Health Care
11:48 am
Tue September 24, 2013

Questions Rise As Health Care Exchange Draws Near

Originally published on Wed September 25, 2013 4:25 pm

Enrollment in the Affordable Care Act health exchanges is set to begin Oct. 1. But many eligible Americans still have questions.

Tell Me More reached out to listeners via Facebook and Twitter in an attempt to help answer their questions about the law. Host Michel Martin spoke with Mary Agnes Carey, a senior correspondent at Kaiser Health News — a news service not affiliated with Kaiser Permanente.

On searching for other affordable care options

Listener Caitlin Stevenson: "When the Affordable Care Act goes into effect, if I'm already covered by an employer's health plan, am I still eligible to shop for more affordable care? The plan that my job offers costs more than $350 a month for my husband and me — that's more than a car payment! Will we — healthy adults, 26 and 31-- be able to find a plan that costs less than this?"

Carey answers: "Anyone can shop on the exchange. The question here is whether or not they can qualify for a subsidy of purchased coverage. ... In order to qualify for a subsidy, two things have to happen. No. 1: The ... health insurance offered by her husband's employer has to cost more than 9.5 percent of their household income or the plan, if it covers at least 60 percent of the covered medical expenses. [What] I mean is that if it pays for 60 percent of the medical expenses, they could not get into the exchange. So it either costs more than 9.5 percent of the income or it doesn't pay for 60 percent of the covered services. If one of those things happen, they might be able to qualify for a subsidy."

On options for graduating students

Graduate student Lorrie Guess: "I obviously don't know yet if I'm going to have a job that offers me coverage and I don't want to pay a fine if I don't buy the coverage in case I get a job that offers me health insurance. On the other hand, I don't want to buy coverage only to get a job that ends up covering me and then find out that I'm paying for no reason."

Carey answers: "Well here's a couple of ideas. No. 1, is there any way to extend her student health insurance for a period of time after graduation as she decides where she's going to go and what job she has and whether or not she has coverage? That's one thing. Secondly, while the enrollment period for the first year of the Affordable Care Act ends at the end of March, there are things called qualifying life events — you lose your insurance at work, you get married, you have a child. I think graduating from college would be one of these. ... [And she] could get coverage on her parents' health insurance plan for a period of time. As we know, the Affordable Care Act allows that up to age 26."

On mental health options

Carey says, "As part of the Affordable Care Act ... there will be more coverage of mental health services. ... And also there has to be parity between what a plan offers on health services and what they offer on mental health services. But this is an area where I would urge caution, for people to look at and see how parity is defined, how it's implemented in a particular policy. Because this has been a concern — the mental health parity law passed a few years ago, [and while] some of the regulations have come through with it others have not. But it's definitely an area worth watching for people that are enrolling in the exchange coverage."

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

MICHEL MARTIN, HOST:

This is TELL ME MORE, from NPR News. I'm Michel Martin. Later this hour, we are going to ask a question that many people have probably been asking themselves in the wake of this past week's violence in the U.S. - which is, what makes sense? We'll talk with mental health and law enforcement experts about what seems to be motivating mass shooters right now, and how they might be stopped. That's ahead.

But first, we want to talk about the Affordable Care Act, and be honest, do you think you understand it? Public opinion polls suggest that not many Americans do. In fact, a recent Pew survey found that only 25 percent of respondents said that they had a very good understanding of what the law means to them.

So with health care exchanges set to open on Oct. 1, we are continuing our Money Coach series, answering your questions about the Affordable Care Act, what it could mean for your health and your finances. We've already received hundreds of questions on Facebook, and Mary Agnes Carey has been trying to help us answer as many of them as we can. She is a senior correspondent at Kaiser Health News. That's a news service not affiliated with Kaiser Permanente. And she's been guiding us through many provisions of the Affordable Care Act all summer, and she's back with us. Welcome back. Thanks for joining us once again.

MARY AGNES CAREY: Hello.

MARTIN: Let's just give people a quick refresher. What are the health care exchanges, and what are the important dates for enrolling?

CAREY: These are the online marketplaces where people can go and shop for coverage. Enrollment starts October the 1st. You go to healthcare.gov, and you can find out in your state, is it run it by the federal government - the exchange? Is your own state running it? You can look at different packages and different rates. There's a six-month enrollment period for the first year. So you could decide to enroll later in the year, up to March 31, but if you want coverage starting Jan. 1, you need to enroll in an exchange plan by Dec. 15. So that's a really critical deadline because the coverage does start on the 1st of January.

