Question: I read an article that said rates of individual insurance would go up as much as 60%. Won’t that erase the savings from subsidies?

Answer: A new study released on Tuesday by the nonpartisan Society of Actuaries estimates that individual premiums will rise 32 percent over 2013 rates on average nationwide within three years, 2014 - 2016, partly as a result of higher risk pools (more sick people in then insured population). Changes would vary by state, from an 80 percent hike in Wisconsin to a 14 percent reduction in New York. For anybody eligible for subsidies, their contribution to the total premium is fixed on a range between 2% and 9.5% of income. So, for the subsidized, it doesn’t make any difference what the final rates are. On an individual basis, age and income will determine how much of an increase. The subsidized group are likely to pay about 47% to 84% less in monthly premiums compared to 2013. The un-subsidized young (below 40) and will see the highest premium increases. Some of older un-subsidized group will have lower premiums than today for better coverage. On a positive note for the un-subsidized, coverage will be more comprehensive for all, meaning less out-of-pocket costs thus reducing the impact of higher rates.

Question: I’ve opted to have an individual health plan because, being in good health, it’s less expensive than buying into my spouses employer plan. As an independant contractor, will I be eligible for a health insurance tax subsidy if our family income is low enough?

Answer: The ACA says that someone with access to “affordable” employer-sponsored coverage cannot get a premium subsidy from state exchanges in 2014, unless the cost of the employer-based health care coverage for that employee exceeds 9.5 percent of the worker’s household income. The IRS ruled recently that the calculation of affordability will be based on the cost of employee-only coverage, not family coverage. For example, if your spouse contributes $300 each month or $3600 for the year for his or her portion of the premium for the employee only, Your family income would have to be less than $37,895 per year no family member would qualify for a subsidy even though they are not covered by the spouse’s group plan.

Question: My child is younger than 26 and i want to remove him from my health insurance. Can i do that under the affordable health care act?

Answer: Yes. Covering your child to age 26 is an option provided by the ACA. It is not a requirement. In 2014, everyone will be required to have health insurance. If your child does not have coverage, they may have to pay a penalty.

Question: If i lose my health insurance thru my husband’s employer do i have to take one offered thru my employer or can i take one thru the health care exchange?

Answer: If your employer offers group health insurance coverage that is “affordable” you should take it, because you will not be eligible for a premium subsidy in the state Health Insurance Exchange.

Question: My son turns 26 next year and is disabled with lyme disease and cannot work (no financial income). Currently, he is covered under my work insurance plan. What options does he have when he can no longer be on my plan.

Answer: Your son will be eligible for coverage in your state health insurance exchange on January 1, 2014, as would any legal resident of your state regardless of medical conditions. You don’t have to wait until he is 26. His income will determine whether he is eligible for Medicaid or subsidized private coverage.

Question:I am 60 and retired. I kept the retiree insurance offered by my previous employer while waiting for a response from an individual insurance application for a plan that was half the cost. I was denied insurance based on pre-existing conditions. It is VERY difficult to continue paying these premiums ($600)and would like to know if I will be able to enroll through an exchange in the fall of 2013 for the 2014 implementation of the health care act, or will I have to be uninsured to do so?

Answer: Yes. You will be able to enroll in a ACA conforming health plan through your state exchange anytime after 10/1/13 and your new coverage will be effective on 1/1/14.

Question: I am a single mom with 2 children. I make about $20,000. We don’t have insurance now. We don’t qualify for Medicaid because I have some savings. Can we get health insurance through the exchange if we do not qualify for medicaid due to assets?

Answer: Starting in 2014, Medicaid will no longer consider assets, only income. So based on your income you will be eligible for free public health insurance from Medicaid. If you choose to opt out of Medicaid in favor of Exchange coverage, you cannot also be eligible for subsidized coverage. You would have to pay the full premium and I don’t think that will be practical for you.

Question: We currently have an Aetna PPO through my employer. My spouse is 53 and has a chronic illness. So far she is doing okay, but our fear is that when I retire next year, and we shop from the exchange, the potential treatment she may need won’t be as good as what I currently have with Aetna. That our options for treatment will be limited. Are these fears unfounded? Will the latest treatments be available?

Answer: The quality of health insurance coverage in 2014 will actually be better - more comprehensive and with fewer restrictions - than it is now as a result of health insurance reforms imposed by the Affordable Care Act.. You can still purchase an Aetna PPO plan if you so choose, either in the state exchange or the outside marketplace.

Question: Will the SHOP exchange will offer the same qualified health plans as the individual exchange?

Answer: The ACA leaves this up to the states. In some states, like California, there will be two separate exchanges one for individuals and one for small-businesses and both exchanges must offer the same standardized plans. In some states the two exchanges may be combined.

Question: Who will be eligible for premium subsidies in the health benefit exchange in 2014?

Answer: Legal residents, under 65, and not incarcerated will qualify for subsidies called advanced premium tax credits in 2014, if their taxable household income (AGI) is between 133% percent and 400% percent of the federal poverty level. The amount of the subsidy decreases as income increases.

Question: Will there catastrophic coverage under Obamacare?

Answer: Yes. But the catastrophic plan can be offered only only for young adults, those under age 30 before the plan year begins. The catastrophic plan will be the lowest priced health plan available within the guidelines of essential benefits. Catastrophic plans will have an actuarial value of about 60% (bronze level). The deductible and out of pocket maximum will be $6400 per year.

Question: What is the individual mandate health care reform amount of tax?

Answer: The Affordable Care Act (ACA) specifies that the “applicable dollar amount” of the tax is $695 per adult to be phased in and adjusted as follows:

• In 2014, the penalty is $95 per adult and $47.50 per child (up to $285 per family) or 1% of family income, whichever is greater.
• In 2015, the penalty is $325 per adult and $162.50 per child (up to $975 per family) or 2% of family income, whichever is greater.
• In 2016, the penalty is $695 per adult and $347.50 per child (up to $2,085 per family) or 2.5% of family income, whichever is greater.

Question: Who is primary when there is adult dependent on both parents policy and parents are divorced?

Answer: Coordination of Benefit Rules were codified by the National Association of Insurance Commissioner in 1986 and each state uses this model with some modifications. The rules cover how the primary payer is determined when an insured employee or dependent has double coverage. To determine who pays first on dependent children’s claims, the plan covering the parent whose birthday is earlier in the calendar year is primary.

Question: I have an employee in Pennsylvania that is recently divorced and was covered under his spouse’s policy. He is currently uninsured and wants to choose the “opt out incentive” and remain uninsured. Are there any legal consequences to this or does he have to accept the coverage since he is uninsured? Answer: If you have elected to pay 100% of the cost-sharing for existing employees he cannot opt out. Otherwise, he can.

