Obamacare: Answers to most your most pressing questions [The Seattle Times]
By Carol M. Ostrom, The Seattle Times | |
McClatchy-Tribune Information Services |
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
BASICS
Q: I'm on
A: The new law requires nearly everyone to have health insurance by
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.
CHANGES
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
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.
EMPLOYER ISSUES
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 employees.
THE EXCHANGE
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
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
When you fill out your application on the exchange, you'll find out how much you can save. Until
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 in Washington Healthplanfinder -- but are 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
A: Individuals who are 65 years of age and over can purchase plans through Washington Healthplanfinder even if they are
If a person is over 65, not
INCOME
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 Medicaid: An assistance unit comprises those household members who must be looked at together due to income, age or tax-filing status in order to determine the household size. Rules can be found in Washington Administrative Code 182-506-0010. Washington Healthplanfinder will create an assistance unit for each family member
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 (
Q: How much income can I make and still qualify for some help on premiums?
A: Legal residents who make up to
Individuals and families who make under 138 percent of the poverty level (
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
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
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 Washington Healthplanfinder 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
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.
PRE-EXISTING CONDITIONS
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
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
Also, you'll have to pay a penalty for not having coverage.
RULES
Q: So how big are those penalties if I don't purchase insurance as required?
A: For 2014, the yearly penalty is
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.
To see what plans are available in each county, you can go directly to http://1.usa.gov/1cMhLIt . To see rates, go to: http://1.usa.gov/1amLURc.
INSURANCE PLANS
Q: Why do I keep hearing about the "metal levels?"
A: In Washington, 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
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: You can search the Healthplanfinder website for a physician or provider by name, physician Zip code, or by hospital name. 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
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
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
If you have a "silver" level plan that pays 70 percent, you'll pay 30 percent of your
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.
IMMIGRANTS
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
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
Q: I have insurance through my workplace. I moved my parents here from another country to live with me. They are legal but not here for five years. Can I insure them through my employer's plan?
A: You would have to meet the
You should check with the insurer or your company on this one.
Q: I moved my elderly parents here from
A: We got this and the following answers straight from
Some immigrants do not have to wait five years to receive
Q: I will qualify for
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
Q: I moved my elderly parents here from another country to live in my house, and I'd like to get health insurance for them. They are legally here but haven't been here for five years, and they don't work at all. I might buy an individual plan on the exchange. Could I include them on my plan, or could they qualify for
A: Since they haven't been here for five years, they do not qualify for
Your parents should apply separately through Washington Healthplanfinder. If you are claiming your parents as tax dependents, then you should be included on their application as the primary applicant, but listed as not seeking coverage. When your parents have been here for five years, assuming they still don't work, they would qualify for
MORE INFORMATION
Q. Where do I go to find out more information?
A. The best places are the state's
Q. What if I don't have a computer?
A. There is now a free call center -- 1-855-923-4633 -- open from
In addition, in each county there is a network of community organizations, public health agencies, community clinics and others where you can find "navigators" or "in-person assisters" who have been trained to help you.
(Sources:
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