the law. They expect to gain a lot of business from the newly insured. Some opposition to ACA is based on mis-information or lack of knowledge about all that is in the law. Some reflects different ideas and preferences as to the role of the federal government in health care. Some reflects concern as to whether the government can effectively manage various complex requirements of the law. You may want to do some Internet searching to see some of specific provisions, their rationale, and various issues that critics are raising.
READER QUESTION: If this Act is so great, why has my premium and my medication all gone up within the last 90 days? I thought it wasn’t going to mean higher premiums or higher cost of medications. Seems somebody didn’t do their homework.
ROBERT KRUGHOFF: The law has had very little effect on either premiums or cost-sharing in health plans so far. The big changes begin in January. It sounds like you have an insurance policy that makes you unhappy. If it is an employer plan, talk to your company’s human resources people to find out what is going on and if you have any options. If it is an individual plan, you may well be able to find a better deal on the health exchange for your state, which lets you compare plans and choose one you like (for example, with better drug coverage). You may also be eligible for a subsidy to reduce your premium costs.
READER QUESTION: We received a letter from our insurance company that our health insurance policy is being eliminated because it no longer meets federal guidelines. So, we have to find new insurance, which we are happy to do. But we’re having terrible problems with the website.
SARAH KLIFF: You’re likely in a situation that other people are facing, on both counts. The health care law does require health plans to cover a set of benefits that, in some cases, is more generous than those insurers currently offer. This is one of the reasons that some will see their premiums go up under the Affordable Care Act.
The websites to purchase coverage have, so far, been pretty glitchy. Health and Human Services says they’re working on fixing the problems but even today, a week after launch, a lot of people are having trouble creating accounts on HealthCare.Gov.
READER QUESTION: As a FEHB participant, I was disappointed to learn that my maximum FSA contributions for 2013 were cut in half, to $2500. I take several non-generic medications, and the now-gone maximum of $5,000 per year was a Godsend to me. What is going to happen to FSA maximums in the future and are they available to people who purchase insurance policies on the exchanges? Thank you.
ROBERT KRUGHOFF: The reduction in FSA amounts affects all persons using those accounts, public or private, and was one of the reductions to help finance the ACA. FSAs are available only through employer/employee arrangements, not through individual plans sold in exchanges. You may want to use the FEHBP Open Season to search for plans in which your medications are “preferred” in the formulary, and costs to you much lower. Your pharmacy is likely to be able to advise you on this.
READER QUESTION: In states that are not expanding Medicaid, if a low-income person with individual, subsidized coverage suffers a serious illness or injury and cannot work, would they lose their subsidies if their annual income falls below the minimum required?
JULIE APPLEBY: People who fall below the poverty line in states that don’t expand Medicaid will not be eligible for subsidies. I don’t know if they would be cut off mid-year from receiving them.
READER QUESTION: It’s been disturbing to me that my parent group is cutting loose some 34,000 veterinarians and dependents from its “group” healthcare. They informed us late Dec. 2012 that after 2013, we must seek health care on our own. I have had health care through them since graduating in 1985 and feel betrayed. They claim it’s the decision of United HealthCare which actually runs the plan. That may be true but now that I am 54, I figure I will fall into that age group which gets screwed into paying higher premiums which were already ridiculous once United took over a few years ago from another company. For those ACA opponents who say delay it at least a year until 2015, they need to understand that many of us who have dutifully paid our own way for years are being cut loose in 2014 and would be without health care. I try to interface with human medicine as little as possible because I question the robotic, mindless over testing that is done. I do recognize we need it even in our 20′s. To the young folks out there, there are many of us middle-aged people who paid our way without any one forcing us when we were your age. Don’t you think you can be hit by a car? Long message but I do not know how this is going to work out for me. Self-employed people have paid more than their fair share as far as I can tell. Most people I know around here have low premiums and copays – I wonder how that happens?
ROBERT KRUGHOFF: Since you are self-employed, you will be eligible to choose among health plans on your state exchange. You will NOT be without health insurance options. To the contrary, you will have many options. As a veterinarian, you are likely to be in a higher income group, and may not get special subsidies, but the only way to find out for sure is to fill out the application form for your state. As an older person, you will likely find quite reasonable premiums relative to what might be available without the exchange. You may also want to consider applying as a small business, if you are considering covering your employees.