Question: My employer just distributed a new copy of the “Summary Plan Description” that says our Cafeteria Plan contributions are limited to $2,500 per year. It used to be higher. They say it’s Obamacare. True?

Answer: Under the ACA, employee contributions to health care flexible spending accounts or Cafeteria Plans will be reduced to $2,500 per year for any plan year starting in 2013. The Plan Year is the 12-month period specified in your Summary Plan Description (SPD) that determines the beginning and ending dates of plan contributions. The plan year should not be confused with the “Claim Period” which is the period specified in the SPD of at least 12 months that determines the beginning and ending dates of expenses eligible for reimbursement. In other words, it is the period of time that claims can be incurred and reimbursed from current plan contributions. The beginning date always coincides with the beginning of the plan year, but the end date may not.

Question: Is the 2% payroll tax increase for 2013 part of Obamacare?

Answer: No. It has nothing to do with Obamacare. Actually, FICA payroll taxes were cut 2% in 2011 and 2012. That cut will expire, effective Jan. 1, 2013. Although the increase is on employee contributions, the increase also affects an employer’s withholding obligations.

Question: My husband was updating his medical insurance papers at work & the HR lady told him that if his spouses employer offered health insurance I had to take it. Is this true? Ive always had coverage with him. Plus if I get my employers I have to pay half which would be 200-300 per month. She told him if he put on his paperwork that my employer did not offer it that it was a felony.. Can i thank Obama for this?

Answer: No, this is not part of Obamacare. Yes, an employer can force its employees to accept the health coverage offered by their employer even if that means more out-of -pocket costs for the employee. Employers can make it a condition of employment if they so choose. There is no law governing this practice, It is similar to a company policy requiring that employees have (and pay for) uniforms.

Question: I had back surgery (a straightforward discectomy) just over six months ago. I am now pain free and no longer receive any kind of treatment. I am at the end of my husband’s group COBRA plan (at the end of 2012), and we need to re-apply for insurance. I was told that I would definitely be denies insurance if I had had back surgery within six months. Now that I am more than six month past my surgery, is an insurance company likely to deny me? Are there any companies that might be more likely to cover me given my surgery? Is there anything I can do to improve my chances of getting approved?

Answer: Sometimes 6 months is enough to satisfy the underwriter. If it is disc related, operated, and sign symtom treatment free for a minimum of six months you could be considered with a physician statement that attests to your treatment and current status. You should work with a good agent. You would benefit from some professional assistance.

Question: As a small group health plan in PA (less than 20 employees), employees/dependents age 65 over increase my premiums substantially. Because of my group’s size, is it legal to offer incentives to entice them to go off the group plan and onto Medicare at age 65…or simply not offer coverage to those actively at work age 65+ since they have other options and the younger employees don’t.

Answer: This one comes up often so I’m going to quote chapter and verse:

“Medicare beneficiaries are free to reject employer plan coverage, in which case they retain Medicare as their primary coverage. When Medicare is primary payer, employers cannot offer such employees or their spouse’s secondary coverage for items and services covered by Medicare. Employers may not sponsor or contribute to individual Medigap or Medicare supplement policies for beneficiaries who have or whose spouse has current employment status.” (Excerpt from CMS Medicare Secondary Payer Manual, Chapter 1, (Rev 34,09-07-05)).

If an employer offers a Medicare beneficiary an incentive, financial or otherwise, not to enroll in the group, the health plan is subject to a civil money penalty of up to $5,000 for each violation. In addition, an excise tax could be applied that would equal 25% of the plan’s expenses incurred during the calendar year. This applies to all groups -large and small.

Question: My daughter is currently on my group insurance from work. I am spending almost $600 a month just for her. I would like her to get on an individual plan, but she is overweight and I am told she will be denied (they cap it at some point). Can you advise me where I can turn? How does Obamacare fit it here?

Answer: My response to your question was forming slowly until you asked how Obamacare fits in here. Obamacare makes your problem go away, but not until January 2014. That’s 14 months from now. In the meantime, you’ll have to stick with what you have.

Question: I am on my husbands insurance but have just gotten a job. My husbands insurance has a working spouse rule but his insurance is less expensive for the two of us than if we each get ours separate. Can they really cancel both of us if they find out that I’ve been offered insurance and how can they find out?

Answer: Your husband’s job could be in jeopardy in addition to loosing his insurance coverage, if you lie about not having access to health insurance from your own employer. While you are thinking about gaming the system, think about millions Americans can’t get health insurance at any price. Not your fault. Just saying.

Question:I have a high deductible Med Supp plan. My health is declining, can Im switch to a comprensive Med Supp Plan during open enrollment without penalty?

Answer: You can apply to switch to a different Medicare supplement plan at anytime of the year. However pre-existing conditions would be considered. In California you are guaranteed to switch to a like for like or lesser plan from any carrier during your birthday month. However, if you want to move to a more comprehensive MedSup plan (considered an upgrade) your health history will be considered and you could be denied the plan change. But it is not too hard to qualify for a supplement plan even for those with pre-existing conditions. One carrier will take people as long as they have not been in the hospital 90-days prior to applying.

A Medicare Advantage Plan would be more comprehensive coverage than your current Original Medicare and a High Deductible Supplement. The Medicare Advantage and Part D Prescription Drug Open Enrollment is between 10/15-12/07. During this time, you will qualify regardless of pre-existing conditions other than End Stage Renal Disease.

Question: I work part time for a very small company and may have an opportunity to be full time. I don’t need health insurance as I have it through my husband. My employer has less than 10 employees and does not offer health insurance. My question is are they required by law to provide me insurance? As I said I don’t need it and I think if they do have to it will cause them to give me less hours as they can’t afford to pay health ins.

Answer: No. There is no law that requires an employer to provide any portion of the health insurance costs for it’s employees. In 2014, when the ACA is fully effective, larger employers will pay a tax for not providing affordable health insurance for its employees, small employers (less than 50 employees) will not be required to provide health insurance even then.

Question: My husband and I were enrolled in his former company’s group insurance plan and when he left the company 3 months ago we decided to go with Cobra instead of enrolling under my company’s group insurance plan because of a medical treatment that they provide coverage for that we need, that my company’s insurance plan does not cover. My question is I don’t know how long we can afford to pay the high Cobra premium. We pay 100% out of pocket for the premium, no government subsidy. In the event we lose Cobra because we can’t afford to pay the premium, will it be considered a qualifying event for us to enroll under my company’s group insurance plan? Thank you.