MARTIN: So let's get to our listener questions. Lori Guess (ph) is a graduate student from North Carolina. She's currently getting insurance through her school. This is her question.

LORI GUESS: My question is, I am not sure how it would apply to students that are set to graduate in May. I, obviously, don't know yet if I'm going to have a job that offers me coverage, and I don't want to pay a fine if I don't buy the coverage in case I get a job that offers me health insurance. On the other hand, I don't want to buy coverage, only to get a job that ends up covering me and then find out that I'm paying for no reason.

MARTIN: So what about that?

CAREY: Well, here's a couple of ideas. Number one, is there any way to extend her student health insurance for a period of time after graduation, as she decides where she's going to go and what job she has, and whether or not it has coverage. That's one thing. Secondly, there are - while the enrollment period for the first year of the Affordable Care Act ends at the end of March, there are things called qualifying life events - you lose your insurance at work, you get married, you have a child.

I think graduating from college would be one of these where let's say she loses her coverage in May. She needs coverage in June. Her ability to enroll could be later. So that's one thought. And secondly, perhaps if she does - as she's deciding where she's going to go and who her employer is, could she get coverage on her parents' health insurance plan for period of time? As we know, the Affordable Care Act allows that up to age 26. So that was one thought I had for her. Maybe she could bridge her coverage for a few months until she gets settled in her new job.

MARTIN: This seems like this would be a pretty common dilemma for a person who's finishing an educational program. So is this a pretty standard question for graduating seniors, or anybody graduating from a program - is to think if you can get some bridge coverage?

CAREY: I think it is important to get some bridge coverage. The thing you don't want to do is fly blind. You don't want to be out there without health insurance. And so I would imagine that colleges all over the country are also looking at this, to try to help their graduates figure out where could they get coverage in the interim period as they're looking for jobs and searching. And that's why I thought maybe her parents' policy might be a good place for her.

MARTIN: I wanted to ask about - I'm speaking of the question we started out with, which is that a lot of people are very unsure, and they don't know what to do. There are something called navigators. They're people who are supposed to be helping people enroll in these exchanges and answering these questions, and yet there - apparently, there's some controversy over government-funded groups that are called navigators. Can you talk about this? The Kaiser news service recently wrote about this.

CAREY: Right. These are the boots on the ground all over the country. As you said, they're supposed to help walk people through the insurance exchanges and explain them - who they are, and so on. It's caused some tension in some states between the insurance brokers and the insurance agents who say, wait a minute, these navigators are going to get 20 hours of training. They don't really know what they're doing. Do they have to register, as we do? Do they have to pay registration fees? Do they need a background check?

And the navigators don't have to have a background check - a state could put that in - but it's caused tension. You've had about 17 Republican-controlled states, and most of these states are letting the federal government run the exchange. They're not doing their own. In these 17 states with Republican legislatures or governors, they've decide to restrict some of the navigators. They may say, you have to meet our certain standards. You need a background check, you need to pay a fine and so on. There's also been hearings on Capitol Hill. Many Republicans have been criticizing the navigators. Can you trust them with your personal information? Do we really know who these people are? - and so on. But the administration counters that they've had these kind of assistors in Medicare for years, and that they've done a good job without problems. And also, if a navigator did anything inappropriate, it's a federal offense, and they'll be prosecuted for it.

MARTIN: If you're just joining us, we're answering your questions about the Affordable Care Act. With us is Mary Agnes Carey, senior correspondent at Kaiser Health News. Here's another question, from Kaitlin Stevenson (ph) in Philadelphia. And she asks: When the Affordable Care Act goes into effect, if I'm already covered by an employer's health plan, am I still eligible to shop for more affordable care? The plan that my job offers costs more than $350 a month for my husband and me. That's more than a car payment. Will we - healthy adults, 26 and 31- be able to find a plan that costs less than this?

CAREY: Anyone can shop on the exchange. The question here is whether or not they can qualify for a subsidy of purchase coverage. And as she mentions, they have health insurance offered already from her husband's place of work. So in order to qualify for a subsidy, two things have to happen. Number one, the cost of the health insurance offered by her husband's employer has to cost more than 9.5 percent of their household income; or the plan, if it covers at least 60 percent of the covered medical expenses - and what I mean is that if it pays for at least 60 percent of the covered medical expenses - they could not get into the exchange. So it's either it costs more than 9.5 percent of the income, or it doesn't pay for 60 percent of the covered services.

