Category Archives: Michelle Andrews

Can I get my insurance to pay for an IUD removal?

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Question marksBy Michelle Andrews
KHN

Q. I have health insurance through my husband’s union. I need to have my IUD removed and replaced and it is not covered by insurance. The self-pay price is over $1,000. Is there anything I can do about this?

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A reader asks: Will a tax lien affect my premium tax credit?

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Question Q&ABy Michelle Andrews
KHN

Q. If I owe state and/or federal taxes and have a lien against me, and I apply for and receive a premium tax credit for health insurance on a state marketplace, will this have to be paid back at some future point?

A. There’s no clear guidance on this issue in the regulations, say tax experts. Continue reading

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Readers Ask: Are premium subsidies permanent; Do I have to meet an asset test tor Medicaid?

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Question Q&ABy Michelle Andrews, KH
January 10, 2014

Q. Are the subsidies under the health law a permanent fixture, or are they only required for the first two or three years, and then we’ll be expected to pay the full premium?

A. Unless Congress and the president enact a law repealing them, the subsidies are here to stay. The premium tax credits and cost-sharing subsidies that can make marketplace plans more affordable are written into the law as mandatory spending, says Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.) Continue reading

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Consumers shopping for coverage outside the marketplaces may be confused by mix of plans offered

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Illustration: Steve Goodwin/7rains

Illustration: Steve Goodwin/7rains

By Michelle Andrews

The state health insurance marketplaces that opened Oct. 1 give consumers who are looking for coverage on the individual market a whole new way to shop for health plans.

At the same time, health insurance brokers and insurers will also continue to sell plans directly to customers. Sorting out who’s selling what can be confusing.

What’s more, some brokers and insurers will not just sell policies that are outside the marketplaces. They may also offer marketplace plans and their customers may be eligible for subsidies for those marketplace plans. While shoppers can find good coverage going any of these routes, the plans and services offered may differ in important ways.

The Affordable Care Act has fundamentally changed the market for individual health insurance. In the past, insurers held nearly all the cards. In most states, they could turn applicants for coverage down if they had even minor pre-existing medical conditions.

The plans that were offered typically failed to cover common conditions such as pregnancy, and insurers generally faced few restrictions on the premiums they charged.

Starting in January, the individual market – including policies sold on the marketplaces and outside them — will become much more consumer-friendly and consistent. Insurers will no longer be allowed to deny coverage to people who are sick, and premiums will only be permitted to vary based on a few factors, including age, tobacco use, family size and where someone lives.

Every individual plan will have to cover a set of 10 comprehensive “essential health benefits,” including maternity and newborn care, hospitalization and prescription drugs, among other things.

Instead of myriad cost-sharing options, consumers will pick from four plan types: bronze plans will pay for 60 percent of medical expenses, silver plans will pay for 70 percent, gold plans 80 percent and platinum plans 90 percent. The maximum amount people will be on the hook for out-of-pocket will be capped at $6,350 for individuals and $12,700 for families.

Whether someone shops on the state marketplaces, also called exchanges, or outside them, these elements will be consistent among all plans starting in January.

The major difference between plans sold only outside the marketplaces by brokers and insurers and those that have been vetted and approved by a state exchange is that only exchange plans will make health law subsidies available to people with incomes up to 400 percent of the federal poverty level ($45,960 for an individual and $94,200 for a family of four in 2013).

But while marketplaces will sell only exchange plans, some brokers and insurers will sell both subsidized exchange plans and standard, non-subsidized individual market plans.

Brokers help consumers drill down for detailed plan information about participating providers and covered benefits, among other things, says Susan Rider, an independent insurance broker with Gregory & Appel Insurance in Indianapolis.

“Just because a plan covers autism benefits, it might not cover the specific benefits I need,” she says. “A consumer may not know to ask, but that’s where brokers come in.”

Still, consumer advocates say they’re concerned that brokers or insurers may not direct consumers first to all the exchange plans for which they could receive a subsidy to reduce their costs.

“I’d encourage anybody looking for a plan to go first to the exchange website and get a full sense of the range of options that are there,” says Sabrina Corlette, project director at Georgetown University’s Center on Health Insurance Reforms.

Insurance brokers and insurers who want to sell exchange plans must undergo training in order to do so. They typically receive a commission on plans that they sell for which they have an agreement with the insurer.

That happens for both plans sold on and off the exchange. Brokers that sell marketplace plans on the Internet must at a minimum provide consumers with the names of every available exchange plan. Other brokers don’t have to present all exchange plan options to consumers.

“They can steer people to the plans that they’re affiliated with and presumably know more about,” says Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation (KHN is an editorially independent program of the foundation.) “It’s not a reason for people not to use a broker, but it’s important for people to understand.”

Likewise, consumers who go directly to an insurer’s website will see all the exchange plans it offers, as well as a link to the marketplace, where they can see all exchange plans available from other insurers.

However, consumers might fail to consider all their options because they’d see just a single insurer’s plans first, says Cheryl Fish-Parcham, deputy director of health policy at Families USA, an advocacy group.

In addition to their expertise, there may be other reasons to consider shopping with a broker or insurer. For one thing, not all insurers are represented on the exchanges; in some cases the number may be very limited. Consumers who want to buy a policy from a particular insurer may need to shop outside the marketplace.

And for people whose income is close to or exceeds 400 percent of the federal poverty level, “it may not be worth the hassle of filling out the subsidy application and maybe changing your carrier and your provider,” says Carrie McLean, director of customer care for ehealthinsurance.com, an online web broker that has been authorized to sell exchange plans in the 34 states in which the federal government is running the exchanges or partnering with the states. “That’s going to be important for consumer choice.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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5 things to remember when shopping on the health insurance marketplaces

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The number five 5By Michelle Andrews

They’re here. The state health insurance marketplaces, a signature feature of the Affordable Care Act, open for business today. More than three years in the making, the marketplaces, or exchanges, allow consumers to compare a range of health plans online that meet the standards of the law, apply for subsidies and pick the best policy for their needs.