Answer: No. Unaffordable coverage is not a qualifying event. So you’ll have to wait until your employer’s open enrollment period to sign up.

Question: My wife and I are both have group health insurance plans through our respective employers. I would like to drop my own coverage and be added to hers, however my employer is refusing to allow me to waive coverage unless “I am the primary subscriber, not a dependent, in an employer-sponsored group medical plan or retirement medical plan.” Is this legal? Why would they want to force me to maintain my insurance with them anyway?

Answer: I don’t know if this practice is actually “legal” in your state or not, but it really does’t matter. If there’s a law against it, it’s not being enforced. The insurance companies created this guideline (let’s call it the “Primary Employer Rule”) to even the playing field among employers and avoid disputes like this. This guideline may seem arbitrary, but If all employers follow the standards there will be fewer misunderstandings. In this case, the *Primary Employer Rule *does not benefit your employer because they would save money if you left their health plan for your spouse’s plan, but it all works out in the long run.

Question: My husband and I are both self employed. We pay $2200.00 out of our pocket for health insurance. It is breaking us. I have a number of pre-existing conditions. Please what are our option. We are going to have to drop our insurance because we can no longer afford to pay the premiums.

Answer: I hope to answer your heartfelt plea with some actionable advice. I’m not sure I can, but I’ll give it a shot anyway. The first move is to talk to your insurance company about another plan with a lower premium. But if $2200 per month for 2 people is the lowest you can get it, I’ll take your word for it, you “can no longer afford to pay the premiums”. If that is truly the case, here’s an option (I would not recommend this except in extreme circumstances). You will have to go without health insurance for 6 months, so stock up on prescription drugs and get any necessary medical care out of the way before you quit. Once you have been uninsured for 6 months you will qualify for Preexisting Condition Insurance Plan (PCIP). It will cost you a lot less than currently and it’s adequate coverage. If you can’t afford to get both you and your husband covered, the person with the highest health risks or most expensive prescription drugs drugs should get covered first. In January 2014, you will be able to buy Obamacare at the same price as everybody else and probably get a federal subsidy to help pay the premium. I wish you the best of uck.

Question: I’m 21 years old and out of college, making 50k a year and I also receive health care thru my employer. My father has no insurance and makes 35k. My younger sister lives overseas but she will be moving here to nj as she cannot live with my grandmother anymore. We are permanent residents living here 5+ years, my father 10+. My sister is 16, she has epilepsy, ADD and depression. She needs constant check ups with theneurologist, psychaitry and daily medication. Is it possible to add her under my employers insurance (horizon hmo)? If not what other options do we have based on our income? Thanks in advance!

*Answer: * No. You cannot add her to your group plan. But your sister should move to New Jersey as soon as possible, because NJ is one of the few states that have guaranteed-issue individual health insurance. What that means to her is that she can buy health insurance from any insurance company in NJ at the same rate as her healthy neighbor.

Question: I’ve viewed your list of qualifying events but still have a question. I have a group plan at my work that covers my family, but I pay a large premium for it. My wife recently landed a new job where she has no-premium coverage for the entire family. This is item 3 on your list. My employer is refusing to let me drop my family coverage because it is outside of the open enrollment period. So, the question is…are all of the listed qualifying events compelled by law? I’m in California. Thanks.

Answer: Your employer could be proven wrong by the right HR lawyer, but it may cost you your job. I would suggest you weigh your job against the cost of waiting for your company’s open enrollment period to opt your family out of your employer’s plan. This creates a qualifying event for your wife and kids and she can enroll in her employer’s plan at that time.

Question: As of right now I am on my dad’s insurance through his work. I lose coverage on Oct. 27th (my 26th birthday).I am also 5/6 weeks pregnant. No insurance will cover me and my husband. What can I do for coverage once mine drops at the end of this month?

Answer: As you know now, you can’t buy private health insurance once you are pregnant. But many states have resources for exactly your situation. Some state programs are for low-income moms and some not. Worth at try. Start your search at coverageforall.org, enter your ZIP code and go.

Question: My employer is telling me that my 16 year old daughter’s baby will not be able to be covered under my insurance plan because it isn’t MY child. However, the state is telling me that if I make too much, they can’t enroll the child on state coverage. How am I supposed to make sure the new baby is covered by insurance?

Answer: You will have to purchase child-only individual health insurance for your grandchild.

Question: I am getting medical coverage from my husband’s work. He is going to retire and I am not at retirement age yet. As I understand, he will start getting medical coverage through Medicare. 1. What is going to happen to my med coverage? 2. What if I have “pre-existing conditions”?

Answer: When your husband retires, your family’s health insurance coverage will end. He will be covered by Medicare (if he is 65 years old or disabled). You will have to purchase your own health insurance and I understand you may not qualify for individual health insurance because you have preexisting medical conditions. If you are declined individual health coverage, you will qualify for guaranteed issue health insurance coverage under the federal HIPAA law. Most health insurance companies who market individual health insurance offer HIPAA qualified coverage. HIPAA plans are usually high deductible PPO plans at a substantial mark-up over the standard rate for a “healthy” applicant. The idea being that HIPAA applicants are a greater risk as a group. You may be able to purchase a HIPAA plan from your current insurer, but can shop for HIPAA plans from any other carrier in your state. A second option may be available - major-risk pool health insurance. Availability varies by state.

Question: I’m the primary carrier (insured). And we will be losing our current family insurance coverage in December. My wife’s open enrollment is October and one of our family members has a preexisting condition and we don’t mind paying both premiums for the 2 months….so is it better to wait for our current insurance coverage to stop in December and add onto my wife’s insurance then as a “qualifying event”? or should we just add onto my wife’s insurance in October and carry both insurances until we lose our coverage in December?

Answer: There is no need to pay for two health plans. Wait until your group health coverage expires in December and apply for coverage on your wife’s group plan to be effective January 1, 2013. You are correct: your loss of group coverage is a qualifying event.

Question: I have unused HSA account money. Do I have to do anything?

Answer: HSA money can be used to pay for many eligible medical expenses beyond what is covered by your insurance plan. These expenses include dental, vision, alternative medicine, long-term care services, prescription drug and certain over-the-counter drugs. Click here for a complete list of qualified medical expenses. If you use the HSA money for anything else, you’ll have to pay income tax and a penalty on the money you take out.

Question: I have an employee in another state than the rest of us. His insurance premium is going to be over $28k a year vs. $13K for and in state family. I don’t want to miss out on this policy since it is very good the the in state employees, but I can’t afford the $28K for one person. Is there a way I can “pass on” more of the premium to this one person, without charging more for the in state employees?

