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Answers to readers' questions about Obamacare marketplaces

The Obamacare marketplaces open for business Oct. 1 to start selling health insurance that will take effect Jan. 1. For the first time, people buying individual policies will be able to compare prices and coverage up front, rather than filling out a complicated underwriting form before learning the cost — or that they've been rejected because of pre-existing conditions. The marketplace is also a one-stop shop to find out if you qualify for insurance subsidies and if you or your kids are eligible for Medicaid.

In Florida, prices haven't yet been announced. But it's not too soon to learn about the marketplace. Here are a few questions from Tampa Bay Times readers; look for more answers, articles and information in the days and weeks to come. We're archiving all this information at tampabay.com. Have a question? Send it to sutton@tampabay.com

My wife and I have Medicare. Should I drop my current coverage and seek coverage on the Affordable Care Act Marketplace?

Don't drop your Medicare! You might risk financial penalties and coverage gaps. Medicare's annual open enrollment period is Oct. 15 through Dec. 7, when you can review your options for 2014 and make any changes.

Medicare is not part of the Health Insurance Marketplace. Whether you have original Medicare or a Medicare Advantage plan administered by a private insurer, you should keep making your coverage decisions as you always have. The marketplace does not offer Medicare supplement (Medigap) or Part D (prescription drug) plans. Visit Medicare.gov for all your needs.

I work for a large employer (more than 50 employees) and get my coverage through work, but I don't care for it. Can I shop on the marketplace?

People who already have what the law considers adequate insurance — and that includes most employer-sponsored policies — are welcome to check out the marketplace. But in most cases you won't be eligible for subsidies because your employer already subsidizes your insurance costs. However, if employer coverage — for you alone — costs more than 9.5 percent of household income (based on modified adjusted gross income) or coverage is inadequate, you may qualify. Apply on the marketplace to find out.

What's the website to find out about the marketplace?

Eligible Floridians will shop for insurance through healthcare.gov, operated by the federal government, because the state chose not to start its own marketplace. The site offers a lot of useful information now, but you won't be able to actually apply for or buy health insurance until Oct. 1. For those who want in-person service, local advisers — called navigators — are being trained and soon will be able to help. We'll announce how to contact them when we know. The National Marketplace Toll-Free Call Center at 1-800-318-2596 (TTY 1-855-889-4325) is open 24/7 and can immediately assist people in both English and Spanish right away, and help also will be available in 150 additional languages.

I've heard about subsidies. Who can get those?

About half the people who are eligible to purchase marketplace insurance will qualify for subsidies to help pay for premiums and, at lower income levels, even out-of-pocket costs. Subsidies are based on your estimated income and are deducted from your premium cost. Generally, individuals with incomes between $11,490 and $45,960 should qualify for some level of aid; for a family of four, the range is $23,550 to $94,200. You can get an estimate using the Kaiser Family Foundation's online calculator at kff.org.

A friend of mine is very poor and relies on a free clinic. How can he pay fines for not having insurance?

The bad news for low-income Floridians is that the state Legislature refused to expand the Medicaid program to more adults. So unless the Legislature changes its mind, many people who can't get Medicaid and can't afford insurance must continue seeking help at community health centers and emergency rooms. The fact that some of the poorest people can't get help is a strange-but-true consequence of the Supreme Court ruling that upheld Obamacare but allowed the states to decide Medicaid expansion.

The good news is that poor people won't be fined for not having insurance. You are exempt if:

• You would have to pay more than 8 percent of your income to buy insurance;

• You don't have enough income to have to file a federal tax return.

• You would qualify for Medicaid but live in a state that hasn't expanded it, like Florida;

• You qualify for a religious conscience exemption;

• You are a member of an American Indian tribe;

• You are an undocumented immigrant;

• You are incarcerated.

I read in the paper some average prices for premiums. But there was great disparity among age groups. I thought this plan was going to even things out. And what about pre-existing conditions?

Insurers will be allowed to charge more to older people and those who use tobacco. Premiums also may vary according to geographic region and family size. But they may not charge more to women than men or to people with pre-existing medical conditions. Only a few states forbid rates to vary based on age — their premiums for younger people, which have been published, are much higher than in states that allow age-rating.

It seems that those who are not U.S. citizens or are of the Muslim faith are exempt from the fines. Also, Congress and the president are exempt from Obamacare. What is fair about this?

Undocumented immigrants do not have to purchase insurance and do not face a fine. However, they are not eligible for subsidies and are not allowed to buy insurance on the marketplace. Neither Muslims nor any specific religious group is named in the law as being exempt. There is a "religious conscience exemption,'' but experts say it applies to groups like certain Amish sects that disavow all forms of insurance, including Social Security. Muslim groups have supported the Affordable Care Act. Congress and the president are not exempt. Sen. Ted Cruz, a Texas Republican who bitterly opposes Obamacare, has said they are, but our colleagues at PolitiFact have debunked that claim. Get details at politifact.com.

I have heard the fine for not buying insurance is very low, and that the IRS will have problems collecting it.

The fines start low, but then increase. In 2014, it's $95 for an individual, or 1 percent of income, whichever is greater. By 2016, the fines reach $695 per year (up to $2,085 for a family) or 2.5 percent of income, whichever is greater. If you don't pay, the Internal Revenue Service can withhold any tax refunds but can't pursue criminal charges or put a lien on your property.

Sources: Healthcare.gov, U.S. Department of Health and Human Services, Kaiser Family Foundation, the Internal Revenue Service

Charlotte Sutton is the Times' health and medicine editor, and Angie Holan is editor of PolitiFact Florida. Contact them at sutton@tampabay.com or aholan@tampabay.com.

Who will be a marketplace shopper?

As this chart shows, even in Florida — with one of the largest uninsured rates in the nation — most people have coverage through an employer, Medicare or Medicaid. They don't need to do anything with the Obamacare marketplaces when they open Oct. 1. But if you have an individual policy or are uninsured (and are above the poverty level), you'll likely be a marketplace shopper.

Mark your calendar

Oct. 1: Marketplace open enrollment starts

Oct. 15: Medicare open enrollment starts

What does it cover?

All policies sold on the Obamacare marketplace must cover at least these essential benefits:

• Outpatient services

• Emergency services

• Hospitalization

• Maternity and newborn care

• Mental health and substance abuse services

• Prescription drugs

• Services and devices to help recover from injuries, disabilities or chronic conditions

• Laboratory services

• Preventive and wellness services and chronic disease management

• Pediatric services

Answers to readers' questions about Obamacare marketplaces 09/11/13 [Last modified: Friday, September 20, 2013 5:23pm]
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