Obamacare: Answers to your most pressing questions

By Carol M. Ostrom • Seattle Times health reporter
© The Seattle Times • September 20, 2013

There are many opinions about the Affordable Care Act — aka “Obamacare” — but it’s heartening that all sides agree on one thing: At this point in the rollout of its most visible feature, the online exchange marketplace, there are plenty of questions.

In this Q&A, we have searched out the most pressing Qs and rounded up as many As as we can get from authoritative sources. Here, in an effort to lose the rhetoric and get to the point, we offer answers to your most pressing questions.

In just a few days, on Oct. 1., The government's Health Insurance Exchange Marketplace will be open for business. There, you will be able to find out if you might qualify for free or reduced premiums for coverage beginning Jan. 1. You’ll be able to navigate to the Exchange Markeplace in your state, enter your income and your family size, choose a plan and get signed up.


Q: I’m on Medicare. Do I have to buy something?

A: The new law requires nearly everyone to have health insurance by March 31, 2014 or pay a penalty. But if you’re on Medicare, you already have insurance. The same is true if you’re on Medicaid, a military or veterans’ health-care program, a tribal health plan, or if you have health insurance through your current or former employer.

In all those cases, you’re covered and won’t be penalized.

Q: So if I have insurance already, will my coverage change?

A: If you have private group insurance, chances are it won’t change drastically, and it may cover more services. If you buy your own insurance, you’ll have to pick a new plan, and it, too, may cover more services.

Q: I’m uninsured. Do I have to buy insurance or pay a penalty?

A: Probably, unless you are exempt because you are one of the following: an undocumented immigrant, incarcerated, a member of an Indian tribe, have such low income you are not required to file a tax return, or are a member of a religion opposed to acceptance of benefits from a health insurance policy.

In addition, you are excused if you are determined to have very low income and coverage would be unaffordable (more than 8 percent of your income). In this case, you could qualify for financial help to buy a plan through the exchange, but you won’t pay a penalty if you don’t.


Q: In general, will the health-care system change?

A: Yes, but over time. You may notice more coordination of your care as doctors, clinics and hospitals form networks, but it also may mean you’ll have fewer choices.

In general, insurers and providers are moving away from paying for each health-care service — “fee for service” — toward incentives that reward quality, not quantity.

Q: Are there going to be enough doctors with all these new people getting insurance?

A: Reimbursement rates for primary-care doctors seeing Medicaid patients are being pushed up temporarily to Medicare levels, which should help. But in rural areas, reimbursement isn’t the only reason for possible shortages.

Doctors may worry about working too many hours if there aren’t enough colleagues for adequate coverage of nights and weekends, or that lack of specialists or high-tech equipment could hamper care.

Dr. Bob Crittenden, senior health-policy adviser to Gov. Jay Inslee, points out that demand drives supply, and predicts that there will be improvements in access. But don’t expect instant change.


Q: I have insurance through a large employer. Why should I care about this law?

A: If you think you might be laid off or want to quit your job, this law could become important to you, because while you might lose your particular group plan, you can’t be denied health insurance.

Q: My employer offers a plan, but I don’t like it. Can I buy an individual plan on the exchange and perhaps qualify for a subsidy? And what about my spouse?

A: Not likely. If your employer offers meaningful, affordable coverage, you cannot qualify for a subsidy in the exchange. A plan is considered unaffordable if the employees’ share of employee-only coverage is more than 9.5 percent of their household income or if the plan pays for less than 60 percent of covered health care expenses.

If your employer plan doesn’t cover dependents, or if the cost to cover you alone is unaffordable, your spouse could qualify for subsidized coverage in the exchange.

Q: I heard that the Affordable Care Act put in place all sorts of requirements for health insurance plans, including group plans by big companies. My company is self-insured. Do they have to comply with the new regulations?

A: Companies that self-insure must comply with some of the new reforms, including: limits on out-of-pocket costs, no annual or lifetime coverage limits, no cost sharing for preventive services, and if they cover dependents, they must allow them to stay on the plan up to age 26. Also, the plans must have internal and external appeal processes. Next year, there will be an employer penalty if they don’t offer coverage or if it’s not adequate or affordable.

