We asked our readers to tell us what they thought was confusing about the Affordable Care Act, and you called, e-mailed and Facebooked us with questions. On Florida Matters, WUSF’s Craig Kopp sits down with attorney Linda Fleming of Carlton Fields; Julian Lago, the regional vice president of the National Association of Health Underwriters, and Health News Florida Editor Carol Gentry to help answer some of those questions.
To listen to the complete show, visit the Florida Matters website.
Here is the transcript:
CRAIG KOPP: Let's admit something up front here. There are a lot of people confused about the ACA. We had one question from somebody who wanted to know if it was the law for all of America, probably a result of the intense political debate around the Affordable Care Act.
We're not talking politics today. We're going to try to get practical today about the ACA. There is an Affordable Care Act. That is the law for all of the land. Parts of it are in effect, including coverage of children on parents' policies up to the age of 26, and no more denying of insurance to children with pre-existing conditions, but there is a lot more to come.
And probably the number one question we heard, and it's really at the heart of this major change in healthcare policy in America: Do I have to buy insurance? Linda Fleming, let's start with you. How do you answer that?
And probably the number one question we heard, and it's really at the heart of this major change in healthcare policy in America, do I have to buy insurance?
LINDA FLEMING: Starting Jan. 1 of next year, yes, you do. It's not really an option any more. You have various avenues you can go about getting your insurance, but the answer is, unless you're exempt -- and there are a few exemptions -- but unless you're exempt, you have to buy health insurance.
KOPP: Julian Lago, do you agree?
JULIAN LAGO: I totally agree. There is what's known as the individual mandate and that requires every citizen of the United States, as Linda said, there are some very few exceptions to that, but for the most part most Americans will be required as of Jan. 1 to show proof of coverage.
KOPP: I think this one from Jack Danine of Largo really sums up that "Do I have to buy insurance?" question and dilemma. Jack called in.
JACK DANINE: If you're kind of a working poor individual, earning maybe $30,000 a year and you've got a wife who earns less than you and children and you can't afford the health care that your employer provides and you can't afford to buy it on your own, and this would be due to living expenses, house payment, car payment, credit card payment, utilities, food, then where does that leave this person who's struggling to get by as it is with the cost of healthcare?
KOPP: So, Julian Lago, do you understand his question? Basically, he's saying, I can't afford health care. What do I do?
LAGO: That's a great question and in fact I've been speaking on this subject matter now for going on several years and when I address audiences and you look out in the audience and you say there is a new mandate that says every citizen is going to be required to cover themselves and their family, it's a difficult question, because most citizens, if the affordability was there, I think they would have already done so, and in some cases through their employer they would have done so.
But there (is) what's called financial assistance within the health care reform legislation; there's tax credits and premiums credits that will be offsetting some of the costs. There's been a lot of discussion here in Florida with what's known as the Medicaid expansion. So we know that Medicaid is at a certain level, poverty level, and those are generally a single, somewhere around under $11,490, but as you go above that with household incomes in incremental amounts up to 400 percent the law writes into, so that would be a single person earning up to about $45,000 and a family of four earning somewhere around $94,000, so anywhere below those thresholds there are what's known as premium tax credits that are available that go directly to offset the cost of individual coverage.
When we're talking about people who are employed and their employer has a plan, that plan has to be affordable. And that's basically 9.5 percent of wages and then it has to cover typically at least 60 percent of the projected medical expenses.
That is the part, I think, that sometimes you miss in the conversation: Do I have to purchase coverage and second part, is there assistance to purchase that policy?
FLEMING: I agree with Julian and when we're talking about people who are employed and their employer has a plan, that plan has to be affordable. And that's basically 9.5 percent of wages and then it has to cover typically at least 60 percent of the projected medical expenses. So from a legal perspective for the employer to provide you affordable coverage, we need to get it within those ranges.
KOPP: Carol, this is kind of at the heart of the Affordable Care Act, isn't it? There will be some adjusting of your home budget, I would guess. The government is saying you might not have to have this in your life because you have to have insurance.
CAROL GENTRY: That's right. And if you want to know how much it's going to cost you and how much you can get in tax subsidies, you can go online to figure that out (premium subsidy calculator).
KOPP: All right, Carol, you have our next question from somebody in Marathon.
GENTRY: Tamara Lamarche asked: My husband's employer does not offer him health insurance. He is however covered on my health insurance through my employer as my spouse and I pay $360 a month at this point for the spouse insurance. What will he need to do about health insurance with the ACA? Will he have to buy his own?
FLEMING: He will still be eligible as long as his wife's employer's plan allows it, he can continue to keep his health insurance with his wife.
KOPP: Julian Lago, this is a big question that came up several times. People think that somehow their insurance has to change when they're covered by their employer because of the Affordable Care Act, that they're going to have to go out and look for insurance. If you're covered by your employer, and your family is covered by your employer, does that change?