Answer: The simplest solution to this problem is to use a defined contribution method of cost-sharing with your employees. For example, you establish a dollar amount that you are willing to contribute towards the family premium - let’s say $1000 per month. The out-of-state employee will have to make up the difference. You should allow them the option of opting out of the group plan and purchasing an individual health insurance policy and still get the defined contribution.

Question: Is it a good idea to drop your individual health insurance for a group plan if you have a pre-existing condition?

Answer: I don’t know the particulars of your situation, but I’m going out on a limb and say, “No. Don’t drop your individual health insurance now.” Why? Because you could loose your group health insurance if you’re laid off later. Your individual coverage is permanent as long as you pay your premium.

Question: I am employed and have health insurance through my company. When my wife and I got married I added her to my policy. Apparently since she’s under 26 she’s allowed to be on her parents insurance as well. We had a baby and now the bills are starting to roll in. The problem is my insurance is refusing to pay because it’s their “policy” to make her secondary since she’s been with her moms insurance longer. Now her moms insurance is saying that since I married her she’s my responsibility and they become secondary. Both insurance claim to be secondary and neither will pay. My question is ..who is my wife’s primary health care? I don’t care which it is I just want the bills paid

Answer: Sorry, I don’t have a direct answer for you. All states have adopted a specific set of rules, called Coordination of Benefits (COB) Guidelines to determine which health insurance plan pays first when double covered. In your case each insurance carrier is interpreting the guidelines differently and you are at a stalemate. It looks like you will have to go to your state’s Department of Insurance to resolve this. I know, it’s a hassle but your medical expenses will eventually be paid. Incidentally, your mother-in-law’s coverage of your wife will not cover your child going forward, so once this claim is satisfied that policy should be cancelled. Of course, you must add your newborn to your group coverage right away. As you can see, double coverage can cause more harm than good and somebody is paying for the extra coverage.

Question: My father and i work for the same company and same corporation, i currently am 22 years of age.i should be able to stay on my fathers plan untill im 22 years of age but because we work for the same company they are denieng me to stay on his policy and making me pay for my own medical insurance. which doesnt make since because he has to pay the same amount whether im on it or not, basically my question is do they have the right to deny me benifits provided by my father as i being 22. because we work for the same company.

Answer: The Affordable Care Act (ACA) (Obamacare) extended dependent health insurance coverage to age 26. Since September 23, 2010, insurance companies nationwide have had to comply with this aspect of the law. However, employers are free to define their employment contract with their employees. They can make it a condition of employment that workers and their dependents choose to be insured by their own employers if available. So yes, your employer has the legal right to do just that. While your out-of-pocket costs may be higher, you are not being denied coverage.

Question: My wife is 52 and is diagnosed bi-polar, paranoid schizophrenia, ptsd, multiple personalities and depression. She has been in psychiartric hospitals off and on since about 1995.The insurance I have at work changed around 2005 and now each family member has a lifetime cap of 50 days inpatient psychiatric. My wife hit her limit in november of 2011. She has been hospitalized twice since then. She never worked enough to get her minimum credits for social security and hasn’t worked much at all since 1979. I live in PA and was told I made too much money for her to get medicaid. The last hospital bill was for 28 days and costs about $25,000. Two months earlier it was 10 days and costs $9000. I don’t make enough money to pay these bills, I don’t want to abandon her or divorce her and sadly, she will probably have problems her whole life. Is there any help she can receive in the form of medical coverage for her psychiatric stays?

Answer: (Please take this to your HR Representative) The Affordable Care Act (ACA) prohibits the imposition of lifetime and annual benefit limits for essential health benefits. Mental health and substance abuse disorder services, including behavioral health treatment are included under essential health benefits. Federal regulations provide for a three-year phase-in period—September 23, 2010 to January 1, 2014—during which a group health plan or health insurer offering group or individual health insurance coverage may establish an annual limit on the dollar amount of benefits that are subject to specified dollar amounts. While any health plan or insurer offering group or individual health insurance coverage may establish a higher limit or impose no annual limits at all, the annual limit on essential health benefits for each of the three years may not be less than the following:

• $750,000 for a plan year (policy year in the case of individual coverage) beginning on or after September 23, 2010 but before September 23, 2011;
• $1,250,000 for a plan year (policy year in the case of individual coverage) beginning on or after September 23, 2011 but before September 23, 2012; and
• $2,000,000 for plan years (policy years in the case of individual coverage) on or after September 23, 2012 but before January 1, 2014.

Group health plans must comply with the ACAs provisions prohibiting annual limits on essential health benefits—including the restricted phase-in limits— whether or not the plans are grandfathered.

Question: My husband works for a mid sized business. They changed health plans a year ago. The premiums are deducted pre tax from his pay. With co-pays and additional bills from doctors the plan is not affordable. The plan promotes “one bill” where the insurance company pays your provider and then bills you. Currently his employer is trying to force employees to payroll deduct for unpaid medical bills. I think we will be forced out of the plan if we refuse. Is this common practice?

Answer: Yes. Your employer can collect what you owe them through payroll deduction. Here’s why you owe the employer that money. The “one bill” plan to which you refer is actually a health reimbursement arrangement (HRA). The HRA works in conjunction with your health insurance coverage. The employer (not the insurance company) pays the employees’ out-of-pocket costs (copays, coinsurance, and other out-of-pocket medical expenses) directly to the providers - doctors, hospitals pharmacies. It’s like an advanced reimbursement. Your employer paid the bill for you, now you owe your employer that money.

Question: We have a child-only policy for our daughter. We have had the plan for about 5 months now. I took her into a new patient well check appointment where the dr found something that he wants to refer her to a pediatric neurologist for. She has not been diagnosed with anything during or prior to this appointment. Will my insurance look at this as something pre existing and deny anything if the specialist finds something to diagnose?

Answer: One of the earliest implemented - September 23, 2010 - consumer benefits of Obamacare was the removal of preexisting condition exclusions from child-only policies. What that means to you is, you never have to worry about coverage for preexisting conditions on your daughter’s insurance. All consumers will have the same benefits starting Jan1, 2014.

Question: An adult needs to buy insurance in Georgia, but plans to be back in California in a few months. Can we get a policy that covers both states?

Answer: Most national health insurance carriers have multi-state networks, so as long as you select a PPO plan you’ll be OK. You have to have a residence in a given state to purchase health insurance, so you will probably be buying your coverage in Georgia. If you maintain a residence in California, I recommend that you purchase coverage in CA. It’s cheaper and you won’t have to change when you move back.

