Q&A: Answers to your most pressing questions about you and the Affordable Care Act
By McClatchy News Service
and The Associated Press
Print This | Email This
Look for Santa's Toy and Food Fire Brigade tonight through Friday night in Sequim neighborhoods -- 12/9/13 -11:20 PM
Today's PDN Page 1 . . . and read faster, absorb more -- 12/9/13 -07:04 PM
PENINSULA HOME FUND — A 'hand-up' as a former social worker remakes his life -- 12/9/13 -07:01 PM
Breakfast special (with a free Peninsula Daily News) continues at 'The Bear' in Sequim -- 12/3/13 -06:20 PM
More local places to get help, information about ObamacareBy MARK HARVEY
For Peninsula Daily News
And, for what may be the last time . . . Obamacare”!
In the interests of full disclosure, this is going to be a rather boring column because it's going to be all about ways/dates/time/places to get help with (or just deal with) Obamacare.
I'm going to try to put everything I know about “help” and “access” in one column.
This Tuesday, Oct. 1 — “open enrollment” begins, which means you can actually do this.
If you do it before late December, your health insurance coverage, be it Medicaid or a Qualified Health Plan, will begin Jan. 1.
If you do it after that (and you can, through March 31), your coverage will begin the first day of the following month, e.g., April 1 (unless you qualify for Medicaid, which can often have a three-month retroactive start date), and you will have avoided the dreaded penalty.
You are not required to have “help.”
You can go directly to www.wahealthplanfinder.org and have at it, or you could give it a shot, and if it gets too weird, you can go looking for help.
You can also call the customer support center at 855-923-4633 any weekday between 7:30 a.m. and 8 p.m., or you can email it at firstname.lastname@example.org and get help. It's all free.
If you prefer face-to-face or more local help — it's all free — here's what you can do.
You can call any of the numbers at the end of this column, and decent people will help you.
In the West End, you can go to or call Forks Community Hospital, 530 Bogachiel Way, 360-374-6271.
In the Port Angeles/Sequim area, you can call us at 360-452-3221 or come into 411 W. Washington in Sequim (I'd call first).
In Port Angeles, you can get help from Olympic Medical Center, 939 Caroline St., 360-417-7000; Volunteers in Medicine of the Olympics, 909 E. Georgiana St., 360-452-3078; or Planned Parenthood at 426 E. Eighth St., 800-230-7526.
In Jefferson County, things are a bit more specific. Ready?
■ Port Townsend Community Center, 620 Tyler St., 360-385-9007 — On Oct. 3, 17 and 31; Nov. 7 and 21; and Dec. 5 and 19 from 1 p.m. to 3 p.m.
■ Tri-Area Community Center, 10 West Valley Road, Chimacum, 360-732-4822 — On Oct. 10 and 24, Nov. 14 and Dec. 12 from 1 p.m. to 3 p.m.
■ Quilcene Community Center, 294952 U.S. Highway 101, 360-765-3321 — On Oct. 23, Nov. 27 and Dec. 18 from 10 a.m. to 1 p.m.
■ Jefferson Healthcare, 834 Sheridan St., 360-385-2200 — Any weekday from 9 a.m. to 4:30 p.m.
■ Jefferson Public Health, 615 Sheridan St., Port Townsend — Any Wednesday from 9 a.m. to noon or 1 p.m. to 4 p.m., or phone 360-385-9400 for an appointment.
Remember, this is all free, and nobody will try to sell you anything because they don't have anything to sell.
They will help you navigate the “Healthplanfinder” and understand what it's saying, what it wants you to do and what the various terms mean, but you will be The Decider.
If you decide to go to one of these locations (or to any of the agencies listed above), you'll want to know how much money you (and everyone who lives with you) make, last year's tax filing status, Social Security numbers for everyone applying for insurance, dates of birth and,
if you are a legal immigrant, bring the passport, alien or other immigration number.
If anyone in your family currently has any kind of health insurance, bring that info, too.
Remember, please, that you don't have to do everything at once or decide everything at once.
If you have a computer and Internet access, you might consider going to the Healthplanfinder at the address above and just “cruising it” — see what you see, what it says, what it seems to want from you, etc. — then go looking for help, but if that doesn't work for you, that's fine.
Take a breath. I just did.
Look, for all the noise and the news and my incessant columns, this is not that complicated.
And for many of us, it's a huge opportunity to find health insurance, which for many of us means finding health care, so just do it.
And if you start messing with it now, you can have some time to think and learn before we all get totally sideways with the holidays.
Here are the two worst things you can do: a) nothing, and b) listen to rumors.
Check it out for yourself, then decide for yourself and do what you think is best for you and yours.
