Sactoking's ACA Q&A Thread

sactoking

Diamond Member
Sep 24, 2007
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#1
Given the level of discourse so far on the Affordable Care Act I debated doing this but I am going to give it a shot. If the thread devolves into partisan bickering I will ask to have it locked.

I am a state insurance regulator charged with implementing various provisions of the Affordable Care Act. I will take questions relating to the implementation of the ACA and how it may impact you, your state, and the country. I'd like to keep things in the vein of the ATOT tax threads. I don't know everything but I have lots of resources at my disposal to find answers. As some of the enacting provisions of the ACA are state-specific I won't be able to answer all questions (just like the tax thread) but will do my best.

My qualifications:
Chartered Property & Casualty Underwriter
Accredited Insurance Examiner
Associate in Insurance Accounting & Finance
Associate in Fidelity & Surety Bonding
Associate in Personal Insurance
Associate in Regulation and Compliance
Associate in Reinsurance
Member of Society of Financial Examiners
Member of Insurance Regulatory Examiners' Society
~ 10 years industry experience
Access to variety of industry resources

Nothing I say should be taken as gospel or a legal opinion. I am not an attorney and do not represent my state in any official capacity in this thread.

Common acronyms used:
ACA- Affordable Care Act
AV- Actuarial Value
BCBS- Blue Cross/Blue Shield
CBO- Congressional Budget Office
CCIIO- Center for Consumer Information and Insurance Oversight
CHIP- Children's Health Insurance Program
COLA- Cost-Of Living Adjustment
EHB- Essential Health Benefit
ERISA- Employee Retirement Income Security Act
FPL- Federal Poverty Level
FSA- Flexible Spending Account
FTE- Full-time Equivalent
HDHP- High Deductible Health Plan
HHS- Department of Health and Human Services
HSA- Health Savings Account
IRC- Internal Revenue Code
MAGI- Modified Adjusted Gross Income
MEWA- Multiple Employer Welfare Arrangement
MLR- Medical Loss Ratio
MSA- Medical Savings Account
NAIC- National Association of Insurance Commissioners
NIPR- National Insurance Producer Registry
SHOP- Small business Health OPtions
TPA- Third-Party Administrator

Below are some of the common questions, more specific questions and answers are contained in the body of the thread.

Mandate/Penalty
Q: How will it be determined/verified that one had coverage and complied with the mandate?
A: Insurers will be required to issue a form similar to a 1099 to each policyholder indicating the months that the person was insured. The forms will be attached to the 1040 filing as proof of coverage when the tax return is filed.

Q: Supposedly there is a 3 month grace period to the mandate on not being covered. What is to stop someone from getting coverage for a month and then dropping it for 3?
A: Section 1501(e)(4)(B)(iii) stipulates that if there is more than one "grace period" lapse in a calendar year only the first such lapse will be forgiven.

Q: What will be the penalty in 2016 when the phase-in is complete?
A: The penalty will be $695 per adult and $347.50 per child. The maximum penalty will be $2,085 per family or 2.5% of Modified Adjusted Gross Income (MAGI), whichever is greater. The penalty will be prorated monthly and any temporary lapse of less than 3 months will not be counted. After 2016 the penalty will have an inflation peg and will increase in increments of $50.

Q: What is the exclusion from the mandate for "affordability"?
A: If the least expensive plan offered by your employer, after your employer's subsidy, is more than 9.5% of your MAGI then you may opt out of your employer's plan(s) and be eligible for the individual exchange. Once you are eligible for the exchange if the least expensive plan offered on the exchange, after government subsidy, is more than 8% of your MAGI then you are exempt from the mandate.

Q: Will those on Medicare be required to sign up for part B, C or D in order to comply with the mandate?
A: Per Section 1501(f)(1)(A)(i) only Medicare Part A will be required to meet the Minimum Essential Coverage (mandate).

Q: Do people earning below the poverty level have to purchase insurance or pay a tax penalty?
A: Yes, they are subject to the mandate but there is probably not a plausible scenario where they cannot fulfill the mandate except by choice.