If one of those things happened, they might be able to qualify for a subsidy. But even if they didn't get a subsidy, if they look at the exchange and it's a better rate and cheaper for them, they can go onto the exchange. They just couldn't qualify for a subsidy.

MARTIN: So to this point, we've been getting questions mainly from young adults. Now we want to go to the other end of the age spectrum - people who are already eligible for Medicare, who are already getting coverage through Medicare, which is the federal program for seniors. What about Medicare? If you're already on Medicare, does anything change for you?

CAREY: It does not, and you're perfectly fine. You get some more benefits. You get a yearly wellness visit. You get more preventive services coverage. You get some help with your prescription drug coverage in this thing called the doughnut hole, which is the gap in coverage. But you do not have to enroll in an exchange.

And it's an important point to note because there are some bad actors out there who may be trying to say to seniors - whether it's in phone calls or any kind of direct-mail things - that you have to take action now to enroll in the exchanges. And the truth is, in Medicare, you don't. Medicare has its own enrollment period. If you were in traditional Medicare and you wanted to go into a private plan called Medicare Exchange, for example, or you're in Medicare Exchange and you want a different Medicare Exchange plan, that enrollment period starts fairly soon. It's Oct. 15th. It goes until December the 7th. That's within Medicare, but it has nothing to do with the exchanges or the ACA.

MARTIN: Here's another category of folks who have questions. We got this question from Jessica Bow (ph), from all the way in Iceland, and she is an American who plans on moving back to the U.S. - an interesting dilemma. Here it is.

JESSICA BOW: For people that are coming back after the enrollment period ends for a year, how are we getting into this system? And if you don't know exactly where you're going to be settled, how do we find a plan that's going to move with us from state to state?

MARTIN: Now, you know, I think that's an interesting question 'cause this could apply to a lot of people who are, you know, leaving graduate programs, leaving government service - you know, moving back, you know, for all kinds of reasons. What do you do?

CAREY: I think it's, again, one of those qualifying life events, those special circumstances, that would allow her to enroll outside of the traditional enrollment period for the exchanges. Now the second part of her question, I think, is the harder part to answer because she doesn't know where she's going to end up. And what I'm wondering is - in the states, we have something called COBRA, where you can take your current health care coverage and extend it for a few months. It costs you more money, but it could cover her - if that's available to her. It could cover her until she knows where she's going to end up because the difficulty is, a lot of these exchanges, they're done on a state basis.

So if you bought in one state and end in the other, you would have a problem. If COBRA's not an option, is there a sort of a catastrophic health care plan? Here, we're talking about - it's typically a low-premium, high co-pays, high deductibles. But you would be covered in the event of some horrible thing, like a car accident or something. Could she get some sort of catastrophic plan on a limited coverage, as she sorts out the details of where she's going to end up and what might be available to her?

MARTIN: And finally, in the time we have left, a big thing on a lot of people's minds these days, for obvious reasons, is mental health. Are there options in the new marketplace for people with a history of mental health issues?

CAREY: As part of the Affordable Care Act, in the small group and the individual market, there will be more coverage of mental health services. It's one of these essential health benefits that has to be covered. And also, there has to be parity between what a plan offers on health services and what they offer on mental health services. But this is an area where I would urge caution, for people to look at and see how parity is defined, how it's implemented in a particular policy - because this has been a concern. The Mental Health Parity Law, passed a few years ago - some of the regs have come through for it; others have not. But it's definitely an area worth watching, for people that are enrolling in the exchange coverage.

MARTIN: Finally, we've been reporting on concerns about a possible government shutdown. Could that affect the implementation of the Affordable Care Act?

CAREY: I've been digging into that for a couple of days. But it seems that it may have a very limited impact because there's mandatory spending and some money that's already gone out the door. And the Affordable Care Act seems to fall into those categories, where you've already got grants that have been awarded for state-based exchanges, the navigator grants to help out people all over the country. That's money that's out the door. So it seems that it may have a limited impact if it were a short-term shutdown. If it went for a longer period of time, I'd have to re-evaluate my last statement. But it seems now that it would not have that big of an impact.

MARTIN: That was Mary Agnes Carey. She's a senior correspondent at Kaiser Health News, that's a non-profit news organization not affiliated with Kaiser Permanente. And she was kind enough to join us once again in our Washington, D.C., studios. Mary Agnes, thanks so much for joining us.

CAREY: Thanks for having me.

MARTIN: Keep the questions coming. If you have a question that you want answered, hit us up on our e-mail TellMeMore@npr.org. Transcript provided by NPR, Copyright NPR.

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