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Health Reform 101

with Lisa Zamosky

WebMD helps readers understand their health insurance and the new health care reform law. The Affordable Care Act is bringing sweeping changes to American health care. Lisa Zamosky is here to help you navigate the health care maze and understand how these changes affect you.


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Thursday, April 17, 2014

4 Ways to Make the Most of Your Drug Benefits

By Lisa Zamosky


Prescription drugs can be a major cost for people with on-going health conditions, especially for people being treated for conditions such as cancer, hepatitis C, diabetes, and multiple sclerosis. New drugs to treat rare and complex conditions are becoming more expensive. At the same time, the health plans sold through the insurance Marketplaces often come with high out-of-pocket costs that leave people who need specialty prescription drugs shouldering more of the expense.

If you rely on medications to manage a chronic or complex condition, here are 4 steps to take to make sure you’re getting the most of your health plan’s drug benefit.

1. Review your plan’s formulary. Your health plan’s formulary, or list of covered drugs, will tell you whether the medication your doctor prescribes is covered by your plan. Often, insurers post this list online, but frequently the list is incomplete, so you always want to check directly with your plan.

With specialty drugs you have less flexibility to switch to another option if the one you’re prescribed isn’t covered by your insurer. Still, checking before you go to the pharmacy gives you the opportunity to discuss it with your doctor. After all, medications don’t work if you can’t afford to buy them.

2. Know your plan’s guidelines. To get the most out of your health plan benefits, you must always be mindful of the rules you must follow before going for care or filling a prescription.

Common requirements include getting prior authorization from your plan to get help paying for a medication you need.  In addition, many plans today require you to try a less expensive, generic drug (if one exists) before approving name-brand medications. Quantity limits that  allow you to buy only a small amount of the medication  at one time also are common.

3. Check your plan’s medical benefits. Specialty drugs, such as those used to treat cancer, are often   delivered to your doctor’s office rather than to your home. In that case, check your plan’s medical benefit, rather than the drug formulary, to see what’s covered.

4. Remember your right to appeal. The Affordable Care Act guarantees you the right to several levels of appeals if your insurance company denies coverage for a medication or medical service you need. Often, consumers are successful when they take the time to appeal. If your insurer says it doesn’t cover a drug, get your doctor’s help in explaining to your insurer why it’s important for your health.

Have your medication costs gone up? Please share your experience in the comments section below.

Posted by: Lisa Zamosky at 12:28 pm

Thursday, April 10, 2014

Data: More People Have Insurance

By Lisa Zamosky

man getting help

The primary goal of the Affordable Care Act is to reduce the number of people in the U.S. without access to health insurance. Now that the law’s first open enrollment period is now closed, some new data has come out that looks at how the law is meeting this goal. A few polls and reports out this week suggest that the law is at least playing a role in helping to increase the number of people with health insurance in this country.

According to the latest Gallup poll, the number of uninsured Americans is at its lowest since 2008.

By the second half of March, 15.6% of the U.S. population was uninsured, a drop from 18% in the last quarter of 2013. According to the survey , “The current figure as of today is likely lower given that uninsured rates declined throughout the quarter, including in late March,” referring to the rush of people signing up for insurance before open enrollment officially closed on March 31.

The poll was conducted between January 2 and March 31, 2014, with a random sample of 43,562 adults over the age 18 and older.

A second report out by the independent, non-partisan RAND Corporation found that since September, Obamacare is responsible for 9.3 million Americans gaining health insurance coverage.

Like the Gallup poll, RANDS’s findings don’t include the last-minute rush of enrollments in late March and early April.  Still, it finds that the number of uninsured Americans has dropped since September, 2013.

Here’s some of what the report found:

  • 8.2 million people gained access to employer-sponsored insurance plans. However, only some of this is likely due to the law, according to the report. The law’s mandate to have insurance may have pushed some people to take up coverage on the job who chose not to before. But another likely cause is the economic recovery that happened between September 2013 and March 2014 coverage, leading more people to find jobs that come with an offer of insurance.
  • Medicaid enrollment increased by 5.9 million.
  • 3.9 million people gained insurance coverage through the state and federal exchanges. Of this group, the report found that 36% did not have insurance before the law. The rest presumably switched from one type of private insurance plan to another.

According to the study, which was based on a sample of 2,425 individuals questioned about their insurance status up to March 28, “further changes in enrollment figures can be expected as people become more familiar with the law, the individual mandate penalties increase to their highest levels, the employer mandate kicks in, and other changes occur.”