Q: Do employers incur penalties for not offering insurance?
A: If the employer has <25 employees and the average wage is <$50,000 then the employer receives a tax credit to offer insurance on the SHOP Exchange.
If the employer has <50 employees the employer is exempt from the ACA mandate.
If the employer has 50+ employees, does not offer coverage, and none of its employees are eligible for a federal subsidy it incurs no penalty.
If the employer has 50+ employees, does not offer coverage, and at least one employee is eligible for a federal subsidy it incurs a penalty of $2,000 per FTE employee for every FTE employee above 30.
If the employer has 50+ employees, offers coverage, and the coverage does not pay at least 60% of the costs for a typical population it incurs a penalty of $3,000 per FTE employee for every FTE employee above 30.
If the employer has 50+ employees, offers coverage, the coverage pays at least 60% of the costs for a typical population but at least one employee fails the 9.5% affordability test the employer incurs a penalty of $3,000 per FTE employee failing the 9.5% affordability test for every FTE employee failing the 9.5% affordability test above 30.

Q: Can an employer avoid the mandate by breaking up into smaller companies, each with fewer than 50 employees?
A: No, the ACA contains common control provisions which extend beyond the legal liability of a company. So long as one individual, or group of individuals, owns multiple companies they are considered one for ACA purposes even if otherwise unrelated.

Subsidy
Q: What will the subsidy calculation look like?
A: A family below 133% of the Federal Poverty Line will pay not more than 2% of their income on the second-lowest price Silver plan. Once income exceeds 133% of the FPL the subsidy decreases to not more than 3% of income. From 133% of FPL to 300% of FPL a sliding scale is applied with the subsidy decreasing to not more than 9.5% of income at 300% of FPL. The subsidy of not more than 9.5% of income is flat up to 400% of FPL, where it disappears completely.

Q: If you work for an exempted company and buy a subsidized plan on the exchange for your family will your employer still be billed for the subsidy?
A: The subsidy is only charged back to the employer when the employer is required to provide adequate and affordable coverage and fails to do so. If the employer is exempt from the requirement, say by having fewer than 50 employees, then they are not charged for the federal subsidy costs.

Q: The ACA gives subsidies to certain people (by income) who purchase insurance on an exchange. Where will that subsidy money come from?
A: From a technical perspective, the subsidies are funded by a combination of direct taxation, indirect taxation, and diverted tax cuts.

Q: What guarantee do we have that Congress will maintain proper funding for these subsidies in the next 5 to 10 years?
A: The "subsidies" are not actually subsidies but instead tax credits and they don't have to be "paid for" in the traditional sense; they are paid for through reduced tax revenue. So long as the law remains as it is now Congress cannot "de-fund" the payments any more than they could refuse to pay a legally obtained tax refund.

Coverage
Q: What are Essential Health Benefits?
A: They are specific categories of health insurance benefits.

Q: How many Essential Health Benefit categories are there?
A: There are ten Essential Health Benefits mentioned in the Affordable Care Act.

Q: What are the Essential Health Benefit categories?
A:
&#8226; Ambulatory patient services;
&#8226; Emergency services;
&#8226; Hospitalization;
&#8226; Maternity and newborn care;
&#8226; Mental health and substance abuse disorder services;
&#8226; Prescription drugs;
&#8226; Rehabilitation and Habilitation;
&#8226; Laboratory services;
&#8226; Preventive and wellness services; and
&#8226; Pediatric services

Q: What are ambulatory patient services?
A: Ambulatory patient services are probably better known as &#8220;outpatient&#8221; services.

Q: I understand what rehabilitation is, but what is habilitation?
A: If you think of rehabilitation as re-learning how to do something, such as re-learning to walk after knee surgery, then habilitation is learning how to do something for the first time, such as overcoming a speech impediment.

Q: Why are Essential Health Benefits important?
A: There are two main reasons:
1. The Affordable Care Act requires most individual health insurance policies and most health insurance policies offered by small employers to cover the Essential Health Benefits; and
2. The Essential Health Benefits cannot have annual or lifetime dollar limits attached to them.

Q: How are the Essential Health Benefits chosen?
A: Your state will choose one &#8220;benchmark&#8221; insurance plan from ten choices and that benchmark plan will set the Essential Health Benefits for the State.

Q: What about all of the benefits that are not Essential Health Benefits, like chiropractic care?
A: If the benchmark plan selected has other benefits on top of the Essential Health Benefits, those additional benefits will become Essential and must be included by many plans.

