Obamacare Implementation: A Health Coverage Guide's Perspective

by Shaker Kate O. This introductory post will help convey some of the basics ahead of a Q&A scheduled for tonight at 8:30pm EST.

Hey folks! I'm really excited about the chance to guest blog for you all about the roll-out of the Affordable Care Act, or "Obamacare." I've been training as a Healthcare Coverage Guide, or Navigator, in Denver for the last few months, and I feel super overwhelmed by all of the details it entails, so I know you all have to be. I've been a fan of this blog and its readers for many years (despite being an irrepressible lurker!), so I thought I would reach out to Melissa to offer any help that I could to my fellow Shakers.

I'm a big old liberal and am pretty excited about this roll out. I'm English, so the idea of having to be wealthy to be healthy grosses me out. I want you all to be able to get the best answers you can to your questions in this field, and I know that so many of you are stuck in states that are not being vaguely helpful to their residents.

That said, ACA isn't perfect, and we are still unsure of lots of the ramifications, but I promise to do my best in answering your questions. We're going to have a Q&A session at Shakesville tonight starting at 8:30pm ET, so get your questions ready!

Please be super aware, though, that rules have a federal aspect, but they are also really state specific. If I can't answer your questions on the spot, I will try and research and either find you answers or resources. Some states are really kicking and screaming about this and are refusing to be any part of it. States like Florida won't even let Healthcare Coverage Guides to counsel people on state property, so those states are probably not going to have anything on their websites. Getting you answers may take me a little time. Plus, I am rolling this out in Colorado and about to be swamped. I beg your patience! But I will do my best.

To the overview!

The ACA is going to help people without healthcare benefits get them. And at group rates. I have clients in COBRA paying over $1,000 a month in premiums currently. COBRA will no longer be considered "affordable" for most people, and so these folks will be allowed into the Marketplace of offered insurance policies. If you are under 400% of the Federal Poverty Level (this is a little over $45,000 for a single adult), you are probably going to be eligible for some kind of government subsidy. Either way, none of the plans I've seen so far have come even close to those kind of premiums. These subsidies will either be extended Medicaid, Advanced Premium Tax Credits, or Cost Sharing Reductions. Honestly, these three things are so complicated, I may do a separate post dealing with them in detail, if there's interest in that.

That said, if you have affordable employer coverage, are on Medicaid or Medicare already, not a damn thing will change for you, so breathe a sigh of relief!

This will be the only year that you will have 6 months to enroll (Oct 1st-Mar 31st). This means that your healthcare guide can get you signed up in that timeframe, but none of the ACA laws go into effect until January 1st, 2014. All future years will be 3 months, with an end date of Dec 15th. Open enrollment periods, whether this year or in future ones, need a bit more detail. Hopefully we can cover that in the future. For this year however, pay attention to this next paragraph…

October 1st

Yesterday was the first day of the roll-out, and a lot of sites were overwhelmed and there were some technical problems. Fear not! Even if you enroll right away, the earliest your healthcare guide can get you insurance, with any kind of subsidy, is January 1st, 2014. I want you to enroll way before that, but the first couple of weeks of October are probably going to be a train wreck! I want you to have the very best experience and the best benefits you can have. Even though Colorado is one of the best prepared states, we're all still figuring out all the kinks, and some states are less prepared or have fewer resources. Give us a couple of weeks to see what we're dealing with in "real time." That said, if you have nothing better to do, lots of places will appreciate very patient guinea pigs. You will get help and help train us to be better at our job!

So don't feel obliged to sign up right away; just make sure you sign up by March 31st.

Individual States

It stinks! The Supreme Court ruled that it was a state's right to decide whether to extend Medicaid. Shockingly, most of the states that chose to refuse the federal dollars are, financially, the ones most in need of them. There are states that you could earn $1,500 A YEAR and not qualify for Medicaid. But you would still be earning too little to qualify for tax credit to apply towards healthcare costs as you don't make enough money! The only recourse you have at this point is to file for an exemption on the basis of un-affordability of coverage.

States are going to really, really, REALLY, vary. I moved from Oklahoma to Colorado early last year and the comparisons couldn't be starker. Colorado has really committed a lot of time, effort, and money into ensuring that its residents are educated about ACA and covered, as much as possible. Oklahoma is sticking its fingers in its ears and doing the "I can't hear you!" dance. There are certain federal specific guidelines (which we will get into later), but the reality is that, regarding ACA, living in a red state may mean obstacles to access, at least in the immediate future.

Federal Guidelines

Yay, it's later!

Okay, so states can throw tantrums, but there are certain things on which they don't have a choice…

You can stay on your parent's (natural, adoptive, or step) insurance until your 27th birthday. You don't have to be living with them. You can be married. You can even have affordable insurance offered by an employer and stay on your parent's plan.

"Pre-existing Conditions." Ummmm…no. It doesn't matter if a plan is part of the Marketplace or not—this term no longer exists.