READER QUESTION: 1. What happens to Health Savings Accounts (HSA’s) if you switch to a plan on an exchange? Will we be able to continue to contribute to HSA’s after January 1st?
2. Cadillac plans. If someone has a condition that requires expensive specialty drugs and they are on a private plan with high premiums, will they most likely be subject to the Cadillac tax even though they are getting purely medical and by no means luxurious benefits?
ROBERT KRUGHOFF: 1. You will be able to keep your existing HSA. Don’t count on finding a plan that includes additional contributions to an HSA by the plan. As to additional contributions by you, the answer may depend on whether any high deductible plans are offered on your exchange that meet the IRS criteria for eligibility for contributions by the enrollee. This is something you should explore online and by telephone for your state exchange.
2. The so-called Cadillac plan provision does not go into effect until 2018. It does not directly affect in any way whether or not a plan pays for specialty drugs or any other particular kind of expense. Exchange plans are required to pay for such drugs as part of their minimum essential benefits package, though not every brand name drug need be on their formularies. Avoiding the Cadillac tax will fall largely on employer plans, through increases in cost-sharing such as having members pay 20% rather than 10% for a particular benefit, increased deductibles, or similar measures.
READER QUESTION: Which religious groups are exempt from having to buy policies under the ACA? I understand that the Amish and Muslims do not have to buy policies; is that correct? As a Christian Scientist who does not use medical care to maintain my health, am I also exempt?
SARAH KLIFF: There is a religious exemption under the Affordable Care Act, which applies to people who belong to a group that has a practice of waiving out of all public insurance programs, such as Medicare and Medicaid. According to the Church of Christ, Scientist, these exemptions do not cover Christian Scientists. This exemption would not cover Muslims either, and is most likely to apply to members of Amish and Mennonite groups.
READER QUESTION: I just assisted my daughter in signing up for health insurance through the exchange by phone. We were treated professionally and by a person with excellent customer skills. Anyone having difficulty signing up online should call directly 1-800-318-2596 and sign up by phone.
ROBERT KRUGHOFF: That is good news. Not everyone has been so fortunate, but hopefully more will have experiences like yours in the days to come.
READER QUESTION: I live in Washington state, where we have a healthcare exchange. I’m just looking for information at this point in time, but the site asks for detailed info (like social security number) and an e-sign just to get basic information. Why?
ROBERT KRUGHOFF: Many states let consumers browse plans without registering, and most have extensive Q&A info on health insurance and how the exchange works. I am surprised you can’t do such info-browsing on your exchange. Maybe contact the exchange’s help line and ask if there are any such resources they can suggest.
READER QUESTION: Why doesn’t the objective media differentiate technical glitches from substantive issues based on the merits of ACA? Every time an opponent of the law uses these technical glitches as “proof” that the ACA is a failure, the media fails to point out the obvious.
ROBERT KRUGHOFF: We agree that such a distinction is important. To the extent that critics of ACA oppose the law because they think government just doesn’t work or that the law is too complicated to implement, glitches support their point. But to the extent they are citing technical glitches in a catch-all way to suggest that ACA policies are wrong, that is misleading.
READER QUESTION: I’m no expert on the ACA details in full, but I’m guessing that the person who says that he’d pay $9,000 in premiums and $11,000 additionally in deductibles is missing part of the equation — there’s a maximum out-of-pocket expenditure, right? Just like most of us in employer provided plans have. Also, I’d bet a chunk of money that another letter writers premiums didn’t go up $2,500 only because of maternity and birth control coverage. I’d guess that he/she didn’t have real insurance before — one of those plans that only paid out until the insurance company realized that they might not make money off of you, at which point they cut you loose. Under the ACA, many Americans will have real insurance for the first time — insurance that must cover you if you actually need it. Imagine that!
JULIE APPLEBY: On out-of-pocket costs, the ACA says those cannot exceed $6,350 for individuals or $12,700 for families annually. Those costs include deductibles and copayments. Advocates say those those limits are expected to be a struggle for some consumers and are higher than what some employees have with job-based coverage. Still, they are lower than about one-third of plans that were being offered to consumers before the new markets opened, according to an analysis KHN and U.S. News and World Report did a while back.
