Everything You Need to Understand Affordable Care Act Open Enrollment
BY HIV Plus Editors
October 04 2013 6:18 PM ET UPDATED: February 20 2014 4:01 PM ET
We want to state up front that if you currently have insurance or are on Medicare or Medicaid, most of the below won’t apply to you and your coverage will continue, with only small changes like free preventive care. For more info on the overall benefits of the Affordable Care Act, see the Task Force's webinar.
If you currently don’t have health insurance, or you aren’t satisfied with your current insurance Obamacare will help you find affordable options.
1. There’s a lot of talk about Open Enrollment, do I need to have insurance by October 1?
- No, open enrollment runs from October 1, 2013 through March 31, 2014. Coverage begins on January 1, 2014. The one deadline between October and March is that if you want your coverage to begin on January 1, you must enroll by December 15, 2013.
2. How do I enroll? What are these exchanges I’m hearing about?
- Exchange is really just a fancy word for a market. The Exchanges are basically online sites where you can shop for health insurance. No Internet access? No problem. You can get to the information in three ways: (1) Talk to a local Navigator, who will help you find the right plan. (2) Call the folks at healthcare.gov at 800-318-2596, who can help guide you to a local resource. (3) Go online to Healthcare.gov and enroll.
3. Wait, what’s a Navigator?
- Basically, a Navigator is your own “personal shopper.” You give them a description of your unique health care needs and they respond with an explanation of the options that are available within the Marketplace. Once you’ve chosen the option that’s right for you, they’ll help you to enroll.
- Who are these people? Are they going to understand that I’m in a same-sex relationship? Are they going to be trans-competent? Honestly, it probably depends on where you live. Many states are providing LGBT cultural competency training to all Navigators. In some areas, LGBT-focused medical centers have applied to house Navigators, like Whitman Walker Health in Washington, DC. Under the law, the Exchanges and health plans offered under them cannot discriminate on the basis of sexualorientation or gender identity. Unfortunately, there’s no guarantee that navigators won’t be under-informed or actively discriminatory. (However see question 4 about filing complaints and appeals)
- How do I find one of these Navigators? Healthcare.gov can direct you to a local navigator. Click Here and enter your zip code to find local resources near you. Keep in mind, though, that the link brings you to a generic site. The resources accessible through healthcare.gov may not be the most LGBT-competent service provider in your area. If you feel uncomfortable about going to the resource listed on the site, try contacting a local LGBT-friendly organization. Local support groups may be aware of a culturally competent Navigator.
- I live in a small town in the middle of the country. Most people here have never even heard the word transgender. Do I have another choice? Yes. You should be able to enroll online, through Out2Enroll.org, or Healthcare.gov. Note, however, that while out2enroll.org is LGBT focused, it isn’t as comprehensive as the government site. Meanwhile, healthcare.gov isn’t the most LGBT specific site in the world. For example, the second question after you click “See my options,” asks, “What’s your gender?” You then have to choose between “male” and “female.” Still, though limited in some ways, the site will lead you to lots of good information. You can also call the help line at 1(800)318-2596. LGBT organizations are working with HHS to ensure that people picking up those phones won’t misgender you, and will understand the needs of the trans community. The call centers certainly need more training, and we will continue to work on making sure that the resources available to you are inclusive.
4. So, under the law I can’t be discriminated against for being in a same-sex relationship and/or being transgender. But what if I am?
- If you do experience discrimination, you can file a complaint with the Department of Health’s Office of Civil Rights. You can also contact us at [email protected] and we can help you file a complaint.
- If you’re denied coverage, or your company won’t fund a certain service, you have a right to an external appeal. The combination of nondiscrimination provisions and external appeals could potentially have a huge impact on a system where transgender people are regularly denied even basic health services because of a Gender Identity Disorder diagnosis.
5. I’ve been denied coverage in the past for being transgender. Are you sure this won’t happen again?
- We’re excited that under the Affordable Care Act transgender people should no longer be denied care because of their identity. In 2014, the Patient’s Bill of Rights under the Affordable Care Act will prevent insurance carriers from denying coverage due to pre-existing conditions, which will be a huge benefit for transgender Americans.
- Many transgender people were denied coverage for routine or regular care based on being transgender. Insurance carriers considered this a pre-existing condition and it is no longer under the Affordable Care Act. Our study, Injustice At Every Turn found that 28% of transgender Americans postponed medical care due to discrimination and 19% were refused health care, with the number being even higher among people of color. We believe the implementation of the Affordable Care Act will help to alleviate this issue.
6. I’ve struggled with my insurance coverage ever since I was diagnosed with HIV or AIDS. Is that really going to change?
- It will, in at least two important ways. First, insurance companies can no longer deny you coverage because of a pre-existing condition, like HIV or AIDS. Second, your insurance company can no longer place caps on how much you spend on health services. Choices about which type of care you need will no longer be limited by the size of your bank account.
7. How am I going to afford this new insurance?
- There are credits and subsidies available to help. If you want to buy insurance through the Exchanges, but you don’t think you’ll be able to afford it, check to see if you’re eligible for a subsidy.
How do I know if I’m eligible for a subsidy?
- If you make between 133% and 400% of the Federal Poverty Level (FPL), and you buy insurance through the Exchanges, you’re probably entitled to a subsidy that will help pay for your health insurance premium. The FPL changes a little bit each year, and the amount is different depending how many people are in your household. To give you a sense of what those numbers look like, in 2013 a single person with income between $15,282 and $45,960 would be entitled to a premium subsidy. A few more examples:
- 2 person households with $20,628 to $62,040 in income will get a premium subsidy 3 person households with $25,975 to $78,120 in income will get a premium subsidy 2 person households with $31,322 to $94,200 in income will get a premium subsidy
How much will my subsidy be?
