News Column

Are You Eligible for Obamacare?

October 1, 2013

Bernard J. Wolfson, The Orange County Register

health care

Oct. 01--Today is an important date in the ongoing rollout of Obamacare. After months of roiling debate over President Barack Obama's signature health care legislation -- which continues, intense as ever -- people can actually begin signing up for medical coverage through health insurance marketplaces. In California, the state-run insurance exchange is known as Covered California. Here are some answers to questions you might have about it.

Q. What is Covered California and what will it do?

A. Obamacare, as the Affordable Care Act is sometimes known, established government-run insurance exchanges in every state to sell insurance primarily to people who do not get coverage through an employer or a government program. Covered California is one of 14 exchanges run by state governments. The other 36 will be operated by the federal government.

Starting today, you can go online at www.coveredca.com to learn what health plans are available to you, see how much they will cost and, if you wish, enroll in one. Many people will be eligible for federal tax credits to help them pay for some of their insurance premiums, and in some cases even the whole premium.

Q. Who will get those subsidies?

A. They are on a sliding scale based on your annual income. A single adult with income between $15,800 and $45,960 would qualify for a subsidy -- much greater at the lower end of that range than at the upper range. A family of four with income between $32,500 and $94,200 would qualify for a subsidy.

Q. If my income is below those levels, won't the subsidy be even higher?

A. No. Below those levels you would qualify for Medi-Cal, the government insurance program for low-income people. You would not be eligible to purchase subsidized insurance through Covered California. However, Covered California can determine if you are eligible for Medi-Cal and help enroll you in it. In Orange County the agency that runs Medi-Cal is called CalOptima, which can be reached at 1-888-587-8088 or www.caloptima.org.

Q. So what plans can I get through Covered California?

A. In Orange County, there are four insurers selling in the exchange: Health Net, Anthem Blue Cross, Blue Shield of California and Kaiser Permanente. They will sell a variety of plans at four different levels of cost. The cheapest ones, known as bronze plans, will provide the skimpiest coverage. The most expensive levels, platinum, pay a lot more of your medical bills.

Q. Do I need to buy insurance?

A. No. It's your decision. But the health reform law says that if you don't have coverage starting next year, you will have to pay a tax penalty. The penalty for next year is $95, or 1 percent of your income, whichever is greater. In 2016 it rises to $695 or 2.5 percent of your income, and is adjusted for inflation after that. That penalty is for each uninsured adult in your family. For uninsured children it is half that amount.

Keep in mind that in addition to the penalty, you could also be on the hook for potentially onerous medical bills should you fall ill or have an accident.

Q. Since I don't have insurance, I guess I have to buy it today to lock in my subsidy and avoid that penalty, right?

A. No. Today is only the starting gun, not the finish line. Open enrollment for Covered California runs through March 31. If you buy insurance on the exchange anytime up to that date, you will still qualify for subsidies if you meet the income criteria. If you buy a policy between now and Dec. 15, your coverage will begin on Jan. 1. But to avoid the penalty, you only need to be covered for nine months during 2014 (12 months after that). That means if your coverage next year starts April 1, you will avoid the penalty.

For coverage to start by April 1, you have until March 15 to buy a health plan. So you have quite a bit of time to shop for plans and evaluate which one is best for you.

Q. I heard Obamacare got delayed.

A. Only parts of it have been delayed. The biggest part is the rule requiring employers with more than 50 full-timers (30 or more hours a week) to provide coverage; that has been effectively postponed by a year, until 2015. Also, the health care exchanges run by the federal government in 36 states, as well as three state-run ones, will not offer online enrollment right away. However, that does not affect Covered California, which says it will have online enrollment capability from day one. In addition, there will be a delay in the full rollout of exchange-brokered health plans for small businesses.