If your employer offers you insurance that costs you over 9.5% of your MAGI (Modified Adjusted Grossly Income), head elsewhere. You're eligible for plans on the Marketplace. Keep in mind, that's if YOUR portion is 9.5% or higher. If it's between 8% and 9.5%, you can get an exception.

Similarly, if your employer's offering of insurance coverage covers less than 60% of your "Actuary Value," go to the Marketplace. You're getting shitty coverage anyway and can actually be fined for that crappy coverage. ACA requires that you have "Essential Health Benefits" to be safe from fines. College plans are really susceptible for these fines. Some schools offer decent coverage. Others are a joke. Beware!

Essential Health Benefits

What a lovely segue into "Essential Health Benefits"! Federal law dictates what all the plans in the Marketplace HAVE to cover. States, again, vary though. They can add stuff to be covered, but they can't remove them from the Federal requirements. These include:

• Outpatient Services
• Emergency Services
• Inpatient Services
• Maternity & Newborn Services
• Mental Health & Substance Abuse Services
• Prescriptions
• Rehab and Habilitative Services& Devices
• Laboratory Services
• Preventative and Wellness Services
• Chronic Disease Management
• Pediatric Services (including oral and vision)

If your existing plan doesn't cover these services, you could be fined.


Always a fun thing to talk about!

For the year of 2014 (payable April, 2015), if you don't have acceptable insurance, the fine will be $95 per adult and $47.50 per dependent child, up to $285 for a family or 1% of income, whichever is greater.

For the year of 2015 (payable April, 2016), the fine will be $325 per adult, $162.50 per dependent child, up to $975 or 2% of income, whichever is greater.

For the year of 2016 (payable April, 2017), the fine will be $695 per adult, $347.50 per dependent child, up to $2,085 or 2.5% of income, whichever is greater.

Okay, these fines will be taken out of your tax rebate or charged to you at that time (depending on your situation). My state hasn't released the cost of programs yet, but I am guessing that for a single person it will be way cheaper to pay the fine. That said, you still wouldn't have health insurance, and, god forbid you need it, you will still get hit with the usual costs of healthcare. And multiple person households could get hit with substantial fines.


This is going to be a happy/sad one for me. For those of you lucky enough to be in states that are extending Medicaid (on the fed's $, at first at least) there is a potential windfall of healthcare for you. In Colorado, a pretty damn progressive state in many ways, you used to have to make 10% or under of the Federal Poverty Level. That's around $133 A MONTH!! WTF???? Those states that have chosen to extend Medicaid; it's now kicked up to 138% of the Federal Poverty Level. 138% means you qualify at a monthly income of around $1,800.

One More Thing for Now…

The Marketplace (where you can purchase insurance and be applicable for tax credits) can only ask you certain things. Your name, Social Security #, age, Zip Code, whether you're a smoker, and if you're pregnant. The smoking and pregnancy thing: Smokers can be charged more and pregnant women are now eligible for more benefits. I was just playing on a "healthcare calculator" online and it asked for my height and weight. This is NOT a requirement, and frankly made me feel kind of icky… Be careful! I don't know that this was a scamming website, but they are going to be out there. If you can, talk to a Healthcare Coverage Guide in person. We are federally mandated to have photo IDs, and ID numbers. Check for that. (I will have ready for the Q&A session information on how a client can call to verify those ID numbers.)

So, I will see you back here tonight at 8:30pm ET to answer follow-up questions you may have.

Again, I can only truly answer questions easily about Colorado and federal policy. But I will do my best to find answers to questions regarding other states, or at least find resources for good guidance.

I guess my final word is much the same as my first: DON'T FREAK OUT!!! We're all trying to work this out. It'll happen, but be patient with us. I wish you the best experience with Healthcare Coverage Guides if you use them.

If everyone finds this interaction useful, I would be happy to hold weekly "clinics" for some of the additional points/thought/updates. Let me know in comments if you think you would make use of regular threads on Obamacare implementation.

In future, I would be happy to address specifics around same-sex marriage/civil unions, Native Americans/Alaskan Natives, and what APTC and CSR means (if you've ever heard of them!).

Here are a few additional links that I think are super helpful and informative, yet general enough to be accessible:

Crooks and Liars: Health Insurance "Coverage Gap" Coming to a Red State Near You.

Kaiser Family Foundation: Status of State Action on the Medicaid Expansion Decision, as of September 16, 2013.

Kaiser Family Foundation: Subsidy Calculator: Premium Assistance for Coverage in Exchanges.

The JAMA Forum: ACA Implementation Starts to Get Real.

[I know that I'm including a lot of Kaiser links. I am in no way affiliated to them, but I'm finding their reporting and documentation incredibly accurate, well informed, and well-written.]

I know I keep saying it, but PLEASE keep in mind how massively important it's going to be for you to really focus on what YOUR state is doing. It will make a huge difference in determining your eligibility.

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