Here are a few things to keep in mind.

1. Don’t wait until the last minute to look for a plan.

Open enrollment lasts through March. If you’re uninsured and want coverage to start on Jan. 1, you must sign up by Dec. 15. But don’t wait until the day before to shop, say experts.

“Start early,” says Cheryl Fish-Parcham, deputy director of health policy at Families USA, a consumer advocacy organization. “If you have questions, that’ll give you time to ask them.”

With an estimated 7 million people expected to buy coverage through the exchanges, building in extra time into the enrollment process will also give you breathing room if, as expected, the marketplace experiences some glitches in processing your application, determining your eligibility for subsidies, and the like.

2. Look beyond the premium when figuring potential costs.

When you evaluate marketplace plans, consider your total potential financial exposure, including the plan’s deductible, copayments or coinsurance, and the maximum out-of-pocket amount you could be responsible for every year.

Exchange plans in every state will cover a similar package of 10 “essential health benefits,” but consumers’ proportion of the costs will vary: they’ll pay 40 percent of costs if they enroll in a bronze plan, 30 percent of costs in a silver plan, 20 percent in gold and 10 percent in platinum.

This year only, some plans may have separate deductibles for medical services and prescription drugs. And a recent analysis by Avalere Health of exchange plans in six states found significant variations in prescription drug cost sharing. Ninety percent of bronze-level plans it examined charged 40 percent coinsurance for drugs in tiers 3 and 4, which typically include pricey specialty drugs. Many silver level plans, in contrast, charged flat copayments averaging $70 for drugs in those tiers.

“Make sure the benefits are covered the way you want them to be … and look for limits on services,” says Kevin Lucia, a senior research fellow at Georgetown University’sCenter on Health Insurance Reforms.

3. Check provider networks.

It’s been widely reported that one of the ways that insurers have been able to keep premiums more affordable on the exchanges is by limiting provider networks. If it’s important to you that certain doctors or hospitals be in your network, check those details before signing up.

Smaller isn’t necessarily less desirable, say experts. “If all your providers participate in a narrow network, it’s not a problem,” says Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

4. Estimate your income carefully.

Roughly 80 percent of people who buy exchange plans will qualify for premium tax credits, according to Avalere Health. The credits, available to people with incomes up to 400 percent of the federal poverty level ($45,960 for an individual or $94,200 for a family of four in 2013) will be based on your projected income for next year. They can be sent directly to the insurer, reducing your monthly premium. If your income estimate is too low, however, you could have to repay at tax time any excess amounts you received.

It will be important to monitor your income during the year. Inform the exchange promptly if it changes and you realize your estimate was too high or too low so your tax credit can be adjusted.

5. Don’t be fooled by lookalike websites.

In a handful of states, experts have already encountered websites that look like official state marketplace sites but aren’t. Now that the marketplaces are open, they expect more of these sites to crop up.

“Some could be deceptive but fairly benign [sites] designed to sell legitimate insurance products,” says James Quiggle, a spokesperson at the Coalition Against Insurance Fraud. “Other sites could be malicious and intended to steal your identity.”

One surefire way to ensure that you’re visiting the official health insurance marketplace for your state is through healthcare.gov.  If you live in one of the 34 states in which the federal government is operating the state exchange, you’ll be directed to information about how to get started picking a plan. If you live in one of the 16 states and the District of Columbia that operate their own state exchange, you can link to your state exchange through the federal website.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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What options do parents have to get coverage for their kids?

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An umbrella sheltering medicines - credit MicrosoftBy Michelle Andrews

As the October launch of the state health insurance marketplaces approaches, parents have many questions about covering their children.

Q. Why is it that the adult children of retired members of the military cannot stay on their parents’ insurance? My husband served for 22 years in the Marine Corps. My adult children are still in college, but they have been dropped from our insurance, Tricare Prime.

A. The Affordable Care Act allows adult children to stay on their parents’ health plan until they reach age 26 in most cases.

But Tricare, the health plan for military service members, is governed by a different set of statutes, and the ACA’s provisions that expand young adult coverage don’t apply to it.

Tricare allows dependent children to remain on their parents’ plan until they turn 21, or until they turn 23 if they’re full-time students who are supported financially by their parents, according to Austin Camacho, chief of the benefit information and outreach branch of Tricare Management Activity.

Once adult children are no longer eligible for regular Tricare, they can enroll in the Tricare Young Adult program, which provides coverage for children up to age 26 who are unmarried and don’t have employer coverage available to them, says Camacho.

Unlike regular Tricare, however, the young adult program is a premium-based plan that costs up to $180 per month.

Q. I am a divorced dad who has responsibility for maintaining my 15-year-old daughter’s health insurance. It was easy when I was working and had a corporate health plan. Now that I am retired and in the Medicare program, I am looking for alternatives when the new exchanges open in October. Can I buy health insurance for just my underage daughter on these new exchanges?

A. Yes, you can. The new health insurance marketplaces, also called exchanges, are required to sell child-only policies for children up to age 21.

If you claim your daughter as a dependent on your tax return and your income is less than 400 percent of the federal poverty level ($62,040 for a family of two in 2013), you may qualify for a premium tax credit to reduce the cost of coverage.

If your ex-wife claims your daughter as a dependent, however, in order to receive the tax credit she would have to apply for it based on her household income, says Brian Haile, a senior vice president for health policy at Jackson Hewitt Tax Service in Nashville.

