Ask an expert!
Sep. 18th, 2013 09:05 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
p_cocincinusSo, as some of you know, I am employed by a major non-profit health insurance carrier, and my days as of late have been spent in learning the details of the Affordable Care Act (aka "health care reform," aka "Obamacare," aka "how to give a Republican an aneurysm"), and what its provisions mean, and how they will impact people in general (and our members in particular).
it occurs to me that some of you might have questions about all this, so here I am.
Full disclosure: I am a licensed health and disability provider in the states of Washington (as a resident) and Oregon (as a non-resident). I can answer specific questions about Cover Oregon and the Washingtonhealthplanfinder, and more general questions about the federal provisions of the Act and the exchanges, but if you're not in Washington or Oregon I may not be able to answer your state-specific questions. (But try me.) My specialty is small businesses, but I have been trained in both individual and large businesses. I do not get any kind of financial compensation for helping people or sending them to my carrier (and in fact being compensated by anyone for doing this would be considered a conflict of interest and I could lose my license, so there you have it).
Feel free to link this around, if you know someone else who might have questions.
it occurs to me that some of you might have questions about all this, so here I am.
Full disclosure: I am a licensed health and disability provider in the states of Washington (as a resident) and Oregon (as a non-resident). I can answer specific questions about Cover Oregon and the Washingtonhealthplanfinder, and more general questions about the federal provisions of the Act and the exchanges, but if you're not in Washington or Oregon I may not be able to answer your state-specific questions. (But try me.) My specialty is small businesses, but I have been trained in both individual and large businesses. I do not get any kind of financial compensation for helping people or sending them to my carrier (and in fact being compensated by anyone for doing this would be considered a conflict of interest and I could lose my license, so there you have it).
Feel free to link this around, if you know someone else who might have questions.
no subject
Date: 2013-09-19 12:17 pm (UTC)no subject
Date: 2013-09-19 02:33 pm (UTC)The ACA isn't really set up to address that kind of issue, in no small part because one of its mandates is that pharmaceutical coverage is considered an Essential Health Benefit and will be included in all plans issued after 1/1/14. Without knowing more about your friend's coverage (where it comes from, what it is, state it's issued in, etc) I can't say whether the change would happen right away, or at a later point in the year, or if they're on a grandfathered plan, but overall standalone prescription plans will most likely be going away because there won't be much need for them.
I hope this helps?
If your friend has more questions and wants to ask me in a non-public forum, they can feel free to PM me directly, as well.
no subject
Date: 2013-09-19 05:52 pm (UTC)Does the requirement for pharmaceutical coverage include mental health drugs? SO is unable to pay for his ADD meds entirely because the plan he is on doesn't cover mental health. He's been without meds for 5 really awful months. Somehow despite the total inability to control his brain he's managed to get a new job that I believe will have private insurance (currently he's on a state low-income plan that is not Medicaid) and we are hoping so hard that it will be forced to cover Adderall so things can stop being a huge disaster all the time, but I know there's no guarantee ... here I am hoping there might be.
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Date: 2013-09-19 06:43 pm (UTC)If he's not offered coverage through his job, he'll be able to get coverage through your Starr's marketplace, which will definitely be a compliant plan effective January 1st. If he has coverage through his employer, that throws in a lot more variables (starting with size of business), and I suggest that he talk to his HR department about their coverage and when it kicks in. (Another requirement of the ACA will be shortening the length of time before a benefit-eligible employee can come on the plan to a max of 90 days, which will be nice.)
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Date: 2013-09-20 07:54 pm (UTC)They get a hard sell to go with the mail order plan every time they call to talk to customer service, the customer service people are apparently instructed to do the hard sell whether or not it would work or even be possible for the person (like, say, the meds have to be refrigerated and therefore might not survive the mail) let alone whether they want to (several are committed to supporting local pharms).
You have to live through the sell before the customer service will begin to address your unrelated problem no matter how serious or urgent it is (this is for the prescription plan, not the full health care) and then the customer service is also noted for being terrible. People who depend on their meds have been told that their (fairly basic) problems are unfixable and not the problem of ES.
And on top of this, they insist on the mail order plan being the default and being opt-out, and you have to fill out the opt-out papaerwork for each individual medication every year, and apparently it´s pretty extensive, and I don´t think they remind you.
As you can probably tell, I´m hoping to not wind up with this. None of these friends are on DW. I appreciate the ACA requires that prescription plans exist, but clearly existing is not enough- do you know if there are other requirements on these plans and where I could read up on them?
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Date: 2013-09-19 08:10 pm (UTC)- I can't afford the health insurance at my company. I can't afford the lowest plan and after being there 3 years (I've been there for 8) they won't let you even take the lowest anymore. You have to spend like at least $90+ a month. Now, while I know that's not as expensive as getting insurance on your own, I don't have that.
- I make too much to qualify for the assistance that the government says they'll give people. I am in debt up to my eyeballs because of various things in the past, and I can't get enough of a break in life to get it paid down. So I basically have no extra income.
- When I have to see a doctor, I pay out of pocket. I either get a temporary loan from my mom to cover it or I scrounge or put it on my credit card. I do not go to our health department for multiple reasons. So I'm not actually burdoning the "state". I went there once in '06 out of desperation, but that's been 7 years ago. I wasn't sure if this would work in my favor for getting the feed waived.
I just feel like I'm being punished for barely keeping my head above water and trying to be self sufficient. I don't really go to the doctor on a regular basis, and I understand that if I had a major medical emergency I'd have a huge bill to pay off from the hospital, however, "you can't bleed a turnip" as my parents say. If they take almost $100 a month from me for insurance, then I won't be able to pay my bills.
