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Insurance Marketplace 101: Answering Consumer Questions

KHN’s Mary Agnes Carey and Julie Appleby were hosted by the Washington Post’s Charity Brown earlier today for a live discussion with Post readers about how the new online marketplaces will work under the health law.

A transcript of that discussion is posted below.

MARY AGNES CAREY: Welcome to today’s chat about the online marketplaces. We are here to answer your questions. Let’s get started!

READER QUESTION: How will this affect people who have already health insurance including Medicare?

MARY AGNES CAREY: If you have Medicare you don’t have to do anything. Medicare is not part of the health insurance exchanges.

READER QUESTION: Under my job. I am covered but my spouse is not. What am I to do? Please advise.

MARY AGNES CAREY: It sounds like your employer insurance does not allow coverage for spouses. If that’s the case, your spouse could go to the exchange to look for a plan and possibly qualify for a subsidy.

READER QUESTION: I am privately paying for my current, individual coverage to the tune of >$520 per month. Will the premiums for existing plans change? Or will I have to apply for a whole new plan in order to reap any savings?

JULIE APPLEBY: Your insurer should send you a notice about whether the plan will be continued next year.  Some existing plans may not meet all the requirements of the law and would have to be either discontinued or modified, which could result in a premium difference.  Even if your plan stays the same, you may want to go on the federal or state exchange serving your area and look at what else is available, compare the cost with your current plan, and check to see if you qualify for a subsidy.

READER QUESTION: Do you have a list of the “specific” people, phone numbers, email, web address and organization they are with? I need to be able to contact someone for sign up into the health care program both nationally and state by state. I have been looking for several months online and calling state officials, and I cannot find anything! Two weeks before enrollment and I have to ask a private news organization who to contact about a federal program.

MARY AGNES CAREY: Start with, which can tell you if your state is running and exchange and if so will send you to that specific web site.  You can also call 800-318-2596 to contact someone at

READER QUESTION: I am currently uninsured, what is the first thing I need to do come Oct. 1st?

JULIE APPLEBY: Starting Oct. 1, you can go on to find out more about the plans available in your area. If you are in a state doing its own marketplace, that website will direct you to your state’s website.

You don’t have to do anything Oct. 1. You have some time to compare the policies available, fill out your enrollment information and learn if you qualify for a subsidy.  Coverage in the new policies does not begin until Jan. 1, 2014.  If you want coverage to begin then, you should enroll by mid-December.  Open enrollment continues into the new year and closes at the end of March.

READER QUESTION: Exactly what is an exchange?

MARY AGNES CAREY: It is an online marketplace where you can go to go to look at various insurance plans to determine what’s covered and how much in premiums and co-payments you’ll pay each month. You’ll also be able to find out if you qualify for financial assistance with premiums and cos-sharing, or if you qualify for the law’s Medicaid expansion. If your state is not running its own exchange the federal government will run the exchange in your state.

READER QUESTION: How will I know if I receive the best deal? Aren’t the exchanges competitive?

JULIE APPLEBY: One of the ideas behind the exchange is that consumers will be able to see all the plans offered, as well as the premiums they would pay for the coverage, in one place.  So you will be able to compare across different insurers, which will be competing for your business. You’ll have to decide what policy makes the most sense for you, based on such factors as premium cost, the annual deductible and any other cost-sharing, such as co-payments for doctor visits or hospital care. Another factor some consumers look at is whether their doctor or hospital is included in the insurer’s network.

READER QUESTION: What will happen on Oct. 1, in those states who have not endorsed the health exchanges?

MARY AGNES CAREY: The federal government will be running the exchanges in those states. More information about plans and prices is scheduled to be published by Oct. 1 on

READER QUESTION: My son has undergone treatment for cancer under my employer’s medical insurance program but it runs out next year when he turns 26. He is presently unemployed and will have no other insurance. What are his options and will his pre-existing medical problems make it difficult to obtain insurance? Will he pay a higher premium?

JULIE APPLEBY: One of the biggest changes under the health law is that it bars insurers from rejecting applicants with pre-existing medical conditions, starting Jan. 1. It also prevents insurers from charging people with health conditions more than those without.  Starting Oct. 1, your son can start looking at these new marketplaces we’ve been discussing here to see what plans are available in his area, and compare prices. Depending on his income, he may also qualify for a subsidy to offset part of the cost of the coverage.