Depending on your income, your daughter might qualify for health insurance through your state’s Medicaid or CHIP programs for lower income people.

As of January 2013, all but four states covered children in families with incomes up to at least 200 percent of the federal poverty level ($31,020 for a family of two in 2013) through one of those programs, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Q. My 21-year-old son is a college student, and I know the Affordable Care Act has made him eligible to remain on my employer-based insurance plan until age 26. However, if it’s cheaper for him to get subsidized coverage through the health insurance marketplace, can he do so?

A. It depends. Almost anyone can shop for coverage on the health insurance marketplace. But your son will only be eligible for subsidies to reduce the cost of coverage under certain circumstances.

If you don’t claim him as a dependent on your tax return and his own income is between 100 and 400 percent of the federal poverty level ($11,490 and $45,960 in 2013), he could be eligible for premium tax credits on the exchange.

But if you do claim him as a dependent, his eligibility for subsidies will be based on your family’s income, not just his own.

It’s also worth looking into Medicaid eligibility for your son. Roughly half of states have decided to expand Medicaid coverage to adults with incomes up to 138 percent of the federal poverty level ($15,856 for an individual in 2013) as provided for under the Affordable Care Act. Medicaid would be even less expensive than a private plan on an exchange.

But if you claim your son as a dependent on your tax return, your family’s income would have to be no more than 138 percent of poverty in order for him to qualify, says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Benefits on health marketplace will be similar but costs will vary

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By Michelle Andrews

Shopping CartAs the state health insurance marketplaces, also called exchanges, get set to launch in October, many people have questions about the coverage that will be offered there. Here are a few that were posed to me recently.

Q. Are there unintended consequences of shopping through an exchange? For example, are the benefits of a plan with a lower monthly premium less comprehensive than the benefits of an expensive plan? And are there plans available only to people who qualify for subsidies, so that once income increases, the consumer must switch to a different plan?

A. All plans sold on the exchanges must cover 10 so-called essential health benefits, including prescription drugs, emergency and hospital care, and maternity and newborn care.

For the most part, the plans will differ not in which benefits they cover but in the proportion of costs that consumers will be responsible for paying.

There will be four basic types of plans: Platinum plans will pay 90 percent of the cost of covered medical services, on average, while consumers will be responsible for 10 percent; gold plans will pay 80 percent; silver plans will pay 70 percent; and bronze plans, 60 percent. Premiums will vary based on those percentages, so platinum plans generally will be pricier than bronze ones.

Individuals and families with incomes up to 400 percent of the federal poverty level ($45,960 for an individual and $94,200 for a family of four in 2013) may be eligible for federal tax credits to help pay premiums.

Consumers “can use the premium subsidy to purchase any plan,” says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities.

If your income increases during the year, you may no longer qualify for the same level of assistance, but you won’t have to switch plans.

However, you may have to repay any overpayments that were made to insurers if your projected income turns out to be higher than your actual income.

On the other hand, if your income falls, you may be eligible for a larger tax credit. That’s why it’s important to report any income changes to the exchange promptly.

second type of subsidy available on the exchanges will reduce the amount that people owe in co-payments, deductibles and other out-of-pocket costs. The cost-sharing subsidy is available to individuals and families with incomes up to 250 percent of the poverty level ($28,725 for an individual and $58,875 for a family of four in 2013).

To qualify for this subsidy, you must buy a silver plan, Park says. If your income changes, however, you won’t be responsible for any overpayments.

Q. Once the exchanges open, how much will an insurer be allowed to increase premiums annually? And are those increases based on claims?

A. Premium increases are driven by many factors, including medical costs and the health of the people covered by a particular plan.

The Affordable Care Act discourages insurers from imposing unreasonable premium increases in a couple of ways. Insurers in the small-group and individual markets that want to raise premiums by 10 percent or more must submit data, projections and other information to justify the increase to state or federal regulators, who review the requests and make the information available to the public.

Asking insurers to justify why they want to increase rates should act as a deterrent to unreasonable increases, experts say.

But the law doesn’t give regulators new authority to refuse rate increases, says Timothy Jost, a law professor at Washington and Lee University in Lexington, Va. It does, however, provide funding for states to beef up their rate-review processes.

The Department of Health and Human Services says that increased scrutiny of insurance rates has led to a decrease in rate increases, says Jost, “and that’s probably true.”

In addition, the law requires insurers to spend at least 80 percent of the money they collect in premiums on medical claims and quality improvements rather than on administrative activities such as marketing. If they exceed that limit, they must rebate the excess to consumers.

Insurers will return $500 million to 8.5 million consumers — about $100 per eligible family — by mid-August of this year for overcharges in 2012, according to the Obama administration. Rebates may come in various ways, including a check or a reduction in the following year’s premium.

Q. My parents are legal immigrants over 65 but not yet eligible to buy into Medicare because they haven’t lived in the United States for five years. Will they be able to buy health insurance on the federal exchange?

A. Yes, legal immigrants will be able to shop for coverage on the exchanges, where they may be eligible for premium tax credits if their income is no more than 400 percent of the federal poverty level ($62,040 for a couple in 2013).

Immigrants living in the United States without legal permission, on the other hand, are not permitted to buy coverage on the exchanges even if they wish to pay the entire premium out of pocket.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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‘Will my family be eligible for subsidized coverage?’

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Question marksBy Michelle Andrews

This week, I respond to reader questions about coverage subsidies for families under the Affordable Care Act, filling the gaps in Medicare coverage and laws governing health plans in companies that conduct business in more than one state.