Q: Wait, so you&#8217;re going to dictate what insurance plan I have to have?
A: No. The benchmark plan will set the minimum insurance benefits that many insurance plans will have to offer but you will still be free to shop for insurance from any licensed insurance company you wish.

Q: But you&#8217;re going to set my deductible, copayment, and coinsurance, right?
A: No. Your deductible, copayment, and coinsurance (collectively called &#8220;cost sharing&#8221;) are actually not directly related to the Essential Health Benefits.

Q: You said there are no annual or lifetime dollar limits for Essential Health Benefits but you did not say anything about visit limits. What&#8217;s the deal?
A: Insurance plans will be able to have visit limits on Essential Health Benefits but the limit cannot be lower than the limit in the benchmark plan.

Q: So what insurance plans will have to offer the Essential Health Benefits?
A: All non-grandfathered individual and small group insurance plans must offer the Essential Health Benefits.

A small group insurance plan is typically offered through an employer and covers 2-50 people. A grandfathered plan is an insurance plan that existed on or before March 23, 2010 and that has not significantly cut benefits or increased costs.

Q: I have insurance through my employer, which has more than 50 employees. Does this mean that I&#8217;m not eligible for the Essential Health Benefits?
A: No. If you have insurance through a plan with more than 50 participants or a plan which is self-funded then your insurance does not have to provide all 10 Essential Health Benefit categories. However, if your insurance does provide an Essential Health Benefit category, the benefits in that category cannot have annual or lifetime dollar limits.

Q: So what does this all mean?
A: Let&#8217;s use an example. Pretend that we have three health insurance plans, Plan 1, Plan 2, and Plan 3. All three plans cover physical therapy after a knee surgery. Plan 1 offers 20 physical therapy visits per year, Plan 2 offers 60 physical therapy visits per year, and Plan 3 offers unlimited physical therapy visits per year.

If Plan 1 is selected as the benchmark then physical therapy with a 20 visit maximum becomes an Essential Health Benefit. Plan 2 and Plan 3 do not have to change since their visit maximums are both greater than 20.

If Plan 2 is selected as the benchmark then physical therapy with a 60 visit maximum becomes an Essential health Benefit. Plan 1 will have to increase its visit limit from 20 to 60 and Plan 3 will not have to change.

If Plan 3 is selected as the benchmark then physical therapy with no visit limit becomes an Essential Health Benefit. Both Plan 1 and Plan 2 will have to eliminate their visit limits.

Q: Why doesn&#8217;t my state just choose the plan with the best benefits as the benchmark?
A: Better insurance coverage is more expensive; we must balance the benefits chosen against the cost to you. Also, not every plan may cover the same items. One plan may have the best benefit in one category and the worst benefit in another category, so the selection must be carefully weighed.

Q: Are dental and vision coverages part of the ACA?
A: Dental and vision are contemplated by the ACA but the rules are not finalized. We do know that pediatric dental will be required under the ACA but we do not know if it will be considered an Essential Health Benefit. Outside of that we do not know if pediatric vision or adult dental and vision will be required or an EHB. It should be possible to purchase standalone dental and vision on the exchange, but again we don't have any preliminary rules for that yet.

Technical
Q: What affect does the ACA have for someone with a "Cadillac" plan?
A: The ACA defines a "Cadillac" plan as one with individual premiums in excess of $10,200 annually or family premiums in excess of $27,500 annually before the employer pays any portion. The ACA has enacted a funding provision which taxes these plans. The tax is 40% of the premium in excess of the "Cadillac" definition. If the "Cadillac" tax is trigger solely by the premiums then the tax must be paid by the insurance company. If the "Cadillac" tax is triggered by HSA/MSA contributions made by the employer then the tax must be paid by the employer. If the employer self-insures and uses a TPA to administer the plan then the tax must be paid by the TPA.

Q: What constitutes a "family plan" for the "Cadillac" tax? The selections have always been employee, employee+1, and employee+family so it is a bit confusing.
A: Under the ACA a "family plan" is considered anything other than a "self-only" plan. In other words, two or more people constitute a family, regardless of composition.

Q: Has the MLR calculation been finalized?
A: Yes, I believe it has been adopted from an interim final rule to a final rule.

Q: Are anti-fraud costs still excluded from the MLR calculation?
A: Yes, anti-fraud costs are not considered in the MLR calculation.