Q. I already have health insurance at work. Should I check out Covered California anyway?

A. That depends. Obamacare requires health plans, including those offered by employers, to be affordable -- which means the employee's premium contribution is less than 9.5 percent of his family income. Employer plans must also contain 10 "essential benefits," which include things like preventive and wellness care, emergency services, hospitalization, prescription medications, and maternity and newborn care. If your employer offers coverage that meets those criteria, you will not be able to get subsidized insurance via Covered California. However, if your employer coverage fails to meet one or both of those conditions, you can shop on the exchange and potentially receive subsidies.

Q. I'm in my early 20s and don't have insurance through a job. Can I go to Covered California?

A. Yes, and it would be very happy to have you. Exchange officials hope to enroll as many young people as possible to offset the cost of older and sicker people with larger medical bills. That said, if you are under 26 and your parents have insurance and can afford to put you on their policy, that is an option, since Obamacare allows people up to the age of 26 to stay on their parents' health plans.

Also, the exchange sells "catastrophic" policies -- much cheaper insurance, which covers only major medical events -- to people up to the age of 30 (though with no subsidies). If you are a college student, you can also check to see if your college sells student insurance that meets the minimum requirements of Obamacare.

Q. I'm over 65 and enrolled in a Medicare plan. Should I switch to the exchange?

A. No. In fact, you cannot switch. You will continue to be a Medicare beneficiary, which is completely separate from Covered California. It is illegal for anybody to try and sell you an exchange plan. If you are satisfied with your current Medicare coverage, you don't need to do anything at all. If you want to change it, you can do so between Oct. 15 and Dec. 7. For more information go to www.medicare.gov or dial 1-800-MEDICARE.

Q. If I don't qualify for Medi-Cal or Medicare, and I don't have other insurance, is Covered California my only option?

A. No. You can also purchase insurance in the open market. But you can only get subsidized insurance through the exchange. The plans to be sold in the open market under Obamacare will look a lot like the exchange plans, including the same standardized set of required benefits and the same four-tier bronze-to-platinum structure. The open market enrollment dates will also be the same as those for Covered California.

Q. I have a chronic disease that has made insurance completely unaffordable. Is there any hope for me?

A. Yes. Starting Jan. 1, no insurance policy, whether purchased through the exchange or in the open market, may exclude people or even charge them more because of a preexisting condition. You will certainly see plans with premiums significantly lower than what you may have been quoted before, and you cannot be barred from signing up.

But be careful. Some of the lower-premium (bronze and silver) plans charge high co-insurance for expensive specialty drugs and scans that are often needed by people with illnesses like cancer. And they require individuals to pay $6,350 out of their own pockets before 100 percent coverage kicks in -- and $12,700 for a family. If you require a lot of medical care, you might be better off paying a higher premium but having much lower costs for the actual care you receive.

Q. Since I can't be prevented from buying insurance if I'm sick, why not wait and see if I need it?

A. That might not be such a great idea. If you don't buy insurance by March 31 -- whether on the exchange or the open market -- you will not be able to get it unless you have a life-changing event such as a divorce or the birth of a child. Getting sick, or hit by a car, won't count. After 2014, by the way, the enrollment period ends Dec. 31, not March 31.

Q. OK, I don't have insurance through my job and I make too much for Medi-Cal. So how do I get started?

A. Covered California has an online calculator at www.coveredca.com that will show you the range of plans available to you, how much they cost and how much of that cost, if any, will be subsidized by the federal government. It will also tell you if you should enroll in Medi-Cal instead.

If you would rather speak with a human being, dial the exchange's call center at 1-800-300-1506. You can also explore your options and enroll face-to-face with one of Covered California's designated enrollment counselors, who include staff members at various community organizations as well as licensed insurance agents.

You can find a counselor near you on the Covered California website or by dialing the call center. Health plans cost the same regardless of how or with whom you sign up.

Contact the writer: 714-796-2440 or bwolfson@ocregister.com

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(c)2013 The Orange County Register (Santa Ana, Calif.)

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Source: (c)2013 The Orange County Register (Santa Ana, Calif.)


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