Q. I expect the annual premium for my company’s group plan to be about $24,000, or 50 percent of my family’s income. Will my family be eligible for subsidized coverage on the state insurance exchanges in 2014, provided we meet the poverty-level requirements?

A. It depends. Under the Affordable Care Act, companies with 50 or more workers must offer health insurance coverage that is both affordable and adequate; otherwise, their workers may be eligible for subsidized coverage on the online health insurance exchanges if their income is less than 400 percent of the federal poverty level ($94,200 for a family of four in 2013).

A plan is considered adequate if it covers at least 60 percent of an employee’s covered medical expenses and affordable if the cost for employee-only coverage doesn’t exceed 9.5 percent of a worker’s income.

Some consumer advocates argued that the 9.5 percent test should also apply to the cost of family coverage, which is generally much more expensive than employee-only coverage.

But in a final rule issued in February, the Internal Revenue Service said that it would not consider the premium for family coverage in determining affordability.

If the premium for employee-only coverage at your company is less than 9.5 percent of your income, your family may be out of luck.

“The whole family could be barred from premium tax credits on the exchange,” says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities.

Depending on family income and size, however, the kids could be eligible for coverage under their state’s Medicaid or CHIP program, Park says.

Q. I am turning 65 in October. I will be selecting a Medigap policy to cover the cost of the coinsurance for charges not covered by Medicare. Are there changes planned in 2014 to govern Medigap costs? And what happens if I choose to change my Medigap policy after one year? Will insurers examine my medical history to determine whether to cover me?

A. Approximately one in four Medicare beneficiaries has a Medigap supplemental policy to cover the gaps in Medicare coverage, including deductibles and 20 percent coinsurance for many charges. Several of the most popular policies cover all of beneficiaries’ deductibles.

In recent years, as part of the effort to bring down the federal deficit, federal officials and policy experts have made several proposals to increase cost-sharing on supplemental policies.

The thinking is that if seniors had to pay for some of the costs of care, they would be more careful in their medical decisions, thus saving Medicare money.

To date, none of those plans has been adopted, and experts say they don’t anticipate major changes anytime soon.

“We do not see any significant changes…in 2014,” says Dan Mendelson, CEO of Avalere Health, a research and consulting firm with experience in Medicare.

After you turn 65 and enroll in Medicare Part B, there’s a six-month open enrollment period during which beneficiaries can sign up for a Medigap policy without having medical conditions taken into account. If you decide to switch plans later on, however, insurers don’t necessarily have to issue you a policy.

Q. I work for a company that is based in one state but has stores in several states. I belong to the company’s group health plan. Which state laws govern my policy — that of the home office or that of the state where I work?

A. Chances are good that your company plan is self-funded, meaning your employer pays for workers’ health-care claims directly rather than contracting with an insurer.

The bigger the company, the more likely it is to be self-funded. Eighty-one percent of workers at companies with 200 or more employees are in a self-funded plan, compared with 15 percent of workers at smaller firms, according to the Kaiser Family Foundation’s 2012 survey of employer-sponsored health benefits. (Kaiser Health News is an editorially independent project of the Kaiser Family Foundation.)

If your company is self-funded, it doesn’t matter where it’s based because self-funded health plans are not subject to state insurance laws.

So, for example, it wouldn’t have to comply with state coverage mandates that require health plans to provide certain benefits, such as treatment for autism or infertility.

Because large companies often provide relatively generous benefit packages anyway, the impact of those exceptions on workers may be small, say experts.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Group appointments with doctors: When three isn’t a crowd

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Photo: Sigurd Decroos

Photo: Sigurd Decroos

By Michelle Andrews

When visiting the doctor, there may be strength in numbers.

In recent years, a growing number of doctors have begun holding group appointments — seeing up to a dozen patients with similar medical concerns all at once.

Advocates of the approach say such visits allow doctors to treat more patients, spend more time with them (even if not one-on-one), increase appointment availability and improve health outcomes.

Some see group appointments as a way to ease looming physician shortages. According to a study published in December, meeting the country’s health-care needs will require nearly 52,000 additional primary-care physicians by 2025.

More than 8,000 of that total will be needed for the more than 27 million people newly insured under the Affordable Care Act.

“With Obamacare, we’re going to get a lot of previously uninsured people coming into the system, and the question will be ‘How are we going to service these people well?’ ” says Edward Noffsinger, who has developed group-visit models and consults with providers on their implementation. With that approach, “doctors can be more efficient and patients can have more time with their doctors.”

Some of the most successful shared appointments bring together patients with the same chronic condition, such as diabetes or heart disease.

For example, in a diabetes group visit, a doctor might ask everyone to remove their shoes so he can examine their feet for sores or signs of infection, among other things.

A typical session lasts up to two hours. In addition to answering questions and examining patients, the doctor often leads a discussion, often assisted by a nurse.

Some of the most successful shared appointments bring together patients with the same chronic condition, such as diabetes or heart disease

.Insurance typically covers a group appointment just as it would an individual appointment; there is no change in the co-pay amount. Insurers generally focus on the level of care provided rather than where it’s provided or how many people are in the room, Noffsinger says.

Some patients say there are advantages to the group setting. “Patients like the diversity of issues discussed,” Noffsinger says. “And they like getting 2 hours with their doctor.”

Patients sign an agreement promising not to disclose what they discuss at the meeting. Although some patients are initially hesitant about the approach, doctors say their shyness generally evaporates quickly.

“We tell people, ‘You don’t have to say anything,’ ” says Edward Shahady, medical director of the Diabetes Master Clinician Program at the Florida Academy of Family Physicians Foundation in Jacksonville.

Shahady trains medical residents and physicians to conduct group visits with diabetes patients. “But give them 10 minutes, and they’re talking about their sex lives.”