READER QUESTION: My daughter and son-in-law live in Arizona and run their own business with no other employees. They do not earn enough to pay income taxes. My SIL and grandson have health insurance by virtue of their Native American heritage. My daughter does not qualify for this insurance. How does she buy health insurance on the exchanges? How is her qualifying income determined?

MARY AGNES CAREY: Arizona is not running its own exchange, so I suggest that your daughter go to to get more information about exchanges and subsidies or if she qualifies for the law’s expanded Medicaid coverage, which Arizona is participating in.

READER QUESTION: Will there be dental insurance plans on the exchange? Will there be any for Northern Virginia? Or do we have to wait to see on October 1?

MARY AGNES CAREY: Dental coverage is an “essential health benefit” for children only on the exchanges, not adults.  Here’s a story I wrote that may be of help.

READER QUESTION: Thanks for offering this Q&A session. My 61 year-old, low income mother lives in VA and will lose her job and employer sponsored coverage on Dec 31. Even if she wasn’t loosing her job, she currently spends more than 30 percent of her income on her insurance premium. Who do we contact to get her enrolled for insurance and subsidies to help defray the cost? I’ve been looking on the page and there are “0” navigators or assistants listed in her area of rural VA. I keep reading that there will be trained professionals to help guide her/us but I haven’t come across any useful contact information.

JULIE APPLEBY: Your mother will be able to go on and learn about what is offered there in rural Virginia. Rates and specifics about the policies should be posted there Oct. 1.  Virginia opted to have the federal government run its exchange. The government has a call center for more information and assistance with enrolling . That number is (800) 318 2596.

Also, see Post reporter Lena Sun’s article on how to buy insurance under Obamacare if you live in Va.

READER QUESTION: Just to confirm: These plans aren’t priced based on weight, correct? This is currently a “pre-existing condition” and a friend of mine who’s overweight, but not obese, and couldn’t get coverage for that reason — plus their age. My impression is that we will not be asked about height or weight at all when enrolling. Is that right?

MARY AGNES CAREY: You cannot be denied coverage based on a pre-existing medical condition or your age. Insurers do have some latitude to charge an older person more than a younger person but it’s limited.  Insurers can’t charge an older person more than three times what they would charge a younger person for the same policy.

READER QUESTION: How can you tell if your pediatrician is in a certain plan on the exchange? If it is a bronze plan and you have to pay 40 percent of every visit, is that based on the amount negotiated with the insurance company or the physician’s own fee schedule?

JULIE APPLEBY: You may be able to get information about which doctors are in the insurers’ network through the online marketplaces — or by going directly to the insurers’s webite, where directories are supposed to be available. Some consumer groups have raised concerns that such directories are not always up to date, so they suggest you contact the doctor’s office directly and ask if they participate in the plan you are considering.   Also, the amount you pay for an office visit would either be a flat dollar amount, or a percentage of the rate negotiated by the insurer with the doctor.

READER QUESTION: Here in Virginia we don’t have access yet to information about the plans — I guess we have to wait until October 1. So, in a general way, my question is about deductibles: Will these be set at a standard dollar figure that is the same for all plans (or all “silver” plans, let’s say), or do they vary from one plan offering and insurer to another?

I have bought individual insurance for many years. When I turned 50, I had to increase my deductible from $500 a year to $2500 so I could still afford coverage. The practical result: when I had chest pains for the first time in my life earlier this year, I did not go to the ER because I figured it would cost me thousands of dollars even though I’m “insured.” Needless to say, I would love to find a plan now with a lower deductible (more like $500 than $2500), so it’s more like real health insurance again. Will that be a possibility?

JULIE APPLEBY: The quick answer is that deductibles will vary. Generally, plans in the “gold” and “platinum” tiers will have lower deductibles than those in the “bronze” and “silver” tiers.  All plans must cap annual out-of-pocket costs, which include the deductible and other cost sharing, such as copayments for doctor or hospital visits, to a maximum of about $6,350 for individuals or $12,700 for families.  Those amounts are lower than about one-third of plans currently offered consumers on the individual market, although consumer groups say that some families will still struggle with those amounts. Lower out-of-pocket limits are set in the law for those with incomes under 250 percent of the federal poverty level, which is about $28,000 for an individual or about $59,000 for a family of four.

READER QUESTION: If you get insurance through an exchange, can it be used anywhere in the U.S. or do some plans have limits?

