Q&A: Health Care Marketplace

What’s about to happen on Oct. 1?
That’s when the federal government begins accepting applications for health coverage policies through its new health insurance marketplace. The policies will take effect Jan. 1. Enrollment for 2014 will continue until March 31.

Is the online marketplace part of Obamacare?
Yes. The marketplace, sometimes called the exchange, is one component of the Affordable Care Act passed by Congress and signed into law in 2010.

Where do I go for information?
The marketplace website is www.healthcare.gov. The toll-free help line is 1-800-318-2596. Information in other languages is available at 1-800-318-2596. Starting Oct. 1, Oklahomans also can dial 211 for information. Licensed insurance agents and brokers can provide assistance, too. The Spanish-language web portal is www.cuidadoesalud.gov/, but it won't start processing applications for several weeks. The Kaiser Family Foundation has a tax credit estimator at kff.org/interactive/subsidy-calculator.

Isn’t Congress trying to shut down Obamacare?
The House of Representatives and Senate are engaged in a budget battle over Obamacare. The House has voted deny funding for many federal functions unless the Obamacare health marketplace is delayed for a year. So far, the Senate has refused to go along. The result might be a partial government shutdown on Oct. 1. For now, Obamacare is still the law of the land.

How many Oklahomans are affected by the health insurance marketplace?
According to the Census Bureau, 685,076 Oklahomans had no health insurance in 2012. Not all of them are eligible to participate in Obamacare programs. An independent research group estimated that 337,000 Oklahomans are eligible to receive subsidized coverage in the marketplace. That’s 9 percent of the state’s population.

Can the government force me to buy health insurance?
No. But if you don’t have health insurance and don’t buy any, you may be subject to a fine, starting at $95 next year and rising to $695 in 2016. Because Oklahoma refused to expand its Medicaid program, people below the poverty line here will not be fined. Native Americans are exempt, too.

Is this government insurance?
No. The policies offered in the marketplace will be issued by private insurance companies. The federal government is creating the marketplace and providing tax credits and cost-sharing payments to participating individuals and small businesses.

Will undocumented immigrants receive coverage under Obamacare?
No. The Affordable Care Act only applies to citizens and lawfully present immigrants.

Who can participate?
Starting Oct. 1, anyone can use www.healthcare.gov to compare plans, determine their tax credit eligibility and apply for coverage. But if you qualify for Medicaid and Medicare, or if you can get affordable and adequate health coverage from your employer, you will not be eligible for tax credits or cost-sharing subsidies.

When does it start?
The application period starts Oct. 1 and ends March 31, 2014. You must choose a plan and make a first payment by Dec. 15 for coverage to start on Jan. 1. You can enroll later or change your coverage status if you lose insurance because of a job change or other qualifying life event.

Which insurance companies are offering plans?
The full list of policies, provisions and premium rates will be available Oct. 1. Five companies applied to provide individual coverage in Oklahoma. Three of them—Blue Cross Blue Shield of Oklahoma, Aetna Life Insurance Co. and Coventry Health Care Inc.—operate preferred provider networks. The other two—GlobalHealth Inc. and CommunityCare—operate health maintenance organizations. Aetna recently acquired Coventry, but they will offer separate plans in the marketplace.

What kinds of plans are being offered?
Individual plans will be grouped into at least three coverage tiers: Gold policies are designed to cover 80% of an average population's health care expenses. Silver polices are designed to cover 70%, and bronze policies 60%. Insurers also may offer platinum policies designed to cover 90% of health care costs, but it is unclear whether any plan to do so in Oklahoma. In addition, insurers may offer less-generous catastrophic plans to people under the age of 30.

What kind of benefits will these plans offer?
All plans sold in the marketplace must provide a number of essential benefits, including doctor visits, hospitalization, maternity care, emergency room care and prescriptions drugs. See www.healthcare.gov/what-does-marketplace-health-insurance-cover.

Are the benefits as good as what I can get through my employer or by purchasing a policy on my own?
It depends. The Obama administration acknowledges that on average, employer-provided policies tend to provide more generous benefits at less cost to participants than marketplace policies will provide. But it says marketplace policies, on average, will be a better deal than the policies that individuals have been able to get on their own in the past. The only way to know for sure is to do your own comparison shopping.

Will the government pay the premiums, or will I?
You will pay the monthly premiums to the insurance company. If you qualify for a federal tax credit, the government will pay that amount directly to the insurance company, and your payment will be lower. Or you can pay the full premium amount and claim the credit on your federal tax return.