READER QUESTION: My income varies depending on investments. Can I wait and claim a subsidy on my tax return after the year for which it applies?
ROBERT KRUGHOFF: You should apply this fall for a 2014 plan, and for a calculation as to the subsidy that will apply to you for 2014. You will be asked for your current (2013) income and your forecast for next year. Your tax subsidy will depend on the 2014 estimate. You will also be asked to report changes in income from your estimate next year, as they occur, so that your subsidy amount can be adusted up or down. Some of the Exchanges may allow you to apply less than your full eligible subsidy. In that scenario, you’ll pay primarily out-of-pocket and get the tax rebate at the time of filing your return for that year.
READER QUESTION: How much can a family of three, that make about $110,000 per year, expect to pay for new healthcare, and, if I choose to keep my current plan, do I still have to contribute money/pay a fine, and how much? Thank you for a response.
SARAH KLIFF: The best place to research this is on a subsidy calculator that the Kaiser Family Foundation helped us here at the Washington Post build. You can find that here. That should give you a sense of some of your options. You can also try to use your state’s health marketplace, located at HealthCare.Gov. That website has had trouble though, so it might not work well enough to show you your options.
As to what happens if you keep your current plan, that depends a bit on the insurance you have right now. If it meets certain health law requirements (like covering certain benefits, for example, or not imposing lifetime limits on coverage), then you would likely be able to keep it. If not, you may need to shop for a new plan. It’s probably best to reach out to your health plan to ask them about an issue like this one.
READER QUESTION: My understanding of the ACA is that mental health care must be covered at the same level as physical care. My understanding (perhaps flawed) is that this means that caps on treatment (inpatient for example) cannot be applied to mental health stays if they are not applied to physical health hospitalization. Is this correct?
My insurance company couldn’t tell me. I’m asking because my small employer (less than 50 people) is exempt from ACA but our HMO plan does institute limits on mental health treatment but not other treatment. I’m wondering if I can shop on the exchanges because my employer doesn’t offer an insurance plan that meets ACA requirements. I’m just trying to get better (not necessarily cheaper) mental health coverage for my unemployed, bipolar spouse.
ROBERT KRUGHOFF: ACA does attempt to create parity between mental and traditional medical healthcare coverage. Plans that are “gradnfathered” however, are not required to meet this requirement. You should explore the plan offerings in your state’s Exchange (Marketplace) paying particular attention to the relative genrosity of the mental health benefits offered.
READER QUESTION: Please define “Affordable” in the context of the ACA. My daughter makes about $3,600 per year right now. And when she checked, using one of the many available calculators online, she should be able to get coverage for about $3,400 per year. This doesn’t sound remotely affordable to me.
ROBERT KRUGHOFF: Since your daughter’s income is below the federal poverty level for a single person (around $11,500), she will not be eligible for a subsidy in an exchange plan. Depending on your state’s Medicaid rules and other facts about her situation, she may be allowed and encouraged to enroll in Medicaid, which is free insurance with no premium. She should use the online application process for the state in which she lives. Since there are start-up glitches, it would be prudent to wait a few weeks to avoid lengthy delays or other problems with the online system.
READER QUESTION: The federal exchange, which covers most of the country, has been an unmitigated disaster so far. Yet journalists continually understate the problems as “glitches.” Why is that? Do they have so little respect for their readers’ intelligence?
JULIE APPLEBY: While “glitch” is a handy headline word because it’s short, there has been no shortage of coverage of problems associated with the rollout of the new marketplaces. State papers are covering the situation in their regions, while papers liek the NYT and WSJ and the wire services are covering the national picture. Here are six stories just from today.
READER QUESTION: I’ve worked part-time or 24 hours a week for the last 25 years. My yearly income is $24,000 and I pay $4,950 in health care insurance a year for myself and husband. My share is $92 bi-weekly ($2,392 yearly). As a part time employee, can I turn down employer provided coverage and shop on the exchanges without my employer being penalized? If I work more hours next year, it may put me under the .095 percent threshold thus making me ineligible to purchase on the exchanges.