MARY AGNES CAREY: That depends on your plan. Some offer broader coverage than others.

READER QUESTION: The very earliest that any new health insurance would start is January 1 (my current individual plan has a February 1 renewal, so I might just have the new one start then). So… signing up on October 1 or November 1 won’t make any difference. It’s all one enrollment period. Do you advise holding off for a couple of weeks, or taking the plunge on October 1? I’m concerned about computer delays due to volume of users online.

MARY AGNES CAREY: Make sure that you enroll in plenty of time for your coverage to begin Feb. 1.  Check with the insurer.

READER QUESTION: How does Oct. 1 enrollment affect a self-employed individual in the District of Columbia currently insured with an individual plan?

CHARITY BROWN: Check out Post reporter Lena Sun’s article “How to buy insurance under Obamacare if you live in the District.”

READER QUESTION: Why should a young healthy single person who makes $45,000 (and gets no subsidy) buy insurance? The premiums are well above the penalties. And if he gets sick, he can just join a plan at that point.

MARY AGNES CAREY: Remember that open enrollment is only for select periods of time each year. The first year it’s for six months and in subsequent years it is for three months.  So if he doesn’t have coverage and gets sick he might have to wait until the next enrollment period to join a plan.

READER QUESTION: Will Obamacare ever be less expensive than an employer offered insurance plan?

JULIE APPLEBY: Generally, employers pay a significant portion of the cost of health insurance. So most workers offered coverage are likely to pay less out of their paychecks by sticking with their employer plan.

READER QUESTION: Can you elaborate on what insurance co-ops are? I understand that these are consumer run – but I’m still not clear on what they are per se. Do they replace insurance exchanges? Are they federally regulated or state regulated? Will they have bronze/silver/etc plans? Why are there so many different options?

MARY AGNES CAREY: Our colleague Jay Hancock just wrote a story about co-ops that I think will answer several of your questions. Here’s the story.

READER QUESTION: If an individual or family are eligible for Cost Sharing Reductions and enroll in a silver plan, how will they be informed about the lowered dollar amounts of their deductibles and co-insurance?

JULIE APPLEBY: That information should be provided when they enroll through the new marketplaces and is based on income.  For those with incomes below twice the federal poverty level, for example, consumers would face a maximum annual out of pocket cost of $2,250 for individuals or $4,500 for families.  Those caps include the deductible and any copayments for such things as doctor visits or hospital care.

READER QUESTION: I’d really like to know the premiums that will be offered for Northern Virginia, at each medal level, for my age (52). Little bits of info and examples are out there, but none really match my situation or give the range of options. Any links to this info now, or just wait?

JULIE APPLEBY: Those haven’t been posted yet. Virginia opted to have the federal government oversee its marketplace. The federal government says it will post the rates for the 33 states it is working with on Oct. 1.  When they do, the rates for Virginia will be on the website.

READER QUESTION: How do the out-of-pocket maximums work if I purchase health insurance on the marketplace? I hear lots of people who worry that between premiums, co-pays, deductibles, they’re going to be out-of-pocket costs, $10,000 – $20,000 a year, and they don’t have that kind of money.

MARY AGNES CAREY: Annual cost-sharing, or the amount consumers must pay for co-payments and deductibles, will be capped at $6,350 for individual policies and $12,700 for family plans in 2014. These amounts do NOT include what you pay for premiums, however.

Also please note that the law also provides some assistance with co-pays and deductibles if your income is up to 250 percent of the poverty line, which is $28.725 for an individual or $58,875 for a family of four.

READER QUESTION: I’m from Indiana – red state – and the governor so far has not allowed the plan to be implemented. How will those of us who want to sign up on the insurance exchange be able to do so? I am low income and so is my adult daughter. We need and want health insurance and we don’t mind paying a reasonable price for policies.

JULIE APPLEBY: You will be able to go on and see what policies are available in Indiana. You can also find out on that website whether you qualify for a federal subsidy to help you purchase.  Price and other information is expected to be available starting Oct. 1.

READER QUESTION: Will plans be allowed to charge more to someone in poor health than someone with no health problems? Assuming they are same age and sex.

JULIE APPLEBY: No.  Unlike the current market, insurers will be barred from charging people with health conditions more than those without, starting Jan. 1. Plans can vary premiums based only on age, where you live, whether you smoke and family size.

READER QUESTION: Is there any limit as to how much premiums can increase when renewal comes?