This is sticky-worthy. Making it a sticky.

Trolls - keep out or you (the troll) and your posts will be removed from this thread.

Administrator Idontcare
 
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glenn1

Elite Member
Sep 6, 2000
23,372
2
126
#2
Has the final rule for calculating medical loss ratio be determined yet? Are anti-fraud costs still being excluded from allowable expenses for purposes of the calcuation? How about compliance costs, such as HIPAA or even the costs associated with Obamacare itself?
 
Dec 9, 1999
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#3
You sound like just the person to answer something that's been bugging me, that I hope I'm really wrong about. Lets use this example, as I have more than a few friends in this situation:

Single, making say (I'll average it out) 40k a year. No insurance, no kids. 2016 hits. How much are they taxed if they do not get insurance? What does the Gov (Fed, state) do to help someone in such a position such as reductions in tax owed, handouts, etc?

Finally: When they show up at the ER with say, a kidney stone that needs lithotripsy, who pays initially, and more importantly, long term?

Thank you for being able to answer any of these!

Chuck
 

sactoking

Diamond Member
Sep 24, 2007
6,083
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#4
Has the final rule for calculating medical loss ratio be determined yet? Are anti-fraud costs still being excluded from allowable expenses for purposes of the calcuation? How about compliance costs, such as HIPAA or even the costs associated with Obamacare itself?
The final MLR calculation has not yet been determined. As of right now anti-fraud, federal compliance, and state level compliance are not part of the calculation.

Edited: I forgot that the MLR has been pretty much finalized; one of my actuaries sent me the CCIIO spreadsheet.

I do have a white paper circulated by the Chicago Actuarial Association about the transition of the MLR from interim final to final. Fraud has officially been excluded as a QIA (quality improvement activity). ICD-10 conversion looks like it will be an included compliance cost in MLR.
 
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Hayabusa Rider

Admin Emeritus & Elite Member
Jan 26, 2000
46,794
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#5
I'm interested in regulatory compliance costs and their effect. HIPAA which was supposed to save money is hideously expensive. This goes way beyond that. Any reasonable predictions? (I know you said the calculations are not complete).

Further, what is the TCO of increasing the medicaid rolls?
 

sactoking

Diamond Member
Sep 24, 2007
6,083
25
126
#6
You sound like just the person to answer something that's been bugging me, that I hope I'm really wrong about. Lets use this example, as I have more than a few friends in this situation:

Single, making say (I'll average it out) 40k a year. No insurance, no kids. 2016 hits. How much are they taxed if they do not get insurance? What does the Gov (Fed, state) do to help someone in such a position such as reductions in tax owed, handouts, etc?

Finally: When they show up at the ER with say, a kidney stone that needs lithotripsy, who pays initially, and more importantly, long term?

Thank you for being able to answer any of these!

Chuck
In 2016 the penalty will be the greater of $695 per adult plus $347.50 per child up to $2,085 per family or 2.5% of Modified Adjusted Gross Income (MAGI). In a hypothetical of single, no kids, with $40k MAGI it would be the greater of the flat fee ($695) or the income-based fee ($40,000 * .025 = $1000). Insurers will be required to issue an annual report to policyholders similar to a 1099 that shows which months they had insurance. Taxpayers will be required to submit this 1099-like form with their return to show compliance. The penalty will be prorated monthly and I believe (I will have to double-check) that lapses of <3 months will not be penalized.

If someone opts to pay the penalty in lieu of insuring they will be personally liable for any medical expenses incurred. It may be possible to get insurance while you are in the hospital, that will depend on your state's implementation of the Navigator program. If you can, then the policy will cover expenses incurred after issuance but will not retroactively cover expenses incurred prior to issuance. Example:

You state allows hospitals to be Navigators. You have a stroke and are taken to the ER via ambulance. After triage and emergent care you are stabilized and admitted. After being admitted you contact a hospital Navigator to purchase insurance. The ambulance and all of the ER expenses will not be covered since they were incurred after the policy was written but rehabilitation and the remaining hospital stay will likely be covered.
 

sactoking

Diamond Member
Sep 24, 2007
6,083
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#7
I'm interested in regulatory compliance costs and their effect. HIPAA which was supposed to save money is hideously expensive. This goes way beyond that. Any reasonable predictions? (I know you said the calculations are not complete).