Network coverage in another state works like this: You are insured by BCBS GA but need medical services in CA. As long as you choose a network provider of either Blue Cross or Blue Shield (separate companies in CA), you will get the in-network benefit your policy provides just as if you were in your home state of GA. This multi-state network benefit is exclusive to PPO plans offered by national carriers.

Question: I am 21 years old and I have a 5 month old son. My fiance and I are ready to get married as soon as we understand our health insurance situation. I am currently covered under my mothers insurance. My fiance is covered by his parents, and our baby has Medicaid right now. What are the options for each of us. I have heard that once you’re married you can not be covered under parents. I have also heard that is not true and that until you’re 26 or graduate college you can be covered. Which is true? And what are the options for our son? I know the new act effective in 2014 will offer us insurance, but for one that is a while from now, and two, is it REALLY affordable? We do not make much money, and won’t for a while. We are still studying in order to get better jobs.

Answer: You heard wrong. You can both stay on your respective parents’ health insurance coverage while married until you reach age 26. Being a student is no longer a consideration either. As long as your son qualifies for Medicaid, you can leave that alone too. In Jan 1, 2014, Obamacare will provide your family with either Medicaid or federally-subsidized private insurance at little or no cost to you (if you are still in the low-income range). So you are good to go. Get married. You have my blessing.

Question: I am about to retire and have secured independent coverage beginning 2 months before my actual retirement date. Can my company insurance carrier require me to stay on my plan until my retirement date or can I drop their coverage now?

Answer: In order to drop your group health insurance before the end of the plan year (open enrollment period), there has to be a qualifying event. For example, your retirement is a qualifying event. So you cannot drop your group health insurance coverage before your retirement date. Your mistake was in setting the effective date of your individual health insurance plan two months early. You can probably change that, ask your individual plan carrier to put off your effective date. If you show that you have coverage until then, there should be no problem.

Question: How much more can a health insurance carrier charge versus quote on internet?

Answer: All health insurance companies who offer individual health insurance must work off a published price list for individual health insurance rates. So the internet rate is the published rate - the lowest rate you can get. During the underwriting process, a risk or a grouping of risks, for example overweight and elevated cholesterol, may cause the underwriter to “rate-up” the applicant. The amount that the insurance company can rate-up the applicant varies among states. but it can be as much as much as 300% in some states. In that case the carrier is saying, “we’d rather not cover you, but if we must, you’re going to have to pay through the nose. Thankfully, this BS goes away in 16 months with health reform.

Question: My employer’s insurance agent is asking me to sign a form saying I deny insurance. I am opposed to signing this because I am not offered insurance since I am considered part-time (16 hrs/week). If I am not offered something, how can I deny it? What would be the reason for the insurance agent wanting the part-time employees to sign this? Couldn’t it potentially hurt me in the long run? In my opinion, I am being asked to lie on the form. Please advise.

Answer: If you are ineligible for your employer-sponsored health insurance coverage because you don’t work enough hours, there is no need to sign a waiver. Your employer’s contract with the insurance company - if self-insured their ERISA plan document - defines who is eligible for coverage. If you refuse to sign a waiver because it’s a matter of conscience for you, I don’t see how that could hurt you.

Question: I am currently covered by my husband’s employers’ plan. I started being covered by it because I was unemployed. Now I will start a new job in September with a company that offers group insurance option. Because of an ongoing medical treatment with the current healthcare provider ( husband’s employers’) I would prefer to stay insured with my husband’s plan. Can my husband’s employer deny me continuing this service? They don’t state it clearly in their policy but they do state that they need to be informed within 15 days of me becoming eligible for another group insurance so I just assume that they will not want to keep me. Is there something I can do about it or is it just perfectly ok because it’s a particular company’s policy?

Answer: There is no federal or state law, regulation or guideline that prevents you from waiving your employer’s group health insurance coverage in favor of remaining covered as a dependent on your spouse’s insurance. When you complete the waiver form, you will indicate that you are covered on your spouse’s plan. This should not be a problem for your employer as they will not have to make a contribution toward your health insurance. Please note: you will not be eligible for your employers health plan until the next open enrollment period unless you have a qualifying event before that time.

Question: We live in PA. In 2010 my husband left his last job and went out on his own as a painting contractor. We shopped for health ins and were told we could no longer get covg as a sole proprietor as we had in the past in that situation. We now had to become an LLC and then they had to have my husband on one plan on his own and me as an “employee” on another plan w/our daughter. We all have pre-existing conditions. I alone had a heart attack w/stents placed in 2009 and we all 3 take about a total of 15 rx meds. Our total ins premiums right now through KHPE are over $1800 per month. That’s 1 1/2 times our mortgage. We can barely make these payments each month and are trying to figure out if there’s something better out there for us. Starting to feel really hopeless.

Answer: There is hope, but not immediately. If you can make those premium payments for another 16 months, you will be off the hook. In January 2014, you will able to purchase individual health insurance form the State Health Insurance Exchange in PA. Rates will be the same for all regardless of health conditions. In addition, federal subsidies will greatly reduce your premium. Hang in there. It’s not hopeless.

Question: My husband lost his job in May. We lost insurance the last day of May. He will now begin a new job next week. Im not exactly sure when we be able to start our insurance with them. My question is that I recently found out I am 5/6 week pregnant. Will I get denied coverage? For example if we can not begin to use the insurance until October? will my pregnancy then be considered a pre-exisiting condition. The insurance the company provides is a group insurance.

Answer: Whenever your group health insurance coverage starts, medical expenses connected with your pregnancy will be covered from that point on.

Question: Is it legal for my boss to pay more fro some employees’ health insurance and less for others?

Answer: Yes! An employer can give employees different contributions based on classes of employees. To comply with federal regulations, employee classes within the health plan must be based on bona-fide business differences. These may include job categories, geographic location, part-time or full-time status, date of hire, etc. Within each class, the employer must treat all “similarly situated” employees equally. By creating classes based on genuine job categories, all employees within a class will be “similarly situated”. Employers must not discriminate against unhealthy people. An employer cannot provide inferior benefits to specific individuals with adverse health conditions. Employers must spell out the requirements for classes and benefits in the ERISA plan document.

Question: I just recently found out my individual insurance with Anthem Blue Cross was canceled due to a book-keeping error on my part. I filed a grievance with them stating I would pay all fees and penalties. In the meantime, they told me to apply again for another plan. Being truthful, I told them that I was in the middle of having a physical and blood work. They denied this new policy and states they need to see the results of the blood work. I literally just received the blood work back today and it says I have high cholesterol (My BMI is 24.3)…I haven’t even had a chance to speak to the doctor about it yet. I’m now terrified to send the insurance company this result for fear of being denied coverage. I’m unsure what to do, this is the first time I’ve ever been without health insurance my entire life.

