Daily Archives: September 28, 2013

Triggering Events for a Special Enrollment Period

Normally you will only be able to apply for ACA plans only during the open enrollment period. An exception is if there is a qualified triggering event. In the case of a triggering event, a Special Enrollment Period (SEP) is opened. Events that permit a SEP include but are not limited to:

  • Gaining or becoming a dependent
  • Gaining status as a citizen, national, or lawfully present individual
  • Loss of minimum essential coverage (e.g., loss of Medicaid eligibility, termination of a QHP), except if enrollment is terminated based on failure to pay premiums
  • Loss of affordable employer-sponsored coverage
  • Determination that an individual is newly eligible or ineligible for premium tax credits or a change in eligibility for cost-sharing reductions
  • Permanent move to an area where different QHPs are available
  • Other exceptional circumstances identified by the Marketplace

In most cases, Special Enrollment Periods will extend for 60 days from the date of the triggering event. Under certain circumstances, such as the pending loss of minimum essential coverage due to the termination of a QHP, a SEP may begin before the triggering event takes place.


ObamaCare Sign-Up Rules Would Reward People Who Fudge Income

ObamaCare Sign-Up Rules Would Reward People Who Fudge Income – Investors.com.

This article is about how the Cost-Sharing Reduction (CSR) benefits change on a Silver plan based on income. CSR benefits are available ONLY on Silver plans if your income is below 251% of the Federal Poverty Level. There are 3 ranges of CSR corresponding to FPL of 100% – 150%, 151% – 200% and 201% to 250%. The lower the range, the higher the CSR.


In California, for example, a childless married couple stating income of $30,000 would face a $1,000 deductible, $15 per primary care visit and a maximum out-of-pocket cost (after premiums) of $4,500.

But for a couple attesting to $32,000 in income, the deductible would be $3,000, primary care visit $40 and out-of-pocket maximum a hefty $10,400.

Though they are separated by just $2,000 in income, the government might provide the lower-earning family as much as $5,900 more in cost-sharing subsidies to defray deductibles and copays.

So what are the odds and ramifications of income fudging?

If the IRS subsequently finds out that households understated income, any excess premium subsidies can be taken out of federal income tax refunds. On the other hand, any excess subsidies paid out to reduce cost-sharing (deductibles and copays) would be water under the bridge. Households that overstate income would likely be in the clear for both premium and cost-sharing subsidies.

So in the example above, if an individual mistated their income by $2000, they would have to refund the extra premium subsidy, which would be a small amount. HOWEVER, if they access their benefits, any advantages they received under CSR is NOT an issue. There’s going to be a lot of “income fudging” going on.

The flip side of “income fudging”, as noted in the IBD article, is to increase your income to above 100% of the FPL (or 133% in states that have enhanced Medicaid) to become eligible for the premium subsidy and to stay off of Medicaid.

Chaos! The temptation for income fudging is going to be very high. Especially for families that have medical conditions and know they will be accessing benefits. We’re creating yet another new tag today, “income fudging”.


A Guide to the New Exchanges for Health Insurance

A Guide to the New Exchanges for Health Insurance – NYTimes.com.

 I recommend following the link for a very excellent Q & A/ FAQ at the end.

But after much anticipation, the curtain will finally rise on the exchanges next week, providing millions of consumers with an online marketplace to compare health insurance plans and then buy the coverage on the spot.

The exchanges are likely to be most attractive to people who qualify for subsidized coverage. Individuals with low and moderate incomes may be eligible for a tax credit, which can be used right away, like a gift card, to reduce their monthly premiums. People with pre-existing conditions will no longer be denied coverage or charged more (this applies to most plans outside the exchanges, too). And all of the plans on the exchanges will be required to cover a list of essential services, from maternity care to mental health care. (emphasis added)

CORRECTION: ALL major medical plans off or outside the exchange offer the exact same benefits and guarantees as plans on the exchanges. Plans on the exchange will also be offered off the exchange.

As the article implies, the only reason to apply on the exchange is to get subsidies or you can apply for Medicaid coverage as well by the exchange process.

I do object to the metaphor that subsidies are like “gift cards”! A subsidy can turn into a substantial liability. If your income changes (increases) and you do not report it to the exchange, you may find yourself with a substantial obligation when you file your taxes to refund subsidies you received but were no longer eligible for.


Florida Among States Undercutting Health Care Enrollment – NYTimes.com

Florida Among States Undercutting Health Care Enrollment – NYTimes.com.


As many states prepare to introduce a linchpin of the 2010 health care law — the insurance exchanges designed to make health care more affordable — a handful of others are taking the opposite tack: They are complicating enrollment efforts and limiting information about the new program.

Chief among them is Florida, where Gov. Rick Scott and the Republican-dominated Legislature have made it more difficult for Floridians to obtain the cheapest insurance rates under the exchange and to get help from specially trained outreach counselors.

Missouri and Ohio, two other states troubled by the Affordable Care Act, have also moved to undercut the law and its insurance exchanges, set to open on Oct. 1. In Georgia, the state insurance commissioner, Ralph T. Hudgens, has said he will do “everything in our power to be an obstructionist.”