Further, what is the TCO of increasing the medicaid rolls?
Short answer: unknown

Implementation of the ACA will easily run into the billions, pretty much all of which will be federal tax dollars. California's web portal contract was awarded for creation and I believe 10 years of upkeep for ~$350,000,000; that's just one state and is just the web portal.

The industry compliance costs aren't really known yet. In some respects ACA might not be too burdensome. Most of the increased costs will be the costs of coverage due to the Essential Health Benefits package of any state, but those can all be recouped via premiums. The ratemaking process may be relatively easy as a plan offered on the Exchange must be offered at the same price as it is off the Exchange. That means that insurers will not have to develop two different loss-costs for on- and off-Exchange plans. Also, insurers will be required to consolidate their individual rate pools into one and small group/employer rate pools into another. By eliminating multiple rate pools the actuarial calculations may be simpler, in some respects.

The Medicaid total costs are also unknown. To the extent that certain states refuse to expand Medicaid there will be cost savings, but the mandate may cause some people who are currently eligible for Medicaid who have (for whatever reason) decided not to participate to enroll, which will push costs higher.
 
Dec 9, 1999
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#8
Ok, two more questions:

1.) What again is this 8% amount that is being thrown around? How does that apply (lets keep the current example).

2.) How long does it take to get insurance? Could someone not have insurance one day and the next be insured, with their condition found yesterday covered? Could someone get a kidney stone tonight, tomorrow get insurance, and be covered for the kidney stone when it's lithotripsy'd in a week (assuming they didn't scream pass it themselves by then)? Does the ACA mandate the insurance companies cover people that have medical issues?
 

sactoking

Diamond Member
Sep 24, 2007
6,083
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#9
Ok, two more questions:

1.) What again is this 8% amount that is being thrown around? How does that apply (lets keep the current example).
One of the provisions of the mandate is an exclusion for anyone who cannot find "affordable" health insurance; the 8% refers to that. If the least expensive plan offered by your employer, after your employer's subsidy, is more than (I think) 9.5% of your MAGI then you may opt out of your employer's plan(s) and be eligible for the individual exchange. Once you are eligible for the exchange if the least expensive plan offered on the exchange, after government subsidy, is more than 8% of your MAGI then you are exempt from the mandate. NOTE: This must be calculated using the individual premium amounts regardless of your family status.

Example: You have a MAGI of $40,000 and your out-of-pocket premium costs on your employers lest expensive plan are $4,000. Your employer's plan is not "affordable" to you since you would be required to spend 10% of your MAGI; you may opt out and be eligible for the individual exchange and subsidy. The subsidy depends on a few other factors, but let's just say the person is 40 and lives in a medium-cost area; their subsidy would be $700 per year. If the cost of the least expensive plan on the Exchange minus the $700 subsidy is more than $3,200 ($40,000 x 8%) the person would be excluded from the mandate.

Interesting note: If your employer's plan is too expensive and you qualify for an individual subsidy the federal government will send a bill to your employer for the cost of the subsidy.

2.) How long does it take to get insurance? Could someone not have insurance one day and the next be insured, with their condition found yesterday covered? Could someone get a kidney stone tonight, tomorrow get insurance, and be covered for the kidney stone when it's lithotripsy'd in a week (assuming they didn't scream pass it themselves by then)? Does the ACA mandate the insurance companies cover people that have medical issues?
Policy issuance will vary state-to-state but the basic premise is it will be quasi-immediate. Since there can be no pre-existing conditions exclusions and the only rate band factors will be age and smoking status a policy should be available almost immediately. You will still be able to be rated by health within the age/smoker rate band and that is where state rules may affect things. Two possible scenarios are that insurers will be required to bind coverage at an "average" rate and do a retro billing if the risk is higher or they may be required to bind coverage at the highest rate in the band an issue a premium credit if the risk is lower.
 
