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2 SATURDAY, OCTOBER 5, 2013

TABLE OF CONTENTS

3 5 6 8 9 12 13 14

Premiums unveiled Obama administration unveils pricing for uninsured in 36 states using the federal system

Obamacare timeline A chronological timeline showing the progress toward the passing of the Affordable Care Act

How will it affect you? An interactive shows how Obamacare will impact different population demographics

For the self-employed Health costs likely on the rise for many self-employed

Health tradeoff With the perks of low tradeoffs come the trouble of high deductibles

Effects on Medicaid Two stories of individuals in poverty end with two different Medicaid results

Legal perplexion Scope and depth of new health law proving to be confusing to many small business owners

Obamacare in Virginia Q&A addresses concerns for the impact of the new law in the commonwealth

AFFORDABLE CARE ACT

The Northern Virginia Daily

Obamacare now a reality By Ricardo Alonso-Zaldivar The Associated Press

WASHINGTON — Contentious from its conception, President Barack Obama’s health care law has survived the Supreme Court, a battle for the White House and rounds of budget brinkmanship. Now comes the ultimate test: the verdict of the American people. A government shutdown could dampen the rollout Tuesday as insurance markets open around the country. But it won’t stop the main components of “Obamacare” from going live as scheduled, glitches and all. The biggest expansion of society’s safety net since Medicare will be in the hands of consumers, and most of their concerns don’t revolve around ideology and policy details. People want to know if they can afford the premiums, if the coverage will be solid, where the bureaucratic pitfalls are and if new federal and state websites will really demystify shopping for health insurance. Full answers may take months. Expect the rollout to get off to a slow start, with some bumps. People who don’t have access to job-based health insurance can start shopping right away for subsidized private coverage. Or they can wait to sign up as late as Dec. 15 and still get coverage by Jan. 1. Many will probably want to see how it goes for the first wave of applicants before they jump in. Glitches are likely to pop up in the new online insurance markets. Over the weekend, several states were still struggling to get plan information to display accurately on their websites. Earlier, the fed-

AP

The Capitol is shown in Washington. President Barack Obama’s health care law might feel like a combination of doing your taxes and making a big purchase that requires research. eral government announced delays for small business and Spanish-language signups. A protracted government shutdown could slow needed technology fixes. Consumers also could run into problems getting their right subsidy amounts. People with complicated tax returns and extended families living under the same roof could find they need personal assistance to work out the issues. Referrals to state Medicaid programs might go smoothly in some states, not so well in others. “As this unveils, it is going to be very clear that everything can’t be done on a computer,” Christine Ferguson, director of Rhode Island’s market-

place, said in an interview prior to the launch. “But by Day 60 to 120, and the year after that, it’s going to get a lot more user friendly and effective.” Eventually, at least half the nation’s nearly 50 million uninsured people are expected to get coverage through the Affordable Care Act, either through subsidized private plans sold in the new markets or an expanded version of Medicaid in states accepting it for low-income adults. Immigrants in the country illegally will be the largest group remaining uninsured. People who do have access to employer-based plans will also see changes. Starting Jan. 1, virtually all Americans will have a legal obligation

to carry health insurance or face fines. Passing up the company medical plan in exchange for a bigger paycheck may no longer be an option. But employees who lose their jobs, entrepreneurs starting their own businesses and people in between school and work could have an easier time getting coverage. Also as of Jan. 1, a preexisting medical condition will no longer be a barrier to getting health insurance. A partial government shutdown, driven by Republican opponents of increasing the federal role in health care, will not stop what they call “Obamacare.” Core provisions and benefits are OBAMACARE, 19


AFFORDABLE CARE ACT

The Northern Virginia Daily

SATURDAY, OCTOBER 5, 2013

3

Premiums unveiled for health overhaul plans By Ricardo Alonso-Zaldivar The Associated Press

Health insurance premiums by age

WASHINGTON — With new health insurance markets launching, the Obama administration is unveiling premiums and plan choices for 36 states where the federal government is taking the lead to cover uninsured residents. Before tax credits that work like an upfront discount for most consumers, sticker-price premiums for a mid-range benchmark plan will average $328 a month nationally for an individual, comparable to payments for a new car. The overview of premiums and plan choices, released Wednesday by Health and Human Services Secretary Kathleen Sebelius, comes as the White House swings into full campaign mode to promote the benefits of the Affordable Care Act to a skeptical public. Congressional Republicans, meanwhile, refuse to abandon their quest to derail “Obamacare” and flirt with a government shutdown to force the issue. Sebelius stressed the positive in a preview call with reporters. Consumers will be able to choose from an average of 53 plan options when the new markets open Oct. 1 for people who don’t have health care on the job. “For millions of Americans, these new options will finally make health insurance work within their budgets,” she said. A report by her department estimated that about 95 percent of consumers will have two or more insurers to choose from. And the administration says premiums will generally be lower than what congressional budget experts estimated when the legislation was being debated. About one-fourth of the insurers participating are new to the individual coverage market, a sign that could be good for competition. But averages can be misleading. When it comes to the new health care law, individuals can get dramatically different results based on their particular circumstances. Where you live, the plan you pick, family size, age, tax credits based on your income, and even tobacco use will all impact the

A new study compares insurance premiums for three age groups under the new health care law in selected states.* Estimated cost for nonsmokers for mid-level coverage known under the law as a “silver” plan: 21 years of age

40

Health premium estimates vary Average monthly premiums for a benchmark health care policy — known as a “silver” plan under the Affordable Care Act — for an individual, based on a federal analysis of data submitted by insurers.

60

$800

700 600 500 400 300 200 100 0

Calif. Conn. D.C.

Ind.

Md.

Ohio

R.I.

S.D.

Va. Wash.

*Carriers are prohibited from rating based on age in Vermont and New York. SOURCE: Avalere Health analysis of health insurance rate filings

bottom line. All those variables could make the system hard to navigate. For example, the average individual premium for a benchmark policy known as the “second-lowest cost silver plan” ranges from a low of $192 in Minnesota to a high of $516 in Wyoming. That’s the sticker price, before tax credits. In the three states with the highest uninsured population, the benchmark plan will average $373 in California, $305 in Texas, and $328 in Florida. Differences between states can be due to the number of insurers competing and other factors. “One surprise is Texas,” said Larry Levitt of the Kaiser Family Foundation. “That is a state that has put up roadblocks to implementation, but the premiums there are below average.” The second-lowest-cost silver plan is important because tax

AP

$373 $305 $328 • Cost of the benchmark plan in California, Texas, and Florida, the states with the nation’s highest uninsured population. Differences between states can be due to the number of insurers competing and other factors.

Wyoming Alaska Mississippi Connecticut Vermont Indiana Maine New Jersey Louisiana California North Carolina Arkansas Rhode Island Wisconsin Delaware New Hampshire South Dakota North Dakota Washington New York South Carolina Virginia Missouri West Virginia Florida U.S. average Ohio Alabama Georgia Montana Nebraska Michigan Colorado Texas Maryland Dist. of Columbia Nevada Iowa Illinois Pennsylvania Idaho New Mexico Oklahoma Utah Kansas Arizona Oregon Tennessee Minnesota

$516 474 448 436 413 403 403 385 374 373 369 366 366 361 360 360 357 353 352 349 339 335 334 331 328 328 321 318 317 316 312 306 305 305 299 297 297 287 286 286 285 282 266 266 260 252 250 245 192

NOTE: Hawaii, Kentucky and Massachusetts data not available. SOURCE: Department of Health and Human Services

PREMIUMS, 19

AP


4 SATURDAY, OCTOBER 5, 2013

AFFORDABLE CARE ACT

The Northern Virginia Daily

State of the health care overhaul Beginning Oct. 1, uninsured Americans can apply for subsidized health care coverage through new online marketplaces sometimes called exchanges. It’s a core provision of the Affordable Care Act, which went into effect in 2010 and has been the subject of political and legal battles since. Some milestones and potholes along the way since the law was passed: March 23: President Barack Obama signs the Affordable Care Act. Within minutes, lawsuits are filed in federal courts challenging the law.

Jan. 13: The GOP-controlled House votes to repeal the law on a partyline vote; the measure fails in the Senate. (Since then, the House has made dozens of attempts to repeal, defund or scale back the law.)

Nov. 14: The Supreme Court says it will take up the challenge to the law.

2011

2010

Nov. 2: Republicans win control of House of Representatives, partly on a platform to “repeal and replace” the law.

Jan. 31: A federal judge in Florida rules the entire health overhaul unconstitutional, handing a victory to the 26 states challenging the law.

June 28: The Supreme Court rules the individual mandate is constitutional but that states can decide whether to expand their participation in Medicaid, a key provision to cover the poor.

2012

Aug. 1: HHS Secretary Kathleen Sebelius declares that most health plans will have to cover birth control for women as a preventive service, free of charge, beginning in 2013.

March 26-28: Supreme Court hears three days of oral arguments on separate aspects of the law.

Medicaid

Employer 20

Other*

Medicare 40

60

June 28: Facing lawsuits by religious groups, the administration issues compromise rules for faith-based nonprofits that object to covering birth control in their employee health plans.

2013

Nov. 6: Obama is elected to a second term and Democrats retain control of the Senate, dimming Republican hopes of repeal.

Jan. 1: Tax increases to finance the law take effect on high-income earners.

March 12: A draft of the application for subsidized coverage surfaces; the 15-page, 21-step form is widely jeered for its complexity. A simplified form debuts a month later.

July 2: Obama delays until 2015 the requirement that companies with more than 50 employees provide coverage for their workers or face fines.

How much they spend on health care:

Where Americans get their health insurance: 0

Nov. 8: House Speaker John Boehner, R-Ohio, says in an interview that “Obamacare is the law of the land.” His spokesman adds that Boehner remains “committed to full repeal.”

