Obamacare is Live: The Exchanges and What You Get


Obamacare is now live!

Though we at TPV have discussed the benefits of the ACA numerous times, the Chuck-Todd-Media remains reluctant to discuss the facts, which they famously do not view as their responsibility. So I'll do it. This will be an extensive post about what the Affordable Care Act means to you - individually. I will be discussing its benefits on you depending on your individual situation, as well as your options.

Everyone:
  • Health insurance companies cannot reject or discriminate on rates against you based on a pre-existing condition.
  • You cannot be denied care for reaching yearly or lifetime "benefit caps." As of 2014, the caps are history.
  • You cannot be dropped from coverage or have your rate increased simply because you get sick.
  • Health insurers must spend between 80-85% of premium revenue on providing care or refund the difference to subscribers. This means a refund to you if you buy your own health insurance, to your employer if they buy it for you.
  • Your out-of-pocket expenses, regardless of what your deductible is and your share of cost is, are capped, depending on your income level. Your employer plans generally must also meet this standard.
  • Your children can stay on your health insurance plan until the age of 26.

Adults (non-elderly) without health insurance:

If you do not currently have health insurance, and have no affordable choice through your employer (or if you are unemployed), you have the option to get affordable coverage through an exchange in your state that will open on Tuesday, October 1. Here is how that breaks down:

States Accepting Medicaid Expansion:

For states that are accepting the Medicaid expansion (see this map to see your state's status), everyone making up to 138% of the federal poverty level will be covered under their state's Medicaid program. This means that if you live in a state that is expanding Medicaid, and you make under roughly $15,900 a year as a single individual or $32,500 as a family of four, you will be eligible for Medicaid, and your premium will be zero.

For All States: The Exchanges

Regardless of whether or not your state is accepting the Medicaid expansion, if you make between 100% and 400% of the federal poverty level (i.e. between roughly $11,500 and $46,000 as an individual or between $23,600 and $95,000 as a family of four) and do not have affordable coverage through your employer (i.e. costing you less than 9.5% of your income) you will be eligible for federal subsidies to buy health care from a health insurance marketplace in your state, also known as your state's 'exchange.' The subsidies you will get will depend on your income. The less you make, the greater your subsidy.

You can find your exact subsidy level by using the Kaiser Family Foundation's calculator, which I am embedding below.


The exchanges will also have a range of plans, in 4 categories: Bronze, Silver, Gold, and Platinum. The Gold and Platinum plans have the highest premiums, but the lowest cost sharing; bronze plans have the lowest premiums but the highest cost sharing. While you can choose any plan you wish, your subsidy is based on the second highest priced silver plan available to you. Your subsidies don't change if you choose a higher-priced plan, but if you do, you pay the difference. If you choose a cheaper plan, you pay less in premiums out of pocket.

When you choose your plans, the first thing to keep in mind is this: no matter what plan you choose, your preventive care - the annual checkups, the flu shots, contraceptive care, etc. are available free of copays or deductibles. Other than that, Bronze plans pay 60% of medical expenses, Silver plans pay 70%, Gold plans 80% and Platinum plans pay 90% of health care costs, but all plans are subject to the same out-pocket maximum. While the bronze plan's cost sharing options may look rather high (in San Jose, California, a bronze plan has a $60 copay for office visits), cost-sharing is generally subject to an out-of-pocket maximum, which is $6,350 for an individual plan and $12,700 for a family plan (regardless of the level of plan you choose), which also includes any deductibles.

However, this amount is moderated by your income. For those making between 100-200 percent of the FPL, the out of pocket max is cut to a third. For those making between 200-300 percent of FPL, the OOP max is cut to a half, and for those making between 300 and 400 percent of poverty, it is cut to two-thirds of the above amount.

In other words, this is how it plays out for individuals and families.

If you are a single adult, buying insurance your state's exchange and:
  • make under $23,000, your out-of-pocket max is $2,117, regardless of what the face value of the plan says.
  • make between $23,000 and $34,500, your out-of-pocket max is $3,175.
  • make between $35,500 and $46,000, your out-of-pocket max is $4,233.
If you are a family of four, buying insurance in you state's exchange and:
  • make under $47,200, your out-of-pocket max for your family plan is $4,233.
  • make between $47,200 and $70,800, your out-of-pocket max for your family plan is $6,350.
  • make between $70,800 and $95,000, your out-of-pocket max for your family plan is $8,467.
This isn't talking points. Consider this information when you are picking your plan. If you don't go to the doctor too often, don't see yourself reaching the out-of-pocket max, and can build a habit of some saving, consider going with a Bronze plan, as it will save you a ton of money up front. If your visits are more often, need a good number of procedures, and see yourself reaching the out-of-pocket max no matter which plan you pick, pick a plan with lower cost sharing.

Keep in mind that for states that are accepting the Medicaid expansion, the sign up for Medicaid is also available through the online exchange. One application - and it will show you what you are eligible for and what your options are.

The Bad News, Brought to You By Republicans

While this is great news for most people without insurance, this includes a cruel reality for the neediest among us. For those living under the poverty line in states that are not accepting the Medicaid extension, no subsidies are available. While they can buy in the exchanges, they are not eligible for subsidies, as they would qualify for Medicaid if Republicans in their states did not resist the fully-federally funded expansion just to give Barack Obama a black eye.

Sign up.

You can sign up on your state's exchange. Go to HealthCare.gov and you can sign up now.

Please feel free to answer any questions you have. I will answer any and all legitimate questions in this thread related to the exchanges. But I will also zap trolls faster than you can say Obamacare.