- The subsidies get smaller as your income gets larger. So, for example, a single person with $16,000 in income will receive a fairly large subsidy, while a single person with income of $40,000 will receive a fairly small subsidy. You can use this handy calculator to find out what your subsidy will be. Not only will the calculator tell you the subsidy amount, it will also tell you about how much your premium will be, your maximum out-of-pocket costs, and other possible coverage options.
How do I get this subsidy?
- Generally, the subsidy will be applied directly to your premium cost. But if, at the end of the year, your income was different than you expected, you might get a bit more money back along with your tax return. (Or, in some cases, you might have to pay a bit back to the government.) Your tax preparer (or your tax software) can help guide you through that process. For more information, you can visit the IRS site on Obamacare tax credits.
8. What happens if I don’t get insurance? Will I go to jail?
- Short answer: No, but there might be a penalty. Does everyone get charged a penalty? No. If you fall into one of the following categories there’s no penalty imposed on you:
- You make less than the filing requirement for your tax filing status which is $10,000 if you file “Single,” $20,000 for “Married filing jointly.” Don’t forget that after the DOMA repeal, people in same-sex marriages can file joint federal tax returns.
- You’re an undocumented immigrant. You’re incarcerated. You’re a member of an Indian tribe. Your religious beliefs won’t let you accept benefits from a health insurance policy. Insurance would cost you more than 8% of your income. (This category is the most complicated. A Navigator can help you figure out if you fall within this group.) You had health insurance for almost all of the year. (There is no penalty if your insurance lapsed for less than three months during the year. Your tax preparer can help you with figuring this out.)
How much is the penalty? Is it worth it to get insurance?
- For 2014, the penalty is the greater of $95 per adult and $47.50 per child OR 1% of your “family income.” Family income ends up being defined as the amount of income over the filing requirement for your filing status. Here are a few examples:
- If you’re single, the filing requirement is $10,000. Last year, you made $25,000. Your family income is $15,000 ($25,000 - $10,000). Your penalty would be 1% of that amount, or $150.
- If you’re a “head of household” (which means you are unmarried, but claim a dependent on your return) and live with one child, the filing requirement is $16,000. Last year, you made $42,000. Your family income is $24,000. Your penalty would be 1% of that amount, or $240.
- You and your partner just got married. (Congratulations!) Neither of you have health insurance. Your filing requirement amount is $20,000. Last year, your combined incomes were $30,000. Therefore, your family income is $10,000. Your penalty is $185. (I know, 1% of $10,000 is only $100! But because the penalty is calculated as the greater of $95 per adult OR 1% of family income, you’re stuck paying the higher amount.) After 2014, the penalty amounts increase to $325 per adult and $162.50 per child OR 2% of family income. In other words, the cost for not having insurance is going to jump up at the end of 2014. Keep in mind the same exceptions will continue to apply.
- Whether insurance is “worth it” should be a bigger calculation than how much your penalty will be. When you’re deciding whether or not to enroll, remember that under Obamacare, you’re entitled to things like free preventive care and free necessary services (like emergency care and prescription coverage). So don’t forget to put those things on the scales when you balance the costs against the benefits.
9. Seriously, I can’t afford any of this. What do I do?
- Short answer: You might be entitled to free health insurance.
What’s this about free health insurance?
- Obamacare gives states the opportunity to expand their existing free health insurance programs to cover more people. These free health insurance programs, which are called Medicaid and Children’s Health Insurance Programs (CHIP), are available in every state. However, the eligibility requirements are different depending on what state you’re in.
Okay, so how do I know if I’m entitled to free health insurance?
- About 29 states have decided, or are working towards, expanding their Medicaid plans to cover people who make up to 133% of the Federal Poverty Level (FPL). Though the FPL changes a little bit every year, in 2014 the FPL for a single person is about $15,800 per year. That means that if you live in one of these expansion states, are single, and make under $15,800 per year, you probably qualify for free health insurance. (The numbers are higher if there are more people in your household – a family of two will qualify with income of up to $20,628, for three-person families the threshold is $25,975, and so on. The level increases by roughly $5,000 per additional family member.)
How do I know if I’m entitled to free health insurance in my state?
- Although many states are participating in the Obamacare Medicaid expansion, some are not. In states not participating in the expansion, the state is allowed to set its own eligibility rules. For information on your state, including whether your state is participating in the expansion and links to your state’s Medicaid enrollment site, Click here.
I thought Medicaid was just for older folks. I’m only 34, am I still eligible?
- Yes. The program you’re thinking of is Medicare, which is a similar program that covers mostly the elderly and younger people with disabilities. Medicaid, on the other hand, is a free health insurance program that covers the rest of us when we can’t afford to buy insurance.
Does Medicaid recognize my same-sex marriage or domestic partnership?
- Medicaid is a state-run program. In states that recognize your marriage or registered domestic partnership, your partnership will be recognized for Medicaid purposes as well. It’s important to note, though, that because of the way the Federal Poverty Level (FPL) is structured, marriage may not benefit your family for Medicaid purposes. (Basically, the FPL for a single person is about $15,800, but the FPL for a couple is about $20,600. If you and your partner both make around $12,000 per year, you’d qualify for Medicaid if you are not married, but won’t qualify for Medicaid if you are.) If you’re able, you might want to speak with an attorney or public benefits assistant about your benefits before you choose to get married.
I’m still not really sure if I qualify. Can someone help me figure it out?
- Yes! The Navigators that are present in every state can help you figure out if you qualify for Medicaid or should be buying health insurance in the Exchanges. If you don’t feel comfortable talking to the Navigators in your area, you can call the government’s 24-hour helpline at 800-318-2596 www.healthcare.gov can also help to clarify your options and figure out how to enroll.