Uninsured 80

100%

Average per-person health spending since 2007: $10,000

2011: $8,680

U.S. average Alabama

Average per-person spending by insurance source in 2011:

Medicare: $11,610

6,000

Arkansas

Medicaid: $7,434

California 4,000

Colorado

Private health insurance: $4,786

Connecticut Delaware

2,000

Dist. of Columbia Florida

0 2007

Georgia

2008

2009

2010

2011

Hawaii Idaho

Medicaid expands in about half of states

Illinois

The Supreme Court ruled that states can decide whether to participate in the expansion of Medicaid, the federal-state health insurance plan for the poor. While the expansion is a key part of the plan to extend coverage to low-income Americans, millions live in states that have opted not to broaden the program. Status of the states as of Sept. 10:

Indiana Iowa Kansas Kentucky

Not expanding

Louisiana

Plans expansion

Decision pending

Maine Massachusetts Michigan

R.I. Del. D.C.

Mississippi Missouri

Major new laws come with their own jargon, and President Barack Obama’s health care overhaul is no exception. With the first open enrollment season kicking off for the uninsured, here are some terms consumers might want to get familiar with: AFFORDABLE CARE ACT — The most common formal name for the health care law. Its full title is the Patient Protection and Affordable Care Act. Opponents still deride the law as “Obamacare,” but Obama himself has embraced that term, saying it shows he cares.

INDIVIDUAL MANDATE — A federal requirement that virtually everyone in the United States has health insurance, either through an employer, a government program or by buying his own plan. Effective Jan. 1, 2014. Exemptions for financial hardship and religious objections. Does not apply to immigrants living in the U.S. illegally. People who ignore the mandate will face fines from Internal Revenue Service. ESSENTIAL HEALTH BENEFITS — Basic health benefits that most health insurance plans will have to cover starting in 2014. They include office visits, emergency services, hospitalization, rehab care, mental health and substance abuse treatment, prescriptions, lab tests, prevention, maternal and newborn care, and pediatric care.

Maryland

Minnesota

The Associated Press

EMPLOYER MANDATE — A federal requirement that companies with 50 or more workers pay a penalty to the government if one of their workers obtains taxpayer subsidized coverage through the law. Delayed one year to Jan. 1, 2015. Intended to keep companies from “dumping” employees into public coverage.

8,000

Alaska Arizona

ABCs of Obamacare:  A consumer’s glossary

Montana Nebraska Nevada

MARKETPLACES — Online health insurance markets in each state where consumers can get private health insurance, subsidized by the government. They used to be called “exchanges,” but the feds decided that was too confusing and started calling them “marketplaces.” Still, some states stuck with the original name. Open enrollment starts Oct. 1, and the coverage takes effect Jan. 1, 2014. Fifteen states and Washington, D.C., are running their own marketplaces, according to a tally by The Associated Press. The Obama administration is taking the lead in 35 states, in some cases partnering with the state government. All the marketplaces can be accessed online through healthcare.gov. Small businesses will have their own marketplaces.

New Hampshire New Jersey New Mexico New York

Patchwork of new health care marketplaces

North Carolina

States have their choice whether to operate their own insurance enrollment systems known as exchanges, let the federal government do it or enter into a state-federal partnership:

North Dakota Ohio Oklahoma

Federal

Oregon Pennsylvania

federal-state partnership

State

Other**

Rhode Island South Carolina South Dakota Tennessee

R.I. Del. D.C.

Texas Utah Vermont Virginia

**State runs small business exchange; market for individual policies federally run

Washington West Virginia Wisconsin Wyoming NOTE: Numbers may not equal 100 due to rounding.

*Includes other public insurance programs and the self-insured

SOURCES: Department of Health and Human Services; Kaiser Family Foundation; Urban Institute

AP

MEDICAID EXPANSION — The health care law also expands the federal-state safety-net program to cover more low-income people. Medicaid is expected to account for about half the 25 million uninsured people who, the Congressional Budget Office estiGLOSSARY, 18


AFFORDABLE CARE ACT

The Northern Virginia Daily

TIMELINE: Key dates in Obama’s overhaul law The Associated Press

The Associated Press

ESSENTIAL HEALTH BENEFITS

AP

Under the law, health insurers must cover 10 essential benefits. This will make health plans more costly, but also more comprehensive. Starting next year, the rules will apply to all plans offered to individuals or through the small-group market to employers with 50 or fewer workers. The essential-benefits requirement does not apply to plans offered by larger employers, which typically offer most of these, already. The covered benefits are: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory serv-

ices; management of chronic diseases, and preventive and wellness services; and pediatric services, including dental and vision care. People will be able to pick from insurance plans with differing levels of coverage and varying costs for co-pays and premiums. But insurers will have to cover a certain percentage of the services’ cost. “Most of the important services people need are covered, though there may be a slight variation (from state to state),” says Jennifer Tolbert, director of state health reform for the Kaiser Family Foundation. DENTAL-VISION Need a teeth-cleaning or eye exam? You still could be reaching into your own wallet to cover the cost even after the Affordable Care Act takes full effect next year. Dental and vision care is considered an essential benefit for children aged 18 and younger whose parents or guardians GLANCE, 19

President Barack Obama talks about the Affordable Care Act in San Jose, Calif.

Nov. 2, 2010 — Democrats lose control of the House in midterm congressional elections. March 29, 2010 —Health Republicans campaigned on a vow to “repeal and and Human Services replace” the law. Secretary Kathleen Sebelius and the health insurance industry reach a Jan. 19, 2011 — The Republican-led House deal to fix the first glitch emerging from the complex votes to repeal legislation: vague language “Obamacare,” but the drive that compromised a guar- falters in the Senate, where Democrats retain a antee that children with pre-existing medical condi- majority. Since then, the House has repeatedly tions could get coverage voted to repeal, defund or right away. in some way scale back the Fall 2010 — During open law. Republican replacement legislation has been enrollment, most health stymied by divisions within insurance plans begin offering coverage to young the party.

Jan. 31, 2011 — Florida U.S. District Judge Roger Vinson rules that the ACA is unconstitutional. The lawsuit by 26 states would ultimately reach the Supreme Court. April 5, 2011 — Congress votes to repeal an unpopular tax requirement in the law that would have forced millions of businesses to file tax forms for every vendor selling them more than $600 in goods. Agreeing to sign it, Obama says he’ll make fixes as warranted. June 21, 2011 — The Obama administration says it will look for fixes to another glitch, a twist that would have let several million middle-class people receiving Social Security payments get nearly free insurance meant for the TIMELINE, 18

Do you have questions about Medicare? Get the simple answers you need.

Keller Insurance Agency, LLC (540) 635-7059 115 Water Street Front Royal, VA 22630 ®

Medicare Plans from

Email: BlaineKeller@centurylink.net

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adults up to age 26 on a parent’s policy. The popular early provision expanded coverage to more than 3 million people. Plans also begin covering preventive services at no charge.

5

AT A GLANCE: Changes to health care under the ACA An overview of some of the key changes to health care services under the Affordable Care Act:

Medicare was signed into law on July 30, 1965, and within a year seniors were receiving coverage. President Barack Obama signed the Affordable Care Act on March 23, 2010, and the uninsured start getting coverage more than three years later on Jan. 1, 2014. Some key dates in the saga of Obama’s signature legislation: March 23, 2010 — Obama signs the Patient Protection and Affordable Care Act (ACA). Democrats hail an achievement their party pursued for more than 50 years — individuals’ right to health care. The law requires most Americans to carry health insurance starting in 2014, and bars insurers from turning away the sick. It creates state markets for middle-class people without workplace coverage to purchase private insurance, subsidized with tax credits. It expands Medicaid for the lowincome uninsured. After long debate, the legislation barely passed a divided Congress, with no Republican support. Public opinion is split.

SATURDAY, OCTOBER 5, 2013


6 SATURDAY, OCTOBER 5, 2013

AFFORDABLE CARE ACT

The Northern Virginia Daily

How health care coverage will change under the Affordable Care Act The wide-ranging overhaul of the U.S. health care system known as the Affordable Care Act is expected to touch the lives of most Americans in some fashion. Here are examples of health care consumers who could see benefits and drawbacks under the law: Person

Job and income

Single woman, 34, with a pre-existing medical condition

Single man, 40, employed part time

Family of four; mother, 44, employed full time with health benefits

Family of three; father, 51, owns a small business

Information technology worker for small startup

Freelance graphic designer

Handyman

Human resources officer for large firm

Restaurateur with 24 full-time employees

Earns $30,000 a year, more than twice the federal poverty level (FPL) for a 1-person household

Earns $48,000 a year, more than four times the FPL for a 1-person household

Earns $13,000 a year, just over the FPL for a 1-person household

Earns $85,000 a year, 3.6 times the FPL for a 4-person household

Earns $90,000 a year, more than four times the FPL for a 3-person household

Single man, 28, employed full time

100% of federal poverty level

Currently insured?

YES

 NO

Employer does not offer insurance; he is mulling whether to purchase it. He has not seen a doctor since aging out of his parents’ policy at age 26.

Eligible for subsidized coverage based on income?

YES

Other benefits under the health overhaul law

He could opt to buy a low-cost, high-deductible catastrophic policy available to those under 30 but would not get a premium subsidy for such a policy.

NO

YES

 NO

Denied insurance due to pre-existing bipolar disorder requiring medications. She pays cash for medical care and drugs.

YES

 NO

 She cannot be denied coverage or charged a higher premium based on her condition or her gender. She will also have a cap on out-of-pocket expenses and no lifetime coverage limit. Mental health care and prescription drugs are included in the core benefits of marketplace-based plans.

Drawbacks under the health overhaul law

 He will be fined for not carrying health insurance: beginning in 2014, 1 percent of his income, eventually growing to 2.5 percent of income or $695, whichever is greater.  As a young, healthy person, he may wind up paying relatively more for a premium, since he will be helping defray costs for older and sicker consumers who cannot be charged more based on health status.

 She makes more than 4 times the federal poverty level for an individual, which means she is not eligible for a government subsidy to lower premium prices.  She is required to carry health insurance or pay a penalty, but she would be exempted if the lowest cost coverage available to her exceeded 8 percent of her income, $3,840 a year.

YES

 NO

YES

NO

Employer does not provide health benefits to part-time workers. He forgoes preventive care and visits a local emergency room when necessary.

Has a generous coverage plan through employer with low deductibles and out-of-pocket costs. The family has a wide range of doctors and specialists from which to choose for care.

YES

YES

NO

 He is eligible for Medicaid, which has expanded in many states for individuals making up to $15,400.  Medicaid for new enrollees will offer core coverage including free preventive care.