MARY AGNES CAREY: It may depend on where you live. Some states give their insurance commissioners greater power to regulate insurance rates. The health law requires that insurers justify any premium increases of 10 percent or higher, but that doesn’t stop an insurer from raising premiums by that amount or more.

READER QUESTION: I am coordinating a program for a state-wide non-profit organization in order to conduct ACA outreach to the Latino population in Northern Virginia. A big part of my job is to develop bi-lingual materials for presentation for broad-based outreach as well as train-the-trainer materials for Latino leaders who will make the program sustainable. We have already developed a flyer that is going to be finalized soon. It was very time-consuming to get the right information together in a concise format. Could you provide any links or best practices from other entities on the local, state, or national level from which I can draw info?

CHARITY BROWN: In “How to buy insurance under Obamacare if you live in the District“, Post reporter Lena Sun says: “People who need help can go online to or contact the marketplace call center at 855-532-5465, which provides assistance in several languages, including Spanish, Amharic, Vietnamese, Mandarin and Cantonese.” Start there!

READER QUESTION: Good Afternoon – I have a question about the various carriers available to choose from in states (Georgia) where a federal exchange is in place. I noticed that many of the major carriers are participating. However there are 2 major carriers that are not, including Aetna and United Healthcare. Why would those carriers choose not to participate? Do you believe they will lose by not participating? Also I am currently insured by one of the latter and would consider shopping an exchange if rates are lower. Do we expect lower rates than those offered to employees?

JULIE APPLEBY: Insurers decide whether to offer coverage in a given region for a host of business reasons. For example:  Do they want to expand their business further into the individual market, or stick mainly with employer-based group coverage? Do they have a network of doctors and hospitals in the region, or would they have to create one? Do their actuaries estimates show them making money  or potentially lose money there?

Rates on the exchange may vary from what you have now and could be higher or lower, depending on your current level of coverage.

READER QUESTION: Some companies are announcing they will no longer cover spouses, just their workers. In that case, can the spouse go on the exchange and get a policy? And would the spouse be eligible for the subsidies and the tax credits, just as an individual?

MARY AGNES CAREY: In that case then yes, the spouse could look for coverage on the exchange and determine if he/she is eligible for a subsidy or the law’s Medicaid expansion.

READER QUESTION: If a job with benefits ends after enrollment ends, do you have wait until the next open enrollment period to sign up? Is enrollment an issue of timing?

MARY AGNES CAREY: There are a few special circumstances — like loss of job-based coverage — that would allow you to enroll in the exchanges out of the standard enrollment periods.

READER QUESTION: Will the structure under ObamaCare offer the same types of organizations (HMO, PPO, etc that we currently select from?

JULIE APPLEBY: Yes, insurers will be able to specify whether they are offering a PPO, HMO or other variation.

READER QUESTION: The ACA allows CMS to reduce Medicare payments if too many hospital patients are readmitted within 30 days: Is this for all types of diseases and disorders or a select few?

MARY AGNES CAREY: It is for a select few: heart failure, pneumonia and heart attack. Here’s a story from our colleague Jordan Rau that may help.

READER QUESTION: I understand one of the main advantages of OC is the elimination of pre-existing clauses. Does this mean an insurance carrier no longer does an intake on your medical history, or simply they cannot deny coverage for such? Further, does OC cap premium costs or could your med history essentially dictate a higher & higher premium/out of pocket costs?

JULIE APPLEBY: You will not have to fill out a detailed list of your health, because the law bars insurers from rejecting applicants with health conditions and also does not allow them to charge people with pre-existing conditions more.

READER QUESTION: Can I go to the exchange to find a plan even though I am eligible for Medicare?

MARY AGNES CAREY: You could but you would not qualify for a subsidy because you are eligible for Medicare. If you are considering the exchange, you might want to do a cost and coverage comparison between what’s offered on an exchange and what’s offered on Medicare.

READER QUESTION: How are subsidies figured?

MARY AGNES CAREY: It’s based on income. Also please note that people who get subsidies are required to pay 2 to 9.5 percent of their income toward premiums, based on how much they make.

READER QUESTION: With only two weeks until enrollment can begin, my doctor’s office says that they “do not know” whether they will be in-network providers on any of the plans to be offered on the exchange in our state. Nor will the insurance company (in this case, a Blue Cross company) confirm who will be in their network. Why is this critical information still being withheld?

