November 17, 2014

Q&A: Affordable Care Act, Round Two

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Healthcare.gov 2015 image

On Saturday, Nov. 15, the federal government began accepting applications and renewals for individual health plans sold through its online insurance marketplace. Open enrollment for 2015 coverage will continue until Monday, Feb. 15.

Here are answers to many key questions about buying insurance on the health-care exchange in Oklahoma.

Where do I go for information?
The marketplace website is www.healthcare.gov. The Spanish-language site is www.cuidadoesalud.gov/. The Henry J. Kaiser Family Foundation has a tax credit estimator at kff.org/interactive/subsidy-calculator.

What if I don’t have Internet access or need help with my application?
The federal government’s toll-free help line is 1-800-318-2596. In addition, you can meet with a federally certified application counselor or a certified insurance agent or broker. For assistance in finding one, see localhelp.healthcare.gov.

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Is the website working better than it did last year?
Apparently so. The Obama administration said about 100,000 people across the country submitted online applications on Saturday, the first day of the 2015 enrollment period. On the first day of enrollment last year, only six people were able to successfully complete their applications.

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

Isn’t Obamacare under attack in Congress and the U.S. Supreme Court?
Some members of Congress would like to repeal the Affordable Care Act. Many political observers consider that unlikely. Congress might attempt to reduce the scope of the law in 2015. But that appears unlikely to occur before the enrollment period ends on Feb. 15. The Supreme Court has agreed to consider a case challenging the legality of premium subsidies provided to policy buyers in Oklahoma and other states that are not operating their own health insurance marketplaces. The court’s ruling is not expected until spring at the earliest.

Can I wait until February to see what happens?
You could. But if you’re currently uninsured and you don’t apply for a plan by Monday, Dec. 15, your coverage won’t start on Jan. 1.

What happens if I already have an Affordable Care Act policy? Do I have to reapply?
No. If you acquired a 2014 policy and you don’t reapply, you will be automatically reenrolled in your existing plan. But your premium probably will increase. According to the Oklahoma Insurance Department, average premiums are rising by about 10 percent. You might want to go through the reenrollment process so you can compare your existing plan to others for which you qualify. In addition, you might want to update your income data to make sure your subsidy amount is calculated correctly for 2015. If it’s too generous, you’ll have to pay back the excess when you file your federal tax return in 2016.

How many Oklahomans are affected by all of this?
Approximately 446,000 Oklahomans are eligible to obtain individual health plans through the online marketplace, according to the Kaiser Family Foundation. That figure includes nearly 70,000 Oklahomans who signed up for coverage in 2014. Of the 446,000 eligible for coverage, an estimated 256,000 are eligible to receive premium subsidies.

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. For 2014 coverage, the fine was 1 percent of annual income, with a minimum of $95 per person. For 2015 coverage, the minimum fine rises to $325 per person. Some uninsured people, including Native Americans and people below the poverty line, are exempt from the fines.

Is this government insurance?
No. The policies offered in the marketplace are issued by private insurance companies. The federal government is creating the marketplace and providing premium subsidies to participating individuals and small businesses.

Who can participate?
Anyone can use www.healthcare.gov to compare plans, determine their eligibility and apply for coverage. But if you qualify for Medicaid or Medicare, if you’re below the federal poverty line, or if you can obtain affordable and adequate health coverage from your employer, you will not be eligible for subsidies.

Which insurance companies are offering plans?
In Oklahoma, four companies will be providing individual plans through the federal marketplace next year: Assurant Health, Blue Cross Blue Shield of Oklahoma, CommunityCare and GlobalHealth. Assurant Health is a new entrant in 2015. Two insurers that provided marketplace coverage during 2014, Aetna Life Insurance and its Coventry Health Care subsidiary, are dropping out of the Oklahoma market in 2015.

What kind of plans are being offered?
Individual plans are grouped into four coverage tiers: Platinum plans are designed to cover 90 percent of an average population’s health care expenses. Gold policies are designed to cover 80 percent, silver plans 70 percent and bronze policies 60 percent. In addition, insurers may offer less-generous catastrophic plans to people under the age of 30.

What kind of benefits do they offer?
All plans sold in the marketplace must provide a number of essential benefits, including doctor visits, hospitalization, maternity care, emergency room care and prescription drugs. Other benefits are optional and vary from plan to plan.

Is the cost as low as what I can get through my employer?
It depends. On average, employer-provided policies tend to provide similar benefits at less cost to participants than marketplace policies because the employers generally pay part of the premiums.

Will the government pay the premiums, or will I?
You will pay the monthly premiums to the insurance company. If you qualify for subsidies, you have a choice. The government can pay the subsidy amount directly to the insurance company, reducing your monthly premium. Or you can pay the full premium amount and recover the subsidy in the form of a credit on your federal tax return.

Who qualifies for subsidies?
Eligibility is based on income and family size. In 2015, subsidies will be provided to single people with incomes between $11,670 and $46,680 a year, two people with incomes between $15,730 and $62,920, three people with incomes between $19,790 and $79,160, and four people with incomes between $23,850 and $95,400.

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 subsidies. The poverty level is $11,670 for a single person, $15,730 for two people, plus $4,060 for each additional person.

Why won’t poorer people receive subsidies?
Because the state of Oklahoma rejected an Obama administration proposal to expand its Medicaid program, known as SoonerCare. An estimated 104,000 to 150,000 Oklahomans fall into that “coverage crater.” 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 operates a separate program called Insure Oklahoma that provides subsidized coverage to about 17,000 working Oklahomans. 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 do the health insurance marketplace policies cost?
The cost varies widely, depending on age, geographic location, tobacco use, plan provisions and subsidy amounts. For people who qualify for subsidies, the net cost can be as little as zero.

What if I have pre-existing conditions?
Under the Affordable Care Act, individual policies can’t exclude people with pre-existing conditions such as diabetes, obesity and high cholesterol. They can’t charge higher rates for pre-existing conditions, either, with the exception of tobacco use.

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.

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 SoonerCare or Insure Oklahoma?
You’ll stay there.

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

What about my college-age kids?
Under the Affordable Care Act, parents can keep children on their family plans until age 26.

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 marketplace.

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. The health insurance marketplace includes a Small Business Health Options Program with plans designed for 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.

Are undocumented immigrants receiving subsidized health coverage?
No. The Affordable Care Act only applies to citizens and lawfully present immigrants.

  • Barbara Osburn

    Came across an article: Q&A: Appeals court rulings on obamacare:
    It had the most comprehensive information regarding healthcare requirements.
    Has our State established any exchanges in the Marketplace since Appeals Court rulings?
    Is Insure Oklahoma only available to working adults that have children?
    What is provided for adults age 50 – 64, who do not have children in the home?
    What is available to adults age 50 – 64, who do not work, and are not Medicare/Medicaid
    eligible? How does the State provide for Pre-Existing situations?