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Health Care Reform:

Health Insurance & Affordable Care Act

Complex Personal Issues Cloud Insurance Decisions

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Here's a case in point. A woman wrote in asking about coverage options for her family, including their two kids with special medical needs. She writes, "My husband and I carry dual coverage through his employer and my employer group plans because neither plan covers our children's needs adequately individually. Because of our children's special needs, it is a hardship for both of us to work. We would like to drop one or both plans and purchase insurance on the exchange in October when open enrollment begins. Is this possible?"

Experts tell me that the simple answer is yes, it's possible. But that may not be the best answer for this family. Most people can shop for coverage on the health insurance marketplaces, also called exchanges. But if people have access to employer coverage that's considered adequate and affordable under the law, they won't be eligible for subsidies to reduce the cost of an exchange plan. (A premium tax credit is available to people with incomes up to 400 percent of the federal poverty level, or $94,200 for a family of four. Cost-sharing subsidies to reduce deductibles and copays will be available to those earning up to 250 percent of poverty, or $58,875 for a family of four.) Since employers typically subsidize a good portion of their employees' health insurance costs, buying an unsubsidized plan on the exchange might not make financial sense.

If both parents dropped down to part-time status, they might no longer be eligible for their companies' health insurance plans and could buy subsidized coverage on the exchange. But if one of the parents kept working full time and had access to good family coverage on the job, no family member would be eligible for subsidized exchange coverage.

It's also unclear whether the plans offered on the exchange would better meet their children's needs than the employer coverage they currently have, say experts. The couple would have to compare coverage specifics and costs carefully.

There's another coverage wrinkle that could affect this family. Depending on their income and the state in which they live and their children’s health care needs, some or all family members could be eligible for any one of a number of Medicaid-related health insurance programs, says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities.

How one of the enrollment assisters will handle a family like this one is uncertain. Under federal guidelines, assisters will generally be required to undergo at least 20 hours of training, and some states require more. Brokers generally are required to have fewer hours of training about the exchanges.

Experts say many people who contact the exchanges will be dealing with disabilities or complex family situations, and assisters should be prepared to either help them or refer them to appropriate state programs or community-based organizations.

Mon, Dec 19 2011

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