We can do this.
Mark Harvey is director of Clallam/Jefferson Information & Assistance, which operates through the Olympic Area Agency on Aging. He can be reached at 360-452-3221 (Port Angeles-Sequim), 360-385-2552 (Jefferson County) or 360-374-9496 (West End); or by emailing email@example.com. The agency can be found on Facebook at Olympic Area Agency on Aging-Information & Assistance.
A. Go to the Washington Healthplanfinder — click on: www.wahealthplanfinder.org — a one-stop shopping site that will take care of a lot of messy details for you.
The Healthplanfinder will do some whiz-bang stuff as you shop for and enroll in insurance policies from the Washington state Health Benefit Exchange.
You'll be able to find out, for example, if your income qualifies you for free or lower-cost insurance.
If you make less than $15,856 ($32,499 for a family of four) you likely will qualify for Medicaid, the federal-state plan that has been greatly expanded.
If you make up to $45,950 ($94,200 for a family of four), you may get a subsidy that will reduce your premiums.
If your income is low enough, you can qualify for a second type of subsidy to help with cost sharing (out-of-pocket costs).
It also will link you with various other services, if you qualify.
(Warning: A website with a similar address — http://washingtonhealthplanfinder.org — is not run by the state but by a Seattle-based health-insurance brokerage called the Health Insurance Team. Don't be fooled.)
For tips on making the best use of Healthplanfinder, go to http://tinyurl.com/healthplanfindertips.
Questions also can be sent by email to firstname.lastname@example.org.
Q. What if I don't have a computer?
A. There is now a free call center — 855-923-4633 or TTY/TTD 855-627-9604 — open from 7:30 a.m. to 8 p.m. Mondays through Fridays to answer your questions, walk you through the enrollment process or suggest other resources. Help is available in up to 175 different languages.
In addition, in each county, there is a network of face-to-face community organizations, public health agencies, insurance brokers, community clinics and others where you can find “navigators” or “in-person assisters” who have been trained to help you.
The state Health Benefit Exchange isn't the only way. You'll still be able to buy individual insurance through a broker or through the insurer the same way you signed up before. But there are no subsidies for purchases outside the exchange.
Q: I'm on Medicare. Do I have to buy something??
A: The new law requires nearly everyone to have health insurance by March 31, 2014, or pay a penalty.
But if you're on Medicare, you already have insurance.
The same is true if you're on Medicaid, a military or veterans' health care program, a tribal health plan or if you have health insurance through your current or former employer. In all those cases, you're covered and won't be penalized.
Q: So if I have insurance already, will my coverage change?
A. If you have private group insurance, chances are it won't change drastically, and it may cover more services. If you buy your own insurance, you'll have to pick a new plan, and it, too, may cover more services.
Q: I'm uninsured. Do I have to buy insurance or pay a penalty?
A. Probably, unless you are exempt because you are one of the following: an undocumented immigrant, incarcerated, a member of a Native American tribe, have such low income you are not required to file a tax return or are a member of a religion opposed to acceptance of benefits from a health insurance policy.
In addition, you are excused if you are determined to have very low income and coverage would be unaffordable (more than 8 percent of your income).
In this case, you could qualify for financial help to buy a plan through the exchange, but you won't pay a penalty if you don't.
Q: My employer offers a plan, but I don't like it. Can I buy an individual plan on the exchange and perhaps qualify for a subsidy? And what about my spouse?
A. Not likely. If your employer offers meaningful, affordable coverage, you cannot qualify for a subsidy in the exchange.
A plan is considered unaffordable if the employees' share of employee-only coverage is more than 9.5 percent of their household income or if the plan pays for less than 60 percent of covered health care expenses.
If your employer plan doesn't cover dependents or if the cost to cover you alone is unaffordable, your spouse could qualify for subsidized coverage in the exchange.
Q: I work for a company that has about 75 workers. We don't get insurance now. Is that going to change for 2014?
A. It might, but your company won't be required to provide insurance this year. You can buy individual/family insurance on the exchange and perhaps qualify for a subsidy.
For 2015, your company, like others with 50 or more full-time employees, will be required to buy insurance for its workers or pay a penalty.
Q. I'm a manager of a small company with six full-time employees and five part-timers. What is our company required to do for our employees under the federal law in the way of health care insurance?
A: You're not required to do anything, because you have fewer than 50 employees.
The Kaiser Family Foundation has a handy chart to walk any company through the requirements: http://tinyurl.com/pdn-kaiserchart.
Q: I am 50-plus and work sporadically. I might make $50,000 one year but none the next year or even two. How will my premiums/subsidies be calculated so I can afford insurance for the whole time? Is there a way to average your income?
