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We have WebMD health care reform experts Sarah Goodell and Lisa Zamosky. Sarah is an independent health policy consultant specializing in private insurance issue, and Lisa is a healthcare journalist and longtime WebMD health insurance columnist and blogger.
We’ve already received a lot of questions from readers, so let’s get to it.
Chantal: Some exchanges that are run by states (CO, KY, WA) have the ability to search for provider networks, but the federal marketplace and most state-run exchanges do not have this capability yet. Once you narrow down a list of insurance plans you are interested in, you can go to the individual plans’ website and search their provider directory. Be sure you know the name of the specific plan you would be enrolling in because many insurance companies offer multiple plans and some may include your doctor, but others may not.
Hi Avatar, If you're eligible for a subsidy, you'll want to shop and buy your plan through the Marketplaces set up under the law. Go to Healthcare.gov. Most people will buy insurance there, though you may live in a state running it's own exchange. Either way, you can get to where you need to be via Healthcare.gov. 2015 plans aren't up yet, but should be within the next week for you to compare. If you're buying outside of the government exchanges, you can try a private exchange like ehealthinsurance.com, where you can compare all plans being offered in your area and buy one if you like.
Andrea: Stand-alone dental plans (health plans that offer only dental coverage and are not part of a broader plan, like an HMO) are generally only offered for children. This is because dental coverage is an essential health benefit for children only. If your exchange does happen to offer a dental plan for adults, you can purchase it even if you have Medicaid. I know the federal marketplace does not offer dental plans for adults, but some state-run exchanges may.
All plans sold must cover at least one of each class of prescription drugs, and surely, medications to treat diabetes will be included. But the details of which specific medications are covered and how much will vary. You need to carefully review each plan's formulary to make sure you're getting the best plan for your needs.
Leslie: The good news is you won’t have to pay a penalty for not having insurance. There is an exemption to the penalty for people who should qualify for Medicaid, but live in a state like Florida that did not expand the program. The bad news is, there’s not much help for you to get insurance. Unfortunately, you among the thousands of people who make too little to qualify for a premium subsidy because they were designed to be available only to people above the poverty level, but don’t qualify for Medicaid because your state has not expanded the program.
BC: The 2015 annual HSA contribution limit for individuals with self-only HDHP coverage is $3,350 ($6,650 for family). The 2015 minimum annual deductible for self-only HDHP coverage remains $1,300 ($2,600 family). The 2015 maximum limit on out-of-pocket expenses (including items such as deductibles, co-payments, and co-insurance, but not premiums) for self-only HDHP coverage is $6,450 (family $12,900). Some marketplaces may sell HSA qualified plans, but you would have to look at your marketplace to see.
Hi Joy, generally speaking an HMO plan will require you to select a primary care physician who will provide most of your medical care. You'll also be required to get all care from doctors/hospitals that participate with your plan and you'll need a referral from your PCP to see specialists. Generally HMOs won't provide any coverage for care received from non-participating providers. Sometimes the benefit can be lower costs at the time of your medical visits (though not always). With a PPO you'll have more flexibility. You'll still pay the least when you care from an in-network doctor but you may also get coverage when you see someone outside of the network. You also won't likely need a referral to see a specialist. However, it's important to mention that while these are general rules, the lines are blurring, so you absolutely must examine the details of each plan you're considering. I'm not sure what you're referring to with regard to vendor lists. Perhaps you mean provider network lists? If so, each plan should have a link on its website with it's list of participating providers. However, though a pain, I highly suggest you call the insurer and the doctor you're interested in to confirm participation.
Unfortunately, Georgia is one of the states that chose not to expand its Medicaid program so there is little help for people below the poverty line ($11,670 for a single person). The premium subsidies to help people buy private insurance are only available to people at or above the poverty line. The idea behind this being that Medicaid would be available to everyone below the poverty line, but the Supreme Court made that optional for states. Many states, Georgia included, chose not to expand Medicaid for people below poverty. You may be able to get low cost care at a community clinic.
We have a question from aakalaka asking about transitioning from an ACA policy to Medicare.
You have a 7 month window to sign up for Medicare, beginning the 3 months before you turn 65 and continuing for your birthday month and the following 3 months. If you sign up in the 3 months before your birthday, your coverage will begin on the 1st day of the month of your birthday. Once you have Medicare coverage, you should contact your marketplace to terminate your marketplace health plan.
Liz: Iowa is one of the states that expanded Medicaid so you should either qualify for Medicaid (income of $16,000/year) or you will be eligible for premiums subsidy to purchase a marketplace plan if your income is below $46,000 for an individual. If your income is above that threshold you can still purchase a plan on the marketplace but you will not qualify for assistance to pay your premiums.
Your premium subsidy is based on your annual income so even if your work is sporadic it should not mater when you go to apply for marketplace coverage.
Kristi G, it may be that your insurer won't be offering your current policy again in 2015 and is suggesting you'll be changed to a different, somewhat similar plan.
I suggest you call your insurer to get clarification about the meaning of the notice. It's hard for me to say for certain what it means based on the information you shared.
You can also get help understanding the notice and determining your best health insurance options for next year by working with a Navigator in your area. This is free, personalized assistance made available under the law. Go to Healthcare.govapply-and-enroll/get-help-applying.