Though group appointments may allow doctors to increase the number of patients they see and thereby boost their income, many doctors are uncomfortable with the concept, experts say, because they’re used to taking a more authoritative approach with patients rather than facilitating a discussion with them.

According to the American Academy of Family Physicians, 12.7 percent of family physicians conducted group visits in 2010, up from 5.7 percent in 2005.

Some studies have found that group visits can improve health outcomes. In an Italian trial that randomly assigned more than 800 Type 2 diabetes patients to either group or individual care, the group patients had lower blood glucose, blood pressure, cholesterol and BMI levels after four years than the patients receiving individual care.

 ” . . . give them 10 minutes, and they’re talking about their sex lives.”

Doctors say patients may learn more from each other than they do from physicians. “Patients really want to hear what others patients are experiencing, ” Shahady says.

Jake Padilla of Westminster, Colo., participated in his first group visit more than a decade ago, shortly after he had heart bypass surgery.

Padilla, now 67, continued to attend group appointments geared to primary-care patients’ concerns for years after that at the Kaiser Permanente outpatient clinic near his home. (Kaiser Health News is not affiliated with Kaiser Permanente.) He usually went once a month or so, and the members of the group constantly changed.

One woman who attended the group was 102 years old, he remembers. Fellow patients wanted to know how she managed to live that long. One of her secrets, she said, was deep breathing. Padilla has since used that advice when his blood pressure gets out of control.

But group visits aren’t for everyone. Padilla’s wife, Tedi, went to one meeting with him and never went back.

“She said she didn’t have time to sit there and listen to all those patients,” he says.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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New coverage may spur younger women to use long-acting contraceptives

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Mirena_IntraUterine_SystemBy Michelle Andrews

Even though they’re more effective at preventing pregnancy than most other forms of contraception, long-acting birth-control methods such as intrauterine devices and hormonal implants have been a tough sell for women, especially younger ones.

But changes in health-care laws and the introduction of the first new IUD in 12 years may make these methods more attractive. Increased interest in the devices could benefit younger women because of their high rates of unintended pregnancy, according to experts in women’s reproductive health.

IUDs and the hormonal implant – a matchstick-sized rod that is inserted under the skin of the arm that releases pregnancy-preventing hormones for up to three years — generally cost between $400 and $1,000.

The steep upfront cost has deterred many women from trying them, women’s health advocates say, even though they are cost-effective in the long run compared with other methods, because they last far longer.

Under the Affordable Care Act, new plans or those that lose their grandfathered status are required to provide a range of preventive benefits, including birth control, without patient cost-sharing.

Yet even when insurance is covering the cost of the device and insertion, some plans may require women to pick up related expenses, such as lab charges.

Long-acting reversible contraceptives (LARCs) require no effort once they’re put into place, so they can be an appealing birth-control option for teens and young women, whose rates of unintended pregnancy are highest, experts say.

Across all age groups, nearly half of pregnancies are unintended, but younger women’s rates are significantly higher, according to a  2011 study from the Guttmacher Institute, a reproductive health research organization.

Eighty-two percent of pregnancies among 15- to 19-year-olds were unintended in 2006, and 64 percent of those among young women age 20 to 24 were unintended, the study found.

Although the use of LARCs has more than doubled in recent years, it is a small part of the contraceptive market. Among women who use birth control, 8.5 percent of women used one of those methods in 2009, according to the Guttmacher Institute.

The use of LARCs by teenagers was significantly lower at 4.5 percent, while 8.3 percent of 20- to 24-year-olds chose this type of contraception.

In October, the American College of Obstetricians and Gynecologists reiterated its strong support for the use of LARCs in young women.

Yet many young women are unaware that long-acting methods could be good options for them, in part because their doctors may be reluctant to prescribe them, experts say.

That is partly the legacy of the Dalkon Shield, an IUD that was introduced in the 1970s whose serious defects caused pain, bleeding, perforations in the uterus and sterility among some users. The problems let to litigation that resulted in nearly $3 billion in payments to more than 200,000 women.

In addition, providers may hesitate because there’s a slightly higher risk that younger women will expel the device, experts say.

But expulsion is a problem more likely associated with the size of the uterus, which is not necessarily related to a patient’s age, says Tina Raine-Bennett, research director at the Women’s Health Research Institute at Kaiser Permanente Northern California and chairwoman of the ACOG committee that released the revised opinion on LARCs. “Expulsion is only a problem if it goes unrecognized.” (Kaiser Health News is not affiliated with Kaiser Permanente.)

The new IUD Skyla became available in mid-February. It is made by Bayer, the same company that makes Mirena, another IUD sold in the United States.

Unlike Mirena, which is recommended for women who have had a child, Skyla has no such restrictions (nor does ParaGard, the third type of IUD sold here).

Mirena is currently the subject of numerous lawsuits alleging some complications, such as device dislocation and expulsion.

Skyla is slightly smaller than the other two IUDs on the market and is designed to protect against pregnancy for up to three years, a shorter time frame than the others.

This shorter time frame may make Skyla more attractive to younger women who think they may want to get pregnant relatively soon, some experts say, although any IUD can be removed at any time.

“More providers are spreading the word that it’s okay, and more young women are demanding it,” says Eve Espey, a professor of obstetrics and gynecology at the University of New Mexico.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Observation units can improve care but may be costly for patients

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Hospital Entrance SignBy Michelle Andrews

There’s a growing recognition by clinicians that some patients who arrive at the emergency department can benefit if they’re kept under observation for up to a day so that staff can run more tests and monitor their progress to see if their condition is improving or deteriorating.