ROBERT KRUGHOFF: For next year, your employer will not be penalized since enforcement of the “employer mandate” has been suspended for a year and even then, if you remain a part-time (less than 30 hours weekly) employee, your employer would not incur a penalty. That said, it doesn’t sound like your employer would be penalized in any event. If we understand your numbers correctly, you and your employer each pay about half the cost of your current plan. But it seems unlikely that $4,950 is the full cost of your plan unless it provides very skimpy coverage. Good family plans generally cost more than twice that much. You don’t give your husband’s income, but that will affect where you stand relative to the 9.5% rule you allude to. Our suggestion is that once the online exchanges get over their start-up problems, a few weeks from now, you and your husband apply online in your state and see what kind of premium cost you face. All the exchange plans offer good insurance that may be substantially better than what you get now. The only way to find out what is best for you is to apply.
READER QUESTION: The health exchange web site is healthcare.gov. You can also find healthcare.COM and healthcare.ORG, commercial sites that sell insurance through brokers. Is there any indication that some of the confusion in the ACA rollout is the result of people going to the wrong web site?
ROBERT KRUGHOFF: We have seen nothing reported on this possibility, but there have been press releases from government agencies and consumer groups warning consumers of possible scammer sites or sites that might trade on confusion. The overwhelming amount of user traffic on healthcare.gov would suggest however, that many consumers ended up at the correct website.
READER QUESTION: We don’t want to do this by phone and be put on hold until doomsday–we want to do this online. The government provided a website which should have been glitch-free. They had three years to get it working.
SARAH KLIFF: This is a frustration that a lot of people are having right now: We’re a week into open enrollment and many people are getting stuck at waiting screens and error messages trying to sign up for coverage at HealthCare.Gov.
If you don’t want to sign up by phone, the good news is you don’t have to: Open enrollment runs through the end of March (although if you want your coverage to start in January, you do need to sign up by December 15). Assuming the White House can get the technological issues worked out, there’s still plently of time to sign up.
If they can’t, the White House may need to think about extending the open enrollment period or examining other ways to get people enrolled in coverage.
READER QUESTION: What happens to you and your provider if you Insurer can no longer pay it’s bills and goes bankrupt? Who’s responsible?
JULIE APPLEBY: State regulators — both before and after the ACA — are responsible for overseeing that insurers who apply to sell coverage have adequate revenue and reserves to cover their expected claims expenses.
READER QUESTION: I work for a community health center with areas of expertise in care for the LGBT community and people living with HIV/AIDS. We are also a navigator organization for the ACA. We see the ACA as a powerful tool to fight discrimination against LGBT patients in health care due to the law’s prohibition of sex discrimination in care. We believe that includes discrimination against transgender persons, and also discrimination based on sexual orientation. Do you feel the ACA could address problems of LGBT discrimination in health care?
ROBERT KRUGHOFF: The Affordable Care Act bans sex differences in insurance premiums, and has a clause (section 1557) that bans sex discrimination in health care. The Department of Health and Human Services interprets this clause as banning discrimination on the basis of gender identity. There hasn’t been much guidance issued yet on just “who” and “what” is covered, but there will undoubtedly be significant effects over time. The official web site on this issue is here.
READER QUESTION: I have very little income, well below the ACA requirements for Medicaid. I do not qualify under the pre-ACA system, however, because my assets are too high (you have to spend down to practically nothing). The ACA seems to use only an income-based measure for Medicaid and subsidy eligibility, however.
Will I be eligible for Medicaid under the ACA? Are more doctors going to accept Medicaid? There’s already such a shortage I worry that Medicaid won’t be much better than no insurance at all. I have managed to register on my state’s exchange, but the site is not yet operational enough for me to see eligibility and plans. Frustrating, but I feel so much more secure knowing I’ll soon have reliable, affordable care.
