ACA... Some questions.

[leebee]

We are 4 reasonably well-educated adults, trying to weed through the "clear as mud" government websites as well as AI, insurance company, and other websites. We have some questions about ACA for which we either can't find answers, or the answers are conflicting. I'm hoping someone here on the DIS has experience/information that might help us. Here's the scene- and yes, they are OK with me sharing this info:

My sister (60F), who lives in Louisiana, lost her job 18 months ago and hasn't found another (nobody in LA hires old, physically disabled women, even remotely). When her company folded, she went on to her husband's (58M) health insurance. However, his company folded so he is unemployed until Monday. The new job will cover his health insurance premiums in full, but none of hers. She has the choice of either a high deductible plan ($600 per pay period) or a PPO ($1200 per pay period- and I think it's a 2 week pay period, although this seems ridiculously expensive). He will be earning $73K. She is looking into ACA for her medical coverage. SO... we have Questions:

1. Because she CAN get insurance thru her spouse's job, is she still eligible to sign up for ACA?
2. We know that ACA tax credits/subsidies/etc. are based on income. Would that be her income, or the income for their family (so basically, her DH's income)?
3. Does ACA require a "life changing" event for her to be able to sign up? If she goes on the new insurance, can she drop it and swap to ACA or would she have to wait for open enrollment in November?
4. If she qualifies, what are the limitations and restrictions? Can she keep her own doctors? She has several complicated medical issues, so keeping her own doc/surgeons/therapists is important (and it's why she really shouldn't be looking at high deductible plans).

If anyone has answers, experiences to share, or a reliable direction in which to point me, I'd appreciate it.

 

[lanejudy]

She should be able to reach out to her state's marketplace for assistance is determining her options and what might be best.

#1 -- since she is not the employee and there is no cost-sharing of premiums for dependents, she still qualifies for ACA and any tax credits/subsidies
#2 -- I believe it's family income, but please confirm that with someone else
#3 -- losing insurance coverage should qualify as a "life changing event" to enroll mid-cycle; however I don't know that she would be able to start the coverage from her husband's new employer and then drop that mid-cycle and still qualify
#4 -- any limitations or restrictions, whether or not she can keep her current providers, will really depend on the plan she chooses so this is something to check before making that decision.

Just a note since you commented about HDHP and complicated medical issues -- my family has both and it has worked out well for us;. Obviously that will depend on the details of all plans available to your sister as well as any resources she can put into a HSA, but high healthcare needs doesn't automatically rule out an HDHP. Ours actually works for us because of the extensive medical needs and may not be our best option if we didn't have so much healthcare. But each plan is different so she needs to look at the specific plans available to her to make an informed decision.

 

[tvguy]

It is my understanding that if you have ANY other health insurance options, you do not qualify for ACA coverage. Cost is not a factor.

We just helped a friend transition from ACA coverage with subsidies to Medicare when she turned 65. She received notice that she would no longer be qualified for coverage from ACA because she qualified for Medicare. Her preference would have been to stay as her subsidized coverage cost $60 a month versus $202.90 for just Medicare Part B, plus another $150 a month for private Medigap Part G coverage.

That was the advice I got in 2021 when I was about to retire. I was told because I had the option of COBRA coverage I did not qualify for ACA coverage.

 

[lanejudy]

It is my understanding that if you have ANY other health insurance options, you do not qualify for ACA coverage. Cost is not a factor.

Cost is a factor in determining subsidies, but not in determining whether one can purchase from the state/federal marketplace. If the cost of the other option (in the OP's case, the DH's employer coverage) is >9.96% of income it is considered "unaffordable" and thus eligible for subsidy. So my answer above was a little brief but based on the figures shared by the OP it hits at just about that cost. If any of OP's figures are rounded they may need to do the calculation themselves. But that doesn't automatically preclude one from buying off the marketplace.

I was told because I had the option of COBRA coverage I did not qualify for ACA coverage.

Unless it's something state-specific, that is incorrect.

 

[tvguy]

Cost is a factor in determining subsidies, but not in determining whether one can purchase from the state/federal marketplace. If the cost of the other option (in the OP's case, the DH's employer coverage) is >9.96% of income it is considered "unaffordable" and thus eligible for subsidy. So my answer above was a little brief but based on the figures shared by the OP it hits at just about that cost. If any of OP's figures are rounded they may need to do the calculation themselves. But that doesn't automatically preclude one from buying off the marketplace.



Unless it's something state-specific, that is incorrect.

I was just speaking of the first step, whether someone qualifies in the first place.

Certainly worthy of seeking professional advise as to whether it is state specific. In my case, they gave me a price quote of $2,000 a month without subsidies for ACA coverage. COBRA was $1,200 so ACA was completely out of the question if I qualified just from a cost standpoint.

 

[disneychrista]

That was the advice I got in 2021 when I was about to retire. I was told because I had the option of COBRA coverage I did not qualify for ACA coverage.

Who told you that?

 

[tvguy]

Who told you that?

The Covered California Representative on the phone when I called to get a price quote in 2021. LOL, but only after I got the price quote and mentioned that was more expensive than what COBRA was going to cost. Only then did she said, "oh, if you qualify for ANY other health insurance, you are not eligible for our coverage".

 

[barkley]

It is my understanding that if you have ANY other health insurance options, you do not qualify for ACA coverage. Cost is not a factor.

We just helped a friend transition from ACA coverage with subsidies to Medicare when she turned 65. She received notice that she would no longer be qualified for coverage from ACA because she qualified for Medicare. Her preference would have been to stay as her subsidized coverage cost $60 a month versus $202.90 for just Medicare Part B, plus another $150 a month for private Medigap Part G coverage.