Unfortunately, many hospitals and insurers haven’t set up their clinical and billing systems or insurance contracts with these patients’ needs in mind.

Not only does this result in a longer stay in some cases, but it also can cause confusion for patients and bigger patient bills. Many experts say that the problem is likely to get worse.

More than a third of hospitals report having an  observation unit today, double the 19 percent that reported having one in 2003.

Experts say that the most effective observation units have a dedicated staff that follows clearly defined protocols. Rather than send a patient home who is at high risk for a heart attack following an emergency department visit because of chest pain, for example, staff might refer him to an observation unit for repeat blood tests, EKGs and a stress test.

A patient with severe asthma who needs time and medication to get an attack under control might be sent to the observation unit for several hours.

By monitoring and treating patients intensively upfront, observation unit staff can forestall problems and help people get better faster. Patients typically stay less than a day, though some may remain longer.

“These are patients who fall between the cracks,” says Michael Ross, an emergency physician who is director of observational medicine at Emory University School of Medicine in Atlanta. “They need more than an emergency department visit, but if managed practically they often need less than 24 hours of care.”

Shorter hospital stays can result in lower hospital costs. But hospital savings don’t necessarily translate into lower costs for patients.

Shorter hospital stays can result in lower hospital costs. A study that Ross co-authored on emergency department patients who had had a transient ischemic attack – a temporary interruption of blood flow to the brain that causes stroke-like symptoms and is sometimes a harbinger of a true stroke — showed that those who were referred to an observation unit were discharged nearly 38 hours sooner than those who were admitted as inpatients. Observation unit patients also cost the hospital less: The median amount was $2,092 versus $4,922.

But hospital savings don’t necessarily translate into lower costs for patients. Insurers treat care provided in an observation unit as outpatient care. That often means patients pay a la carte for every X-ray, blood test or scan.

In contrast, if patients are admitted as inpatients, they may owe only a single co-payment, after which all or nearly all services are covered. And for Medicare patients, being assigned to observation care rather than inpatient care can bring higher drug bills and affect coverage of subsequent nursing home care.

Part of the problem is that many hospitals that place patients on observation status don’t necessarily have a designated unit where such patients are treated.

Instead, they may place emergency department patients on observation status and put them in a bed on one of the regular inpatient hospital floors.

Such patients frequently don’t receive the care based on clearly defined protocols shown to be successful in designated observation units, experts say.

Adding to the confusion, the patient may think he’s been admitted and not realize he’s going to be billed for outpatient rather than inpatient care.

“It’s a terribly inefficient way to provide observation services,” Christopher Baugh, medical director of the emergency department observation unit at Brigham and Women’s Hospital in Boston, says of care that isn’t provided in a separate unit. “It’s also difficult to communicate [the difference] to patients who are in an inpatient area and sharing a room with an inpatient and spending sometimes a long time there.”

But the arrangement can be attractive to hospitals. Placing patients on observation status and putting them in a bed somewhere in the hospital reduces crowding in the emergency department.

It may also reduce the number of admissions. The Centers for Medicare & Medicaid Services and private insurers are monitoring hospital admissions closely and have been retroactively denying payment if they determine an admission wasn’t warranted.

“We’re going to see an explosion in observation status,” says Arthur Kellermann, a physician and senior researcher at Rand, a public policy research organization. Under the Affordable Care Act, hospitals with high readmission rates for Medicare patients with pneumonia, heart attack or heart failure are financially penalized.

The health law could prompt hospitals to use the observation designation with more patients, even if they don’t receive special care, say experts.

Unfortunately, the “complexity of this fragmented, loophole-ridden payment system has taken one of the best ideas in medicine and made it confusing to patients and doctors,” Kellermann says. “It could undermine what is one of the best ideas in health care.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Please send comments or ideas for future topics for the Insuring Your Health column to:

questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Answers to readers’ questions about health insurance

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By Michelle Andrews

This week, I am answering readers’ questions about maternity coverage requirements in the new health insurance exchanges, long-term-care insurance and switching employer health plans.

Q. Under the Affordable Care Act, will all plans have to cover maternity benefits in 2014? I do not want maternity coverage. Will I have the option to decline maternity coverage in an individual plan?

A. Maternity and newborn care are together considered one of the 10 “essential health benefits” that most individual and small-group plans sold on the state-based health insurance exchanges and the private market will be required to offer in 2014. (If the plans have grandfathered status under the law, they’ll be exempt, however.) Declining coverage will not be an option.

This requirement will bring small-group and individual plans into line with the coverage that’s already required under the Pregnancy Discrimination Act for companies with 15 or more workers, says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a research and policy center on issues of sexual and reproductive health.

“Not offering maternity coverage when you cover other types of care is sex discrimination,” he says. “The Affordable Care Act is trying to close that loophole.”

From a practical standpoint, there’s another consideration. Insurance is intended to protect people against the unexpected, explains Sonfield. Nearly half of all pregnancies are unintended, according to the federal Centers for Disease Control and Prevention.

“Pregnancy happens,” he says. “They’re not always planned.”

Q. If I purchase a long-term-care insurance policy in my 60s and don’t need to use it for another 10 or 20 years, what happens in the event that the company that I’ve contracted with goes out of business or changes corporate structure and assumes a different identity? Are there any states that have protections in place for cases like this?

A. Every state and the District have life and health insurance guaranty associations that protect consumers if they buy a long-term-care policy from an insurer that later fails.

Funded by insurers that do business in a state, the associations ensure that coverage continues and benefits are provided even if an insurer is no longer in existence.

The associations do this by either taking over the policies themselves or placing them with another, healthy insurer.

Insolvencies are uncommon but not unheard of, says Bonnie Burns, a policy specialist at California Health Advocates, a Medicare advocacy and education organization.