LAGO: Well, it's an interesting question, because candidly, when we use the word change, most policies effective Jan. 1, the policies themselves, will see some change with the exception of plans that were grandfathered in.
As far as the direct question, this year in particular, open enrollment is going to be critical, both for individuals because they have certain timeframes when they have to make sure they go in and obtain the subsidies and find out what those things are. At your place of employment, for those folks that covered family members and so on, open enrollment is going to be critical because you're going to have to identify what is your best structure. Is it to go through the exchanges and receive some subsidies through that, or take advantage of what your employer's plan is offering for both yourself.
One of the points that was clarified was the whole affordability and enrollment. It does allow for employees to say, I'm going to take advantage of my employer plan, however my family may opt to participate with some type of subsidies, so there is that type of opportunity but again, a lot of attention has to be paid at this year's open enrollment which is scheduled to begin in October.
If I'm offered health care through my employer, can I still opt to obtain health insurance through the new marketplace if I wish?
KOPP: Let's talk about employer offered insurance and whether it's the best option, and we can use a great question from Beth Harrelson from Lakeland, who wrote: If I'm offered health care through my employer, can I still opt to obtain health insurance through the new marketplace if I wish? My employer offers health insurance, but my only choices are a major medical individual (underwritten) plan with an extremely high (unaffordable) deductible OR a limited indemnity (mini-med) plan that has little or no catastrophic, hospital, lab or diagnostic coverage. That's a mouthful. This is one of the reasons people don't like to talk about their insurance. But her employer is offering this kind of insurance, is that her best option? Does she have to take that or can she shop on the marketplace?
LAGO: Craig, if I can jump in for a second, one of the questions was the medically underwritten. Understand that one of the dynamics of the legislation is that it changes the type of policies that are going to be offered in the fact that individual policies can no longer be medically underwritten, therefore they are issued on a guaranteed-issue basis, and pre-existing conditions must be covered. We've had that in the group marketplace for some time, as long as people had prior coverage, but that's now being introduced to the individual policies.
KOPP: Linda Fleming, as an attorney, how would you advise all of these clients out there? How will they look at their employee's insurance offering to make sure it meets the grade asked for by the ACA?
FLEMING: I would say that it's up to us as individuals to really shop around. We have more options now, and hopefully more affordable options. You should analyze what your employer is offering you, what the plans are, what the premiums are but then also go out on the government-sponsored exchanges and look and see what's available for you. What kind of coverage you would get, would you get a subsidy, what's the bottom line to you and your family? And then there's another avenue which is the marketplace. You don't necessarily have to stick with what your employer says or what the government says. You can deal with the insurance companies yourself, though the theory is that might be more expensive for you.
GENTRY: Usually, if you get it through your employer, it's cheaper because the employer pays.
KOPP: But here's my question: How do I know if my employer's insurance meets the standards that are now being set for that insurance by the Affordable Care Act?
How do I know if my employer's insurance meets the standards that are now being set for that insurance by the Affordable Care Act?
FLEMING: OK, so there are a couple of things. You know how much you make, so is it 9.5 percent of your income that you're being asked to pay? Is it under that? Is it generally inclusive and what kind of services are covered? The types of services that should be covered under your employer plan are ambulatory care, emergency services, maternity and newborn services, hospitalizations, labs, prescription drugs, pediatric services and then something that's different than what I have now: oral and vision care.
KOPP: So a mini-med, that we just heard, wouldn't cut it?
FLEMING: Doesn't sound like it.
KOPP: All right, let's move on to a question that we got on the phone and this is from Matthew McDevitt. He called from Sarasota.
MATTHEW McDEVITT: I am with a company that offers health insurance. They had open enrollment in June and I decided to opt out. I'm still with the company. Can I just go back onto my company's health insurance at any time?
KOPP: Julian Lago with the National Association of Health Underwriters, what's the answer to that question?
JULIAN LAGO: Well, the open enrollment that's scheduled to take place for October is for the individual policies and basically for anyone who has opted off their employer plan, they're going to be best suited to make sure they take advantage of the individual open enrollment, so that they comply with the law effective Jan. 1.
I would certainly encourage that individual to take advantage of the open enrollment through the individual policies to have qualifying coverage to bridge the gap until their employer's open enrollment occurs. At that time, they would not be subject to [preexisting condition exclusions] or restrictions, but they do have to make sure they walk through that process carefully.
KOPP: Linda Fleming, attorney with Carlton Fields, how come we didn't get a big heads-up? Hey, if you've gotta enroll in your employer's insurance you better check it against the ACA requirements? I think people are kind of getting caught here a little bit.