So far the article hasn’t given specifics as to actions the states have taken. We do get this specific example…

Even among states hostile to the law, Florida became an outlier this year when it passed a bill removing for two years the state insurance commissioner’s ability to approve insurance rates for new health plans, she said. This leaves Floridians vulnerable to higher rates at a time when the new health plans will be introduced.

It will soon become apparent if this resulted in higher rates for Floridians or not. It could be that they have higher rates BUT more complete doctor/facility networks.


Study: Insurance costs to soar under Obamacare

Study: Insurance costs to soar under Obamacare – CBS News.

New research from the Manhattan Institute estimates that insurance rates for young men will rise by 99 percent. Rates for younger women will rise between 55 percent to 62 percent, according to the right-leaning New York think tank.

The precise impact of the new health law is likely to vary markedly from state-to-state, however. That’s largely because different states have had different requirements for what had to be included in health insurance policies in the past. The Affordable Care Act, commonly known as Obamacare, overrides these rules and sets a federal overlay that demands a wide array of mandatory coverages. The Manhattan Institute has drawn up an interactive map that may help forecast the rise in cost for individuals.

Avik Roy of the Institute and Forbes magazine columnist notes…

“You hear all these excuses from the [Obama] administration — that people are exaggerating the effect of the law,” he says. “But real people are getting notices from their insurers now. My blog is flooded with comments from people saying that they just got a huge premium hike.”

Then there’s the “keep your policy promise…

Additionally, the promise that you could keep your old policy, if you liked it, has proved illusory. My insurer, Kaiser Permanente, informed me in a glossy booklet that “At midnight on December 31, we will discontinue your current plan because it will not meet the requirements of the Affordable Care Act.” My premium, the letter added, would go from $209 a month to $348, a 66.5 percent increase that will cost $1,668 annually.

The conclusion…

“This is a redistribution of wealth from the healthy to the sick, from the young to the old, from the people who have always had insurance to the uninsured,” Roy said.

A standard policy for wellness and catastrophic coverage for an unexpected, unavoidable ailment or accident could have been provided for a fraction of what Obamacare coverage costs, Roy added. “Obamacare forces insurers to offer products that carry all sorts of bells and whistles that most people don’t want but everyone will now need to pay for.”

Of couse the overriding question is: “Why don’t these people have insurance”? And there are a wide variety of answers….

  • Once they see even todays rates, many people decide their fortune telling crystal ball is very clear and they can see the future. Their vision of the future tells them there is no need for insurance. Translated: They don’t see the value.
  • There is certainly a group that can’t afford the premiums
  • The “pre-existing conditions” issue. Keep in mind almost all states have (or had) state risk pools to cover those who couldn’t qualify for private individual plans. Of course affordability could still be an issue.
  • There is a group of people who decide that using the ER is the best way to receive medical care and purposely don’t have insurance.
  • And finally the group that expects the government to provide it.

The solution for all of these people is apparently Obamacare which provides:

  • Extensive up front coverage, although deductibles can be fairly high
  • Guaranteed issue with no medical underwriting
  • The 10 “essential” health benefits
  • Subsidies for applicants with household incomes in the 133% – 400%  range of the Federal Poverty Level (FPL)
  • Does very little if anything at all to lower the cost of medical care
  • Has led to Hospitals buying private practices leading to higher costs of medical treatment. (For example, if your doctor prescribes an MRI, that send you to the hospital he’s associated with. Any idea what the most expensive facility to get an MRI or CT scan is? Yep, you guessed it.

A Very Quick Guide To Health Insurance Exchanges

Very informative: A Very Quick Guide To Health Insurance Exchanges – Kaiser Health News.

Do keep one thing in mind as you read the article. If you are not subsidy eligible, there is no reason to purchase through the health insurance exchange/marketplace. There will be additional ‘metal’ plans available outside the marketplace that will provide the same bronze, silver, gold and platinum coverage that is availble through the marketplace.


Why Congress is (or isn’t) exempt from Obamacare

Why Congress is (or isn’t) exempt from Obamacare. The Obamcare government exemption explained…

Of all the arguments against the Affordable Care Act that congressional Republicans are mustering in the debate over the spending bill, one hits closest to home. Congress, they say, is exempt from the very law that applies to everyone else.

The truth: Members of Congress are treated differently under Obamacare, but they’re not exempt. In fact, by forcing them to purchase health insurance through publicly run exchanges, they’re impacted more by that key provision than similar employees in private sector — or even in government.

But members of Congress will also be able to purchase their insurance under terms that are more favorable than other employees — in government or in business — who have access to employer-provided health care.

Not a bad deal to be living inside the castle walls!


Washington Health Insurance Exchange Set To Open

The exchanges are getting ready for blast off – Washington Health Insurance Exchange Set To Open | KUOW News and Information.

Starting Tuesday, Oct. 1, uninsured people will be able to shop online for private insurance in health insurance marketplaces, also known as exchanges. In Seattle, nonprofits and other organizations have been out educating people about how to sign up for insurance through the exchange.

And insured people can sign up too!

Washington state set up a website called the Health Benefit Exchange where people can compare healthcare plans, find tax credits and get financial aid. The healthcare marketplace goes live and open enrollment runs from Oct. 1 to March 31.