Health Insurance Navigator

By Lisa Zamosky

As the full implementation of the Affordable Care Act approaches, readers of this blog have asked questions about what’s to come.

Today, I respond to two questions about Medicaid – the government health insurance program for people with limited income. Readers are interested to know how the health reform law will impact the program and their particular situations.

Reader Question: My gross income places me in the federal Medicaid eligible group, however, in my state, Texas, I do not qualify since I am single with no children and am not disabled. I work in the healthcare field and would not want to see any of the Medicaid providers that I am familiar with anyway.  Will I be allowed to participate in the Health Insurance Marketplaces if I am willing to pay?  Will any of the premium assistance programs be available to me?

Answer: There’s a good chance you will be able to buy a health insurance policy through your state’s marketplace, and qualify for a tax credit. The tax credit will reduce the cost of your insurance premium (the monthly payment you make each month for a health insurance plan).

Under the health reform law, states have the option to expand their Medicaid programs and to extend insurance to many more people. If they do, people like this reader will, for the first time, have access to Medicaid. But not all states are choosing to expand their program.  And, Texas is among the states declining the option to do so.

Whether or not you will be able to buy insurance through your state’s marketplace and get help from the federal government to lower your costs will depend on two things:

1.      Whether or not your state expands its Medicaid program

2.      Your household income

In states that do expand, if you are a single person making $15,856 or less a year, you will qualify for Medicaid.

But let’s say you live in a state such as Texas, and the Medicaid program will not be expanded. If your income is at the poverty level — $11,490 in 2013– and you have no other access to an affordable health plan through an employer, Medicaid or Medicare, you can buy coverage on the marketplace starting October 1 and get a tax credit.

Reader Question: If someone does not sign up for insurance during the open enrollment period, pays the penalty and then gets sick and runs out of money to pay their medical bills, will Medicaid then be on the hook for their bills?

Answer: No, the person on the hook for the medical costs in this situation is you. This is exactly why the choice to not buy coverage is never one’s best option.

If you can afford to purchase a health plan, it’s advisable for you to do so. And remember, most people who buy a health plan through the marketplaces will be eligible for steep tax credits that will lower the cost of coverage.

If you miss the open enrollment period, which will run from October 1, 2013 through March 31, 2014, you will have to wait to buy an insurance policy until the next open enrollment period comes around. If you have an accident or become ill during that time, you’ll be left to pay the penalty for failing to have health insurance as well as any medical bills you incur.

What questions do you have about the Affordable Care Act and how it might impact you and your family? Please ask your questions in the comments section below.

By Lisa Zamosky

Earlier this week, actress Angelina Jolie made headline news when she announced in a New York Times Op-Ed she’d undergone double mas­tec­tomies to reduce her risk of devel­oping breast cancer.

Jolie wrote that she carries the BRCA1 gene, which sharply increases her risk of developing breast cancer and ovarian cancer.

She explains  that her doctors estimated she had an 87% risk of developing breast cancer and a 50% risk of developing ovarian cancer like her mother, who died of ovarian cancer at the age of 56.

No doubt women with a family history of breast cancer have taken notice of Jolie’s announcement and medical decision. Many may  consider following in her footsteps, at least when it comes to undergoing genetic testing to determine their own risk for breast and ovarian cancers.

Naturally, the decision is a very personal one that needs to be made thoughtfully with one’s doctor.

But once you move beyond the medical consideration, financial realities also come into play. Few of us have the financial means Jolie has at her disposal. And, the total cost of her medical procedures has been estimated around $20,000.  Genetic testing alone can run between $300 and $3,000.

Is it Covered?

Due to changes brought about under the Affordable Care Act, new health plans are required to pay for genetic counseling and testing for women at high risk of having the BRCA gene. In addition, mammography screening for breast cancer risk is now paid for by insurers without you having to kick in a co-pay, co-insurance or meet your health plan’s deductible. You can read more about the preventive services available to women under the law at Healthcare.gov.

However, should you take the genetic test and discover that you have the BRCA gene(s) and are at high risk of developing cancer, you likely would be on your own if you also decided to undergo mastectomy as a preventive measure.

It’s worth noting, however, that the health reform law also puts in place new options for appealing your insurer’s decision when it refuses to pay for a medical procedure. One could make the argument — with the support of her doctor — that preventive measures to head cancer off at the pass are not only potentially better for one’s long-term health but also less costly. Cancer treatment, after all, can easily run into the hundreds of thousands or even millions of dollars.

What do you think about Jolie’s decision? Would the high cost of treatment stop you from undergoing care you thought could extend your life? Please comment in the section below.