You will have to look at the individual plan to figure out how much a therapy session costs. While all plans sold on the marketplace must cover mental health care, plans may still vary on how much they charge for a copay for a session. You do not have a flexible savings account with a marketplace plan. FSAs are only available through employers. Some plans sold on the marketplace may have an HSA option, but you would have to look at your particular marketplace. Finally, if you get a job that changes your income, your premium doesn’t go up, but your subsidy will likely be affected so the plan may now cost more to you. You should report any changes in income to your marketplace so they can adjust your subsidy accordingly. Otherwise you may be stuck with a tax bill at the end of the year.
Hi Melissa, when you lose job-based insurance, you have the option of continuing with your existing plan through COBRA (you should receive an information packet explaining the costs and how to sign up). You can also buy coverage through the government Marketplaces.
Losing job-based insurance is considered a qualifying event and allows you to buy insurance outside of open enrollment. But you need to act within 60 days of losing your coverage if you want a plan for the remainder of this year. Or you can just sign up for 2015 starting on November 15 for coverage that will start January 1, 2015.
Go to Healthcare.gov to see your options and whether you'll qualify for a subsidy to help lower your insurance costs.
Lee: The Affordable Care Act does not apply to people not living in the US. Also, seniors who are eligible for Medicare do not need to shop on the marketplace because they already have insurance coverage.
I'm a little unclear about why your son would be denied.
It's not legal for insurers to any longer deny people insurance coverage on the basis of their medical condition, so that's not likely what's happening. And, Medicare is for people age 65 and over or for those with disabilities.
I'm wondering if he didn't apply for Medicaid (government insurance for people with low incomes) and possibly lives in a state that did not expand this program under the ACA. If that's the case, and he has a very low income, he may be falling into a coverage gap in which he earns too little to qualify for Marketplace subsidies, but too much to qualify for Medicaid.
Feel free to write back with more details if I've missed the mark here.
We've received several questions from people who have ACA plans now and want to re-enroll. What do they need to know?
Plans sold in the marketplaces run on a calendar year and coverage terminates Dec. 31, 2014 unless it is renewed. In the federal marketplace and some state run exchanges, your coverage will be automatically renewed if you checked the box in your initial application allowing the marketplace to access your federal tax return. While automatic renewal will keep you covered and prevent a gap in insurance, it is to your advantage to go online, update your information, and take a look at your plan options. If you don’t update your information, your premium subsidy will be the same for 2015 as it was for 2014 and that will likely be lower than you are due (you will get any remaining subsidy you are due when you file your taxes). Also, the plan you are in may have increased its premium and you may want to shop around for a lower cost plan. If you want to chose a new plan, you must enroll by Dec. 15th in order for you to have coverage by Jan. 1st, 2015.
Go to HealthCare.gov to start. Even if your state is running its own exchange, healthcare.gov will direct you to the appropriate site. Open enrollment for 2015 begins on Nov. 15th, but you can gather information now to prepare you to sign up on the 15th.
Johnna, Healthcare.gov is the best place to start. You'll find lots of basic information about the law, what people are entitled to and what steps to take to sign up. There, you can also find links to people in your area who can sit with you and help you go through the process from beginning to end.
We have a question from Flor Cast asking about coverage for glaucoma treatment.
Treatment for glaucoma would most certainly be covered, but exactly how and what kind of financial help you'll get to do so will vary by plan.
You need to compare the plans available to you carefully to determine how the care you need is covered and which doctors participate. You may want to work with a health insurance agent in your area who is certified to sell through the Marketplaces. These professionals generally have a strong understanding of plans in your area. Go to Healthcare.gov and/or NAHU.org to find someone in your area who can help. The assistance is free of charge.
We have a question from readysater1, who is asking about financial aid for insurance in Pennsyvlania.
Without knowing your individual circumstances, the best place for you to go is to HealthCare.gov. Here you can find out if you qualify for Medicaid as well as shop for private health plans. By your question, it seems that you think you may qualify for Medicaid (annual income below $16,100 for a family of 1). If you qualify for Medicaid you don’t have to wait for the open enrollment period to enroll.
Without a defined open enrollment period but the requirement that insurers offer everyone coverage, most people would simply wait until they got sick to buy insurance. That would be deathly for the insurance market, causing costs to dramatically rise. We've seen that before the ACA in states that guaranteed everyone coverage but didn't require people to buy insurance. The reason you could sign up at any time before the ACA became law is because insurers had the freedom to turn down anyone for a pre-existing health condition. That's no longer allowed.
Your only option for buying insurance outside of open enrollment is if you experience some kind of a life changing event that would be considered a qualifying event. This may be the loss of job-based health insurance, the birth of a baby, marriage, etc. If your income drops and puts you into range for Medicaid, that can also be obtained throughout the year outside of the open enrollment period.
There should be a summary of benefits available online in the Marketplace for each of the plans you are considering. All plans have to cover the 10 essential health benefits but the details of copays, co-insurance, and deductibles vary from plan to plan. Each plan also has its own network of doctors and hospitals that you have to use. To find out who is in each plan’s network, you will likely have to go to the individual plan’s website because most exchanges do not have the capability to search provider networks.
Cdollerd wants to know why people have to answer so many questions again when they don't want to change their plan.
Even if you do not want to change your plan and want to just re-enroll in your existing plan, it benefits you to update your information. If you do not update your information, your premium subsidy will be the same in 2015 as it was for 2014 even if your income of family circumstance changed. Also, the premium for the plan you have this year may be very different for next year and you may end up paying a lot more. You may want to see what other plans are available.