Answer: Based on what you’ve told me, I recommend that you comply with Anthem’s request for the records and finish that application. Your high cholesterol is not a “knock out factor” by itself. Your height and weight are within the guidelines, so you could be approved for coverage, but will probably be looking at a 25% to 50% rate increase for the cholesterol. If you don’t get what you want from Anthem, call my office at 800-557-5693 and we will try to find coverage for you.

Question: We purchased a short term policy for our family when I was between jobs. One of my daughters has pre-existing health conditions (one being asthma). The plan did cover her - but then did not pay for a hospitalzation which they say resulted from her asthma. These type of plans do state that they only pay for emergency care and not routine care and pre-existing conditions - but for children - aren’t they now required by law to cover emergency care related to a pre-existing conditions? Or, are they just required to cover them only for accidents etc… and not for hospital stays related to their pre-existing conditions?

Answer: The main caveat that goes with short-term health insurance is that all medical conditions that existed at or before the date of the application are considered pre-existing condition and thus not covered. So the insurance company was “right” in this case. The ACA rule regarding exclusions in childrens’ health insurance does not apply to short-term health insurance.

Question: While I am in the 3-month waiting period for group health coverage with my new employer, my husband decided to add me to his health plan because he didn’t want me to be without insurance for 3 months. His employer contributes toward the plan for him, leaving him responsible for only paying $28 a week for his own coverage. They allowed him to add me, but do not contribute to my cost at all, so he pays $75 a week out of pocket. I just submitted the forms to sign up for insurance with my own company, which should go into effect Sept 1. However, my benefits administrator called me today and told me I was not eligible to enroll myself for coverage since my husband’s employer insures me. I told her that they technically don’t insure me, they don’t pay toward my premium at all. She said it doesn’t matter, and that my employer will not cover me. This seems COMPLETELY wrong to me. How can they deny me coverage in a group that I qualify for??? This woman is relatively new in her position, and I think she’s mistaken. I could understand denying me if my husband’s employer was paying for my coverage, but they’re not. What should I do?

Answer: Not complaining, but I get this question very often. You are correct. Your employer can’t do that, I have only seen this in some funky self-funded union plans because they draft their own plan documents. However not for the majority of employers. Without knowing anything else other than what you wrote, you should insist on your right to be covered on you new employer’s health plan. If you haven’t already done so, your application should indicate that your coverage under your husband’s plan is ending September 1st. Once you are approved, cancel your coverage under your husband’s plan.

Question: My boss had said that I could pick an individual health insurance plan and he would pay the premium, but his accountant told that there were tax penalties for doing that. Is that true?

Answer: Yes. Paying for your individual health insurance will put your employer out of compliance with federal regulations and increase the company’s tax liability and your’s also. There are two major reasons an employer should never pay for its employee’s individual health insurance plan:

1. Federal Compliance Issues - Paying for Individual Health Insurance without a HRA Plan Causes the Employer to “Endorse” the Individual Health Insurance Plans
2. Increased Tax Liability - Paying for Individual Health Insurance without an HRA Plan Causes the Payments to Become Taxable Income to the Employees.

When an employer pays directly for an individual health insurance plan, they effectively endorse each employee’s individual insurance plan as part of an employer-sponsored group health benefit offering. In other words, according to federal law, the employer is treating the individual plan as part of an employee welfare benefit plan regulated by ERISA. Because most individual health insurance plans, do not meet minimum ERISA group plan requirements, the employer is out of compliance.

Separately, an employer is not allowed to know the details of employees HIPAA-protected medical expenses. Because most individual health insurance costs are based on an employee’s health, the health insurance details must be HIPAA protected. When an employer pays for the individual policy, they can violate HIPAA-privacy requirements because they know the details of a HIPAA-protected employee expense.

The federal government has guidelines for employers who want to contribute to employee’s individual health insurance premiums without violating the HIPAA and ERISA regulations. An ERISA and HIPAA-compliant HRA health plan will ensure compliance with federal law. The IRS requires that legal plan documents be established in order for employees to deduct the individual health insurance premiums from taxable income on the annual W-2. An IRS-compliant HRA plan will ensure the tax deductibility of employee’s individual health insurance premiums as well.

Question: I’m a union employee with health coverage at a minimal cost. My wife has health insurance thru her employer but pays approximately 50 percent of the premium. We also have two children and my wife has them on her policy. We’re thinking of saving money by adding everybody to my policy and dropping her insurance. I’m wondering if my insurance will say that her employer offers a policy even though we’re paying high premiums that her policy is primary coverage for the family. I would love to drop her policy and add the whole family to my policy. I would appreciate any feed back…Thank you, James.

Answer: James, your insurance company cannot refuse to cover your wife and kids as dependents on your group health insurance plan because your wife has access to coverage with her employer. However, your union may have their own rules or regulations that you need to inquire about.

Question: Hi my wife is 24 and is still on her mom’s group coverage through work, I recently graduated grad school and now have group coverage through my place of employment. I am wondering if we can use both group coverage plans as a primary/secondary for the operation, or is her mom’s group coverage not valid now that she is on mine?

Answer: The benefit of double coverage is limited. The secondary plan will only pay for the difference in coverage for a given medical expense where the primary plan’s coverage is not as good. For example, say the primary plan has a $500 copay for the in-hospital benefit and the secondary plan has a $250 copay for the same benefit. You would get an additional reimbursement of $250 from the secondary coverage. If the primary plan’s benefits are as good or better than the secondary plan, there is no real benefit in having double coverage.

Question: I had medical insurance until 7/31/2012 through my mother’s group plan coverage, when it expired due to the fact that I graduated form college. Before that coverage expired I applied at a different medical insurance plan but was denied due to a pre-existing condition (Chron’s). Can I be denied even if I am insured or have been during the preceding six months?

Answer: Yes. You can be denied for individual coverage for preexisting conditions regardless of your previous coverage. Chron’s Disease is a denial condition for all the individual health insurance underwriting guidelines that I know about.

However, (and here’s where you need to pay attention) the fact that you graduated from college is not a reason to be dropped from your parents coverage. You can stay covered on your mother’s health insurance until age 26. If you are not yet 26, have you mother reinstate you on her insurance right away.

Question: Can i cancel cobra and keep my wife covered under cobra who has a preexisting condition?

Answer: The former employee (husband in this case) must be covered under COBRA continuation coverage in order for any dependent to be COBRA covered. If you wife has been without coverage fro 6 months or more, PCIP coverage is another option.