By Lisa Zamosky

By the end of 2012, more than 50 parts of the Affordable Care Act had already taken effect. Yet, a number of the law’s benefits are being overlooked. It’s no surprise, given that a recent poll conducted by the Kaiser Family Foundation found that 42% of Americans don’t realize that the Affordable Care Act is law.

Here are three rights now available under the law that you may not realize you have.

1. You don’t have to pay for preventive care

I talk to a lot of people who have high-deductible health plans who put off going to the doctor to avoid paying the full cost of care.

What most people don’t realize, however, is that the law allows them to get preventive care – services such as annual flu shots, screenings for blood pressure, cholesterol and colorectal cancer, mammograms and well-woman visits – at no cost. That means your visit is not subject to your plan’s deductible and you won’t be required to pay a co-payment, or co-insurance.

View a full list of no-cost preventive services at Healthcare.gov.

2. Your kids can’t be turned down

Many people are aware that young adults are now allowed to remain on their parents’ health plan until they reach age 26. This is one part of the law that’s gotten a lot of media attention.

But what many people don’t realize is that if you have a child younger than 19 who has a health condition and he or she isn’t covered by your employer’s plan, you can buy a new policy on the private insurance market without the threat of your child being turned down.

Insurers selling new policies are no longer allowed to deny any child younger than the age of 19 a health plan, even if he or she has a pre-existing medical condition.

3. If you’re 65 or older, you may save money on your drug costs

If you have Medicare coverage and take a lot of medications, you may be familiar with the Medicare donut hole—the gap in prescription drug coverage that starts once you’ve spent $2,970 on your medications and ends only once you’ve spent $4,750.

Because of health reform if you enter the donut hole you’ll now receive a 52.5% discount on name brand drugs and an 11% discount on generics. The government estimates that in 2013, Medicare recipients who reach the prescription drug donut hole will save $766 as a result of the law.

What’s more, the discounts grow over time. By 2020, if you hit the donut hole you’ll pay just 25% of the cost of both name brand and generic prescription drugs.

Are you taking full advantage of the benefits available to you? Share your thoughts in the comments section below.

By Lisa Zamosky

Keep it simple: that was the government’s goal in creating one application to sign up for health insurance starting this October. That’s when online health insurance markets being set up under the Affordable Care Act will open across the country for people who don’t get health insurance at work.

Several months ago, the government came out with a 21-page application to fill out when applying for a new health insurance policy. Needless to say, the criticisms were sharp.

In an effort to make good on the promise of a simplified application process, The Centers for Medicare & Medicaid Services (CMS) just announced a revised three-page version for individuals applying for coverage.

Once filled out, consumers will be able to see all of their coverage options, based on income.

Options will include:

• Plans in the Health Insurance Marketplace (insurance exchanges), which in many cases will include tax credits to help you pay your insurance premiums
• Medicaid (for people with lower incomes)
• The Children’s Health Insurance Program (CHIP)

Details of the Forms

There will be three different forms available to apply for a health insurance policy through the state Marketplaces, and which one you use will depend on your circumstances:

1.      There’s a three-page version for single adults who don’t currently get health insurance at work.

2.      Families will have to fill out a 12-page application.

3.      A third application is for people who want to buy an insurance plan through the Marketplaces, but who won’t be getting a tax credit to help pay for it.

Laying out Your Finances

A shorter form doesn’t mean the process will be a cake walk. You’ll still have to gather up your financial information, along with some other documents, such as tax returns, pay stubs and other records. If you receive income from Social Security, retirement accounts, pensions, unemployment or alimony, you’ll be required to report that as well.

Also required will be information about one’s citizenship and immigration status. All of this will be verified through a central data ub that will tap into Social Security, Homeland Security and the Internal Revenue Service to determine a person’s eligibility for coverage and tax credits.

You can apply for an insurance policy online through Healthcare.gov starting October 1, 2013. But you’ll also have the option of filling out the application in paper form and mailing it into an address provided within your state, as well as filing out an application in person or with someone by phone. The details of how to do so will be coming in the months ahead.

Simple or Just Too Complicated

Filling out an application for health insurance today, or a credit card, or any number of other financially related goods or services, requires us to gather a lot of financial information to complete the process.  In that way, this is really no different.

Still, some say the application process remains too complicated, particularly when you consider a Kaiser Family Foundation poll just out that finds that 42% of Americans are still unclear that the Affordable Care Act is the law of the land.

What do you say?

Share your thoughts in the comment section below.

By Lisa Zamosky

A central feature of the Affordable Care Act is that it provides tax credits to help people afford health insurance.

