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Questions And Answers About Obamacare Marketplaces

KHN’s Mary Agnes Carey and Julie Appleby were hosted once again by the Washington Post’s Charity Brown  for a live discussion with Post readers about how the new online marketplaces will work under the health law. KHN reporters will participate in more live discussions with Post readers in the coming days.

A transcript of today’s discussion follows.

CHARITY BROWN:  Thanks for joining us. A quick note on how this chat will work before we get started. Over the next several days, reporters and experts will be dropping in here to answer your questions about Obamacare. You can submit questions 24/7 using the “Submit Your Question” link at the top of this page.

Answers will appear below this message in chronological order. Scroll to the bottom of the page to see the newest responses.

We won’t be able to answer every single question that comes in, but we’ll do our best to get to as many as possible.

To kick us off, we have Kaiser Health News correspondents Mary Agnes Carey and Julie Appleby taking your questions live, in a follow-up to last week’s chat on shopping for Obamacare.

READER QUESTION:  I understand there are many requirements surrounding income eligibility for the tax credit; what are health care options for individuals that do not meet income requirements for receiving a subsidy/tax credit but live in states that are not expanding Medicaid?

MARY AGNES CAREY:  As you note, in states that are not expanding Medicaid, individuals with incomes between 100-400 percent of the poverty level, or $11,500 to $46,000 for an individual (incomes increasing based on family size), may be able to qualify for a subsidy to purchase  insurance on the health law’s online marketplaces, or exchanges.

But if your income is below 100 percent of poverty, you cannot qualify for the law’s tax credits. In that case, you may be able to receive health care from a local community health center  You can find one near you at this link.

READER QUESTION:  I’m a full time college student, age 20, and currently insured by my father’s plan through his job, but he is retiring and eligible for Medicare. My mom is 61 so she will need to obtain insurance. Since I have no income, would it be better for me to obtain insurance alone or with my Mom? Does the answer depend upon my parent’s income?

JULIE APPLEBY:  You may want to check the numbers both ways.  Go online to the state marketplace where you live and check the cost for a plan that would cover both you and your mom, then the cost for plans that would cover you separately.  You will need to enter your household income information to find out if either or both of you qualify for a subsidy.

READER QUESTION:  Will any of the plans cover mental health costs at a similar level as physical health is covered? How does the law treat mental health coverage?

JULIE APPLEBY:  The law says insurers must include mental health and substance abuse treament as covered benefits — and generally requires those services to be comparable to other medical services. Here is more information.

READER QUESTION:  If I enroll in a plan where I live, am I covered while traveling outside my state, but in the US?

MARY AGNES CAREY:  Health insurers often cover medical expenses from health care providers, like hospitals and doctors, outside of your immediate area when you are traveling but you might face higher deductible and co-payments. Check the terms of your health insurance plan.

READER QUESTION:  I live in northern Virginia and I have so-so individual health insurance. I’m in my 50s and in the “old” system could never get different insurance. So I’m eager to get new options through Obamacare. Here’s my question: Should I jump right in on October 1, or are experts encouraging people to wait a few weeks so the system is not overwhelmed? The last thing I want to do is to overload our new website, so if it’s more responsible to wait and spread out the load, I’ll do it. If not, I’d love to get started right off.

MARY AGNES CAREY:  You can start shopping on Oct. 1 but have until March 31 to enroll. However, if you want health insurance that begins on Jan. 1 you need to enroll by Dec. 15. When you enroll is up to you.

READER QUESTION:  I am on Medicare and have a surrounding plan – gap plan. Do I need to do anything different from the usual such as just letting the surrounding plan roll over?

JULIE APPLEBY:  People who enrolled in Medicare don’t have to do anything different this year.

READER QUESTION:  My understanding is that there is no assistance for paying premiums if your earnings are below the poverty level. I lost my job after having a stroke. Since I was unable to perform my duties, it was fair that I was let go. I am not eligible for unemployment. Since I am over the age of 18 and under 65, do not have children at home, and am not disabled, I am not eligible for Medicaid. How do I pay for these required premiums when I have no income?

JULIE APPLEBY:  If you live in one of the states that has opted to expand Medicaid, you would be able to enroll in that program. In states that have decided not to expand, people earning below the federal poverty level will not be able to get subsidies to help them purchase coverage.  With little or no income, however, policy folks say you will likely qualify for an exemption from the penalty fine for not having coverage.

READER QUESTION:  What will happen to the initial enrollment period if we have a government shutdown starting October 1st? Would the state run exchanges start if the federal government enrollment stalls?