Dec 9, 1999
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#10
Ok, so if your employer doesn't offer insurance, are they hit by the Gov for not doing so? If you work at such a place, then the 9.5% calc goes out the window and you go straight to the exchange?
 

sactoking

Diamond Member
Sep 24, 2007
6,083
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#11
Ok, so if your employer doesn't offer insurance, are they hit by the Gov for not doing so? If you work at such a place, then the 9.5% calc goes out the window and you go straight to the exchange?
Potentially.
If the employer has <25 employees and the average wage is <$50,000 then the employer receives a tax credit to offer insurance on the SHOP Exchange.
If the employer has <50 employees the employer is exempt from the ACA mandate.
If the employer has 50+ employees, does not offer coverage, and none of its employees are eligible for a federal subsidy it incurs no penalty.
If the employer has 50+ employees, does not offer coverage, and at least one employee is eligible for a federal subsidy it incurs a penalty of $2,000 per FTE employee for every FTE employee above 30.
If the employer has 50+ employees, offers coverage, and the coverage does not pay at least 60% of the costs for a typical population it incurs a penalty of $3,000 per FTE employee for every FTE employee above 30.
If the employer has 50+ employees, offers coverage, the coverage pays at least 60% of the costs for a typical population but at least one employee fails the 9.5% affordability test the employer incurs a penalty of $3,000 per FTE employee failing the 9.5% affordability test for every FTE employee failing the 9.5% affordability test above 30.

If your employer offers no plan at all the 9.5% affordability test does not apply and you may purchase directly from the individual exchange.
 

lopri

Elite Member
Jul 27, 2002
12,563
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#12
A young single adult (say in 30's) living in Jersey. Self-employed. Thanks to the state's failed insurance policy in the past, s/he has been paying ridiculous premiums (say, $600+ a month and growing annually and now $800+) while incurring minimal medical costs. All s/he's got for a decade is a couple visits to a doctor and a couple of blood tests in any given year. Obviously s/he is subsidizing others or making profits for the insurer, but s/he can't forgo medical insurance because, well, you never know.

Is there a chance premiums will go down for similarly situated persons? (Self-employed young adults) Will there be a cheaper alternative for her/him?

I realize that these will be a small minority in the demographics. Still, can they benefit from the so-called "community rating" provision? Then again, what if their "community" had such high premiums thanks to the state's idiotic policies in the past?
 
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sactoking

Diamond Member
Sep 24, 2007
6,083
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#13
A young single adult (say in 30's) living in Jersey. Self-employed. Thanks to the state's failed insurance policy in the past, s/he has been paying ridiculous premiums (say, $600+ a month and growing annually and now $800+) while incurring minimal medical costs. All s/he's got for a decade is a couple visits to a doctor and a couple of blood tests in any given year. Obviously s/he is subsidizing others or making profits for the insurer, but s/he can't forgo medical insurance because, well, you never know.

Is there a chance premiums will go down for similarly situated persons? (Self-employed young adults) Will there be a cheaper alternative for her/him?
Impossible to say, too many variables. In general I would expect premiums for someone <40 and in good health to increase but it will depend on your state and market.

Self-employed person will be eligible for the individual exchange and federal subsidy, it's possible that the subsidy might help. Worst case the exchange should make comparing plans easier and this hypothetical person might find that their current plan is equivalent to a gold or platinum level and that a silver or bronze level plan may suffice.

Edited: Of course, for someone in Jersey it may be a crapshoot. There's a strong possibility Christie follows his fellow R Governors in Louisiana and Florida in refusing to implement an exchange. If 10/1/13 comes and a state doesn't have an exchange or their exchange fails federal testing the federal gov't will step in, take over, and implement the exchange for the state. Nobody knows what they'll get if the feds to the exchange; it's supposed to be substantially the same, but I wouldn't bet on it.
 
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lopri

Elite Member
Jul 27, 2002
12,563
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#14
What's covered by the Platinum/Gold/Silver plans (edit: levels) defined by the exchange is the state's decision? (with federal subsidy)
 
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sactoking

Diamond Member
Sep 24, 2007
6,083
25
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#15
What's covered by the Platinum/Gold/Silver plans (edit: levels) defined by the exchange is the state's decision? (with federal subsidy)
Yes and no. There are certain Essential Health Benefits mandated by the ACA which much be covered by all plans with no dollar limit. Beyond that the states are free to determine their own "model" plans to use to set the benefit levels for the metal tiers. If the states don't set the "model" plans they default to the most popular plan in the state as determined by CCIIO (Center for Consumer Information and Insurance Oversight).