NO

 Can keep existing health plan, provided her employer continues to offer it.  The plan must offer free preventive services, allow children under 26 to remain on the plan and cap out-of-pocket costs.

YES

NO

Covers family through individual policy; does not provide coverage to workers. The family visits doctors in the plan’s network for care.

YES

 NO

 Because he has fewer than 25 full-time employees, he is eligible for a tax credit of up to 50 percent of his contribution toward workers’ health insurance premiums if he covers at least 50 percent of the total premium cost when buying through an exchange.  His child could stay on his coverage until age 26.

 If his state doesn’t expand Medicaid, he may not be able to afford private insurance through a new marketplace, which, given his income, should not exceed 2 percent of his annual income, $240 a year.  If his income drops below $11,490 — the federal poverty level for an individual — he will not be eligible for a premium subsidy, due to a quirk in the law.

SOURCES: Department of Health and Human Services; Kaiser Family Foundation; Robert Wood Johnson Foundation

 Considered a “Cadillac Plan” under the law (a plan valued at more than $10,200 for an individual or $27,500 for a family), a tax of 40% will be levied on the value of the plan exceeding those amounts, payable by the insurer. This could lead the insurer to modify the plan, drop it or pass the tax on to the worker through higher premiums, deductibles or copays. The tax will be assessed beginning in 2018.

 Even with the tax credit, the cost of providing health insurance may be more than he can afford.  If he expands his business to employ more than 50 full-time employees, he will be required to provide health insurance or face a fine of up to $2,000 for each employee after the first 30. He could also be fined if he chooses a plan that is not considered comprehensive or affordable. Businesses will not have to comply with this provision of the law until 2015. AP


AFFORDABLE CARE ACT

The Northern Virginia Daily

SATURDAY, OCTOBER 5, 2013

7

Applying for coverage: Navigating the new health insurance marketplaces Beginning Jan. 1, most Americans will be required to carry some form of health insurance. Getting that coverage under the Affor Affordable dable Care Act might feel a little like filing your taxes and re re-searching a big purchase at the same time. Here is what you will need, based on preliminary forms released by the government:

1. Starting the process Marketplaces open for business Oct. 1, beginning an “open enrollment” period that runs through March 31, 2014.

ONLINE: Go to www.healthcare.gov and www.healthcare.gov click “Get Insurance,” then choose your state of residence to be connected to a marketplace (more than half of states have left it to the federal government to ou o run their marketplaces). Y You will create an account with a user name, password and security questions.

TIP: T Treat reat your account as you would a banking, credit card or other site you want to keep secure security.. — create a hard-to-guess password for security

BY MAIL/IN PERSON: Call 1-800-318-2596 to apply by phone or for a list of locations near you where applications are available available.. In-person assistance is available in many areas from helpers known as navigators. vigators. Call the number above or get a list of community-based organiza organiza-tions from localhelp.healthcare.gov localhelp.healthcare.gov..

2. Applying for tax credits Be sure to have:  Social Security numbers for everyone on your tax return  Employer and income information for everyone in your family (W(W-2s, -2s, tax statements, pay stubs)  Policy numbers for any current health insurance plans

Enter detailed information about yourself and each member of your household, including citizenship status (only U.S. citizens and legal residents can get subsidies) and whether anyone is pregnant or disabled.

Fill out the online form, providing personal and financial information on yourself and everyone for whom you are seeking coverage. If you are not seeking a subsidy to defray premium costs, you do not have to share your financial information. Based on the information provided, low-income applicants will be steered toward Medicaid in states that are expanding the program; otherwise, subsidies in the form of tax credits are calculated after an electronic verification process. Generally Generally,, households earning up to four times the federal poverty level ($94,200 for a family of four) are eligible for tax credits.

TIP: Read the privacy page — It will tell you how your information is being used and where it is being sent.

Financial information to enter includes employer ’s employer’s address, wages, extra income and deductions claimed on your income tax.

TIP: Provide an accurate estimate of your low, you 2014 income. If the number is too low, year. If it is might see a smaller tax refund next year. too high, you won’t get as big a tax credit now now..

TIP: A shorter shorte form skipping the financial disclosure is available for those who are not applying for tax credits.

ou o do not have to plow through t TIP: Y You the entire process in one sitting; you can save your work and come back later later..

3. Picking a plan All plans are required to of ffer f offer the same basic benefits. Consumers can pay more up front in premiums and face lower out-of-pocket expenses, or pay a cheaper premium but shell out more in medical costs. Levels to consider:

If you are eligible for a tax credit, you can determine how much to apply to premiums – all, some or none. Credits not applied will go to next year ’s year’s tax refund. The amount is keyed to the cost of a midlevel “silver” policy policy..

After receiving your application, the government will determine your eligibility and may get in touch with you if more information is needed. The form promises a follow-up in one to two weeks.

Bronze: Covers 60 percent Bronze: of medical costs on average (lowest premium)

Y ou o will be shown a number of o You plans available based on the level of coverage you select. Y ou o may narrow the selection You by criteria such as price, copayments or benefits and compare plans side by side. Detailed information will be available. The government is not allowed to make recom recom-mendations, only display choices.

A packet will be mailed that will include information on your eligibility for public programs, such as Medicaid s Health or the Children’ Children’s Insurance Program (CHIP), the amount of any tax credit and the plans from which you You may also may choose. You be eligible for additional subsidies to reduce your out-of-pocket medical costs, but only if you choose a silver plan.

Silver: Covers 70 percent Silver: of medical costs Gold: Covers 80 percent of Gold: medical costs Platinum: Covers 90 Platinum: percent of medical costs (highest premium) Low-priced “catastrophic” Low-priced plans are available to people under 30 but tax credits cannot be applied

Once you have settled on a plan, you can pay online or contact the plan’ s customer plan’s service representative for payment. Coverage will begin Jan. 1.

SOURCE: Department of Health and Human Services

spitals are in TIP: Make sure your doctors and ho hospitals the plan you pick to avoid “out of net work” costs. network” Y ou o may have to check the plan’ pla s website or call You plan’s your medical provider provider.. TIP: While the tax credit amount is g eared geared toward a benchmark silver plan, you can apply it to any level, including cheaper “bron ze” plans for “bronze” further premium savings. TIP: Premiums will be significantly h igher for higher tobacco users and tax credits canno cannott be applied toward reducing them.

Mail your completed application to:

Health Insurance Marketplace Dept. of Health and Human S ervices Services 465 Industrial Blvd. London, KY 40750-0001

TIP: Using an online marketplace or working through a navigator with Internet access will be faster faster.. AP


8 SATURDAY, OCTOBER 5, 2013

AFFORDABLE CARE ACT

Health costs likely rising for many self-employed

Applying for health insurance? Expect to do some homework. By Ricardo Alonso-Zaldivar The Associated Press

WASHINGTON — Getting covered through President Barack Obama’s health care law might feel like a combination of doing your taxes and making a big purchase that requires research. You’ll need accurate income information for your household, plus some understanding of how health insurance works, so you can get the financial assistance you qualify for and pick a health plan that’s right for your needs. The process involves federal agencies verifying your identity, citizenship and income, and you have to sign that you are providing truthful information, subject to perjury laws. You heard it was going to be like buying airline tickets online? Not quite. But even if the process triggers some anxiety, it’s not the government poking in your medical records, as “Obamacare” foes have suggested. After state health insurance markets open Oct. 1, consumers can apply online, via a call center, in person or by mail. Trained helpers are supposed to be available, but there may not be enough of them.

By Donna Gordon-Blankenship The Associated Press

SEATTLE — President Obama’s health care reforms will be a huge boost to the working poor but are likely to make life more expensive for Aaron Brethorst and others like him. The Seattle software developer and consultant doesn’t have a problem with that because he figures he’ll be able to afford quality insurance. He says his annual income is in the low six-figures, and he expects to receive better coverage once the Affordable Care Act kicks in. The 31-year-old says the ability to buy his own health insurance, because he is relatively young and healthy, has given him the creative freedom to start his own companies and explore new ideas. He spends a little more than $300 a month on catastrophic coverage with a high deductible. He recently got an email from his health insurance company informing him that the plan he bought on the individual market is going to be cancelled. Brethorst said he does not know whether he will buy his next policy from the same company -- a local version of Blue Cross -- or through the state insurance exchange, the Washington HealthPlan finder. He does expect to add a better dental and vision plan in the new year, however. “I’m not worried about it, quite frankly,” Brethorst said. “My income today is more than enough to pay for health insurance.” That outlook is not likely to be universal among those who are self-employed. The income threshold for a government subsidy offered on the state exchanges varies based on a number of factors, but generally tops out at $46,000 a year for an individual. Depending on their health, age, family circumstances and income, the cost of insurance could become a burden for those who make too much money for govern-

The Northern Virginia Daily

THE MAIN STEPS ARE: — Identify yourself and your family members. — Provide current information on income, jobs and any available health insurance options. — Learn how much financial assistance you’re entitled to. — Shop for a health plan and enroll. Many people, ranging from lower-income workers to the solid middle class, will qualify for tax credits to help buy a private plan through the state markets. The government will send money directly to your insurer, and you’ll make arrangements to pay any remaining premium. The poor and near-poor will be steered to Medicaid in states that agree to expand that program. Here’s an overview of what to expect applying online, with tips: Go to healthcare.gov and click on “Get Insurance.” The site has links to every state market. You’ll set up an account and password. You’ll provide your contact information and the best way to reach you. Tip — Treat your password like a bank account or credit card password. It’s not a good idea to set it as “1234567.” AP

Aaron Brethorst poses for a photo while walking his dog, Moxie, in Seattle. Brethorst says he doesn’t have a problem with President Obama’s health care reforms because he figures he’ll be able to afford quality insurance. ment subsidies but not enough to be considered well-off. Insurance companies say the cost of their polices will have to reflect the new government mandates under the Affordable Care Act, including the requirement to cover all people, regardless of their medical condition, and to provide coverage for 10 new essential benefits that include

Now you can tackle the actual application. You’ll need birth dates and Social Security numbers for yourself and other family members listed on your federal tax return. You’ll also be asked if you’re a citizen. Legal immigrants will need their immigration documents. Tip — You don’t have to plow through the entire application in one sitting. You can save your work and come back later.