MARY AGNES CAREY:  Much of the money for federal or state-run exchanges is “mandatory” spending and would likely not be impacted by  a shutdown. See this Bloomberg story for details.

READER QUESTION (FROM SAN DIEGO):  I’m confused (shocker). I have to decide now whether to sign up for my employer insurance (premiums are 15 percent of my salary, so I believe I qualify for subsidies), but the ACA rates won’t be available until Oct 1, and I understand the plans aren’t effective until Jan1? What is the latest date I can sign up for an Obamacare health plan (i.e. how long do I have to do my price comparison between employer and Obamacare health plans)?

JULIE APPLEBY:  The California exchange director said in a briefing this morning that consumers can look on the state’s website now to get an idea of premiums and subsidies. You might want to check there at Covered California.  He added that if consumers enroll by Dec 15, their coverage would begin Jan. 1  You might qualify for a subsidy through the new marketplace if the cost of an employee-only plan (not family coverage) at your job exceeds 9.5 percent of your household income.

READER QUESTION:  If someone qualifies to buy insurance on the exchange but can’t afford the premium and copays even with the subsidy, what happens?

JULIE APPLEBY:  The law allows for exemptions from the penalty fine for not having insurance. One of those exemptions is if the cost of buying coverage exceeds 8 percent of your household income. So you could get an exemption from the penalty, which is $95 the first year or 1 percent of income, but you would still be uninsured.

READER QUESTION:  I own a benefits communications and enrollment firm in North Carolina. Two questions: 1) Will my current enrollers (licensed health insurance agents) be able to become navigators? 2) According to NC Small Group Reform, I cannot strip commissions from the exchange products to make them cheaper, relying on the ancillary lines for revenue. Will the Affordable Care Act allow me to do this?

JULIE APPLEBY:  State rules vary, but insurance agents likely can help people enroll, according to the Obama administration.   They’ve put more information here.

READER QUESTION:  My COBRA continues until April 2014. Can I enroll during open enrollment in October and drop COBRA on January 1, 2014?

MARY AGNES CAREY:  Yes but make sure you are enrolled in a plan by Dec. 15. Here’s more information from

READER QUESTION:  We can’t afford our monthly cost for employer based insurance with our family plan. Can we shop at the marketplace for a family plan even if our work provides insurance? An individual plan with my employer is low cost, but a family plan costs as much as my mortgage every month.

JULIE APPLEBY:  You can shop in the exchange, but whether you qualify for a subsidy depends on whether the cost of an employee-only plan (not family coverage) exceeds 9.5 percent of household income. If it does, you can qualify for a subsidy.

READER QUESTION:  I am a full-time family caregiver earning money through part-time contract work. Because I care for my mother, and not a spouse, I do not qualify for family coverage under her Federal Employees Health Benefits (FEHB) program. I currently pay for private insurance out of pocket, but I am hoping to get a better policy in the exchanges. I earn so little I probably qualify for Medicaid, but, given the dearth of Medicaid docs and other major problems with the program, I would rather continue to pay for private coverage.

Will those of us eligible for Medicaid also be eligible for subsidies if we would rather pay the balance of the premiums? Or, do we have to choose between Medicaid and footing the entire bill?

JULIE APPLEBY:  It is my understanding that if you qualify for Medicaid, you cannot qualify for a subsidy.

READER QUESTION:  How difficult will it be to make a selection of products based on price, provider selection, quality and benefits?

MARY AGNES CAREY:  The exchanges will list plans in an easy-to-compare format in the areas of price, benefits and provider selection. Some state exchanges will post quality ratings, others won’t until 2016, when the law requires it.  Federal officials have said they intend to provide quality data as well for plans on the federal exchange. This KHN story will provide more details.

READER QUESTION:  Can you please elaborate on the metal levels? Please explain the difference between “actuarial value” and co-insurance.

JULIE APPLEBY:  All the plans must cover a set of essential health benefits, including hospital care, doctor care, prescription drugs, etc. The metal levels correspond with how broad the financial coverage is within each plan, with the bronze plans being the least generous. Those plans must cover at least 60 percent of the cost of an average person, while platinum plans will cover 90 percent. That means things like co-payments or co-insurance, which is what you pay when you go to the doctor or are admitted to the hospital, will be higher in the bronze and silver plans than in the gold and platinum ones.  The law limits annual out of pocket costs, which include copayments and deductibles, to no more than about $6,350 for an individual or $12,700 for a family.

More info here.

READER QUESTION:  I’m hearing a lot about this MAGI as it relates to health insurance coverage. What is the difference between Adjusted Gross Income and Modified Adjusted Gross Income?

MARY AGNES CAREY:  This Kaiser Family Foundation paper may help.

