ACA (“Obamacare”) Questions (sort of) Answered

I’m getting a lot of questions about this now that we’re nearing the end of open enrollment (March 31, 2014).  Here is some basic information that may help.  To be clear, I don’t think the ACA solves all our problems.  Affordable insurance is not the same thing as affordable medical care.  Many people are still spending a lot of money for insurance they are hoping to never use because of a uselessly high deductible.  But it’s progress.  I’m hoping to never again recommend to a patient that they declare bankruptcy because of a twist of fate that landed them in the hospital for a few days.

Nothing significant is changing at my practice.  Medicaid has been expanded to include everyone under a certain income level (see below) so I am accepting Medicaid from current patients who now qualify.  People have asked why I’m not accepting new patients with Medicaid…it’s nothing against Medicaid, I assure you!  I just want to make sure I have room in my practice for people who are still uninsured or who have ridiculously high deductibles so still don’t have access to affordable care.  If you know someone who would benefit from joining the community ($30 a month for each of the first two members of a household and $15 a month for each additional member), please pass on my information to them.

Here’s some information about the Affordable Care Act that many people don’t understand:

1. While we are all expected to have coverage, we are not all expected to pay $1000 a month to get it.  How much a family pays depends on that family’s FPL (what percent of the federal poverty level they have gross income).  Here is a chart of FPL:  Notice that the larger the family, the higher the income for a particular percent.  A baby in utero counts as an additional family member (so a couple with two kids and a baby on the way will be a family of five).  This is based on gross income in order to make it fair for everyone.  It’s basically adjusted gross income (line 36 on the 1040) but there are a few modifications that can be made so it’s called MAGI (modified adjusted gross income).  The MAGI is higher and includes things like student loan interest and IRA contributions that would not be in the AGI.  If someone is right on the border of getting or not getting a benefit they should discuss it with someone more knowledgeable than I.
2. If a family or individual makes less than 133% of the FPL they automatically qualify for Medicaid.  The entire family, not just mom, not just the kids. 
3. If a family or individual makes between 133% and 250% of the FPL they get both premium subsidies (to help pay their insurance premium) and cost sharing subsidies (to improve the value of the plan by decreasing maximum out of pocket/deductible/coinsurance/copay).  Kids and pregnant women in this group still generally qualify for CHP+.
4. If a family or individual makes between 250% and 400% of the FPL they get just the premium subsidy (to help pay their insurance premium).
5. If a family or individual makes over 400% of the FPL they don’t get any subsidy and should refrain from whining because they are better off than almost everyone I know.  🙂
6. The amount a family or individual pays is figured as a percent of their income and that percent is less for lower incomes and more for higher incomes.  With the premium subsidy, the subsidy amount is based on what a family would pay for the second cheapest silver level plan; however, they can take that money and use it to buy whatever plan they want.  If they buy a bronze plan they’ll pay less; if they buy a gold plan they’ll pay more.
7. All plans, even the cheapest bronze level plans. are required to cover preventative care (such as paps) without a copay/coinsurance.  That said, they will do everything they can to pay for as little as possible. 🙂
Here’s a calculator where you can find out about how much you can expect to receive in subsidy and how much you can expect to pay for a silver level plan per month:
Here’s where you can go shopping for plans:

 One thing that has continued to confuse people is that everyone at a particular FPL is expected to pay the same amount for insurance whether they are buying insurance for one person or for eight family members.  What this means is that you may be in the income bracket where you should get a subsidy but you don’t, or you get less than someone else you know.  It’s because insurance is more expensive for larger families and for older adults.  If you are young and healthy and buying insurance for just one person, you may be paying less for insurance than the legal cut-off for your income.  This is especially true here in Colorado where people are generally healthier than other states so our insurance is more affordable to begin with.

If you need help figuring this out, I’d recommend you go to an assistance site for help.  The closest I know of is at DoctorsCare in Littleton.

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