mental health treatment and maternity care. Glen Melnick, a health economist at the University of Southern California, said he believes many younger singles who are self-employed will decide against buying health insurance despite the government mandate,

Next, you’ll be asked about income. You may need your most recent tax return, pay stubs and details on other kinds of income, such as alimony, pensions and rents. You can still apply if you haven’t filed a tax return. You’ll also be asked about access to health insurance through your job. You may be required to take that insurance if available. Your personal and income details will be routed through a new government entity called the data services hub, which will ping agencies

RISING, 17

HOMEWORK, 17


AFFORDABLE CARE ACT

The Northern Virginia Daily

Health tradeoff: Low premiums, high deductibles

9

Government health spending set to jump starting next year

By Ricardo Alonso-Zaldivar

By Andrew Miga

include an improving economy and the aging of the nation’s population. Over the longer term, the health care WASHINGTON -- The nation’s health overhaul would only be a modest contribcare spending will jump by 6.1 percent utor to spending increases, the report next year as the big coverage expansion said. From 2012 to 2022, the new law is in President Barack Obama’s overhaul projected to add about 0.1 percent to kicks in, government experts predicted average annual health spending growth. Wednesday. In all, Obama’s plan will add $621 bilThat’s more than 2 percentage points lion to health care spending over that 10higher than the growth rate forecast for year period, while expanding coverage to this year, and compares with a growth some 30 million uninsured people, rate that has hovered under 4 percent, experts said. historically low, for the past four years. Some 11 million people are expected to Much of the increase projected for next gain health insurance coverage in 2014, year is attributed to the new health care mostly through new state insurance marprogram, which is expected to provide kets the law sets up or through expanded insurance coverage to millions of current- eligibility for Medicaid, the federal-state ly uninsured Americans beginning Jan. 1. insurance program for low-income people. Without it, the estimated growth would Medicaid enrollment alone is expected to be 4.5 percent, according to the report increase by 8.7 million people next year. Wednesday from Medicare’s Office of the Many of the newly insured are expected Actuary. The findings were published to be younger and healthier. They’re online by the journal Health Affairs. Other factors driving up spending SPENDING, 17

The Associated Press

WASHINGTON -- You might be pleased with the low monthly premium for one of the new health insurance plans under President Barack Obama’s overhaul, but the added expense of copayments and deductibles could burn a hole in your wallet. An independent analysis released Wednesday, on the heels of an administration report emphasizing affordable premiums, is helping to fill out the bottom line for consumers. The annual deductible for a mid-range “silver” plan averaged $2,550 in a sample of six states studied by Avalere Health, or more than twice the typical deductible in employer plans. A deductible is the amount consumers must pay each year before their plan starts picking up the bills. Americans looking for a health plan in new state insurance markets that open next week will face a tradeoff familiar to purchasers of automobile coverage: to keep your premiums manageable, you agree to pay a bigger chunk of the repair bill if you get in a crash. Except that unlike an auto accident, serious illness is often not a self-contained event. Avalere also found that the new plans will require patients to pay a hefty share of the cost -- 40 percent on average -- for certain pricey drugs, like the newer specialty medications used to treat intractable chronic diseases such as rheumatoid arthritis and multiple sclerosis. On the other hand, preventive care will be free of charge to the patient. “Consumers will need to balance lower monthly premiums against the potential for unpredictable, expensive

SATURDAY, OCTOBER 5, 2013

The Associated Press

Need health insurance?

AP

Health and Human Services secretary Kathleen Sebelius addressed local health care providers and community leaders in Jacksonville, Fla., on details of Affordable Care Act. out-of-pocket costs in plans with higher deductibles,” said Caroline Pearson, a vice president of the private market analysis firm. “There is a risk that patients could forgo needed care when faced with high up-front deductibles.” Responding to the Avalere study, the Obama administration acknowledged the new plans aren’t as generous as employer coverage, but said they nonetheless represent a big improvement over currently available individual policies, which can have gaps in coverage and even larger out-of-pocket costs. Also on Wednesday, the administration unveiled premiums and plan choices for 36 states where the federal government is taking the lead to cover uninsured resi-

dents. Insurance markets that go live Oct. 1 will offer subsidized private coverage to people who do not have health insurance on the job, including the uninsured and those who currently buy their own policies. Before new tax credits that work like a discount for most consumers, premiums for a mid-range “silver” benchmark plan will average $328 a month nationally for an individual, the administration report found. Beneath that average are wide differences for individuals, depending on where they live, how much they make, and other factors. Health and Human Services Secretary Kathleen TRADEOFF, 18

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Insurance within reach for bipolar sufferer MIAMI -- Before she was diagnosed with bipolar disorder, 32-year-old Jessi Spencer-Hammac thought she was just a moody, restless dreamer who had trouble finishing projects. At times, she alternated between being hyper-social and abruptly ending relationships. She also made rash decisions, such as moving across the country and losing contact for a couple years with her young daughter, who was living with the girl’s father at the time. Up one day, she could swing quickly to sad and withdrawn. Spencer-Hammac said she did not seek mental health treatment until a few years ago. Because she cannot afford health insurance, she pays for the counseling and prescriptions out-of-pocket. But under the Affordable Care Act, insurers will be prohibited from turning away Spencer-Hammac and millions of other Americans with pre-existing medical conditions, as they can now. Insurers that do offer coverage to those with existing conditions typically charge such high premiums that the cost makes it unaffordable. For Spencer-Hammac, the provision in the federal health care law could mean an end to buying her $100a-month mood-stabilizing medication at a discounted price in Canada, as well as the chance to see her therapist more regularly. Her husband Chris, a 40year-old bartender who makes about $35,000 a year, has health insurance through the Veterans Administration, but his policy does not cover family. He was recently diagnosed with testicular can-

I know I’ll feel relieved. It’s a burden to walk around and hope that nothing happens to you, and then with bipolar that you don’t do anything drastic and stupid. JESSI SPENCER-HAMMAC, BIPOLAR SUFFERER

cer and underwent surgery in August, further stressing the family’s finances. Their 12-year-old daughter, Marley, has coverage through her step-mother’s job. The National Institute of Mental Health estimates that 6 percent of Americans live with a serious mental illness. One in four adults, or about 57.7 million Americans, experience a mental health disorder in a given year. Many don’t have access to treatment or lack insurance plans that cover mental illness. The Tampa mom tried to get health insurance about eight months ago and was told by one consultant that she would never get coverage for mental illness as an individual. She searched for plans online but was inundated with phone calls from insurance companies she said were so manipulative that she gave up. “I felt marginalized, like I didn’t matter, and mad ... that my struggle and the things that I deal with don’t matter,” she said. Spencer-Hammac, who is about to start working again as a waitress, pays $40 for a family physician to write the prescription for her mood stabilizer. She can’t use the generic brand, so she buys it in Canada and orders several months’ worth to avoid

AP

Jessi Spencer-Hammac, 32, poses with her dog Rocco, in Tampa, Fla. Decades before being diagnosed with bipolar disorder, Spencer-Hammac thought she was just moody, a restless dreamer with grand plans who had trouble finishing projects. high shipping costs. Sometimes, she worries the order will not arrive on time, so she regulates her dosage. “If I stop it abruptly, I’m looking at being very unstable. That’s always been a stressor,” she said. When she’s feeling overwhelmed and needs to talk to her therapist, it costs about $100. That’s why she’s only been twice in the past five months. A few months ago, she attended a town hall meeting and learned she might be able to get affordable insurance through the new state health insurance exchange under the Affordable Care Act. She also might also qualify for a federal subsidy to help offset the cost. “I know I’ll feel relieved,” she said. “It’s a burden to walk around and hope that nothing happens to you, and then with bipolar that you don’t do anything drastic and stupid.”

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AP

In this photo, a woman smokes a cigarette while sitting in her truck in Hayneville, Ala. The federal health care law requires insurers to accept all applicants regardless of pre-existing medical problems.

To qualify for insurance, smoker will have to quit By David Eggert The Associated Press

LANSING, Mich. -- Eric Jones has an incentive to end his trips to the party store for cigarette tubes and tobacco, the roll-yourown supplies used to fill his pack-a-day habit. The 40-year-old has no health insurance from his $9-an-hour job at an icemanufacturing plant in Lansing. Under the federal health care law, he’s eligible for help from the government to buy insurance. But to qualify, he’ll almost certainly have to quit smoking. A baseline insurance plan could cost Jones, who makes $22,000 working seasonally from February to November, $775 a year in premiums. Or he could pay no premiums in the cheapest plan, which has higher deductibles and copayments. Yet if he keeps smoking, he could face an annual

I’d rather have health coverage than cigarettes, if it comes down to it.” ERIC JONES,

SMOKER

financial penalty ranging from $1,600 to $1,900 that will make coverage unaffordable. The numbers were estimated using the online Kaiser Health Reform Subsidy Calculator. “I’d rather have health coverage than cigarettes, if it comes down to it,” Jones said. The law requires insurers to accept all applicants regardless of pre-existing medical problems. But it also allows them to charge smokers premiums that are up to 50 percent higher than those offered nonsmokers -- a way for insurers to ward off bad risks. Jones is not without health problems. He said he should be taking medications for gout, high blood pressure, high cholesterol and severe acid

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reflux but instead just suffers through his conditions. “I can’t afford them,” he said. “So I just don’t take them.” Jones, who first smoked at age 12, has tried quitting. He stopped about four years ago with no help from nicotine patches or gum. But he started up again this year. “Everybody around me was smoking except my wife. Everywhere. All my friends,” he said. Nearly one of every five U.S. adults smokes. That share is higher among lower-income people such as Jones, who are more likely to work in jobs that do not offer health insurance and are a major reason the law was enacted. SMOKER, 16

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Effects of Obamacare on Medicaid recipients WINNER

LOSER

Morgan Kinney, 31, clinical professional counselor

Chris Gatliff, 38, part-time worker at a pizza restaurant

AP

Morgan Kinney, 31, a clinical professional counselor working part-time while his girlfriend finishes medical school, sits on his couch in his apartment in Denver.