A: Whether you get a subsidy depends on your annual income and will be calculated on 2013 estimated income for insurance next year.
If your income changes throughout the year, you may receive more or less on your tax refund depending on your income level.
You also may report any income changes to Washington Healthplanfinder to redetermine your eligibility. In the end, you may owe money on your taxes or get money back. It all will be reconciled on your tax return.
Q: When I tried to get individual insurance before, I had trouble because they said I had a pre-existing condition. Has that changed?
A: For the first time, insurers are required to accept you — at the same price as everyone else — even if you have a pre-existing condition.
Q: If I can't be denied insurance because of a pre-existing condition, why don't I just wait until I get sick, and then I'll buy it?
A: If you miss signing up for coverage before March 31, 2014, you'll have to wait until next fall to buy a health plan — the next open enrollment period.
There are some exceptions, but most people will be out of luck until next year.
Also, you'll have to pay a penalty for not having coverage.
Q. So how big are those penalties if I don't purchase insurance as required?
A: For 2014, the yearly penalty is $95 per year for an adult, $47.50 per child and up to $285 per family, or 1 percent of family income, whichever is greater. That will rise in coming years.
Q. What if I'm an illegal immigrant?
A. Undocumented immigrants won't get any subsidies. Immigrants here illegally will continue to try to patch together care in community clinics and emergency rooms.
Legal immigrants can buy insurance on the exchanges and qualify for subsidies, if their income qualifies them for help.
Legal immigrants here for five years or more can qualify for Medicaid with the same income limits as others.
Q: How much will I have to pay in premiums?
A: That depends on your age, how many people you want to cover and their ages, tobacco-use status, where you live and whether you'd rather spend more in premiums and less in deductibles and other co-payments, or the other way around.
For most people, new plans will cover more. For older people, they may cost less. Younger people may pay more. There won't be lifetime limits on these “essential services,” and your yearly out-of-pocket expenses will be capped.
To see what plans are available in each county, you can go directly to http://tinyurl.com/approvedplans.
To see rates, go to http://tinyurl.com/plans-rates.
All plans have to cover certain health services, in addition to complying with existing state laws. Plans do not have to include dental care for adults.
Here is the list of “essential health benefits” that all plans must cover:
■ Ambulatory patient services.
■ Emergency services.
■ Maternity and newborn care.
■ Mental health and treatment of substance abuse disorders, including behavioral health treatment.
■ Prescription drugs (See PDN story “Consumers fear what they'll pay for drugs under new health-care law”: http://tinyurl.com/medscost).
■ Rehabilitative and habilitative services and devices.
■ Laboratory services.
■ Preventive and wellness services and chronic disease management.
■ Pediatric services, including oral and vision care.
Dental benefits for kids are usually offered through a stand-alone dental plan, separate from your family's health plan.
Q: How will I know which plan is accepted by my doctor? Will we still have to call around for doctors who will take a particular plan?
A: You can search the Healthplanfinder website (click on: www.waHealthplanfinder.org) for a physician or provider by name, physician ZIP code or by hospital name.
Before you buy a health plan, it's always a good idea to double check the list of hospitals, clinics, doctors and other providers in the plan's network; that information is usually available on insurance company websites.
Q: I did the math, and it seems like a family of four (two adults age 40) and two children would pay about $12,000 a year in premiums for a silver plan, along with 70 percent of the medical costs and $1000 to $3,000 deductibles.
That's a lot of money. I heard there are limits on how much you have to spend on premiums and out-of-pocket expenses. Can you explain?
A: The law limits the percentage of your income that you have to spend on premiums, as well as the amount you have to spend out-of-pocket on deductibles and cost sharing.
The premium limits vary from 2 percent to 9.5 percent, depending on income. Out-of-pocket expense limit, which changes each year; will be $6,350 for an individual and $12,700 for a family in 2014.
Out-of-pocket expenses include money spent on reaching your deductible and cost sharing (co-insurance and co-pays) but not premium costs. This applies to individual plans sold both inside and outside the exchange.
Q: Can you give me an example of how the out-of-pocket cap works?
A: Say you have a plan with a $2,500 deductible. You fall off your skateboard and break a lot of things you think you might need later on in life.
If you have a “silver”-level plan that pays 70 percent, you'll pay 30 percent of your $50,000 hospital bill — you needed lots of fixing — until you've paid out $6,350, which is your maximum out-of-pocket for the year.
Insurance kicks in at that point. You still have to pay the premiums, but you're done paying health care expenses — so long as they are for “essential health benefits” — for the year.
Last modified: September 29. 2013 12:28AM