A new report by the health consumer organization, Families USA, finds that nearly 26 million Americans will qualify for financial help to lower the cost of their health benefits. Will you be among them?

Tax Credits in Action

There are a few requirements for receiving a premium tax credits.

Income: If you’re an individual with an annual income of $47,100 or less, or if as a family of four you earn up to $94,200 a year, you’ll meet the income requirements to qualify for a tax credit.

Where you buy matters: You’ll need to buy insurance through the new online health insurance marketplace being set up in your state. These markets are scheduled to be operational by October 1 of this year for coverage that takes effect January, 2014. If you haven’t heard much about the marketplaces yet (also called exchanges) or how to access the one where you live, don’t worry; a big advertising push by federal and state governments to educate the public is headed your way this summer.

No work-based coverage: You won’t qualify for tax credits if you’re offered affordable health insurance at work. Under the law, “affordable” means your health plan won’t cost you more than 9.5% of your annual income (whether or not you find that affordable is a separate issue!). If you have access to coverage through work, and you buy insurance through the marketplace anyhow, you won’t get the tax credit, even if your income falls within the eligibility range.

Monthly price breaks: The tax credits will be sent directly to the health plan in which you’ve enrolled, which will offset the total cost of your plan’s premiums, thereby lowering your monthly expenses.

Who is Getting Help?

In addition to finding that 26 million Americans will be eligible for financial help under the law, the Families USA report, “Help is at Hand: New Health Insurance Tax Credits for Americans,” found the following:

• Nearly 9 in 10 people eligible for a tax credit will be part of a working family
• Over one-third of those eligible – 36% — will be young adults between the ages of 18 and 34
• 56% will be people earning between $47,100 per year and $94,300 for a family of four
• The majority will be white and non-Hispanic (58%), about 11% will be African American, 23% will be Hispanic.

The states with the most citizens eligible for tax credits are:

• Texas
• New York
• Florida
• California

You can see how many people will qualify for the premium tax credit, broken down by employment status, age and ethnicity in each state by checking out the report.

And to see if you personally qualify for a premium tax credit, visit the ACA calculator on the Kaiser Family Foundation website.

By Lisa Zamosky

As the implementation of the Affordable Care Act marches on, readers have questions about how the law is going to play out.

Although the number of Americans with employer-based insurance has dropped over the last decade from nearly 70% in 2000 to about 60% in 2011, according to a Robert Wood Johnson Foundation report released this month. Even so, most people with health insurance still get it at work. It’s not surprising, then, that I regularly receive questions about how the health reform law will impact employer-sponsored coverage.

Today’s question comes from a reader named Bud:

If you are currently employed by a large employer (over 50 employees), and are on that employer’s health care plan, and have a second job with a small employer (under 10 employees), is the small employer required to offer you a health care plan if he employees you over 30 hours per week?

Not All Employers on the Hook

In this case, it’s only the employer with more than 50 workers that has any responsibility under the Affordable Care Act to offer you health insurance coverage. Small businesses with fewer than 50 workers have no obligation to do so, meaning your employer with just 10 employees is off the hook, no matter how many hours a week you put in there.

Here’s what the law says about the requirements employers will face under the law:

• Starting in 2014, any company employing more than 50 employees will either have to provide workers with health insurance or pay a penalty of $2,000 for each employee that works an average of 30 hours or more each week.

• The health plan has to include a set core of benefits, called Essential Health Benefits.

• The insurance coverage cannot cost more than 9.5% of your annual income. If it does, your employer could be on the hook for a penalty. And, you, the worker could then buy insurance through one of the new state-based marketplaces and possibly get financial help from the federal government to reduce the cost. If your employer’s plan costs less than 9.5% of your income, you will not qualify for the federal subsidies.

• The plan must cover at least 60% (on average) of your healthcare expenses.

More Questions?

As the full implementation of the law comes closer (January 1, 2014), you may find yourself wondering how you and your family will be impacted. I invite you to send in some questions of your own, and to look for an answer here at the Health Insurance Navigator.

By Lisa Zamosky

How much do you know about the kind of health insurance plan options that will be available to you through new health insurance Marketplaces being set up under the Affordable Care Act? If you’re like most people, not much.

HealthPocket.com, a website that allows you to compare health insurance plans in your area, side-by-side, conducted a recent survey that highlights just how much education the public needs in the six months left until the Marketplaces are scheduled to open for business.

The survey of nearly 1,000 people found that more than 85% had no idea how the new Affordable Care Act health plans will differ from one another.

“The survey results suggest that the Act’s pending impact to the health insurance market is still a mystery to the average American,” the report said.