Q: I work for a company that has about 75 workers. We don’t get insurance now. Is that going to change for 2014?

A: It might, but your company won’t be required to provide insurance this year. You can buy individual/family insurance on the exchange and perhaps qualify for a subsidy.

For 2015, your company, like others with 50 or more full-time employees, will be required to buy insurance for its workers or pay a penalty.

Q. I’m a manager of a small company with six full-time employees and five part timers. What is our company required to do for our employees under the federal law in the way of health care insurance?

A: You’re not required to do anything, because you have fewer than 50 employees. The Kaiser Family Foundation has a handy chart to walk any company through the requirements: http://kff.org/infographic/employer-responsibility-under-the-affordable-care-act/


Q: Explain more about this “exchange.”

A: It’s an online marketplace where people shopping for individual and family health insurance, can compare benefits and prices, find out if they qualify for tax-credit subsidies to help afford the premiums, and sign up for insurance.

Behind the curtain in the exchange, your premiums can be automatically reduced if you qualify for a subsidy. It will be open for business on Oct. 1.

Q: Why are plans sold “inside” the exchange and “outside?”

A: If you think you might qualify for a subsidy, you’d want to shop inside the exchange, where you can find out if you qualify.

If you don’t qualify, there will be more individual insurance choices — but no subsidies — outside the exchange. All individual plans, both inside and outside of the exchange, must include the same benefits and cost-sharing levels.

Q: I don’t have insurance, but I’m worried about the costs. What are the ways my costs might be reduced?

A: You can save money through the exchange in three ways. All of them depend on your income and family size.

• You could lower costs on your monthly premiums through a subsidy or tax credit when you enroll in a private health insurance plan.

• You may qualify for lower out-of-pocket costs for co-payments, coinsurance, and deductibles.

• You or your child may get free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP).

When you fill out your application on the exchange, you’ll find out how much you can save. Until Oct. 1, you can get a rough estimate of your costs and savings by using the calculator at www.kff.org.

Q: What if I don’t qualify for a subsidy but I still need insurance?

A: You can still buy a health plan through the exchange even if you don’t qualify for a premium subsidy. There are also more individual plans available outside the exchange.

Q: I am 29. Can I buy a plan on the exchange that just covers me for big problems?

A: Yes. Individuals under 30 can purchase catastrophic plans but are then generally not eligible for tax credits. You might find that a bronze-level plan, which does allow tax credits, is a better deal

Q. I’m over 65 but I don’t qualify for Medicare. Can I buy a plan on the exchange?

A: Individuals who are 65 years of age and over can purchase plans through Health Insurance Exchange even if they are Medicare eligible. But they are only eligible for the tax credits if they are not Medicare eligible.

If a person is over 65, not Medicare eligible, and meets the other eligibility criteria, he or she could purchase a health plan and receive tax credits, too.


Q: What does “household” mean when I’m adding up income to see if I qualify for insurance? I only want to insure myself, but I live with other people who are working.

A: For a Qualified Health Plan (sold in the exchange): A QHP household is based on a “tax filing unit,” which comprises the Primary Tax Filer, his or her spouse or domestic partner, and anyone who can be claimed as a qualifying tax dependent.

Q: How will income be defined?

A: Income is defined as total income in excess of the filing threshold ($10,000 for an individual and $20,000 for a family in 2013). In most cases, household income is the same as what you file on your income tax — not simply all the income of all the people who live with you.

Q: How much income can I make and still qualify for some help on premiums?

A: Legal residents who make up to $45,950 and families of four making up to $94,200 may qualify for subsidies, but the amounts are small at the upper income limits.

Individuals and families who make under 138 percent of the poverty level ($15,856 for an individual and $32,499 for a family of four) may qualify for Medicaid’s free or nearly free insurance.

Q: Are there any limits on how much I’ll have to spend if I buy insurance inside the exchange?

A: If your income is below 400 percent of the poverty level, premiums for plans inside the exchange are limited to a certain percentage of your income. Depending on income, that percentage ranges from 2 to 9.5 percent.

