The Daily Item, Sunbury, PA

September 25, 2013

"Is my spouse covered?" and other questions about the new health-care law

By Julie Appleby and Mary Agnes Carey

Special To The Washington Post

How is the health-care law going to affect you as new state insurance marketplaces, or exchanges, open Oct. 1? Julie Appleby and Mary Agnes Carey, senior correspondents at Kaiser Health News, recently answered online questions from Washington Post readers about this. Here is an excerpt:

Q: Exactly what is a state exchange?

A: It is an online marketplace where you can look at various insurance plans to determine what's covered and how much in premiums and co-payments you'll pay each month. You'll also be able to find out if you qualify for financial assistance or for the law's Medicaid expansion.

Q: How will the exchanges affect people on Medicare?

A: Medicare is not part of the health insurance exchanges. If you have Medicare, you don't have to do anything. (The exchanges also have nothing to do with Medicare supplemental policies.)

Q: Under my job, I am covered but my spouse is not. What am I to do?

A: It sounds like your employer insurance does not allow coverage for spouses. If that's the case, your spouse could go to the exchange to look for a plan and possibly qualify for a subsidy.

Q: I am currently uninsured; what is the first thing I need to do come Oct. 1?

A: Go to to find out more about the plans available in your area. If you are in a state running its own marketplace, that Web site will direct you to your state's Web site.

You don't have to act right on Oct. 1. You have some time to compare the policies available, fill out your enrollment information and learn if you qualify for a subsidy. Coverage in the new policies does not begin until Jan. 1, 2014. If you want coverage to begin then, you should enroll by mid-December. Open enrollment will close at the end of March.

Q: How will I know if I receive the best deal?

A: One of the ideas behind the exchange is that consumers will be able to see all the plans offered, as well as the premiums they would pay for the coverage, in one place. So you will be able to compare across different insurers, which will be competing for your business. You'll have to decide what policy makes the most sense for you, based on such factors as premium cost, the annual deductible and any other cost-sharing, such as co-payments for doctor visits or hospital care. Another factor some consumers look at is whether their doctor or hospital is included in the insurer's network.

Q: My son has undergone treatment for cancer under my employer's medical insurance program, but it runs out next year, when he turns 26. He is unemployed and will have no other insurance. What are his options, and will his pre-existing medical problems make it difficult to obtain insurance? Will he pay a higher premium?

A: One of the biggest changes under the health law is that it bars insurers from rejecting applicants with pre-existing medical conditions, starting Jan. 1. It also prevents insurers from charging people with health conditions more than those without.

Starting Oct. 1, your son can start looking at these new marketplaces we've been discussing here to see what plans are available in his area and compare prices. Depending on his income, he may also qualify for a subsidy to offset part of the cost of the coverage.

Q: Will there be dental insurance plans on the exchange?

A: Dental coverage is an "essential health benefit" for children only on the exchanges, not adults. For adults, dental coverage may be sold as part of a health plan or as stand-alone coverage. You'll have to look to see what's offered on the exchange where you purchase coverage.

Q: Just to confirm: These plans aren't priced based on weight, correct? This is currently a pre-existing condition, and a friend of mine who's overweight but not obese couldn't get coverage for that reason — and for age reasons.

A: You cannot be denied coverage based on a pre-existing medical condition or your age. Insurers do have some latitude to charge an older person more than a younger person, but it's limited. Insurers can charge an older person no more than three times what they would charge a younger person for the same policy.

Q: Will plans be allowed to charge more to someone in poor health than someone with no health problems, assuming they are same age and sex?

A: No. Starting Jan. 1, plans can vary premiums based only on age, where you live, whether you smoke and family size.

Q: My question is about deductibles: Will these be set at a standard dollar figure that is the same for all plans (or all "silver" plans, let's say), or do they vary from one plan offering and insurer to another? I have bought individual insurance for many years. When I turned 50, I had to increase my deductible from $500 a year to $2,500 so I could still afford coverage. The practical result: When I had chest pains for the first time in my life earlier this year, I did not go to the ER because I figured it would cost me thousands of dollars even though I'm "insured." Needless to say, I would love to find a plan now with a lower deductible (more like $500 than $2,500), so it's more like real health insurance again. Will that be a possibility?

A: The quick answer is that deductibles will vary. Generally, plans in the "gold" and "platinum" tiers will have lower deductibles than those in the "bronze" and "silver" tiers. All plans will have a cap on annual out-of-pocket costs, which include the deductible and other cost-sharing, such as co-payments for doctor or hospital visits, to a maximum of about $6,350 for individual policies or $12,700 for family plans, in 2014. Those amounts are lower than about one-third of plans currently offered consumers on the individual market, although consumer groups say that some families will still struggle.

Q: Why should a young, healthy, single person who makes $45,000 (and gets no subsidy) buy insurance? The premiums are well above the penalties. And if he gets sick, he can just join a plan at that point.

A: Remember that open enrollment is only for select periods of time each year. The first year it's for six months, and in subsequent years it is for three months. So if he doesn't have coverage and gets sick, he might have to wait until the next enrollment period to join a plan.

Q: Will Obamacare ever be less expensive than an employer-offered insurance plan?

A: Generally, employers pay a significant portion of the cost of health insurance. So most workers offered coverage are likely to pay less out of their paychecks by sticking with their employer plan.

Q: How does the new health-care plan affect military retirees?

A: It does not impact your military retiree health coverage.