Four Health Plan Types

The health reform law creates four health insurance plan types that are referred to as the “metal plans” (each one is named after a different type of metal).

All health policies sold through the Marketplaces must include a basic benefits package, called Essential Health Benefits that include coverage for services such as outpatient and emergency services, hospitalization, maternity and newborn care and oral and vision care for children, among other things.

The single difference among the four plan types is the percentage of medical expenses each pays. Here’s how it breaks down:

• Bronze – The insurer covers 60% of medical expenses (you pay the remaining 40%)
• Silver – 70% of costs are covered
• Gold – 80% of costs are paid by the insurer
• Platinum – 90% is covered.

Individuals must carry a bronze-level plan or higher in order to meet minimum requirements for insurance coverage under the Affordable Care Act.

Only 4% of those polled in the Health Pocket survey correctly identified the differences among the various plans as the percentage of medical costs paid by insurance.

Getting Ready

The Marketplaces are scheduled to open around the country in October. As I’ve discussed before, previous polls have shown that the majority of people who will be newly eligible in 2014 for insurance coverage because of the law don’t know a thing about the new marketplaces. Now we know not much is understood about the plans that will be sold on them either.

What questions do you have about the kind of health insurance that will be available to you? Ask your questions in the comment section and look for an answer in upcoming posts.

By Lisa Zamosky

Three years after the Affordable Care Act was passed, Americans still have many basic questions about the law and the impact it will have on them and their health insurance coverage.

Here, I respond to some reader questions.

 Q: Will all preexisting conditions be covered?

One of the biggest changes the law makes is that it guarantees health insurance coverage to anyone who applies. If you have a medical condition and have been turned down for insurance before, that’s all about to change. Starting January 1, 2014 it will no longer be legal for insurers to turn anyone down or charge them more for a health plan because of a medical condition.

Q: If I can’t be declined can they price the plan so high that I can’t afford it?

There are only a few reasons insurers can charge more for coverage: age, smoking and geography.

Older people can be charged rates as much as three times that of a younger person and smokers may pay 1.5 times more for their health plan as people who do not use tobacco. Rates will also vary based on where you live. Under the law, insurers will be allowed to charge more for people who live in areas where medical costs are high.

There have been many reports warning of potential rate increases once the Affordable Care Act takes full effect.  One of the biggest concerns is that limits on how much insurers can charge older people will cause premiums to skyrocket for young people. That, critics warn, will keep young, healthy people out of the insurance pools, which will in turn cause costs to rise.

As I wrote a few weeks ago, a recent report by the Urban Institute found that most people buying plans through the state-based insurance markets being set up under the law will qualify for financial assistance to help pay for the cost of their coverage. Individuals earning nearly $46,000 and families of four earning up to $94,000 annually will qualify for a tax break to help lower the cost of coverage. That means that even if in some cases actual rates are higher, most people will pay less for their coverage because of the subsidies.

Q: What if I don’t buy insurance? Can’t I just pay the penalty and sign up for insurance if I need it?

People who choose not to buy health insurance will be charged a penalty of just $95 or 1% of their annual income, whichever is higher, in 2014.  That penalty grows over time.

A big concern is that in order to save money, people will decide to pay the penalty instead of purchasing coverage, and simply wait until they become sick to sign onto a health plan.

If that’s your plan, you may want to reconsider.

Open enrollment periods will be set up to discourage people from doing this. In most states, you’ll be able to buy insurance through your state’s new marketplace beginning October 1, 2013 through March 31, 2014. If you don’t sign up for insurance you’ll be locked out of the market until the following year. If you become sick during that time, you’ll be left to pay for your medical care on your own.

What questions do you have about the Affordable Care Act? Please share them in the comments section.

By Lisa Zamosky

If you get your health insurance at work, there’s a good chance you’ve been feeling pressure from your employer to take better care of yourself.

As health care costs eat up a greater portion of employers’ costs, companies search for ways to help employees change behaviors that lead to health risks mainly due to obesity and smoking.

A firestorm was set off over a story out last week about pharmacy giant, CVS requiring its employees to take a health screening that captures body weight, blood pressure and other health measures or pay a $600 annual penalty.

As I’ve discussed before, wellness programs that tie financial incentives to not only participation, but to proof that employees are meeting their health-related goals is a growing trend. In fact, a survey just out by consulting firm AON Hewitt found that 83% of firms offer some kind of incentive to encourage participation in their wellness programs.

But the CVS program seems to take things a step further by punishing employees who don’t participate with a financial penalty.