Making only $10K a year, counselor will benefit from expansion that includes single adults By Kristen Wyatt

friend, ‘This thing is broken, it won’t let me in,’ and she looked and said, ‘I DENVER -- He makes think it’s because you’re just $10,000 a year as a supposed to be on clinical professional counMedicaid.’ I said, ‘No, that’s selor, so Morgan Kinney for poor people.’ Well, sure decided to spend what little enough, that was me.” extra money he had this Colorado is one of at least year paying down student 24 states expanding debt rather than buying Medicaid access for adults health insurance. under the Affordable Care The 31-year-old Denver Act. In Colorado, that man figured he would have means single adults who no choice but to buy insur- earned less than $15,400 ance next year to comply last year will have access to with the new federal health Medicaid. Childless adults insurance mandate, so last in the state currently qualimonth he entered his perfy for Medicaid only if they sonal information into the make less than $95 a online calculator of the month. Colorado estimates Colorado insurance about 160,000 people will exchange. be added to state Medicaid Yet instead of a cost esti- rolls under the new guidemate, he received a rejeclines. tion notice saying he was Medicaid expansion is a not eligible to shop on the major plank of the adminisexchange. tration’s plan to get every “I was telling my girlAmerican covered by health The Associated Press

insurance. But the U.S. Supreme Court last year limited the federal government’s ability to penalize states that decide against the expansion, leading to a patchwork of Medicaid eligibility standards. The Congressional Budget Office has projected 11 million Americans will get coverage through the Medicaid expansion by 2022. Kinney said he feels incredibly fortunate to live in a state where he will receive basic coverage through the government program. He has seen firsthand just how expense medical expenses can be. He broke his leg last April in a car accident heading home from a cross-country skiing trip. But the other driver was at fault, sparing Kinney from having to pay WINNER, 16

AP

Chris Gatliff stands outside his home in Lawton, Okla. Gatliff, 38, a parttime worker at a pizza restaurant, said he’s not sure how he will be able to afford medication to control his diabetes and high blood pressure.

Oklahoma man one of thousands in state left in limbo about their health insurance By Sean Murphy

In mid-September, however, Oklahoma Gov. Mary The Associated Press Fallin announced a tempoLAWTON, Okla. -- Chris rary reprieve for the 30,000 Gatliff, a 38-year-old diabet- Oklahomans who receive ic, says he feels like a victim coverage through Insure of politics. Oklahoma, saying the proHis home state, Oklahoma, gram would remain operatopted against accepting the ing for one more year. expansion of Medicaid Gatliff said he was grateful under the Affordable Care for the temporary extension Act. The result is that thou- but said he felt like a victim sands of Oklahomans who of Oklahoma’s resistance to would have qualified under implementing the the expanded program are Affordable Care Act. left in limbo about their “I’m glad she did it,” said health insurance. Gatliff, who makes between At the same time, a $7,000 and $9,000 annually Medicaid-linked program . “It’s a year, which is good, called Insure Oklahoma but it’s still only a year. that provides Gatliff with After that, I’ll have to worry his current coverage was about it.” due to expire Dec. 31. That He said he believed the left him facing the prospect governor should have simof having no insurance at ply accepted the Medicaid the end of the year, so the expansion that was offered part-time pizza shop to states under the federal employee began planning to health care reforms. The stockpile his medications. federal government pays for

the full expansion for the first few years and 90 percent thereafter. Opting for the Medicaid expansion under the federal law would have provided medical coverage to as many as one-third of Oklahoma’s 636,000 uninsured residents, about 17 percent of the state’s population. But for Fallin, agreeing to an expansion of Medicaid would be politically dangerous. She voted against the Affordable Care Act when she served in Congress, railed against it during her campaign for governor and consistently opposed it during her first term. She said she is concerned the expansion could cost Oklahoma $850 million through 2020. Although the Insure LOSER, 17


AFFORDABLE CARE ACT

The Northern Virginia Daily

SATURDAY, OCTOBER 5, 2013

13

New law perplexing to small business owners By Michael Virtanen The Associated Press

ALBANY, N.Y. -Restaurant owners Colleen and Tim Holmes were considering opening a third business in a growing upstate New York suburb but decided against it. One factor was the risk from expanding their staff beyond 50 full-time employees and having to provide them federally mandated health coverage. Despite knowing the penalty for that part of the Affordable Care Act had been postponed for a year, the couple said their margins are thin and the requirements and costs under the law remain unclear. They also face some disruption from their current health plan, with some coverage moving to the new insurance exchange after

this year. They’ve discussed whether they need to hire a consultant to help them understand what the law means for the owners of small businesses, but it’s an expense they’d rather not have. Yet they have little time to research the act on their own, since they already work more than 70 hours a week. “As small-business owners we take all the risk and we employ a lot of people, so any additional cost is difficult for us to justify without having additional revenue,” Colleen Holmes said. Even though they offer health insurance, the couple said most of their employees refuse it because of the cost of premiums and because most are young and feel they don’t need it or can now get coverage under their parents’ policies through

age 26. At costs ranging from $300 to $500 a month for one healthy employee, the business could not afford to pay a fraction of the premiums, they said. At even $100 a month, it would be $5,000 monthly for 50 workers. “Where’s that money going to come from?” Colleen Holmes said. Her husband said it would be more advantageous for their employees to go directly to the new health exchange for individual coverage because it can be subsidized by the government. Since 2004, they’ve owned and operated Wheatfields Restaurant and Bar in Saratoga Springs, an upscale city with a thorAP oughbred track, performing Bartender Sara Tucciarone, left, talks about a wine selection with hostess arts center and Skidmore Hillary Len, right, and Wheatfields Restaurant owners Tim Holmes and his OWNERS, 16 wife Colleen at the business in Clifton Park, N.Y.

The federal government form for applying for health coverage is shown.

Health overhaul confuses Medicare beneficiaries By Kelli Kennedy The Associated Press

AP

MIAMI -- Dear seniors, your Medicare benefits aren’t changing under the Affordable Care Act. That’s the message federal health officials are trying to get out to elderly consumers confused by overlapping enrollment periods for Medicare and so-called “Obamacare.” Medicare beneficiaries don’t have to do anything differently and will continue to go to Medicare.gov to sign up for plans. But advocates say many have been confused by a massive media blitz directing

consumers to new online insurance exchanges set up as part of the federal health law. Many of the same insurance companies are offering coverage for Medicare and the exchanges. Medicare open enrollment starts Oct. 15 and closes Dec. 7, while enrollment for the new state exchanges for people 65 and under launches Oct. 1 and runs through March. “Most seniors are not at all informed. Most seniors worry they’re going to lose their health coverage because of the law,” said Dr. Chris Lillis, a primary care physician in

Fredericksburg. “I try to speak truth from the exam room but I think sometimes fear dominates.” Next month, roughly 50 million Medicare beneficiaries will get a handbook in the mail with a prominent Q&A that stresses Medicare benefits aren’t changing. Federal health officials have also updated their training for Medicare counselors, and are prepping their Medicare call center and website. “We want to reassure Medicare beneficiaries that they are already covered, their benefits aren’t MEDICARE, 16


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FA

the lowest premiums, WHAT IF I HAVE A while platinum have the PRE-EXISTING RICHMOND — Hundreds highest. But low premiums CONDITION? of thousands of Virginians could result in big bills lacking health insurance later if your expenses An estimated 3.4 million can start enrolling Tuesday exceed what’s considered Virginians with pre-existin the health insurance reasonable. ing conditions can no marketplace created longer be turned down or through the federal HOW MUCH charged for more coverage. Affordable Care Act. To WILL IT COST? receive benefits at the start WHAT IF I AM ON of 2014, consumers must The average premium, MEDICARE? enroll by Dec. 15. without tax credits, would Virginia is among 36 be $237 a month for the Medicare beneficiaries states in which the federal lowest-cost bronze plan don’t have to do anything government is running all and $335 a month for the differently. or part of the health bene- second-lowest silver plan. fits exchange. Following For a family of four makWHAT ABOUT are some questions and ing $50,000, a midrange MEDICAID? answers about key eleplan, after tax credits, ments of the act in would be $282 a month A commission in Virginia Virginia. under the second-lowest currently is working silver plan. Without a tax through a process to deterWHAT IS A HEALTH credit, $799. mine whether to expand CARE EXCHANGE? For a 27-year-old person Medicaid. The legislature earning $25,000 a year, the set up the commission this It’s created by the federal premium would be $80 a year and tasked it with Affordable Care Act. The month, with a tax credit, determining whether ceronline marketplace allows for the bronze plan and tain cost-cutting and effifor side-by-side comparison $145 for the silver plan, ciency reforms in the of coverage options before also with a tax credit. Medicaid program were enrolling. Six out of 10 Virginians met. If so, Virginia would who are uninsured will be expand Medicaid to cover HOW MANY able to find coverage for an additional 400,000 VIRGINIANS LACK less than $100 a month Virginians. HEALTH INSURANCE? when tax credits and Medicaid coverage are CAN SOMEONE An estimated 844,753 are included HELP ME? uninsured and eligible for coverage through the marWHY SHOULD Virginia will have navigaketplace, according to the I SIGN UP? tors, independent counU.S. Department of Health selors who work under fedand Human Services. The If the government decides eral grants to help people largest percentage of uninyou can afford health find the best coverage sured — 333,428 individuals insurance and you don’t plan. Many hospitals and or 39 percent of all uninhave it by 2014, you may health care facilities will sured people— are between have to pay a fee. You also have on-site navigators, the ages of 18 and 34. have to pay 100 percent of and information about your medical bills on your other places to find them WHO IS SELLING own. will be coming out soon. IT IN VIRGINIA? The fee is 1 percent of your yearly income, or $95 WHERE CAN I LEARN Virginians will get to per person for the year, MORE? choose from an average of whichever is higher. For 47 different health plans children, it’s $47.50 per http://www.HealthCare.gov in the marketplace. People child, up to $285 total. U.S. Department of can choose from four levels The fee increases every Health and Human of coverage — bronze, silyear. In 2016, it will be 2.5 Services: ver, gold and platinum. percent of income, or $695 http://www.hhs.gov/ The big difference is cost per person, whichever is FamiliesUSA.org sharing. Bronze plans have higher.