It goes on to say: “Early evidence from our nationally representative survey indicates that the ACA has already led to a substantial increase in insurance coverage.”

Share your story: Did you sign up for health insurance during open enrollment? If so, had you been uninsured prior to the Affordable Care Act becoming law? Share your experience in the comments section below.

Posted by: Lisa Zamosky at 1:31 pm

Friday, April 4, 2014

Getting Insurance After Enrollment Ends

man on computer

By Lisa Zamosky

The first Obamacare open enrollment period came to an official end earlier this week, though people attempting to sign up at the last minute through government-run health insurance marketplaces will have until April 15 to finish their applications.

Despite the end of open enrollment, millions of people will continue to make health insurance changes throughout the year for many reasons.

Here are four ways you can sign up for coverage outside of the open enrollment period.

1. You have a qualifying event. If certain life circumstances change for you, you may qualify for a special enrollment period that would allow you to get private health insurance.

Qualifying life events include divorce, marriage or the birth of a baby, job loss, losing employer-based health insurance, or moving to a new state or region. You can see a full list of events and how to report them at

Special enrollment periods are expected to bring millions of additional people into the insurance market, says Linda Blumberg, senior fellow with the Urban Institute’s Health Policy Center.

“I’m expecting that there will be a significant increase in coverage as a consequence of this in the course of the year even after all the open enrollment loopholes are closed,” she says.

Some news outlets have mistakenly reported that people will still be able to buy a health plan through the Affordable Care Act directly from insurance companies. That is false.

“The open enrollment period is done,” Blumberg says. “There is no guaranteed issue outside the open enrollment period.”

2. You qualify for Medicaid and/or CHIP. If you qualify for Medicaid or the Children’s Health Insurance Program (CHIP), the state-federal health insurance programs for people with low incomes, you can sign up at any time.  These programs do not come with specific open enrollment periods.

Not all states have expanded their Medicaid programs, but those that did allow individuals earning a little more than $16,000 per year to gain coverage. You can see if your state has expanded its program to cover more people here.

3. Employer-based insurance. Many employers have open enrollment periods mid-year to sign up for health insurance. July is the second most common open enrollment period for businesses. If you work for an employer that allows changes to coverage mid-year or you change jobs, you will be able to get insurance before 2015.

4. Alternate insurance products.  Many private companies are selling insurance products that help to fill coverage gaps that result from high deductible health plans, or for those who have missed the deadline to buy a new health plan through the federal Marketplaces.

Short-term health insurance policies can range from  30 days to 12 months. So too are supplemental plans, including accident and critical illness insurance.

According to Blumberg, these products can offer some level of protection. However, they will not meet your coverage requirements under the Affordable Care Act, and you may still be subject to a tax penalty.

Be careful about weighing the value of the protection these policies offer you relative to what you spend.

Did you miss the open enrollment deadline? Share your story in the comments section below.

Posted by: Lisa Zamosky at 1:58 pm

Thursday, March 27, 2014

Obamacare Extension: What You Need to Know

By Lisa Zamosky

woman at computer

The first open enrollment season under the Affordable Care Act is about to come to a close. Anyone interested in buying a health insurance policy for 2014 has until next Monday, March 31st to sign up.

But earlier this week the Obama administration said it would give people using the federal Marketplace in 36 states a little extra time to complete the enrollment process. If you started applying for health insurance before the end of the month but weren’t able to finish on time, you won’t be shut out if you started the process before open enrollment technically ends on March 31st.

“Just like Election Day, if you are in line when the polls close, you get to vote,” says Julie Bataille, director of communications with the Centers for Medicare & Medicaid Services (CMS) in a blog post announcing the change. “We won’t close the door on those who tried to get covered and were unable to do so through no fault of their own. So, those who were in line or had technical problems with the website can quickly come back and sign up as soon as possible,” she said.

The government says it is anticipating heavy traffic on the federal website,, leading up to the March 31 deadline. This past Tuesday alone, there were over 1.2 million visits to the website and more than 390,000 calls to the call center, the HHS announcement says. There have been reports that officials are concerned that a surge of last minute applications would overwhelm the system.

If you’re a last minute shopper and worried about finishing your application on time, here’s what you need to know about the extension just announced:

  • If you log onto and can’t complete your application before midnight March 31, you can request an enrollment extension by checking a new box created on the website.
  • As long as you were “in line” in time either online or over the phone and you pay your first month’s insurance premium by the deadline set by your insurer, your coverage is expected to take effect on May 1st.
  • CMS says it will process paper applications received by April 7th for those applying on paper or by phone. This group will then have until April 30th to select a health plan that will also start on May 1st.
  • Consumers who follow this process will avoid paying tax penalties in 2014.