In practice the metal tiers will be differentiated by financial factors (deductible, copay, coinsurance amounts) and the plans within the metal tiers will compete on premium, service, and nonessential health benefits.

Edited: The subsidy will be determined by a federal formula. Whether that subsidy helps a little or a lot will be determined by the state's decisions in setting up their exchange.

Edited 2: The metal tiers are actually set by the federal government. The states may impose requirements that bring a "minimum" metal plan above the fed minimum, but in no case can a metal plan offer less coverage than the federally-defined minimums. Because of this, we fully expect there to be no platinum plans offered on the individual exchanges due to adverse selection.
 
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JACKHAMMER

Platinum Member
Oct 9, 1999
2,870
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#16
Don't have a question, but thanks for doing this.
 
Dec 11, 2006
19,947
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#17
In 2016 the penalty will be the greater of $695 per adult plus $347.50 per child up to $2,085 per family or 2.5% of Modified Adjusted Gross Income (MAGI). In a hypothetical of single, no kids, with $40k MAGI it would be the greater of the flat fee ($695) or the income-based fee ($40,000 * .025 = $1000). Insurers will be required to issue an annual report to policyholders similar to a 1099 that shows which months they had insurance. Taxpayers will be required to submit this 1099-like form with their return to show compliance. The penalty will be prorated monthly and I believe (I will have to double-check) that lapses of <3 months will not be penalized.

If someone opts to pay the penalty in lieu of insuring they will be personally liable for any medical expenses incurred. It may be possible to get insurance while you are in the hospital, that will depend on your state's implementation of the Navigator program. If you can, then the policy will cover expenses incurred after issuance but will not retroactively cover expenses incurred prior to issuance. Example:

You state allows hospitals to be Navigators. You have a stroke and are taken to the ER via ambulance. After triage and emergent care you are stabilized and admitted. After being admitted you contact a hospital Navigator to purchase insurance. The ambulance and all of the ER expenses will not be covered since they were incurred after the policy was written but rehabilitation and the remaining hospital stay will likely be covered.
Hypothetically, if I go to the hospital with a kidney stone and my state allows Navigators, will I be able to obtain insurance before they admit/treat me and have all costs covered by insurance?
 

sactoking

Diamond Member
Sep 24, 2007
6,083
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#18
Hypothetically, if I go to the hospital with a kidney stone and my state allows Navigators, will I be able to obtain insurance before they admit/treat me and have all costs covered by insurance?
Your state has to allow Navigators, that's a federal requirement of the ACA. Navigators are supposed to be the "community outreach" people who can reach groups traditionally underserved by the agent/broker model.

That being said, states have a lot of leeway in how they set up their individual Navigator programs. I know our state has had requests from hospitals to allow them to have Navigators on staff for that very situation, but the licensure, education, continuing education, and accountability (fines, censure, E&O coverage, etc.) are all things that have yet to be determined.

It would not surprise me if some states think that having Navigators in hospitals is a wonderful idea and other states think that it will be a huge conflict of interest.
 

sunzt

Diamond Member
Nov 27, 2003
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#19
Thumbs up for sactoking. To preserve the sanity of this thread I suggest mods move this to OT and not here.
 

sactoking

Diamond Member
Sep 24, 2007
6,083
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#21
Thumbs up for sactoking. To preserve the sanity of this thread I suggest mods move this to OT and not here.
Thank you.

I had considered OT, since there was potential for the partisanship of P&N to derail the thread, but I wasn't 100% sure that ATOT was the best location either. In any event, I am happy to help and will do so in whatever location the benevolent forums deities deem appropriate.
 
Apr 9, 2000
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#22
You are the da man. Thanks again.
 
Oct 10, 1999
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#23
To OP, perhaps you could edit your first post to include relevant Q&A from this thread so we don't have to read a potential 100 page thread just to find an answer.
 

sactoking

Diamond Member
Sep 24, 2007
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#24
To OP, perhaps you could edit your first post to include relevant Q&A from this thread so we don't have to read a potential 100 page thread just to find an answer.
Good suggestion. I will "genericize" certain Q&A items and edit them into the OP for a reference, though I will leave the specifics in the original posts for those who want details.
 
Oct 6, 2009
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#25
Great idea and many thanks for doing this. Maybe Health & Fitness since OT and P&N have equal potential for idiocy.
 

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