Update on Healthcare Exchanges

Healthcare Exchanges, how they work and how you get on one.

I have been wanting to write up something about the Healthcare exchanges and here is my first stab.   I will probably start blogging about this, to give you information as I get it.  First, here are some important facts about what the exchanges are and how you obtain the insurance.

Some important facts about signing up for health insurance in 2014

The new healthcare exchanges are difficult to understand at best. Many people still have a lot of questions, but as we learn answers we want to do our best to try to share with you what we learn.

Hemophilia is so expensive to manage that knowing the type of coverage you are applying for, who can service you, what doctors are covered, and how much out of pocket you will have to pay are extremely important to understand.

Each county is different as to how many plans that area has available on the exchange, in addition to the fact that each plan is different in what it covers. We recommend finding a qualified and trusted health insurance agent in your area that can help you find the right combination of benefits for your personal needs.

There are two ways to get an insurance policy:

1)   Go directly to the insurer and pay full price. If you make less than about 12k, you will need to go this route and try to apply to PSI and see if they can help with the premium.  If you are in a state that expanded Medicaid, you then might can get Medicaid, but if you are in a state like Texas which the state did not expand Medicaid, then you will have to find resources to work it out.

2)  Go to the exchange (Healthcare.gov)  and apply for a subsidy (premium tax credit)

If you go directly to the insurer (ie://Blue Cross, Aetna, etc.) you will not be eligible for getting a subsidy and will be required to pay full price for your policy. One major change is that you can get a policy this way as an individual and you will not be denied because of a pre-existing condition or having to worry about a lifetime cap.

If you think you qualify for a subsidy, you will need to apply through an exchange.   You can either go through Healthcare.gov or call them live and go through the application over the phone.    Healthcare.gov is simply a website that has been set up to help you apply, pay for, and manage your policy. Your coverage will still be issued by the insurance company you choose and that is available in your area.  You will ultimately deal with whatever insurance company you chose.

When you apply for a subsidy through the marketplace, you will be given a choice to receive your tax credit at the end of the year (ie:// 2014 taxes filed in 2015), or to be advanced and paid directly to your insurer, monthly. The monthly option is the most common; however it is calculated on your estimated income for that calendar year. If you claim more or less on your income taxes at the end of the year, your credit may be adjusted and you could be responsible for more or less of the premiums due to the insurer.

In order to receive a subsidy, you will be required to file taxes, and reconcile your premium payments at the end of each year.

You can find out more information about the tax code and how your Premium Tax Credit will be evaluated and processed by visiting http://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-for-Individuals-and-Families.

You can also learn more about your options by visiting https://www.healthcare.gov.  Make sure you do all the research because the subsidie will be taken out of your tax refund you normally get but is supposed to be above what you normally get but I am still not convinced of that and I would urge you to call Healthcare.gov and talk to them about that.   I work for a Specialty Pharmacy and help our patients with this and if you want to call me, I would be happy to see if I can help you.  Most of my experience is with the Federal side and not the state exchanges and that is about half the states and usually the ones that opted out of expanding Medicaid.

Call me if I can be of any help and I will tell you that there are not many people in this business that know much about how this all works.


Andy Matthews


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