JULIE APPLEBY: Some states and the federal government have not yet released specifics on premium rates or other details about the plans.  That information should be available after Oct. 1. You don’t have to enroll in a plan until about mid-December for coverage that begins Jan. 1, so you should have time to check back with your doctor’s office.

READER QUESTION: While I wait to see if I qualify for a subsidy, where can I get health care? I live in Virginia and I do not have insurance. Our state has not decided to expand Medicaid.

MARY AGNES CAREY: Try a local community health-care center. Type your zip code into the box on this link to find one near you.

READER QUESTION: Can you please explain the difference in the maximum allowance for insurance costs relative to income? I have seen two different figures for exemption – 8 or 9.5 percent of income (i.e. health insurance cannot exceed x percentage of income).

JULIE APPLEBY: If buying your own coverage would cost you more than 8 percent of your household income, you can get an exemption from the part of the law requiring nearly all Americans to carry coverage. That means you would not pay a fine  for not having insurance.

The 9.5 percent of income releates to coverage offered through your job. If your cost (for employee-only coverage) of enrolling in insurance through your job exceeds 9.5 percent of your household income, you can then opt not to enroll in job coverage and go to the online marketplace and potentially qualify for a subsidy.  If it does not exceed 9.5 percent of your income, you cannot get a subsidy through the marketplace.

READER QUESTION: How does the new health-care plan affect military retirees?

MARY AGNES CAREY: It does not impact your military retiree health coverage.

READER QUESTION: As someone who has just graduated from graduate school but is unemployed and is also not eligible to be placed on a parent’s health insurance, am I eligible for health insurance now through “Obamacare”?

JULIE APPLEBY: You would be able to enroll in coverage that begins Jan. 1.

READER QUESTION: My employer offers health insurance, but it is very expensive. What is the percentage of my pay that my premiums must eat up if I’m to qualify for subsidies?

JULIE APPLEBY: If the cost of your employer coverage (based on the employe-only premium, not the family premium) exceeds 9.5 percent of your household income, you can go to the marketplace and potentially qualify for a subsidy. If it is less than 9.5 percent, you cannot.

READER QUESTION: My brother-in-law lives in Md. and receives about $16,500 in disability. From that, he pays about $400/mo. for private health insurance. It looks like he doesn’t qualify for Medicaid, but would he benefit from the new exchanges?

JULIE APPLEBY: At that income level, your brother-in-law might qualify for a subsidy. He could go to the Maryland marketplace for more information.

READER QUESTION: My husband and I are on his COBRA coverage for $1,220/mo. We are having to dip into our retirement fund to keep up. We hit the 12 month mark this month and I’m hoping we will be allowed to keep it until the end of the year. I’d like to enroll in the NYS exchange. Can I wait until the COBRA coverage is exhausted or should I try the exchange as soon as possible?

JULIE APPLEBY: You can start looking at what is available starting Oct. 1.  The coverage offered through the exchange won’t kick in until Jan. 1.   You do not have to wait until COBRA coverage is exhausted.  But, if you are going to switch to a new policy, make sure you enroll before the end of March, 2014, when open enrollment closes.

READER QUESTION: I am eligible for my employer’s health-care program, but I have not enrolled because it is too expensive. Am I eligible to enroll as an individual through an exchange?

MARY AGNES CAREY: If your employer’s plan costs more than 9.5 percent of your income you should qualify for a subsidy. This 9.5 percent of income is based on the cost of individual — not family — coverage.

READER QUESTION: I’m researching health plans for my elderly grandparents. They are currently covered under Medicare but pay into an additional supplement for coverage. Should they be researching for new supplemental coverage through the exchange?

MARY AGNES CAREY: They don’t have to do anything if they have Medicare coverage. The exchange will not be selling Medicare supplemental policies.

READER QUESTION: Just to clarify: I did not ask whether dental insurance was an essential benefit. I asked whether I could buy dental insurance on the exchanges, specifically for northern Virginia. I am confused because many reporters like you say no. But the site says yes! “In the Health Insurance Marketplace, you generally can get dental coverage as part of a health plan or by itself through a separate, stand-alone dental plan.” Are insurers offering any dental plans as described, or is this just something that could come along in future years?

MARY AGNES CAREY: I’m sorry I misunderstood your question. You are correct that dental coverage may be sold as part of a health plan or as stand-alone coverage. You’ll have to look to see what’s offered on the exchange where you purchase coverage.