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SATURDAY, OCTOBER 5, 2013

15

States resist, build nascent insurance markets By Emery P. Dalesio The Associated Press

RALEIGH, N.C. — With new online health insurance exchanges launching this week, consumers in many Southern and Plains states will have to look harder for information on how the marketplaces work than their counterparts elsewhere. In Republican-led states that oppose the federal Affordable Care Act, the strategy has ranged from largely ignoring the health overhaul to encouraging residents not to sign up and even making it harder for nonprofit organizations to provide information about the exchanges. Health care experts worry that ultimately consumers in these states could end up confused about the exchanges, and the overall rollout of the law could be hindered. “Without the shared planning and the cooperation of the state government, it’s much harder for them to be ready to implement this complicated law,” said Rachel Grob of the University of Wisconsin-Madison, who has studied differences in how states are implementing segments of the law. Several of the 14 Northeast, Midwest and Western states running their own insurance exchanges have spent weeks on marketing and advertising campaigns to help residents get ready to buy health insurance. At least $684 million will be spent on publicity explaining what people need to do next and persuading the doubtful to sign up for coverage, according to data compiled The Associated Press. By contrast, most states across the South have declined federal grants to advertise the exchanges and ceded the right to run the marketplaces themselves. Governors from the

Carolinas to Kansas have decried the exchanges and the rest of the law, which was passed by Congress in 2010 and many argue reaffirmed when voters re-elected President Obama in 2012. The Supreme Court in 2012 upheld the constitutionality of most of the law; a piece of the Medicaid expansion was an exception. “When it came to Obamacare, we didn’t just say ‘no,’ we said ‘never,’” South Carolina Gov. Nikki Haley said last month alongside U.S. Sen. Tim Scott, whom she appointed last December when Jim DeMint resigned. “And we’re going to keep on fighting until we get people like Sen. Scott and everybody else in Congress to defund Obamacare.” Others have gone beyond fiery rhetoric. Missouri’s lieutenant governor urged residents to refuse to sign up for federal health insurance, while Kansas legislators and the state’s governor enacted a law symbolically declaring that residents can’t be forced to buy health insurance. In Florida, state officials ordered county health departments to bar from their property navigators hired under federal grants to explain the plan’s complexities. Broward County commissioners last week ignored that ban and voted to allow navigators and other counselors into county offices, including health departments. ‘We’ve encountered many, many issues with this, and this is a breakthrough for us to be able to go into the libraries, the health departments,” said Jerson Dulis, who was trained to help enroll people in the state exchange. He works for Broward Community & Family Health Centers Inc., which received a federal grant to provide consumers

understand and enroll in health insurance plans. In places where state officials have declined to disseminate information, the work is left to nonprofit organizations and word-of-mouth among consumers. North Carolina is among the states that have left the running of its exchange to the federal government. This year, the state refunded what remained of a $74 million federal grant that would have helped consumers and linked computers. North Carolina Gov. Pat McCrory’s health agency recently urged county social services departments to discuss the insurance exchanges when people come in seeking food stamps or child care help. The Republican governor’s administration also encouraged social services agencies to offer space as available to navigators. In South Carolina, which also left advertising and running the exchange to the federal government, the state Medicaid agency ramped up its call center to handle 50 percent more calls as people have questions about the law, deputy director John Supra said. In Kansas, a 2011 law Republican legislators and Gov. Sam Brownback enacted declared that residents can’t be forced to buy health insurance or penalized. The measure was largely a symbolic protest, given supremacy of the federal law. Missouri bars state employees from helping implement an insurance exchange, leaving it entirely to federal direction. Last week, Lt. Gov. Peter Kinder urged Missouri residents to resist the federal law by refusing to sign up for health insurance. They could be forced to pay a fine of $95 or more if they don’t.

This undated image at right, provided by the Illinois Health Insurance Marketplace, shows one of three print ads that Illinois launched Tuesday in an advertising campaign to inform Illinois residents about the health insurance marketplace opening that day that will connect people with new benefits under President Barack Obama’s health care law.

AP


16 SATURDAY, OCTOBER 5, 2013

Smoker Continued from 11

The smoking penalty has drawn criticism for effectively pricing people out of insurance. Jones already is worried that he won’t be able to afford insurance even if he does quit. He has trouble paying the rent. He takes the bus from rural Charlotte 20 miles each way to work in the city every day. Yet if Jones keeps smoking, he said there is no way he could afford the estimated $1,600 yearly smoking penalty in the least expensive plan, equaling 7 percent of his income. Michigan is not among the few states that have banned tobacco surcharges on their insurance marketplaces. At least in the interim, Jones may get some relief. A glitch will limit penalties that insurers can charge smokers until it’s fixed next year. The government’s computer system has been unable to accommodate a provision

Winner Continued from 12

the hefty medical bills for his treatment. Kinney said he is thankful every time he sees the tab for his care: $500 for the ambulance ride; $150 just to consult with a doctor by telephone; $100 for a pill. “Even though I know I’m going to get my bills paid, it’s incredibly scary watching the number of zeros on the letters that roll in saying these are the bills we owe,” said Kinney, who is working part-time while his girlfriend finishes medical school. He is just beginning his career with a startup counseling company and expects to increase his earnings sig-

AFFORDABLE CARE ACT that prevents companies from charging older customers more than three times what they charge younger adults and the provision letting smokers be charged higher premiums. In addition, Jones and other smokers newly insured through exchanges or Medicaid will benefit from requirements that tobacco cessation treatments be covered. Experts say with the prevalence of high tobacco taxes and workplace smoking bans, those able to quit more easily already have done so. Long-time smokers such as Jones -- who wants to quit but has found an inexpensive way to keep the habit -- usually need nicotine replacement therapy and classes. Jones spends under $10 a month to roll his own cigarettes with a machine. But he’s taking notice of the penalty that could keep him without insurance. “I guess it’s an incentive to quit,” he said. “I’d much rather be able to take care of myself, take proper meds than smoke cigarettes.”

nificantly in the years ahead. For now, though, Kinney said he is happy to be caught in the Medicaid safety net because Colorado opted for the expansion. The cost will be covered entirely by the federal government for the first few years, with that share eventually falling to 90 percent. He wants a checkup and maybe a trip to the dentist. “Until now, I’ve used delusion and denial to pretend something wouldn’t actually happen to my health,” Kinney said. “So now it’s nice to think about actually having coverage. It didn’t click when I saw all the ‘Obamacare’ stuff on the news; it was just people yelling at each other. ... It was just politics. Now it feels real.”

Owners

business strategy in expanding,” Colleen Holmes said. Another was New York Continued from 13 lawmakers this year boosting the state’s miniCollege. In 2009, they opened a cafe in the near- mum wage, which will rise incrementally from by Albany suburb of $7.25 an hour to $9 an Clifton Park and more recently considered open- hour in 2016. In addition to the New ing a third restaurant in between in Malta, a town York health exchange, a that’s been growing with a separate one will serve new semiconductor manu- small businesses, defined as having 50 or fewer elifacturing center. gible employees. Many “There’s a lot of other owners expect to rely on issues out there, but the brokers to help them find health care definitely the best deal. made us re-evaluate our

Medicare Continued from 13

changing, and the marketplace doesn’t require them to do anything different,” said Julie Bataille, spokeswoman for the Centers for Medicare and Medicaid Services. But she said call centers for the state exchanges are already fielding questions from Medicare recipients and rerouting them to the Medicare line. Bob Roza attended several meetings trying to figure out exactly what the Affordable Care Act means for him and his 69-year-old wife Gail, who has diabetes. “At that time, I didn’t know if Medicare would be secondary to some Affordable Care Act option. It was just a myriad of concerns and not knowing,” said the 72-year-old Roza, a retiree who lives in Oakdale, Calif., and is recovering from hip replacement surgery earlier this year. He now knows that his Medicare coverage won’t change, but says he’s now worried about the impact on the $614 a month he pays for Medicare supplemental insurance. Federal health officials said seniors will not be able to purchase Medicare supplemental

insurance or Part D drug plans through the state exchanges. Jodi Reid, executive director of the California Alliance for Retired Americans, worries there hasn’t been enough outreach to seniors and that advocacy groups are spending the bulk of their advertising funds targeting those impacted by the exchange. Her organization, which represents nearly 1 million seniors in California, is putting together a one-page fact sheet to help dispel myths. “Nothing has been done that I have seen to deal with the 4.4 million people in California who are on Medicare who are not going to be impacted the same way as the rest of us so it’s causing a lot of confusion,” she said. AARP officials said they anticipate a spike in calls after the October launch date for the new state exchanges. To help clarify everything for seniors, the organization is holding various events around the country, such as a senior day next month at the state fair in Columbia, S.C. Next month, the group is also hosting 21 telephone town halls, which will include hundreds of thousands of phone calls to seniors. “Usually the marketing is just targeted to the

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The definition of a small business will increase from 50 to 100 full-time employees in 2016 in New York, expanding access to the state-run exchange and possible tax credits for providing coverage. However, businesses with 50 or more full-time staff still will be required to provide affordable coverage or face tax penalties, which start in 2015. Employee premiums cannot exceed 9.5 percent of gross income. Several city and regional chambers of commerce,

which have traditionally offered pooled insurance coverage for small businesses, plan to continue. However, sole proprietors now will have to go to the exchange. For now, the Holmes and other small-business owners are trying to understand the law’s effect on them and their employees, as well as figure out what the related costs might be. “When you can’t pinpoint your costs,” said Tim Holmes, “you can’t make strategic decisions regarding your business.”

Medicare beneficiary, this time it’s going to be spread out a little bit more. If they call the wrong places, we’re doing our very best to make sure they’re guided back to the correct place,” said Nicole Duritz, vice president of health education. In Illinois, it’s not only seniors who are confused, but also the social workers who help them, said Erin Weir of AgeOptions, suburban Cook County’s lead agency on aging. The agency coordinates a statewide training program for groups that work with older adults. During these trainings, Weir said, she’s repeatedly heard questions from social workers who think seniors will be able to sign up for Medicare programs on the new marketplace websites, even though they cannot. “We’ve been focusing on people who are already on Medicare, calming them down and saying, ‘You don’t have to do anything, you’re fine,’” Weir said. Advocates are also warning of scams that may pop up alongside legitimate door-to-door outreach about the Affordable Care Act ramps up and advising seniors not to give out personal information. Senior groups are also devoting resources to educating the 50- to 65-yearold group who are next in

Nothing has been done that I have seen to deal with the 4.4 million people in California who are on Medicare who are not going to be impacted the same way as the rest of us so it’s causing a lot of confusion.” JODI REID,

EXECUTIVE DIRECTOR OF THE CALIFORNIA ALLIANCE FOR RETIRED AMERICANS

line for Medicare, a segment that could be greatly affected by the health reform. Under the new law, insurers will have to offer more benefits in some cases and are restricted in how much they can charge older, sicker people. They’re also banned from turning away those with pre-existing conditions. Anthony Wright, executive director of Health Access California, said many people nearing retirement age stand to benefit the most by the health care reform. “They’re the ones most likely to have pre-existing conditions, most likely to be charged more because of their age and medical condition and very likely to be an early retiree,” he said.