I also saw that the pentalty is gonna be like $90-something the first year, then over $300 the 2nd and over $600 the third!? If I can't afford insurance how am I supposed to cover that!? I don't get a big tax return. I have them take out as little as possible because I need the money check to check. Last year from feds and state combined I only got like $20. That's not goig to cover a huge penalty that I don't even think I should be getting penalized to start with because of the reasons listed above.
Sorry this question ended up so long, but I'm just very confused about this whole thing and not sure if I'm understanding it properly. If you need more information let me know.
no subject
Date: 2013-09-20 04:57 am (UTC)Now, when it comes to being offered employer-sponsored coverage, there is a requirement that the coverage be affordable, which is defined as being no greater than 9% of your income. If what your employer is offering is more than that, you would be eligible to apply for individual coverage via the marketplace, which offers subsidies for people with income up to 400% of the federal poverty line.
If you are younger than 30, you may be eligible to purchase what is called catastrophic coverage, which is technically not minimum value, but is much less expensive and would at least cover you if something drastic happened.
Obviously I work in the insurance industry, so I believe that health insurance is very important. I've also seen my husband through two cancer scares and a brain tumor. My mother literally fell off a mountain and had to be air-evacuated and required multiple surgeries and nearly 400 stitches, and I had a skiing accident that also required surgery and months of physical therapy. Any one of those things, without insurance, could have been enough to bankrupt us.
I understand being heavily in debt, though, and I understand wanting to be self-sufficient. At the same time, not having any kind of coverage is risking your financial future.
You can, however, apply for an exemption for the penalty at your state Marketplace once it's available (should be right around October 1st). I don't know what they'll accept as a sufficient reason, but I will wish you good luck.
no subject
Date: 2013-09-20 05:03 am (UTC)We'll have to see if they change the coverage then next June when we sign up. Ours switches in July instead of the end of the year. Hopefully they have more affordable options. It probably is within that 9%, but considering I have basically nothing left over every month, unless I can manage to get better squared away which considering every time I have a chance something happens I doubt it, I'll see what I can find out about the other options applicable. Do you mean October of this year or next year?
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Date: 2013-10-04 02:22 am (UTC)I would also suggest seeing if you could negotiate with your debtors to see if you could get them to reduce your payments by that $90 ("I am required by law to purchase health coverage now" should be a good reason), because not only will there be penalties, but you are one health crisis away from complete financial disaster without it.
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Date: 2013-09-19 10:33 pm (UTC)First off - the ACA (I read above) is going to say that pharmaceutical coverage is necessary? Right now I have ZERO coverage for ANY medication and I spend literally hundreds. HOWEVER since I have insurance through school I'm afraid they're going to be able to do whatever the hell they want and I still won't get meds (like I can't get an Epi Pen even though I'm insanely allergic to bees since those things are like $200+.)
Secondly - Businesses are being mandated to provide healthcare but isn't that only to full time employees? So part time employees are still shafted and I feel like many businesses (especially retail ones) are just going to cut people's hours to avoid having to pay them insurance. I don't know where to go to do the research on what is true in a way that doesn't cross my eyes so...I'm asking you! |D
To piggyback on that, I've seen that most employers are offering these horrible high deductible plans where basically unless you get cancer you're paying out of pocket for EVERYTHING ALL YEAR and honestly...I can't afford that, ON TOP of the ridiculous cost of having insurance in the first place. Is there anything in line to make actually seeing a doctor a doable thing, or are we just stuck with these high deductible plans?
Is the cost of insurance outside employers supposed to come down?
I am honestly so confused about what the ACA even DOES at this point because I've read so many different things, I'm sorry for too many questions. @_@
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Date: 2013-10-04 05:08 am (UTC)Pharmaceutical is a required health benefit. So is mental health coverage, which is also relevant to your interests. I don't know whether the school's plan counts as "grandfathered" or not, and it probably qualifies as a large employer, so it won't be required to be ACA-compliant for another year. However, since you're not getting coverage through an employer, you are eligible to go onto the individual Exchange and apply for a subsidy and see what you can get. Worst case scenario, you keep what you have, but I bet you can do better that way.
Second - businesses are only required to provide coverage to full-time employees, yes, and some companies will respond by cutting hours - but some (probably most) won't. Walt Disney World has already "promoted" their part-timers to full time so they can be covered. Good companies will realize that benefits attract quality employees AND a healthy workforce helps EVERYONE. Companies that choose not to cover their employees will essentially be sending them to the Exchange, where they'll probably be eligible for subsidies.
Basically, the ACA means you're not reliant on your employer to provide you decent insurance, even if you have chronic health problems.
As far as high deductible plans, one of the provisions of the ACA restricts the maximum deductible level and max out-of-pocket amounts. Those plans with $7500 or $10,000 deductibles will no longer be available.
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Date: 2013-09-25 07:14 pm (UTC)I am in a domestic partnership - my state does not do same-sex marriage. So, when I and my partner apply for the insurance, do we do so individually or as a family since I don't currently work? I am assuming that it would be as a family if same-sex marriage was legal in our state...but I am hoping that we could still apply as a family regarding insurance.
no subject
Date: 2013-10-04 02:29 am (UTC)The benefit to this for you, since you don't work, is that you'll be eligible for a full subsidy - probably Medicaid or your state's adult equivalent.
no subject
Date: 2013-10-05 06:57 am (UTC)Okay, I just found out that I don't qualify for my state's extra coverage (I'm unemployed but I don't have any kids). Is there something I need to fill out so I don't get fined?
(Here via finch's journal and I wasn't sure up until today if I was going to qualify or not, so I didn't have any questions!)
Never mind, the website came back up; I don't have to do anything. -_-; sorry for the comment!