FLEMING: Well, most employers actually have their open enrollment period in the fall, so it shouldn't be that much of an issue, and also while employers can establish their own open enrollment periods, there are certain things that might happen in your life that would allow you to go ahead and enroll. Some of those things are you had a child, you get married, you get divorced...
KOPP: The Supreme Court upholds the Affordable Care Act? Does that count?
FLEMING: No. We've had a long time to get prepared for this. It's been a year now. So, I think the government is saying to us, even though they're saying it in a soft way at first, Craig, because while you're required to have health insurance, if you don't have it next year, the penalties aren't very steep.
KOPP: Our next question comes from Carolyn Murray, who owns a franchise and has an individual policy. She left us this message on our answering machine.
CAROLYN MURRAY: I have health insurance right now but on my health care policy I have several exclusions of several body parts and I'm wondering if that type of exclusion on a health care policy will be allowed under the new health care act and if you currently have that type of exclusion on your policy, will it automatically be revoked once the health care law takes effect?
I have health insurance right now but on my health care policy I have several exclusions of several body parts and I'm wondering if that type of exclusion on a health care policy will be allowed under the new health care act?
KOPP: Who wants to jump in on this one first? Julian Lago or Linda Fleming? I'm not sure I understand body part exclusion. Does the ACA keep what you have now or wipe things out?
FLEMING: Well, basically the big change, one of the big changes for next year in adult policies is they can't charge you more or exclude certain body parts. We call it pre-existing conditions and it's already gone away for children.
LAGO: Florida is just starting to release what some of the plans are going to look like in the individual marketplace and we anticipate there are going to be rate increases on the individual.
Speaking of how policies are rated a little bit, the whole rating calculation has changed. The caller mentioned she had an exclusion. Typically, when we were writing policies, unfortunately, the carriers would look at it and make determinations based on medical conditions. If the condition was a pre-existing , they could write or exclude that condition or even decline coverage. Now we're in community ratings, so the only factors they take into effect is age, your family status, smoking status and your geographic location. Notice I didn't mention male or female. Gender is not included in there.
And the ratings, it's a 3-to-1 ratio in community ratings so the differentiation between a young person at the low end of the scale and someone all the way at the top end of the scale can only be three times the difference, so that's going to raise in essence the younger rates slightly, potentially reduce the older ages and overall have an increase in that middle category.
KOPP: I'm not going to say, because it will expose my age, which one makes me happier.
We have a question from Charles Toler who is now a full-time student at Florida Southern College in Lakeland. He recently left the military after seven years of service with the Army. He wrote: I have limited health care coverage through the VA medical center only with my service-connected injuries. Would I need to obtain health care through the Affordable Care Act? How would I access the program being I am otherwise unemployed? Would my limited VA coverage be considered health care and therefore allow me to opt out of Obamacare? Are there penalties if I do not have health care through the Affordable Care Act since I am unemployed and wouldn't be able to afford it?
Complicated question -- any help for Charles?
LAGO: Well, I would think Charles, within the realm of what's considered to be coverage that meets the individual mandate, coverage through your work, coverage through an exchange or individual. It also lists Medicaid, Medicare, CHIP and what we know as Tricare, or VA care. In addition, they have the student health plans. In his case, I would be looking at the Tricare or VA care, or possibly even student health plans as eligible coverage that would meet that mandate.
KOPP: Carol, you have our final question of the day, and this is an interesting one and very applicable to our neck of the woods because it involves snowbirds.
Would snowbirds have to change and reapply every time they came to Florida?
GENTRY: Lynda Schwemmer e-mailed: I am a 62-year-old Florida resident, but I am also one of Florida's snowbirds. I live in Colorado during the summer every year. I am concerned about coverage when I am out of Florida. I asked this question on the live chat function at the Federal Healthcare site (www.healthcare.gov) and they told me that a person must reapply for the insurance of the state where they are, even temporarily. Can this possibly be true?
KOPP: All right, Linda Fleming, can this possibly be true? Would snowbirds have to change and reapply every time they came to Florida?
FLEMING: No, it would be pretty much a mess if every time we traveled out of state we had to change our health insurance policy. The real answer is, if you're going to access the change, access the change where you have declared that as your state of residence. And then, when people like Lynda are shopping for insurance, what they need to do is make sure they get a multi-state plan so it doesn't matter if she spends a couple of months here in Florida and the rest of the year in Colorado. She just needs to make sure she purchases a plan that is going to cover her in both places.
LAGO: You want to be working with an agent that helps you understand the plan designs, because so much is not just the policy. The network of providers is critical as well. You want to know as a snowbird, your state that you're traveling from and the state you're going to be spending additional time in that the network is adequate for both of those.
More resources on understanding the Affordable Care Act:
- The federal government’s website HealthCare.gov
- Premium subsidy calculator
- Coverage from Health News Florida