There is also an out-of-pocket expense limit, which changes each year; for 2014, the limits will be $6,350 for an individual and $12,700 for a family.

Q. I’ve heard about a tax credit or subsidy, but I need to have my premium reduced each month to be able to afford it. Can I get that?

A: You can elect to have the advance credit sent directly to your insurer during 2014, to reduce your monthly premiums, or wait to claim the credit when you file your tax return in 2015.

If you have advance payments sent to your insurer, you will have to reconcile the payments on your tax return. More info at www.irs.gov/aca or www.healthCare.gov.

Q: What if I expect my income to change drastically sometime during the year?

A: You have to estimate your annual income as best you can for the year in which you file your taxes.

You can choose to take part of the subsidy as a reduction in your premiums, and delay part of it so it would appear as a tax credit — which, if you made a lot more, might disappear.

Also, you can go back to the Healthplanfinder and re-estimate your income every month if you need to. That will recalculate what you pay in premiums.

Q: I am 50-plus and work sporadically. I might make $50,000 one year, but none the next year or even two. How will my premiums/subsidies be calculated so I can afford insurance for the whole time? Is there a way to average your income?

A: Whether you get a subsidy depends on your annual income, and will be calculated on 2013 estimated income for insurance next year. If your income changes throughout the year, you may receive more or less on your tax refund depending on your income level.

You may also report any income changes to redetermine your eligibility. In the end, you may owe money on your taxes, or get money back. It will all be reconciled on your tax return.

Q: Some years I don’t make enough to pay taxes. Can I still buy insurance on the exchange if I can scrape together the money? Will I get a subsidy?

A: If your income is low enough, you could qualify for coverage through Medicaid. Either way — Medicaid or the exchange purchase — apply through the Exchange. Depending on your income, you could get free or low-cost coverage.

And if you don’t make enough to pay taxes, you won’t pay a penalty if you choose not to buy.

Q: I am self-employed and have my own medical insurance and my husband has a plan through his employer. Do I qualify for an exchange plan based on my income or on the household (combined) income of myself and my husband? We file taxes jointly.

A: If you file jointly, your eligibility for a subsidy depends on that joint income.


Q: When I tried to get individual insurance before, I had trouble because they said I had a pre-existing condition. Has that changed?

A: For the first time, insurers are required to accept you — at the same price as everyone else — even if you have a pre-existing condition.

Q: After Jan. 1, will there be a waiting period for those with pre-existing conditions when acquiring individual health-care coverage?

A: No, there won’t be a waiting period to get individual insurance.

Q: If I can’t be denied insurance because of a pre-existing condition, why don’t I just wait until I get sick and then I’ll buy it?

A: If you miss signing up for coverage before March 31, 2014, you’ll have to wait until next fall to buy a health plan — the next open enrollment period. There are some exceptions, but most people will be out of luck until next year.

Also, you’ll have to pay a penalty for not having coverage.


Q: So how big are those penalties if I don’t purchase insurance as required?

A: For 2014, the yearly penalty is $95 per year for an adult, $47.50 per child, and up to $285 per family, or 1 percent of family income, whichever is greater. That will rise in coming years.

Q: How much will I have to pay in premiums?

A: That depends on your age, how many people you want to cover and their ages, tobacco-use status, where you live, and whether you’d rather spend more in premiums and less in deductibles and other co-payments, or the other way around.


Q: Why do I keep hearing about the “metal levels?”

A: Individual insurance plans both inside and outside the exchange are divided by particular levels of cost sharing to make it easier to compare what you get.

Those that cover 80 percent of expenses (while the individual pays 20 percent) are called “gold” plans. Those that have a 70-30 split are “silver.” The plans that require the individual to pay 40 percent are “bronze.”

The plans that pay the higher percentages have the highest premiums, but you’ll end up paying less each time you get medical care (through co-pays, for example).

Q: Do all the plans have to cover certain things?

A: Yes, all the individual plans, whether they are sold inside or outside the exchange, have to cover certain health services, in addition to complying with existing state laws. Plans do not have to include dental care for adults.

Here is the list of “essential health benefits” that all plans must cover.