AFFORDABLE CARE ACT

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Loser

the federal poverty level, or $15,400 for an individual and about $31,000 for a family of four. Under Insure Continued from 12 Oklahoma, he currently Oklahoma program was pays a $27 monthly premipushed by former um as well as co-pays for Democratic Gov. Brad Henry doctor visits and the five and uses federal Medicaid medications he takes regudollars, Republicans prefer it larly. to a Medicaid expansion “I don’t mind paying it,” because thousands of small Gatliff said from the mobile businesses use it to provide home he shares with a coverage to their employees. friend at the Sherwood Recipients also are required Village Manufactured Home to make modest premium Community in Lawton, payments and medical coabout 90 miles southwest of pays. Oklahoma City. “I’m not “There’s some personal looking for a handout. I responsibility in the plan,” want to pay something.” Fallin said. If Insure Oklahoma had Gatliff would have qualinot been extended for a fied for the Medicaid expan- year, Gatliff would have sion offered under the been caught in a coverage Affordable Care Act, which gap: He would not have gives eligibility to those qualified for Medicaid, but making up to 138 percent of he also did not earn

Spending

sharing for people with improved coverage. The report said the recent low rates of spending Continued from 9 growth are a persistent expected to devote a larger effect of the economic recession, which includes share of their health care employers shifting more spending to prescription health care costs to employdrugs and physician and ees, pressure on governclinical services and a ment budgets and consmaller share to hospital sumers forgoing or delaying spending. Out-of-pocket spending for treatment. National health spending individuals and families is projected to fall 1.5 percent is expected to grow at an in 2014 because of the new average annual rate of 5.8 percent from 2012 to 2022, coverage and lower cost-

Continued from 8

opting instead to pay the fine. “They’re going to decide not to play. They are risktakers to begin with,” he said. Yet the additional benefits under the law could outweigh the added costs for some, said Dylan Roby, assistant professor and researcher at the University of California, Los Angeles Center for Health Policy Research.

1 percentage point higher than the growth rate for the overall economy in that period, the experts said. As a result, the share of gross domestic product devoted to health care is forecast to rise from 17.9 percent in 2011 to 19.9 percent by 2022, the report said. The most significant onetime effects on spending of the coverage expansions under Obama’s plan are expected to subside beginning in 2016.

Homework

can finally shop for insurance. Beware: you’ll probably have to live with your decision until the next Continued from 8 annual enrollment period. like Social Security, You’ll have up to four levHomeland Security and the els of coverage to consider: Internal Revenue Service for bronze, silver, gold and platverification. The feds will inum. Plans at every “metal also rely on a major private level” cover the same benecredit reporting company to fits and have a cap of verify income and employ$6,350 a year in out-ofment. pocket expenses for an indiHow smoothly all this vidual, $12,700 for families. works is one of the big Bronze plans generally unknowns. It could get have the lowest premiums, tedious if discrepancies but cover only 60 percent of take time to resolve. medical costs on average. Tip -- Provide the most Policyholders will pay the accurate estimate of your difference, up to the annual expected income for 2014. out of pocket cap. Platinum Lowball the number, and plans have the highest preyou might see a smaller tax miums, but cover 90 perrefund in 2015. cent of costs. Young adults If you’re like most people, up to age 30 can pick a you’ll be getting a tax credit skinny “catastrophic” plan to help pay your premiums. - but you can’t use your tax The credits are based on credit on a catastrophic your income and keyed to plan. the premium for a benchTip -- Make sure your mark plan known as the doctors and hospitals are in “second-lowest cost silver the plan you pick. You may plan” in your area. have to check the plan’s own website, or call your With your tax credit, you

doctor. Tip -- Your share of the premium could be lower -even zero -- if you apply your tax credit to a bronze plan. It’s because the credit is keyed to the cost of a silver plan, which is generally more expensive. Tip -- Check if you are eligible for “cost-sharing subsidies,” in addition to your tax credit. Extra help with out-of-pocket costs is available to people with modest incomes. But only with a silver plan. Head spinning? Richard Onizuka, director of the Washington state market, says picking a plan could be the most difficult step. Most of his customers were previously uninsured, so insurance jargon could seem like a foreign language. “The biggest challenge for consumers will be understanding health insurance and how to purchase it,” he said.

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Another positive of the federal reforms is the ability to more easily comparisonshop between insurance companies and policies, he said. Brethorst said the Affordable Care Act is likely to provide freedom to those who currently cannot afford to escape employerbased coverage to pursue their own dreams. The iPhone app developer and business consultant cites as an example a friend and colleague with asthma. They started a new company together a few years ago while his friend was buying

his insurance from a former employer through the federal COBRA plan. When the venture capital funding they were seeking fell through before his access to company health insurance ran out, Brethorst’s friend left for another company job where he could get health insurance as an employee. “We’ve been talking about working together again at some point,” Brethorst said. “Once these provisions go into effect, it’s going to be significantly easier to go off and pursue his entrepreneurial dreams.”

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Rising

enough to qualify for tax subsidies to purchase insurance on the federal exchange. The gap exists because the Obama administration did not anticipate a U.S. Supreme Court ruling giving states the option to reject the Medicaid expansion. Individuals with an income of 100 percent to 400 percent of the federal poverty level would be eligible for government subsidies on the exchange, but Gatliff does not qualify because he earns less than 100 percent of the federal poverty level. He hopes the decision to extend Insure Oklahoma for one year gives the firstterm governor a chance to change her mind and agree to the Medicaid expansion.

SATURDAY, OCTOBER 5, 2013


18 SATURDAY, OCTOBER 5, 2013

Tradeoff Continued from 9

Sebelius said the average consumer will be able to choose among more than 50 plan options. “For millions of Americans, these new options will finally make health insurance work within their budgets,” Sebelius told reporters in a preview call Tuesday. The markets -- called “exchanges” in some states - are the only place where consumers will be able to get a tax credit for health insurance. HHS estimated that about 95 percent of consumers will have two or more insurers to choose from. And the administration says premiums will generally be lower than what congressional budget experts estimated when the legislation was being debated. About onefourth of the insurers participating are new to the individual coverage market, a sign that could be good for competition. But averages can be misleading. When it comes to the new health care law,

Timeline

AFFORDABLE CARE ACT individuals can get dramatically different results based on their particular circumstances. Where you live, the plan you pick, family size, age, tax credits based on your income, and even tobacco use will all impact the bottom line. All those variables could make the system hard to navigate. For example, the average individual premium for a benchmark policy known as the “second-lowest-cost silver plan” ranges from a low of $192 in Minnesota to a high of $516 in Wyoming. That’s the sticker price, before tax credits. In the three states with the highest uninsured population, the benchmark plan will average $373 in California, $305 in Texas, and $328 in Florida. Differences between states can be due to the number of insurers competing and other factors. “One surprise is Texas,” said Larry Levitt of the Kaiser Family Foundation. “That is a state that has put up roadblocks to implementation, but the premiums there are below average.” The second-lowest-cost silfor women as a preventive service, free of charge. The coverage became available in 2013, as lawsuits proliferated from groups and businesses objecting on religious grounds.

ver plan is important because tax credits are keyed to its cost in local areas. But consumers don’t have to take silver. They can pick from four levels of coverage, from bronze to platinum. All the plans cover the same benefits and cap annual out-of-pocket expenses at $6,350 for an individual, $12,700 for families. The big difference is cost sharing through annual deductibles and copayments. Bronze covers 60 percent of expected costs; silver, 70 percent, on up to platinum at 90 percent. Bronze plans have the lowest premiums and the highest cost sharing. As the Avalere study showed, premiums aren’t the only factor consumers should weigh. The flurry of new reports comes as the White House swings into full campaign mode to promote the benefits of the Affordable Care Act to a skeptical public. Republicans, meanwhile, refuse to abandon their quest to derail “Obamacare.”

their determination to repeal “Obamacare.” Former Massachusetts Gov. Mitt Romney, whose Continued from 5 state health law was seen as a model for Obama’s, poor. Enacted later, the fix says he’d sign an executive saved an estimated $13 order on Day One of his billion over 10 years. Oct. 14, 2011 — Sebelius presidency granting a Summer 2011 — Seniors pulls the plug on the ACA’s waiver to all 50 states. long-term care insurance hitting Medicare’s preprogram, because of doubts March 26-28, 2012 — scription drug coverage gap start getting a 50 per- over its long-term financial Supreme Court holds three solvency. The program was days of oral arguments on cent discount on brand the ACA. The administraname medications, part of a priority of the late the health care law’s grad- Massachusetts Democratic tion’s lawyer fumbles his Sen. Edward M. Kennedy. defense, and opponents ual closing of the “doughfeel momentum breaking nut hole.” In 2011, the typNov. 14, 2011 — The their way. ical senior in the gap Supreme Court announces saved about $600 on bills it will hear the constituJune 28, 2012 — With averaging $1,500. tional challenge to the the unlikely support of Aug. 1, 2011 — Sebelius, ACA, setting the stage for conservative Chief Justice John Roberts, the Supreme on the recommendation of an election-year decision. Court upholds the law’s an expert panel, declares core requirement that that most health plans will Fall/Winter 2011-2012 have to cover birth control — Republican presidential most Americans carry candidates are united in health insurance, ruling

In Brief • HEALTH INSURANCE COSTS: The Obama administration is unveiling premiums and plan choices for 36 states where the federal government is taking the lead to cover uninsured residents. New health insurance markets launch next week. • STICKER PRICES: Premiums for a mid-range benchmark plan will average $328 a month nationally for an individual. That is before tax credits that work like an upfront discount for most consumers. •VARIETY: But averages can be misleading. Consumers will be able to choose from an average of 53 plan options when the new markets open Oct. 1 for people who don’t have health care on the job. Individuals can get dramatically different results based on their circumstances. — Source: AP

that the penalties to enforce it are a tax Congress is authorized to levy. But the court allows states to individually opt out of the Medicaid expansion, which accounts for about half the law’s coverage expansion. Summer 2012 — Employers and consumers receive more than $1 billion in rebates from their insurers, which are required under the ACA to spend at least 80 cents of every premium dollar on medical expenses and quality improvement, or refund the difference.