ROBERT KRUGHOFF: The Medicaid expansion under the ACA will broaden Medicaid eligibility for low-income, non-elderly adults without regard to assets. One exception for that age group are those with incomes above the threshold but with high out-of-pocket medical costs. Such individuals will be required to spend their assets down to the existing asset limit, which varies by state and is typically a few thousand dollars. So assets should not be a problem for you. As to physician participation, that problem varies widely by state and locality. While you may only be able to use certain physicians, the great majority of hospitals and most other service providers accept Medicaid patients. One other factor that may affect you is that in many states Medicaid uses HMOs to serve most enrollees. So you may well have a limited network. But the care will be there.
READER QUESTION: Early on, I got the impression that Kynect in Kentucky was far and away the most successful of the state exchanges. Has that continued to be true? Could you tell us which states are standout successes or least successful? I’m in the federal exchange so I’m curious about other experiences in other states.
JULIE APPLEBY: Kentucky says it has enrolled more than 7,000 people, which is second to Washington state, which says it has signed up 9,500. States having troubles include Maryland and Minnesota.
READER QUESTION: What was the planned density (ratio) for navigators in states? Our state has only 135 navigators “certified” at this point to cover 56,000 square miles with 5.7 million residents. The state government has obstructed the process by adding fees and tests to certification. Were fees and testing part of the law for ACA navigators.
ROBERT KRUGHOFF: Official Navigators are not the only way to get advice. You can use healthcare.gov which has rich resources, and the telephone help available through the federal government. Yes, some states have placed barriers on Navigator qualifications. But the federal government has standards and training requirements in place as well, including testing. In many states more Navigators will shortly be available.
READER QUESTION: The person who wrote in about OOP expenditures, questioning a previous writer’s calculations of premiums plus OOP amounts needs to understand that premiums are not counted as out-of-pocket expenses. So the first writer was correct: premiums of $9,000 plus out of pocket expenses of $11,000 (or more – estimate for me was more than $12,000) is a typical total cost for an ACA plan without subsidies.
JULIE APPLEBY: Correct. Premiums are not counted as out of pocket expenses.
But deductibles and copayments for such things as doctor office visits, prescription drugs or hospital care are included in the out of pocket maximum.
One other thing for consumers to note: costs for going out of network do not apply to the out-of-pocket maximum. Consumer advocates say shoppers should check to see if their doctors and hospitals are included in the insurer’s network before selecting a plan.
READER QUESTION: Can someone who is currently receiving health care through their employer elect to leave the employer based insurance and buy through the ACA marketplace?
ROBERT KRUGHOFF: Yes you can. However, unless you meet a test of “affordability” and spend more than 9.5% of your income on your employer plan, and meet a “minimum essential coverage” test, you will not receive any premium subsidies on the exchange. It is very likely that your employer’s share of the premium for his plan would make it a better deal. There is more information here.
READER QUESTION: The media reports about the website problems including slow downs, missing data incomplete transactions. How many of these problems have been traced back to intentional obstruction from the states that have governors that want to see it fail?
ROBERT KRUGHOFF: None of these online start-up problems are due to state obstruction. The states that have declined to participate have no role in the federal exchange web site that covers their states. Certain online “hub” functions that serve all states are totally under federal control. That said, there have been press reports that some states have placed some obstructions on who is eligible to serve as in-person Navigator advisors.
READER QUESTION: The ACA says that there can be no annual dollar value limits placed on benefits after Jan. 2014 and the implementing regulation says that there can be no annual dollar limits. But now some insurers are saying that they can do actuarial equivalent visit or frequency limits instead. Is this correct?
And do you know of any regulatory guidance that says they are actually allowed to do this? It seems to me that these visit limits are functionally the same as a dollar value limit. Thoughts?
JULIE APPLEBY: The law does bar insurers from setting annual or lifetime dollar limits on coverage. But it does allow them to set frequency limits, such as X number of physical therapy visits in a year. The plans, however, must still fall within the actuarial value for their coverage level: covering 60 percent of expected medical costs for bronze, 70 percent for silver, 80 percent for gold and 90 percent for platinum.
READER QUESTION: Every year, an organization called Consumers CHECKBOOK puts together a cost-comparison for the insurance plans participating in the FEHB (for federal workers). It estimates “total cost” for each plan, including not just the premiums, but also the co-payments, co-insurance, and deductibles for low-use, average-use, and high-use policy holders. It helps you figure out what the complete cost of a policy is. Most federal agencies buy/purchase the right for their employees to use the database. The ACA should have required the compilation of this data, and its posting on the exchange website, for people to use when shopping. If we don’t know the costs of a plan, how can we make a rational decision?