There is one potential wrinkle, however, she says. Although your coverage and benefits will continue if your insurer fails, each state caps the maximum amount that policies taken over by the guaranty association pay out, typically between $100,000 and $300,000.

It’s much more common for insurers to change hands or sell their long-term-care insurance business than to shut down. If that happens, your coverage shouldn’t be jeopardized.

“It doesn’t affect the policy,” Burns says. “That’s a legally binding contract that’s guaranteed under state law.”

Q. My family and I are members of my employer’s health insurance plan. We are considering opting out at the next available opportunity and switching to the plan offered by my spouse’s employer. However, my employer has recently decided that soon employees will no longer be allowed to opt out and that all of those who opted out in the past will be recalled. Can they do that?

A. If both spouses have health insurance through their jobs, they can generally choose the plan that best meets their needs. Switching from one plan to the other is typically allowed, although there may be enrollment periods or other rules.

The experts I asked think that your employer’s decision to soon disallow opting out may be a misreading of a provision of the health law.

Under the law, most people are required to have health insurance starting in 2014 or pay a penalty. A provision in the law requires employers with more than 200 employees to automatically enroll employees in a company health plan, although the government has announced it is pushing back implementation of that requirement. Employees can decline the coverage if they choose.

The provision applies to new full-time employees and to current employees who are enrolled in a company plan. Your employer appears to believe the law applies to any current employee, including those who may have opted out in the past.

That’s not what the law says, according to J.D. Piro, a senior vice president at Aon Hewitt who leads the firm’s health law consulting group.

“There’s nothing in the law about recalling previous opt outs,” he says.

Originally, the Department of Labor was to have issued rules about implementing automatic enrollment by 2014, but that process has been delayed, according to DOL.  The department says it “has concluded that its automatic enrollment guidance will not be ready to take effect by 2014.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Health law offers dental coverage guarantee for some children

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Child having teeth examined at dentistsBy Michelle Andrews

Tooth decay is the most common chronic health problem in children. By the time they enter kindergarten, more than a quarter of kids have decay in their baby teeth.

The problem worsens with age, and nearly 68 percent of people age 16 to 19 have decay in their permanent teeth, according to the Centers for Disease Control and Prevention.

Starting in 2014, the Affordable Care Act requires that individual and small-group health plans sold both on the state-based health insurance exchanges and outside them on the private market cover pediatric dental services. However, plans that have grandfathered status under the law are not required to offer this coverage.

The requirement also doesn’t apply to health plans offered by large companies, although they are much more likely to offer dental benefits than small firms.

Eighty-nine percent of firms with 200 or more workers offered dental benefits in 2012, compared with 53 percent of smaller firms, according to the Kaiser Family Foundation’s annual survey of employers health plans. (Kaiser Health News is an independent project of KFF.).

The changes in the health law apply specifically to children who get coverage through private plans. Dental services are already part of the benefit package for children covered by Medicaid, the state-federal health program for low-income people.

But many eligible kids aren’t enrolled, and even if they are, their parents often run into hurdles finding dentists who speak their language and are willing to accept Medicaid payments.

The health law encourages states to expand Medicaid coverage for adults, which advocates say will have the added benefit of probably bringing more children into the system. Despite the challenges, advocates say they anticipate that many low-income children will gain dental coverage.

Dental health advocates say they’re pleased that pediatric dental services (along with other pediatric care) were included among the 10 “essential health benefits” that new health plans must cover in the exchanges and the small-group and individual markets under the law.

When it comes to health care, “oftentimes the mouth is separated from the body,” says David Jordan, dental access project director at Community Catalyst, a consumer health-care advocacy organization in Boston.

Poor oral health care can have a significant impact on overall health, causing pain and weight loss, missed school days and reduced self-esteem, say experts.

Still, some advocates are concerned that the new benefits may not be sufficiently comprehensive or affordable.

Specific coverage requirements will be determined by each state within guidelines set by the federal Department of Health and Human Services.

HHS guidance to date suggests that medically necessary orthodontia — to correct a problem with chewing, for example — may be required in addition to preventive and restorative care.

Dental coverage may be embedded in a medical plan that’s sold on the exchanges or offered on a stand-alone basis.

In private dental plans, preventive care such as teeth cleanings, topical fluoride and sealants are typically covered at 100 percent, but such other services as fillings, crowns and root canals require patients to pay up to half the cost, and coverage maxes out at about $1,500 a year.

Under the health-care law, pediatric dental health coverage sold on the exchanges cannot have annual or lifetime limits on coverage.

But families who buy dental coverage on an exchange may be subject to an annual out-of-pocket cost-sharing limit of up to $1,000 for dental care. A rule proposed by HHS suggests there be a “reasonable” annual limit. The National Association of Dental Plans has proposed $1,000. Experts expect that the final rule, when issued, will clarify the amount.

“That would be on top of whatever out-of-pocket limit people are already facing [for medical coverage],” says Colin Reusch, senior policy analyst at the Children’s Dental Health Project, who co-authored a recent report on the health law’s pediatric dental benefit. “We see that as being in conflict with what the law intends.”

Evelyn Ireland, executive director of the National Association of Dental Plans, says families who need expensive dental care such as braces may fare better in dental plans sold on the exchanges than in the plans many employers currently offer.

Nationwide, medically necessary orthodontia costs roughly $6,500 per person, Ireland says. Currently, if a private dental plan covers orthodontia, the benefit typically covers 50 percent of the cost, up to a lifetime limit of $1,000 or $1,500. “So it ends up basically being a down payment,” she says.