That was the advice I got in 2021 when I was about to retire. I was told because I had the option of COBRA coverage I did not qualify for ACA coverage.

if your friend qualified for subsidized coverage of that magnitude under ACA in california she needs to research if she's eligible to one of the Medicare Savings Programs which may reduce or entirely zero out her Medicare premium AND (with some programs) eliminate all co-pays and deductibles. for many people this not only saves money but eliminates the need for a medigap plan.

 

[lanejudy]

The Covered California Representative on the phone when I called to get a price quote in 2021. LOL, but only after I got the price quote and mentioned that was more expensive than what COBRA was going to cost. Only then did she said, "oh, if you qualify for ANY other health insurance, you are not eligible for our coverage".

From the Covered California website (bolding is mine):

If your employer offers COBRA coverage when you leave a job, you have options:

1. Continue coverage under COBRA. You might choose this option if you are undergoing medical treatment or if you don’t want to change anything about your plan or current network of doctors and hospitals, for example.
2. Decide not to participate in COBRA and apply for special enrollment through Covered California. Because you will be newly uninsured, you will be eligible for special enrollment in a Covered California health insurance plan outside of the annual open-enrollment period. To take advantage of the special-enrollment opportunity, you have 60 days before and 60 days after your health insurance through your job ends to apply for and select a Covered California plan. It is important to note that if you miss this special-enrollment period, you have to wait for the next annual open-enrollment period to enroll in a health plan unless you have a major life event that makes you eligible for another special-enrollment period.
3. Seek coverage elsewhere, in the individual market outside of Covered California or through a spouse’s employer-sponsored health plan, for example.

 

[easyas123]

I’m by no means no expert, although I really get your frustration w/ the ACA as I found it really frustrating myself.my though was given your sister is disabled, would she qualify for Medicaid? Or disability benefits? Alternatively perhaps she should seek out t one of these consultants who specializes in insurance to help walk her thru what she can or can’t do/qualify for/how to qualify for what specific to her situation & her state.
Or perhaps she could seek full time employment with one of these companies that are nationally known employers who offer health benefits- pay might be less but by the time it all shakes out after paying for out of pocket insurance . Good luck to her

 

[tvguy]

From the Covered California website (bolding is mine):

If your employer offers COBRA coverage when you leave a job, you have options:

1. Continue coverage under COBRA. You might choose this option if you are undergoing medical treatment or if you don’t want to change anything about your plan or current network of doctors and hospitals, for example.
2. Decide not to participate in COBRA and apply for special enrollment through Covered California. Because you will be newly uninsured, you will be eligible for special enrollment in a Covered California health insurance plan outside of the annual open-enrollment period. To take advantage of the special-enrollment opportunity, you have 60 days before and 60 days after your health insurance through your job ends to apply for and select a Covered California plan. It is important to note that if you miss this special-enrollment period, you have to wait for the next annual open-enrollment period to enroll in a health plan unless you have a major life event that makes you eligible for another special-enrollment period.
3. Seek coverage elsewhere, in the individual market outside of Covered California or through a spouse’s employer-sponsored health plan, for example.

I did not pursue it because if was unaffordable compared to COBRA. I guess I took option 3.

 

[lanejudy]

I did not pursue it because if was unaffordable compared to COBRA. I guess I took option 3.

I thought you took #1 (COBRA) which was why you claim you didn't qualify for Covered California. So again having another coverage option does NOT disqualify one from purchasing on the state marketplace. You simply chose a different option that was a better fit for your needs.

 

[tvguy]

if your friend qualified for subsidized coverage of that magnitude under ACA in california she needs to research if she's eligible to one of the Medicare Savings Programs which may reduce or entirely zero out her Medicare premium AND (with some programs) eliminate all co-pays and deductibles. for many people this not only saves money but eliminates the need for a medigap plan.

She has said she did. Just a casual search seems to show that you can't make more than $1,816 to get Medicare Savings help. That isn't even minimum wage if you are working full time.
To be honest, I have no idea how she qualified for ACA subsidies. And her coverage was awful. She had a major surgery in 2019 and the insurance only covered 80% and it took her 5 years to pay off her 20%

 

[disneychrista]

The Covered California Representative on the phone when I called to get a price quote in 2021. LOL, but only after I got the price quote and mentioned that was more expensive than what COBRA was going to cost. Only then did she said, "oh, if you qualify for ANY other health insurance, you are not eligible for our coverage".

Sounds like you may have been given some misinformation.

 

[tvguy]

Sounds like you may have been given some misinformation.

Like I said, the premiums were too high so it was off the table as an option.

 

[tvguy]

I thought you took #1 (COBRA) which was why you claim you didn't qualify for Covered California. So again having another coverage option does NOT disqualify one from purchasing on the state marketplace. You simply chose a different option that was a better fit for your needs.

I took COBRA in part because I was told I did not qualify for ACA . Ultimately COBRA was cheaper.

 

[disneychrista]

Like I said, the premiums were too high so it was off the table as an option.

Premiums were too high because you didn't qualify for any subsidies? That is the only plus of COBRA is that your employers group rates are likely less than an individual policy.

 

[tvguy]

Premiums were too high because you didn't qualify for any subsidies? That is the only plus of COBRA is that your employers group rates are likely less than an individual policy.

That is my assumption. ACA made healthcare available to people who could not get coverage in the past. The trade out, base private marketplace rates soared. That would be rates without subsidies. We planned for years on retiring before we qualified for Medicare, so our Financial Planner always tracked private rates and our employers COBRA rates. I think he has the figures still back to 2000. Private insurance was always cheaper than COBRA. That changed in the years after ACA.