Some States Offering Extra Time

If you live in a state that runs its own health insurance Marketplace, you need to check to see if a similar grace period will be allowed – several states will.

California, for example, just announced that it will allow residents who start an application by 11:59pm March 31 through the end of the day on April 15 to complete the application and select a plan. It outlines the steps you must complete before the last day of open enrollment to earn this extension. You can see those steps here.

And to find the website for your state, go to

Are you waiting until the last minute to sign up for insurance for 2014? Have you faced long telephone wait times or technical errors? Share your story in the comments section below.

Posted by: Lisa Zamosky at 11:40 am

Thursday, March 20, 2014

Buy Insurance or Pay the Penalty: 3 Things to Consider

By Lisa Zamosky

woman at computer

Will you buy insurance before open enrollment under the Affordable Care Act ends on March 31st or pay the tax penalty for going without coverage in 2014?

Readers frequently question the value of buying a health plan in the face of high out-of-pocket costs and low tax penalties for 2014. They are no higher than 1% of household income.

If you’re on the fence about whether or not to buy health insurance, here are three things to think about.

1. Consider your level of risk tolerance

The purpose of insurance of any kind – health, home-owners or car insurance – is to protect against unforeseen events that could wipe you out financially.

In most cases, we pay for a policy each month that we hope we’ll never have to use.

We don’t expect to get in a car accident and get injured. A cancer diagnosis often comes as a tremendous shock. Even a relatively minor surgery, such as an appendectomy, could easily cost $16,000 or more without insurance.

If you have no medical expenses, there’s no doubt going without insurance will save you money.  But if the unexpected occurs, will you – and your bank account – be able to weather the storm?

Remember that if you have any resources at all – a home, savings, investments – hospitals will come after you to pay up, increasing the risk of losing all that you’ve worked for.

In addition, it’s critical to understand that without the ability to pay for medical care, you can be denied access to needed services.

2. Know about the law’s new benefits

A recent survey conducted by WebMD found that more than 65% of people who are uninsured didn’t know that preventive services such as mammograms, colonoscopies, flu shots and diabetes screenings are now available through all new health plans without additional cost at the time of the visit. Some health plans even waive costs for common generic drugs.

In addition, the law places a cap on how much money you’re required to spend on covered services over the course of one year. For 2014, individuals won’t spend more than $6,350 and there is a $12,700 cap for families.  Although that’s still a lot of money, these caps go a long way toward reducing your overall financial exposure if you become very sick and require a lot of medical services.

3. Look for plans both on and off the Exchanges

If you qualify for a tax subsidy, you must buy insurance through your state’s health insurance exchange to take advantage of it. However, if you earn too much money to qualify for financial assistance, you’d be well served to cast a wider net by looking at health plans sold both on and off the government health insurance exchanges. Generally, there are more options available off the exchanges.

Without charge, you can go online to sites such as GetInsured and ehealthinsurance to shop, and also get personalized assistance selecting a plan. You can also work with an insurance agent certified to sell health plans both on and off the state’s insurance exchange. Go to the National Association of Health Underwriters.

Do you plan to buy health insurance before open enrollment closes on March 31st or will you pay the penalty? Please share your thoughts in the comments section below.

Posted by: Lisa Zamosky at 8:01 am

Friday, March 14, 2014

President Obama Answers Your Questions

By Lisa Zamosky

Earlier this week, I sat down for a WebMD exclusive interview with President Obama at the White House. I asked him questions about the Affordable Care Act that were submitted by you, the WebMD community.

The President answered a number of your questions during our interview, which lasted for more than 25 minutes. We talked a lot about health insurance costs, a topic on your minds more than any other. Hear what he said about costs and affordability on the video clip above. We also talked about how the law is affecting employer-sponsored health plans, the plight of millions of low-income people in the states refusing to expand Medicaid, and what will happen if enough people don’t sign up for insurance.

He also shared his views on the role of private insurance companies in healthcare, and responded to the deep concern many people expressed about the limited number of doctors and hospitals available to them through health plans being sold on the Marketplaces.

For all of the president’s answers, watch the interview here and let us know what you think.

Posted by: Lisa Zamosky at 11:15 am

Monday, March 10, 2014

WebMD Interviews President Obama

By Lisa Zamosky

President Obama

As we near the March 31 enrollment deadline under the Affordable Care Act, there’s still widespread confusion about the law and how it works. If you have questions about the law and how it affects you, here’s your chance to get answers — from the president himself. This week, I will be taking part in a WebMD interview with President Barack Obama. We are asking you – our readers – to send questions about the new health care law that we can take to the interview. You can submit your question here and then come back to watch the interview March 14.