• Ambulatory patient services.
• Emergency services.
• Hospitalization.
• Maternity and newborn care.
• Mental health and treatment of substance abuse disorders, including behavioral health treatment.
• Prescription drugs.
• Rehabilitative and habilitative services and devices.
• Laboratory services.
• Preventive and wellness services and chronic disease management.
• Pediatric services, including oral and vision care.
 Dental benefits for kids are usually offered through a stand-alone dental plan, separate from your family’s health plan.

Q: It sounds like the plans will all be the same. How will they differ?

A: They will have different networks of providers such as doctors and clinics. They may also have different requirements for whether you can get brand-name drugs, for example, and may cover some health areas that the others don’t.

Also, although plans have to meet the same cost-sharing levels, they may have different deductibles, co-pays and premiums.

Q: Will the plans have different requirements in regards to, say, a person with a previous history of cancer or diabetes?

A: No. Starting Jan. 1, 2014, the law forbids health plans from considering your health condition or history. The phrase “pre-existing condition” will become meaningless.

Q: How will I know which plan is accepted by my doctor? Will we still have to call around for doctors who will take a particular plan?

A: Before you buy a health plan, it’s always a good idea to double check the list of hospitals, clinics, doctors and other providers in the plan’s network; that information is usually available on insurance company websites.

Q: I did the math and it seems like a family of four (two adults age 40) and two children would pay about $12,000 a year in premiums for a silver plan, along with 70 percent of the medical costs and $1000 to $3,000 deductibles. That’s a lot of money. I heard there are limits on how much you have to spend on premiums and out-of-pocket expenses. Can you explain?

A: The law limits the percentage of your income that you have to spend on premiums, as well as the amount you have to spend out-of-pocket on deductibles and cost sharing.

The premium limits vary from 2 percent to 9.5 percent, depending on income. Out-of-pocket expense limit, which changes each year; will be $6,350 for an individual and $12,700 for a family in 2014.

Out-of-pocket expenses include money spent on reaching your deductible and cost sharing (coinsurance and co-pays) but not premium costs. This applies to individual plans sold both inside and outside the exchange.

Q: Can you give me an example of how the out-of-pocket cap works?

A: Say you have a plan with a $2,500 deductible. You fall off your skateboard and break a lot of things you think you might need later on in life.

If you have a “silver” level plan that pays 70 percent, you’ll pay 30 percent of your $50,000 hospital bill — you needed lots of fixing — until you’ve paid out $6,350, which is your (maximum out-of-pocket for the year).

Insurance kicks in at that point. You still have to pay the premiums, but you’re done paying health care expenses — so long as they are for “essential health benefits” — for the year.


Q. Some of my relatives are immigrants without documents. Others have green cards, or various types of documents, and some have been here more than five years. Who qualifies for what?

A: An immigrant who is here legally, with documentation, for more than five years, can qualify for Medicaid or a tax credit on the exchange, depending on income. Those who are here legally for less than five years can buy insurance on the exchange and qualify for a tax credit if their income is low enough.

If they don’t make enough to file an income tax return or if insurance premiums would be more than 8 percent of household income, they’re likely exempt from a penalty if they don’t buy insurance.

Undocumented immigrants won’t qualify for subsidies or Medicaid, and will have to continue to seek care in community clinics and hospital emergency rooms.

Q: I will qualify for Medicaid for 2014. My elderly mother, from another country, moved in with me and I support her. She does not qualify for Medicare or Medicaid. Can I insure her on my policy?

A: Two separate applications will need to be completed. You need to include your mother on your application as a member of your household. The result of submitting that application will be that you will be found eligible for Medicaid, and you will be told that your mother has to complete a separate application.


Q. Where do I go to find out more information?

A. The best places are the state’s Office of the Ohio Department of Insurance www.Insurance.Ohio.gov.

Q. What if I don’t have a computer?

A. There is now a free call center — 1-800-318-2596 — 24 hours a day, 7 days a week to answer your questions.

(Sources: Washington Office of the Insurance Commissioner, Washington Health Benefit Exchange, Kaiser Family Foundation, Internal Revenue Service, Washington Office of the Governor.)


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