Question: I had health insurance coverage on my son when I was working for 2 years. In March I resigned from my job… filled out paperwork (to be added to father’s group coverage) on 6/30. The HR Department said that he will not be added to the insurance until the 1st of the year. Everyone is telling me that he should qualify for “special elections” and there is no time limit on that. Is this true? I think the employer is trying to say we waited too long to add him to his dad’s insurance.

Answer: Yes, apparently you did wait too long. You may enroll a dependent during the period beginning 31 days before and ending 60 days after a qualifying event (in this case the end of your employer-sponsored coverage - probably March 31). That would make May 31 the deadline adding to his father’s plan

You mentioned that your son has preexisting conditions. When he has been without health insurance for 6 months, he can apply for coverage in the Preexisting Conditions Insurance Plan (PCIP). unless there is another event during this time that would permit an enrollment change).

Question: My employer offers me health insurance for me and my family, however the cost deducted from my pay check is outrageously high, were talking about $500 a pay check. I can’t afford that payment, and on top of that, the coverage is horrible. It would be far cheaper for me to purchase an insurance policy myself though a company outside of work, at half the cost, and with far better coverage. However all insurance companies I’ve called have denied coverage because my employer offers me insurance. Is this a law that Insurance companies can’t offer insurance for individuals who are given the option through their work?

Answer: You cannot be denied individual health insurance because you have group health insurance available. I don’t know why you were told otherwise. Perhaps, you are being denied individual health insurance because you do not meet the underwriting requirements - most frequently for preexisting medical conditions.

Question: I had a chiro adjustment 4 times, and electric stimulus and my insurance paid. Then for the next three, exact services, they denied. Then 4 times after the denial they paid again for same service. I appealed but they denied. Why would they pay for a service, then not pay, then at later date pay again. I’m confused. If I bring this to their attention, can they go back and deny the previously paid claims?

Answer: The most frequent reason for claims payment variations is the service codes the provider enters when submitting the claim are incorrect. You can also have errors in the carrier’s claims department. That may account for the hit or miss nature of your chiropractor claims. First of all, you need to know your coverage. Call your member services hotline. The number is on your insurance card. Have them explain your chiropractic coverage so that you know it. If you have been paid for benefits you are not due, you will probably want to keep quiet. If they owe you, raise hell.

Question: I’m currently 24 years old and my parents include me on their health insurance. There insurance renews in October. If I get married after October, will I still be included on their insurance through October 2013?

Answer: Your marriage does not affect your parents’ right to include you as a dependent on their health insurance coverage to age 26. Your husband, however, may not be included on your parents’ coverage.

Question: Child with born with health issues. So this child already has preexisting conditions from birth and her parents can”t pay the bills.

Answer: A newborn with preexisting conditions has a couple of options to obtain coverage: child only individual coverage and the Preexisting Conditions Insurance Plan (PCIP). Neither of these options will help the parents pay the baby’s medical bills while uninsured, but will cover medical expenses going forward regardless of preexisting conditions.

Question: My daughter who is 23 and is a covered dependent on my husband’s insurance policy is pregnant and Maternity is excluded on the policy. My question is that in California Maternity Benefits are now mandatory as of July 1, 2012. Would this apply to her as well? If so, who do I contact to get her covered? Thanks so much!

Answer: Yes. Maternity coverage is a mandated benefit in California on new plans issued after July 1, 2012. However, your husband’s coverage was issued prior to that date. It does not automatically include maternity coverage now. If his coverage is part of an employer sponsored group health insurance plan, maternity coverage will be included at open enrollment, when the entire group renews or moves to a new plan. If your husband’s coverage is an individual plan, he would have to reapply for a new plan effective July 1 or later and go through the underwriting process. Your daughter’s pregnancy is a preexisting condition that will result in the application being rejected. I’m afraid there is no way your daughter’s prenatal and normal delivery expenses can be covered now. However, her current policy will cover medical complications during pregnancy and delivery should that occur.

Question: I was scheduled to have gastric bypass surgery July 31. My surgeon’s office contacted me and told me coverage was denied. My employer will add the coverage effective Sept 1, only if they do not have to cover every employee (we total under 10). Does my employer have to cover every employee or can she just cover me since no one else is obese?

Answer: While it was generous of your employer to offer the additional coverage for bariatric surgery for you, the coverage change would have to be added to the entire group.

Question: I am 21 years old and on my parent’s insurance. I just got a job that offers insurance but it is not as good as my parents. Can I deny my employer’s insurance and just stay on my parents?

Answer: Yes. You may sign a WAIVER OF GROUP HEALTH INSURANCE COVERAGE. The waiver says something like this, “I hereby certify that I have been given the opportunity to participate in the group health insurance plan provided by my employer through XYZ Insurance Company and have been informed of the consequences of not enrolling in such plan at this time. I understand that if I reject the group health plan on behalf of myself and/or my spouse or other eligible dependents, the group health plan will not provide any benefits on behalf of those individuals for whom I have waived coverage. With this knowledge, I decline to enroll.” You will usually be asked to list your current coverage.

Question: I am married but am still covered under my mothers group insurance plan. I have maternity coverage but I am wondering if the insurance will cover the baby after birth and for how long. Also if my husband does not currently have medical insurance will his employer still have to open his enrollment after the baby is born?

Answer: Generally, your insurance coverage will cover your newborn for the first 30 days after birth, but please confirm that with your insurer to make sure. Your husband apparently waived employer-sponsored group health insurance and will not be able to enroll until the his employer’s next open enrollment period. The baby’s birth is not a “qualifying event” for your husband. It would be a qualifying event for the child were your husband insured. You can purchase an individual health insurance plan for your baby in the meantime.

Question: I currently am 100% covered by my employer but will be going part-time My employer will not pay any of my health insurance costs as a part-time employee. To make ends meet I will need to also be self-employed. I have a pre-existing condition that requires very pricey drugs. Is my best option to elect COBRA and hope that they don’t repeal the health care act so that I can get affordable coverage in 2014?

Answer: Yes. Your best option is to elect COBRA. It will cover you until you can enroll in guaranteed health insurance coverage available through your state health insurance exchange in January 2014. If your income is still on the low side by then, you will probably qualify for a subsidy to help pay your premium. And of course, your preexisting conditions will no longer affect the availability or cost of health insurance.

Question: Will i get cheaper coverage from a state health insurance exchange?

Answer: No and yes. In general qualified health plans sold through the state-based exchanges starting in 2014 will be higher-priced than the average plan today. That’s because they must contain a minimum of essential benefits which today’s cheaper plans do not cover. However, many millions of Americans will qualify for “advance tax credits” which are federal subsidies for the purchase of private health insurance available only through the exchanges. These subsidies are based in income and are quite generous. For example, subsidies will be available to a family of four with annual income up to $92,000.