In preparation for the interview, I’ll be reading every question you’ve sent in to see what’s on your mind. Although there won’t be time in the interview for me to ask each one, it will help me understand your most pressing concerns so I can share them with the president.

Here are other ways to get information about the Affordable Care Act:

State Marketplaces: Navigators can help people understand their options and how to enroll. You can chat with someone online, or speak with a live person by phone through each of the state websites.

Check WebMD’s State Health Insurance Marketplace pages to see what assistance is available and how to get in contact with folks in your state.

Private health insurance exchanges: You can also sign up for Marketplace health insurance through private web-based brokers such as,, and The plans also include information about financial assistance for people who qualify. Each has call centers with staff available to answer your questions and help you through the process.

Insurance brokers: You can work with a licensed insurance broker or agent who has had special training and met certification requirements to offer plans through your state’s Marketplace. Contact the National Association of Insurance Commissioners to find an agent near you:

In-person assistance: Community health centers, hospitals, other healthcare providers or social service agencies are able to provide consumers with help.  Your county office of public health will answer questions, enroll people in Medicaid and assist with plans sold through the Marketplace. You can contact your state’s Marketplace for a referral to a location in your area providing on-site help.

Posted by: Lisa Zamosky at 12:25 pm

Friday, February 28, 2014

Paying for Health Insurance on Time

By Lisa Zamosky


New numbers from the Obama administration show that enrollment in health plans sold through the Affordable Care Act Marketplaces has reached 4 million people. What’s not clear is how many people have actually paid their insurance premiums.

Once you’ve selected your health plan, you’ll need to pay for your first month’s premium for your coverage to take effect. After that, if you fail to make on-going payment, you’ll lose your coverage. You won’t be eligible to purchase another plan until the next open enrollment period in November.

Payment Leeway

The law does allow for a 3-month grace period of nonpayment for people who have purchased insurance through the Marketplaces and who qualify for premium tax credits.

For people with low incomes, the 90-day grace period gives them the chance to catch up on their payments before losing insurance coverage.

While this part of the law offers important consumer protections, it poses a real problem for doctors and other healthcare providers. Here’s why: Under the rule, insurers are required to pay claims for services provided during the first 30 days of the 90-day payment grace period. But during the next 60 days, insurers can suspend claims and withhold payment to healthcare providers. If you don’t pay your outstanding premiums before the 90-day grace period has ended and your plan is cancelled, your insurer can deny all claims for care you received during that time. That leaves your doctor out the money he or she is owed.

Doctors’ Problems Become Yours

Understandably, healthcare providers have real concerns about this – especially doctors working in smaller practices that operate on slim margins.

As a result, many doctors are becoming even more diligent about verifying your eligibility for insurance when you come for a visit. They may ask you to pay in cash upfront if your policy’s account isn’t in order. That can be a real challenge for people in need of care.

I’ve received a lot of questions and comments about delayed paper work from insurers. People are concerned that their insurance plan won’t be in place in time, and a number of people have written in to ask how they even go about paying their premiums because they’ve not yet received an invoice from their insurer.

If you’re in that boat, bring any information you have from the health insurance exchange to your doctor’s appointment proving you’ve completed the application process, as well as any proof that you’ve paid your premium.

And, of course, you need to keep paying your premiums.

Share your experience. Have you had trouble paying your insurance premiums or convincing your doctor that your plan is in place? Please leave your comment below.

Posted by: Lisa Zamosky at 10:20 am

Friday, February 21, 2014

Readers Continue to Question ACA Affordability

By Lisa Zamosky


Recent blog posts here at Health Reform 101 about the roll out of the Affordable Care Act have generated a lot of comments from readers. Many people have expressed a high level of frustration over the cost of health insurance and the enrollment process.

But what’s also clear is how confused people remain about the law and the benefits available to them. What concerns me most is that in the absence of information, people run the risk of missing out on benefits that could make insurance more affordable or at least more accessible to them than in the past.

Low Income, High Insurance Costs

Many readers have written to complain about how high the cost of insurance is and how they had failed to qualify for assistance despite their low incomes. The details many readers are providing about their incomes suggest to me that something may be getting lost in translation.

If your income is low or you’ve just lost your job, you should be eligible for financial assistance available under the law to lower your monthly insurance premium, and in some cases, your out-of-pocket expenses when you go for care.