Violating Privacy

Naturally, privacy is a main concern for many people, as it is for the employers collecting this information, experts say. But does it represent a breach of law?

Not according to John P. Hancock, employment attorney with the law firm, Butzel Long. Hancock says the only way to argue a legal case is by looking for violations of the Americans with Disability Act. And these programs do not discriminate against people with handicaps.

“Employers want people to focus on losing weight and not smoking and not drinking too much. None of these are protected classifications,” Hancock says.  “It’s not a legal issue, it’s a nuisance,” he says of pushy employer-based wellness programs.

Where’s the Proof?

According to Joshua Klapow, Ph.D., chief behavioral scientist for Chip Rewards Inc., a Birmingham, Alabama-based health engagement technology company, many employers are implementing wellness programs that lack the scientific evidence to support what they’re doing.  

Let’s say your employer is offering an incentive for you to make just one health-related change – say, getting you to give up cigarettes. There is good scientific information available to guide the employer in building a program from which you stand to benefit.

But these days employers want people to complete a list of behaviors (preventive screens, vaccinations, prescription refills) as opposed to focusing on just one. Klapow says the science isn’t quite there to determine how best to get people to make changes in multiple areas over the same period of time.

Why does this matter?

If, as in the case with CVS employees, you’re being asked to change a number of health behaviors over time – lose weight, stop smoking, increase your level of exercise – it’s not clear that these programs are going to work.  

“Unfortunately most employers desire employees to engage in a much longer list of behaviors. There aren’t large scale data on what type of incentive structure is most effective for engaging people in a more complex variety of health behaviors over time.  The research is needed and employers should be utilizing principles of behavioral science to help guide their decisions in engagement program design,” Klapow says. 

What’s in it for You?

So, what should you, the employee consider when faced with the choice of whether to participate in your employer’s wellness programs? Klapow suggests asking yourself three questions:

1.      Do I fully understand the programs and incentives I’m being asked to participate in, i.e. blood tests, an annual physical, a weight loss or exercise program?

2.      Are the programs and services good for me and my health?

3.      What’s in it for me to participate in the program? What do I risk if I don’t?

He adds: “You have every right to ask your employer ‘what’s the game plan here?’ Why am I being asked to do this and how does it benefit my health?” Klapow says.

What’s your take? If your employer provides health insurance, does it have the right to reward or penalize you to take better care of your own health?

Share your thoughts in the comments section below.

By Lisa Zamosky

There have been many dire predictions made about the effects of the Affordable Care Act, including that employers are going to stop offering health insurance to employees.

However, the latest annual survey by consulting firm, Towers Watson and the National Business Group on Health, found that large companies with at least 1,000 employees remain committed to providing employee health benefits, at least for the foreseeable future.

Still, changes are ahead. According to the survey, employers will design their benefit packages differently in an effort to gain control over rising healthcare costs.

Most people still get their health insurance through their employer. If that’s the case for you, here are 5 changes you might see in your health benefits over the next several years.

1. Your coverage will cost more. Today, employees pay 42% more for their health care than they did just five years ago. That’s a trend likely to continue. More than 80% of the 583 employers surveyed said they plan to continue to raise the share of premiums employees pay for their health benefits.

2. You’ll pay more for your spouse. Increasingly, companies are making it costlier to add your spouse onto your work-based plan. Today, 20% of companies questioned said they add a surcharge for spouses, and an additional 13% say they plan to add one next year.

3. You’ll take on more responsibility. For years now, employers have been encouraging employees to think more carefully about the medical services they use by moving them into plans that require them to spend more of their own money up front. Today, 66% of companies offer high-deductible health plans combined with medical savings accounts in the form of either a health reimbursement arrangement (HRA) or health savings account (HSA). By 2014, another 13% expect to offer them.

More drastically, 15% of companies are now offering only high-deductible health plan options, and nearly 25% say they may offer only these types of plans by 2014.

4. Retiree benefits are fading. The last two decades have seen a sharp decline in companies providing employee health benefits for retirees; currently, only 15% of companies make retiree benefits available to newly hired employees. Those that do continue to offer some assistance to pay for retiree health benefits increasingly plan to shift them into account-based plans like those described in #3.

5. Wellness programs become more important. Almost seven in 10 companies responding to this survey report offering both employees and their spouses financial rewards to participate in wellness programs. What’s more, employers are getting tougher about doling out rewards – this year 16% of companies (up from 10% last year) only pay up when you show measurable results. That means simply signing up for a weight loss program won’t cut it; you need to show some progress on your weight-loss goals.

What changes have you seen in your work-based health benefits? Share your experience in the comments section below.