READER QUESTION:  I am 55 years old, currently without income, living off of savings, cashing-in retirement savings, and paying over $400 a month for a basic health insurance policy. I am very hopeful that the new system can help me get more comprehensive coverage at a more affordable price. My health is good, but I am on meds for cholesterol and blood pressure, which was factored in by my current insurance company when they established my rate and “tier” of coverage.

Will this happen under Obamacare? Can I get better coverage and still pay less than what I pay now?

MARY AGNES CAREY:  The best answer I can give you is to look at the exchanges to see if you can get a better deal. Go to and if your state is running an exchange you will be directed there. If not, rates for the federal exchanges will be available Oct. 1.  You’ll also be able to determine if you qualify for a subsidy to help finance your coverage.

READER QUESTION:  If a student goes to college out of state, would it be better to get coverage where the college is located or where they live permanently? If they spend more time at college maybe that’s the right choice, but they are not a resident of that state. I’m not sure what to do.

MARY AGNES CAREY:  I would check with your college to see what health care coverage it offers and does that cover you when you are not on campus? If not, could you be covered on your parents’ health plan for that time period?

READER QUESTION:  I buy employer based coverage through my job for myself and my 1-year-old son. My husband buys a separate (cheaper) policy directly from BCBS. I have heard he can’t utilize the exchanges unless the cost to cover him via my company policy is greater than 9.5 percent of my paycheck (just him or all 3 of us)? Is that net or gross? I am confused about all that.

Also, are the exchanges the only option to buy coverage? Can he no longer directly buy a policy? I live in Missouri, if that matters.

JULIE APPLEBY:  The 9.5 percent threshhold is based on your household’s modified adjusted gross income, which for most people includes wages and any social security payments and tax exempt interest.  Your husband can still directly buy  a policy outside the exchange, although  those policies are not eligible for a subsidy.

READER QUESTION:  My employer covers my health care premiums at 100 percent, but pays nothing for family coverage. Family coverage at my job costs approximately $1050 per month. My husband and children are covered through an individually-purchased plan at a cost of $400/month. The cost for their coverage is going to more than double. We are not eligible for a subsidy based on the fact that my company offers family coverage (even though it is not affordable).

My question is whether my children can be covered separately from my husband, so that they have a gold/silver plan and he gets a bronze or catastrophic-only plan. Is something like that possible?

JULIE APPLEBY:  You can buy separate policies for the children and your husband. Check the premium costs for doing it that way and also don’t forget to check the annual out-of-pocket maximums.  Those maximums can be no more than $6,350 for an individual plan or $12,700 for a family plan.  As a result, you might have less exposure in out of pocket costs — deductibles and copays — if your husband and children are in one plan.

READER QUESTION:  Americans need more than a website and an 800 number. CVS has said they are stepping up on this in all states. Would they or another pharmacy be a good place to find in-person help?

MARY AGNES CAREY:  Yes. Try CVS. Walgreens is doing this as well.  The health law also offers specially trained “navigators” and other personnel to help you enroll. Find one here.

READER QUESTION:  My husband and I are offered insurance through work. The total cost individually is less than 9.5 percent of our income, however, we cannot afford the cost for a family plan (we are a family of four). That monthly cost exceeds 9.5 percent. Will we qualify for a subsidy if only the family plan rate is over 9.5 percent? We do make less than $60,000 a year.

JULIE APPLEBY:  No, the threshhold of 9.5 percent is based on the workers’ share of the cost of employee-only coverage, not the family coverage.

READER QUESTION:  With greater volume likely for applicants, how long should I anticipate it will take to actually select and get enrolled in a plan through the marketplace?

MARY AGNES CAREY:  If you want coverage to begin Jan. 1, federal officials are saying that you must be enrolled by Dec. 15.  As you may know, the enrollment period lasts until March 31 of next year. But if you find a plan that you like, It’s probably not a bad idea to enroll as soon as you make that decision.

READER QUESTION:  COBRA for my wife expired more than a year ago. When she got a private plan, they screwed up and said she was more risky because of high cholesterol and blood pressure. She has had to pay for high risk coverage. I know the ACA bans pre-existing conditions. Does it also prohibit rating or charging more for pre-existing conditions for plans on the new exchanges?

JULIE APPLEBY:  The law bars insurers from charging people with health conditions more than those without, starting Jan. 1.

Starting with policies that become effective Jan. 1, insurers are only allowed to vary premiums based on where you live, whether you smoke and your age.  And, insurers are not allowed to charge older people more than three times what they charge younger consumers.