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Glossary Continued from 4

mates, eventually will gain coverage through the law. The federal government will pay the full cost of the new coverage from 20142016, then phase down to 90 percent. Twenty-four states plus Washington, D.C., have accepted the expansion, according to AP’s count. Eight states are still considering it. And 18 have rejected it, including Texas and Florida, which have many uninsured residents. Many adults below the poverty level will remain uninsured in the refusing states. A state can change its decision at any time, but the full federal payment for the expansion is only available through 2016. Metal levels — The four levels of coverage available through exchange plans, called bronze, silver, gold, and platinum. Bronze plans feature the lowest monthly premiums, but cover only 60 percent of average costs. Platinum plans have higher

premiums and cover 90 percent of expected costs. Pre-existing condition — An ongoing or past health problem. Currently insurers can use pre-existing conditions to deny or restrict coverage, or charge more. Those practices will be barred by federal law starting Jan. 1, 2014, and insurers will have to accept all applicants. Tax credits — Government health insurance subsidies for individuals will come in the form of tax credits. The money will be paid directly to the consumer’s health plan, to help cover premiums. The subsidies are on a sliding scale based on income. Each year, people will have to “true up” with the IRS to make sure they got the right amount. People who receive too generous a tax credit may owe money back to the government. Tax penalty — The fine levied on individuals who disregard the individual insurance mandate. In 2014 it’s $95 or 1 percent of taxable income.

Speaker John Boehner says in an interview that “Obamacare is the law of the land.” His spokesman quickly adds that the Ohio Republican remains “committed to full repeal.”

simplified forms consumers will use to apply for health insurance and financial assistance to pay their premiums. The first version was criticized as too complicated.

Jan. 1, 2013 — Tax increases to finance the ACA take effect on about 2.5 million households, individuals making more than $200,000 per year and couples over $250,000.

July 2, 2013 — In a surprise, the White House announces a one-year delay — until 2015 — of the law’s requirement that companies with 50 or more workers must provide affordable coverage or pay fines. The administration says it’s trying to iron out burdensome reporting requirements.

Winter/Spring, 2013 — States decide whether they’ll run the new insurance markets and expand their Medicaid programs. The ACA advances mainly Nov. 6, 2012 — Obama is in blue states, while most re-elected to a second Republican-led states conterm, deflating Republican tinue to oppose the law. repeal hopes. April 30, 2013 — Obama Nov. 8, 2012 — House administration unveils

Oct. 1, 2013 — Online insurance markets are scheduled to open in every state. Consumers must sign up by Dec. 15 for coverage to take effect Jan. 1.


AFFORDABLE CARE ACT

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Obamacare

numbering supporters. Nonetheless, a Kaiser Family Foundation survey released over the weekend Continued from 2 found 56 percent of Americans disapprove of shielded from annual cutting off funding to budget battles. If other expand coverage for the government services are shut down, the health care uninsured, as congressionoverhaul can largely keep al Republicans are pressing to do. going — much like Social The poll also found that Security and Medicare. The federal government is people are in a fog about taking the lead in running what the law means for the new insurance markets them. Nearly three-fourths of the uninsured were in 36 states. unaware of the new insurPolls show the country ance markets opening to remains divided over the serve them. law, with opponents outIn states not expanding

Glance Continued from 5

get insurance through the individual or small-group plans. The law does not mandate this coverage for adults, but some states could choose to have them covered. Still, getting dental coverage for children and teenagers might be a bit complicated depending on where you live. States can

Premiums

SATURDAY, OCTOBER 5, 2013

19

Medicaid, millions of uninsured people below the federal poverty level will likely be shut out of coverage. That’s the case in Texas and Florida — both of which have large uninsured populations — and in many, but not all, Republican-led states. It’s because under the law, people below the poverty line — an individual making $11,490, a family of four $23,550 — can only get the new coverage through expanded Medicaid. And the Supreme Court gave states the right to opt out.

The other arm of “Obamacare’s” coverage expansion — subsidized private insurance through the new markets — is mainly geared to uninsured people in the middle class. The administration is hoping to sign up 7 million the first year. Young, healthy adults are prime customers, since they’ll help offset the cost of caring for sicker people sure to sign up once insurers can no longer reject them. Kevin Maass of Fairfax, has been uninsured for more than a year, since he

turned 26 and could no longer stay on his parents’ insurance. He’s got a background in statistics that he hopes to apply to criminology, but he’s been waiting tables while looking for a job in law enforcement. “Not having health insurance has made me a little bit more cautious,” said Maass. “I like to snowboard, but it’s given me second thoughts. Heaven forbid I should break my wrist or my arm.” Maass thinks he might be able to afford $100 to $200 a month for insur-

ance. Early indications are that he’ll find plenty of options. However, plans with the lowest premiums will have high deductibles and copayments, which means sizable out-of-pocket costs if he gets sick or has an accident. Nonetheless, Maass says he’s definitely planning to check out the health insurance market. “My parents have been pushing for me to get health insurance,” he said. “I might as well at least get something rather than pay (a fine) to not have anything.”

However, if you have what is known as a grandfathered individual plan -- a plan you buy yourself that was in existence before PRE-EXISTING March 23, 2010, and has CONDITIONS remained unchanged -then this rule would not This is a major change apply. So check the details under the law. Starting in on your plan and consider 2014, most plans -- whether shopping around. obtained through an employer or on the marketOUT-OF-POCKET place -- cannot deny coverSPENDING/LIMITS age or charge more money because of a pre-existing Under the law, the amount health conditions. of money people will have

to pay out-of-pocket each year for medical and prescription drug costs will be capped at $6,350 for individuals and $12,700 for a family. These limits are separate from the monthly premiums people pay. The limits take effect in 2014 for those buying insurance on the state health insurance exchanges. For those with employer-based coverage, the restrictions will be fully in place in 2015. In addition, most insurance plans will be prohibit-

ed from setting lifetime cost limits on coverage for essential health benefits. This means your insurer cannot deny you coverage because your medical bills have gone over a certain amount.

26. This also covers dependents, including step-children, adopted children and some foster children. This benefit will be required of all plans that provide dependent care. Starting in 2014, younger people can remain on a parent’s or caregiver’s plan even if they have an employer option of their own.

dent of the market analysis firm Avalere Health, said the focus on premiums is too narrow. “The analysis doesn’t account for cost sharing,” Mendelson said. “This is a limitation.” To get an idea of the true cost of coverage, consumers have to add up premiums and their expected out-of-pocket costs. “Consumers are going to need to shop,” Mendelson added. “Sometimes a silver offering doesn’t cost much more than a bronze.” He added two other caveats: Be ready for significant cost sharing, and check carefully that your doctors and nearby hospitals are in the plan’s network. Starting Jan. 1, virtually all Americans will be

required to carry health insurance or face fines. At the same time, the health care law will prohibit insurance companies from turning away people in poor health, or charging them more. And it will limit what insurers can charge their oldest customers. Experts say the plans under the health care law are not comparable to what’s currently sold on the individual health insurance markets, because the coverage is broader and the financial protection for policyholders is more robust. Obama is directly engaging in the promotional campaign for the health care law. Tuesday, he and former President Bill Clinton talked health care during a session sponsored by

choose to offer those items as stand-alone plans, and federal subsidies would not help pay for the costs.

The administration report found that factoring in tax credits, a 27-year-old making $25,000 a year would Continued from 3 see the premium for the credits are keyed to its cost benchmark silver plan drop to $145 in nearly every in local areas. But consumers don’t have state. But if that hypothetito take silver. They can pick cal young adult used the from four levels of coverage, tax credit to buy the cheapfrom bronze to platinum. All est bronze plan, he or she could cut the monthly prethe plans cover the same benefits and cap annual out- mium to $74 in the Dallasof-pocket expenses at $6,350 Fort Worth area, $102 in Orlando, and $119 in for an individual, $12,700 Pittsburgh. for families. For a family of four makThe big difference is cost ing $50,000, the tax credit sharing through annual would cut the monthly predeductibles and copaymium for the benchmark ments. Bronze covers 60 silver plan to $282. But if percent of expected costs; the family used its tax credsilver, 70 percent, on up to it to buy the cheapest platinum at 90 percent. Bronze plans have the low- bronze plan, the premium est premiums and the high- would be $26 a month in Dallas-Fort Worth, $126 in est cost sharing.

Orlando, and $209 in Pittsburgh. In the Washington, D.C., metro area, the hypothetical family could find a zero-premium bronze plan, while the lowest an individual could get after applying their tax credit would be $66. Such differences are sure to leave many people scratching their heads. Officials said they’re due to complicated interactions between the tax credits and insurance company pricing strategies in dynamic markets. Another outside analyst said the administration analysis of premiums is consistent with what the 14 states running their own insurance markets have reported. But Dan Mendelson, presi-

AGE 26

One popular provision of the health care law already is part of most insurance Associated Press writer plans -- allowing young peo- Catherine Lucey contributed ple to stay on their parents’ to this report. insurance plans until age

Clinton’s foundation. And Obama is planning a speech on the law on Thursday. In response to the administration’s premium and plan-choice information, a spokesman for Senate Republican leader Mitch McConnell, R-Ky., said that premiums that are “lower than projected” are not the same as “lower than they are now.” “The White House is making every effort possible to spin the bad news that seems to come every day, but the American people know that even this rosy scenario is not what they were promised when Democrats were ramming this bill through Congress on a party-line vote,” McConnell spokesman Don Stewart said in a statement.


20 SATURDAY, OCTOBER 5, 2013

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A guide to the Affordable Care Act