ROBERT KRUGHOFF: I am with Consumers’ Checkbook and I appreciate your positive words. I hope our plan comparison tool for federal employees and retirees has helped you make easy–and good–health plan choices. We have written papers and articles recommending that the exchanges include for each plan a single dollar-amount estimate of out-of-pocket costs for someone of the same age, family composition, health status, and other characteristics as the person comparing plans on the exchange. It is too difficult for consumers on their own to figure out the relative value of different benefit packages (different deductibles, co-payments, out-of-pocket limits, etc.).
READER QUESTION: I’m still getting e-mails about these. The e-mails inform me that a panel of government bureaucrats will decide whether I get needed health care or not based on my age, effectiveness of treatment, and cost. I thought this part of the ACA never made it into the final bill.
ROBERT KRUGHOFF: The “death panel” story was always much exaggerated. There is no such thing in the ACA as enacted. There is a group (not yet in place) called the Independent Payment Advisory Board (or IPAB) which is given the job of recommending cost-saving measures to the Secretary of Health and Human Services if Medicare expenses rise too quickly. The ACA specifically notes that this group is not allowed to do anything that would “ration” healthcare. The law also makes sure that the IPAB is not in a position to make policy, but instead to simply make recommendations to the Secretary of Health and Human Services, proposals that Congress is specifically empowered to override if it sees fit.
READER QUESTION: I think maybe I shouldn’t have set up my healthcare.gov “account” in August! It was very minimal — username, password, name, address, phone — and I was excited to do it, obviously. But I think they have slightly tweaked the requirements for “usernames” and mine doesn’t meet those rules, so it won’t get me in. I also can’t get a new username because … I already have one. Yesterday, excitingly, I got elevated to the next level of text support, so I am hopeful this issue will clear up when I hear back. During all this, btw, the 800 number has always answered within a couple of minutes at most, and usually less, the online chat has had similar waits, and the representatives have been friendly, smart, and informed. So this makes me hopeful. Can’t wait to get in and actually see my choices soon. I was unhappy with my old individual insurance, which is going away anyway.
JULIE APPLEBY: Difficulties being reported with the federal exchange and some state markets do include big problems creating accounts. In those states that don’t require setting up an account just to browse premium prices, such as Colorado or Connecticut, consumers have reported fewer problems logging in.
READER QUESTION: “If they can’t, the White House may need to think about extending the open enrollment period or examining other ways to get people enrolled in coverage.” Frankly, the White House should simply waive the individual mandate and the associated penalty for 2014. It’s shameful to penalize people for the government’s own software problems.
SARAH KLIFF: It’s probably a bit too early to jump to this option quite yet, given that we’re one week into a six-month long open enrollment. If these problems do persist though, its unlikely that the White House will waive the individual mandate. That policy change would be a huge shock to the individual insurance markets, where health plans submitted premiums that assumed people were required to purchase health coverage. They would likely balk at the change, which is likely to lead to a healthier pool of people signing up for coverage in the new exchanges.
READER QUESTION: Original poster here. I said that, by the way, as a liberal Democrat who voted for Obama twice. I’m happy to have the ACA and am glad to support the program. But this sort of snafu is exactly why people have no faith in government (either party) to get things done properly.
JULIE APPLEBY: The problems with the rollout of the marketplaces certainly have political ramifications. Opponents, for example, have pointed to the troubles as another reason why the law should be delayed or repealed. But the problems may also have other impacts, depending on how long it takes to fix them. If they are solved soon, supporters expect interest in the program will likely remain high and consumers will be able to enroll well before the mid-December cutoff for coverage that begins Jan. 1. (Open enrollment lasts until March 31). But if troubles continue, it could cause some consumers to give up and enrollment could fall below projections. Economists and health policy experts say the law’s success depends on getting a good proportion of young and healthy people to sign on, which will help cover the costs of older or sicker Americans. If enrollment falls short the first year, economists say that could cause premiums to rise faster in future years, leading to further declines in enrollment.