READER QUESTION:  When you use the exchange, does an insurer have to show a link to its formulary, including Tier 4 and high co-insurance drugs? Some of the cancer consumer groups, have expressed concerns about high co-pays plans in California, saying the state will allow high percentage co-pays.

JULIE APPLEBY:  Covered California’s director, at a briefing this morning, said the drug formularies will not be on the marketplaces this year, but there will be links to the insurers’ own websites. Those sites will include lists of drugs covered.  California has also standardized its plans, including the copayment or coinsurance amount for drug formularies.  Those are also posted on the Covered California website.

READER QUESTION:  I understand that the prescription plan will be included in the deductible so until the deductible has been met, prescriptions will not be covered. Is this correct?

MARY AGNES CAREY:  Check the terms of the particular plan you choose to know for sure.

READER QUESTION:  The health care law will require most persons who do not obtain health insurance to pay a penalty. Is there a minimum age at which a person is required to get health insurance? For example, if a parent chooses to pay a penalty for some reason, his kids are also not insured – are the kids subject to a penalty?

JULIE APPLEBY:  For the first year, the penalty is $95 per adult who doesn’t have insurance and $47.50 per child, to a maximum of $285 or one percent of family income, whichever is greater.  More info is available here.

READER QUESTION:  I am a retired fed with Blue Cross. Am I correct in hoping and/or assuming I won’t have to do anything different?

MARY AGNES CAREY:  You don’t have to do anything. Your federal retiree coverage will stay the same.

READER QUESTION:  My son is fully employed, but doesn’t make much (he’s in social services). He gets coverage through that employer, but has a huge deductible. Where is the cut-off for income, and does that include investments? In other words, he make less than $2,000 monthly, but has some investments, would that disqualify him from subsidies?

MARY AGNES CAREY:  Subsidy eligibilty is based on income, not assets. So if he’s making less than $24,000 a year, he’s just over 200 percent of the poverty line, so may qualify for a subsidy. Here’s a subsidy calculator from the Kaiser Family Foundation.

READER QUESTION:  I have been a freelancer for years, buying my own insurance policy. I plan to get married soon, and my future husband is currently working, with typical workplace insurance. Since he doesn’t plan to stay there, I would prefer to keep paying for my own insurance.

Here’s my question: If I am married to someone who is still employed and could put me on his insurance, am I allowed to use the exchanges at all? This is not a question about subsidies — let’s assume I won’t get those anyway — just about my access to the exchange.

JULIE APPLEBY:  Yes, you can continue to buy on the exchange yourself. But, as you note, you would not be able to get a subsidy if his employer covers spouses and if his cost of employee-only coverage is less than 9.5 percent of your household income.

READER QUESTION:  How are assets such as real estate, savings, stocks etc. figured into your income total or is it strictly income?

JULIE APPLEBY:  The law uses modified adjusted gross income, which for most people is wages, social security payments and tax exempt interest.

READER QUESTION:  Currently, my husband works for a small business in VA and has health insurance for himself, but not us. The rest of the family has coverage on the individual market. How will that work in the future? Do we have to buy on the exchange as an entire family? His employer may send us all to the exchange.

MARY AGNES CAREY:  Anyone can purchase on the exchange, so if you want to look for family coverage you can do so there.

The question is whether or not you can qualify for a subsidy. Since your husband’s employer provides insurance, it would have to cost more than 9.5 percent of your family’s income or cover less than 60 percent of allowed medical expenses in order for you to qualify for a subsidy.

If your husband’s employer does not offer family coverage, however, he could keep getting his health insurance at work and perhaps your family could get coverage through the exchange and receive a subsidy.

READER QUESTION:  I am self employed in Maryland and currently purchase a plan on the individual market. I tried to switch plans last year, but was denied due to preexisting conditions. I know that on the exchange, they won’t be able to deny for that reason anymore. But it is my understanding that there will still be an open market, will insurers still be able to deny due to preexisting conditions if you buy a plan outside of the exchange? I am not going to qualify for subsidies, and I really like my current plan, I was just trying to change my deductible levels. I am worried that a plan like it won’t be offered on the exchange.

JULIE APPLEBY:  Starting Jan. 1, insurers cannot reject applicants with pre-existing conditions, either inside or outside the exchange.

READER QUESTION:  Why is the cost-sharing assistance for out-of-pocket expenses only available if you purchase a silver plan? The gold level plans claim to have a higher actuarial value, but without the cost-sharing that lowers your co-pays and deductible, wouldn’t they often cost more than a silver plan — and have the higher premiums?

MARY AGNES CAREY:  I’m not sure why that’s the case, but this KHN story may provide more clarity.