Assuming braces are a covered benefit, the family of a child with dental coverage through an exchange might have to pay the maximum out-of-pocket limit — $1,000, perhaps — and owe nothing more that year for the child’s dental care. But any other expenses would be covered, since plans can’t have dollar limits on coverage.

That unlimited coverage will probably add to the premium for pediatric dental coverage, however.

Ireland’s group asked the benefits consultant firm Milliman to estimate how much pediatric dental premiums might change if the coverage provisions of the law were incorporated.

Milliman estimated that premiums currently range from $21 to $25 per child per month, depending on whether a plan covers orthodontia services, among other things. After incorporating the health law’s requirements, Milliman projected that premiums would probably rise to $34 a month, Ireland says.

“That’s a nine-dollar-to-13-dollar-a-month jump, which is a pretty significant increase for a family,” she says.

Please send comments or ideas for future topics for the Insuring Your Health column toquestions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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When employers’ health plans disappear, workers often have few options

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An umbrella sheltering medicines - credit MicrosoftBy Michelle Andrews

For some people, the promise of employer-provided health insurance is reason enough to take a job or stay put in one. But unexpected events — a corporate bankruptcy or sale, for example — can undermine the security of on-the-job coverage and leave both employees and retirees with few affordable options.

Starting in 2014, the Affordable Care Act will make it easier for people who lose their job-based coverage to get comprehensive health insurance at a price they can afford through the state-based health insurance exchanges.

For Robin Hunt, however, 2014 seems like a long way off. Diagnosed with breast cancer two years ago, Hunt, 57, had been insured through her husband’s employer, a construction company near their home in Tyler, Tex.

The couple finds their plan very expensive: They pay a premium of $240 a week to cover both of them, and they have a $5,000 deductible.

Last year, Hunt caught viral pneumonia; they are still paying off the out-of-pocket expenses from that illness. But the plan helps Hunt cover the cost of follow-up care and pay for several medications, including Arimidex, a drug that helps reduce the likelihood of a recurrence of her breast cancer.

In December, the Hunts learned that their premium would rise to $400 a week. Then they got even worse news: The company said it couldn’t find enough people to sign up for the plan among the firm’s 50 employees and their family members, and so coverage would end on Dec. 31.

Hunt fears that with her cancer history, buying a plan on the individual market will be impossible. “I don’t know what I’m going to do or where I’m going to turn,” she said in an interview. “I shudder not to have insurance for the first time in my life.”

Under a 1996 federal law known as HIPAA, people who lose their group coverage and don’t have other health insurance options may be eligible for guaranteed individual coverage in a state-designated plan without facing preexisting condition exclusions.

Similarly, some states require that some people who lose their group coverage be offered a “conversion policy” that lets them convert their group coverage into an individual plan. But benefits in these plans may not be as good as those in the group plan, and their prices may be high, experts say.

“In most states, there’s no limit on how much more a HIPAA policy can cost than a regular plan,” says Cheryl Fish-Parcham, deputy director of health policy at Families USA, a consumer advocacy group. “The plans often only include high-risk people, and rates are high.”

The couple is not eligible to retain their insurance through COBRA, a federal law that allows workers at companies with 20 or more workers to pay the full price of their employer-sponsored coverage for 18 months after they are laid off or leave their job.

In Hunt’s case, her husband is remaining in his job but the health plan is being discontinued. So there is no job loss and no health plan to continue with, even if they wished to buy it.

Other types of corporate changes can also spell trouble for employee health insurance plans.

For example, if a company is reorganizing under Chapter 11 of the bankruptcy code and plans to continue operating, the health-care plan may change but often continues to operate, says Tom Billet, a senior consultant at human resources consultant Towers Watson.

But if a company is liquidating under Chapter 7, laid-off workers may be in a tougher spot. COBRA is not helpful because there’s no longer a company health plan to buy. If that happens, they may be eligible for guaranteed coverage on the individual market as Hunt was.

In situations where one company buys another, “there’s a whole spectrum of possibilities,” says Bruce Richards, chief health-care actuary for human resources consultant Mercer. The acquiring company may continue the same health coverage that employees at the acquired company had, at least for a time, or it may merge the new employees into the acquiring company’s health plans.

“It could be better or worse than their current employer’s plan,” Richards says.

Although active employees face uncertainty when a company changes hands or goes through bankruptcy, retiree health coverage may be particularly vulnerable, experts say.

Retirees who are 65 or older can rely on Medicare and a Medicare supplemental plan to fill in coverage previously provided by their retiree medical plan.

Retirees younger than 65 are not so lucky. “Early retirees are in the worst spot possible if there’s a bankruptcy,” Richards says. Chances are, “their benefit plan will be terminated.” If a company is sold, retiree benefits may or may not change, say experts.

“In general, a company continues the retiree coverage for those that are in the plan,” Richards says. However, “that doesn’t mean that at some point they can’t terminate it.”

Workers and early retirees alike will have more options in 2014 when the state-based health insurance exchanges begin selling comprehensive coverage to people who don’t have access to health insurance elsewhere. Those with incomes up to 400 percent of the federal poverty level may be eligible for premium tax credits to help defray the cost.

At that point, even if workers are eligible to continue on their employer’s plan under COBRA, they may not want to, experts say. Under COBRA, people have to pay 100 percent of the premium, plus a 2 percent administrative fee, in many cases.

Buying coverage instead on the exchanges would probably be a better deal. “You’re unemployed; your income just dropped,” says Paul Fronstin, director of the health research and education program at the Employee Benefit Research Institute. “If you go onto the exchange and buy coverage, you might be eligible for a subsidy.”

As for Robin Hunt, she says she may remain uninsured. In the meantime, she’s been applying for any job that might offer health insurance, but so far without success.

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Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

 

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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