As a reminder, you’re eligible for premium tax subsidies if you are an individual with an income below $45,960 or a family of four earning less than roughly $94,000 per year. To learn very quickly whether you’ll qualify for financial help, and if so, how much, visit WebMD’s health insurance cost calculator.

Yet, survey after survey has demonstrated that the public’s awareness about the tax subsidies is low. In fact, a recent poll conducted by WebMD found that of the nearly 1,000 people surveyed who didn’t have insurance, more than six of ten (61%) did not know whether they qualified for a subsidy to help lower their insurance costs.

The Medicaid Gap

There is, however, an explanation as to why the readers are reporting very low incomes yet being turned away for a subsidized health plan.

Under the law, if you earn less than the federal poverty level – just under $12,000 per year for an individual – you should qualify for Medicaid, the insurance program for people with low incomes. States have the option of expanding their programs to include more people than in the past. However, to date just 26 have chosen to do so.

That means if you live in a state that has not expanded its Medicaid program you could be left out in the cold with no good insurance options. People earning between about $12,000 and just less than $46,000 per year can qualify for a subsidy to help pay for private insurance in states without an expanded Medicaid program.  If you earn less than $12,000 per year as an individual, however, you likely won’t have access to Medicaid and also won’t qualify for a subsidy.

This is the unfortunate consequence of states being allowed to opt out of the expansion – it’s our poorest citizens who will be left with the least amount of help to gain coverage.

Alternatives for Care

If you fall in this gap, one possible option for gaining access to needed medical care is to utilize the services available at community-based health clinics. Generally, they offer primary health care, dental, mental health and pharmacy services. They charge on a sliding scale, and so can be less expensive than going to a private doctor’s office.

There are about 1,200 health centers operating around the country. To find a clinic near you, search the U.S. Health Resources and Services Administration website.

And to gain help exploring all of your options for health insurance, take advantage of free information and advice available through the navigators available at and state-based insurance exchanges.

Posted by: Lisa Zamosky at 11:46 am

Friday, February 14, 2014

More ACA Deadlines Ahead

By Lisa Zamosky


Open enrollment under the Affordable Care Act will continue through the end of March. Between now and then, there are a few deadlines that anyone considering buying a health insurance policy should be aware of.

Here’s how it all breaks down.

February 15: Generally, you need to enroll in a health plan by the 15th of the month if you want your coverage to start on the first day of the following month.

That means that this Saturday is the last day to enroll in a health plan for coverage that takes effect March 1st. Enrolling just one day later will push your start date back by one full month to April 1st.

But here’s an important detail to bear in mind: If you live in a state that uses the federal health insurance exchange, to enroll in Obamacare health plans, you’d be best served to complete the application process by this Friday or at least early in the day on Saturday.

The government has announced that it will be shutting down the Data Services Hub for maintenance beginning at 3:00 PM Eastern time on Saturday the 15th. The Hub helps to verify information used to determine if you’re eligible to buy a health plan through the Marketplace, and your eligibility for tax subsidies. Without the ability to access the Hub, your application cannot be completed.

While will still be online, people who start their application after 3:00 PM Eastern on the 15th will miss out on a March 1st insurance start date.  In its notice about the maintenance shut down the government said, “those consumers will need to save their application and return to on or after 2/18 to complete the enrollment process for coverage beginning on 4/1.

To find your state’s health insurance Marketplace, check this map.

March 15th: This is the last day to enroll in a health plan that will take effect April 1, 2014.

March 31st: Those who enroll between March 16th and March 31st will have health insurance that takes effect May 1, 2014.

Under the law people who go without insurance for a period of more than three months are subject to the tax penalty. However, the government altered that rule. You won’t have to make the payment for any month before your coverage took effect as long as you completed your application process by March 31st.

Missing the open enrollment window

If you fail to buy coverage before the end of March, you won’t have another chance to sign up until the next open enrollment period, which begins November 15, 2014. The only exception to that is if you qualify for a special enrollment period as a result of a qualifying life event such as marriage, divorce, birth or adoption of a child, or loss of a job.

It should also be said that this only applies to private health insurance plans. If you or a member of your family qualifies for Medicaid or the Children’s Health Insurance Program (CHIP), you can sign up at any time.

If it turns out you don’t qualify for a subsidy, it’s worth shopping your options outside of state marketplaces too because you’ll likely find a broader range of options.

You can shop websites such as or You can also contact an insurance broker to help you sort through your options free of charge at the National Association of Health Underwriters at

Posted by: Lisa Zamosky at 10:49 am

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