Who gets the tax credits?
Eligibility is based on income and family size. Credits will be provided to single people with income between $11,490 and $45,960 a year, two people with income between $15,510 and $62,040, three people with income between $19,530 and $78,120, and four people with income between $23,440 and $94,200.

What if my income is less than that?
You can still shop for policies on the exchange. But if your income falls below the federal poverty level, you are not eligible for tax credits or cost-sharing. The poverty level is $11,490 for a single person, $15,510 for two people, plus $4,020 for each additional person.

Why can’t poor people receive Obamacare tax credits?
Because the state of Oklahoma rejected an Obama administration proposal to expand its Medicaid program, known as SoonerCare. Unless you already qualify for SoonerCare, which covers only a portion of the working poor, the Affordable Care Act won’t change your situation.

Do other programs offer low-cost coverage for poor people?
Yes. The state oversees a separate program called Insure Oklahoma that provides subsidized coverage to about 30,000 working Oklahomans. It’s future has been clouded by the arrival of Obamacare, but it will continue at least through 2014. For some people, it offers health coverage at even lower costs than the Affordable Care Act. For more information, see www.insureoklahoma.org.

How much will the health insurance marketplace policies cost?
Complete information about the Oklahoma plans won’t be available until Oct. 1. Public documents filed by three of the five participating companies contain a range of plans and policy rates ranging from less than $100 a month to more than $1,000, before tax credits are taken into account. An Oklahoma Watch analysis suggests that after tax credits, most participants will wind up paying monthly premiums of no more than $300 or so, and in some cases, considerably less.

Why is there such a wide range of policy rates?
Several factors are involved. One is the type of plan you choose. In Oklahoma, gold plans have the highest premiums but provide the most coverage. Silver, bronze and catastrophic plans have lower premiums but require you pay more expenses out-of-pocket. Another big factor is age. In most cases, the pre-tax-credit policy rate for a 64-year-old is three times higher than for a 21-year-old. Tobacco use makes a difference, too; in Oklahoma, posted rates are 10 percent to 30 percent higher for smokers than for non-smokers. Rates also vary by geographic region.

What if I have pre-existing conditions?
Policies offered in the marketplace can’t exclude people with pre-existing conditions, such as diabetes, obesity, high cholesterol and tobacco use. They can’t charge higher rates for pre-existing conditions, either.

What if I make too much money to qualify for tax credits?
You can still purchase a policy in the marketplace, which might make sense if you don’t qualify for employer coverage and have been rejected for private insurance because of pre-existing conditions.

If I buy a policy, does everyone else in my family have to buy one, too?
No. You can purchase a policy for yourself only, for yourself and your spouse, or for any or all of your dependent children. The cost of the policies and tax credits for which you qualify will vary depending on how many people are involved.

What if I’m on Medicaid?
You’ll stay there.

My kids are covered by SoonerCare, but I’m not. Will they lose their coverage?
No.

I’m retired and enrolled in Medicare. Will I be affected?
No. The Affordable Care Act has no direct effect on Medicare beneficiaries.

I’m retired from the military and receive TriCare. Will I be affected?
No. The Affordable Care Act has no direct effect on TriCare beneficiaries or veterans benefits.

What if I get my health insurance from my employer?
You won’t be affected, as long as your employer’s health benefits are considered adequate and affordable. If they’re not, you can buy an insurance policy in the federal marketplace.

What if I already have a private-market individual insurance plan?
You can keep it. But it might make sense to compare your plan’s cost and coverage to the policies offered in the marketplace. You can do this starting Oct. 1.

I operate a small business. Does the marketplace affect my firm?
Employers with fewer than 50 full-time workers are not required to provide health coverage. But the health insurance marketplace includes a Small Business Health Options Program with plans designed for people businesses with fewer than 50 employees. The SHOP program might provide a tax credit for your business. See www.healthcare.gov/what-is-the-shop-marketplace.

Why isn’t state government involved?
Oklahoma is one of 27 states that declined to set up its own health insurance marketplace.

QUESTIONS FROM READERS

Will Obamacare affect the health plans that some colleges offer their students?
If the plans were created before March 23, 2010, they might be considered "grandfathered" plans, in which case they would not be affected. Newer plans provided to college students must offer the full list of essential benefits required by ACA, including preventive services.

I'm attending grad school and working part-time. My employer doesn't offer health coverage. My 26th birthday is next year. Can I stay on my parents' health plan?
Yes, you may stay on your parents' policy until you're 26. After that, you probably will qualify for low-cost individual coverage through the Obamacare marketplace. Your employer might be able to offer low-cost coverage through the new SHOP program.

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>