Question: I was laid off - my medical coverage ended on 3/31/2012. I did not elect cobra. I purchased a high deductible, no prescription coverage, bare bones health insurance policy that begain on 6/1/2012. On 6/14 I was diagnosed with multiple Sclerosis. I am a Pennsylvania Resident. I have a meeting with an Attorney to start filing for disability, but this could take a year or more and possible denial. What is my best option to obtain better coverage at this point, so I’m not buried medical expenses?

Answer: You cannot improve your health insurance coverage at this point. On the plus side, you do have coverage and help is coming. Assuming the Affordable Care Act stays in force, you will be able to upgrade your coverage on January 1, 2014. With MS, the big out-of-pocket expense for you will be prescription drugs. Please read this article 7 Ways to Cheaper Drugs.

Question: My nineteen year old son just graduated from high school in May and will be attending college full time in August. He has a part time job at Burger King working about thirty-two hours a week. Burger King offers insurance to it’s part-time workers but it costs more than he makes. My employer is kicking him off my insurance because he “has health insurance available through his employer.” He either has to quit his part-time job or go without health insurance until august. Is this legal? They state that this is Obama Care.

Answer: Your employer has no legal grounds for denying your dependent son coverage under your group health insurance plan - certainly not any part of “Obamacare”. But keep in mind that your employer can insist on a “company policy” that has no legal basis. That’s his prerogative. You may be legally right and loose your job.

Question: I have bariatric surgery scheduled for July 3rd under my Group Plan. Today I received notificaiton from my company this plan is being withdrawn and preplaced with 2 other options as of July 1st. I’ve had 6 months of workup prepration for this surgery and now I’m loosing the insurance. I’ve called my surgeon to see if we can move up the date. I have a few questions: even if I selected a new goup plan that my company is forcing me to pick from and different than what I have now, assuming this procedure will be coverd under a new plan, will I be forced to go through all the work up again for the new plan? Can I be denied for pre-existing condition - whether I have the surgury sooner and not be forced to the new plan or wait and have surgery under the new plan? What if I have complicaitons after the surgery on the new plan. Mindful, the new plan is not my choice, but my employer will drop what I have now and offer other plans. Please advise. (I live in CT, have a primary Dr. in CT, but my insurance company is out of Mass.)

Answer: The crux of your question is which insurance company is responsible for a claim when there is a change of insurers. In your case this change is taking place on July 1st, so the current insurance company is responsible for all medical services you receive prior to July 1st. These responsibilities are based on the dates-of-service not the date the claim is submitted or received by the insurer. The “new” insurance company would be responsible for your surgery assuming it’s done as scheduled on July 3rd. If you have the surgery done before July 1 you will need routine follow-up and if there are complications that require treatment, those claims will be the responsibility of the “new” company. No - you cannot be denied coverage for preexisting conditions under Massachusetts laws.

Your primary problem right now is that you don’t know if the new insurance plan will cover the bariatric surgery. You need to find that out right away. It either does or it does not. It’s not based on your circumstances. If the answer is “no”, you have to move up your surgery up. If the answer is “maybe”, I would still advise you get it done before July 1st.

Secondarily, you will have to find out if your surgeon is in the new insurance company’s provider network. If not and you have to switch surgeons, then it’s quite possible the new surgeon will require additional surgical workup and your surgery will have to be rescheduled.

Question: If a dependent loses coverge on their parents policy due to reaching the maximum age, is that a qualifying event to pick up coverage under their own employer?

Answer: Yes. See #4

List of Qualifying Events

1. Change in legal marital status, including marriage, death of a spouse, divorce, legal separation and annulment.
2. A change in the number of dependents, including birth, death, adoption, and placement for adoption.
3. A change in employment status of the employee, or the employee’s or retiree’s spouse or dependent, including termination or commencement of employment, a strike or lockout, a commencement of or return from an unpaid leave of absence, a change in worksite, and a change in working conditions (including changing between part‐time and full‐time or hourly and salary) of the employee, the employee’s or retiree’s spouse or dependent which results in a change in benefits they receive under a cafeteria plan or health or dental plan.
4. A dependent ceasing to satisfy eligibility requirements for coverage due to attainment of age, student status, marital status, or other similar circumstances.
5. A change in place of residence of the employee, retiree or their spouse or dependent and the current carrier is not available.
6. Significant cost or coverage changes (including coverage curtailment and the addition of a benefit package).
7. Family Medical Leave Act (FMLA) leave.
8. Judgments, decrees or orders.
9. A change in coverage of a spouse or dependent under another employer’s plan.
10. Open enrollment under the plan of another employer.
11. Health Insurance Portability and Accountability Act (HIPPA) special enrollment rights for new dependents and in the case of loss of other insurance coverage.
12. A COBRA‐qualifying event.
13. Loss of coverage under the group health plan of a governmental or educational institution (a state’s children’s health insurance program, medical care program of an Indian tribal government, state health benefits risk pool, or foreign government group health plan).
14. Entitlement to Medicare or Medicaid.
15. Any other situations in which the group health or dental plan is required by the applicable federal or state law to allow a change in coverage.

Question: My employer has told me that he is changing to a defined contribution plan in July. He said that my healthcare it will cost me the same as it did this year but that I will have more choice of plans. Is it a good deal for me or am I getting screwed?

Answer: Compared to the old “defined benefit” plan where employers determined a set of health-insurance benefits, under “defined contribution” plans employers pay a fixed amount for each employee, and employees use the money to buy or help pay for insurance they choose themselves. It’s a good deal for employees in the sense that it puts you in the driver’s seat as far as selecting the plan you want, but if the defined contribution amount doesn’t go up to match the inevitable premium increases for health insurance, it will leave the employee holding the bag for more and more of the costs. It’s a better deal for employers because it puts them in control of their health benefit outlay regardless of health plan rate increases.

Health-Care Reform will push the transition to defined-contribution health insurance in 2014. If most employers do retain their health plans, the state health insurance exchanges created under the law will make the basic idea of a defined-contribution health plan more prevalent, and thus may speed its adoption. If defined-contribution plans that are sufficiently generous count as employer-based coverage — as is generally expected — the trend toward such plans will probably accelerate.

*Question: *My sister is fortunate to work for a company that offers several medical plans to choose from. She was thinking of switching plans at the next open enrollment time but she has been diagnosed with fybroid tumors. At this point they are large enough that medical would cover her for the removal but not critical enough that she has to have them out this very minute. If she waits and changes medical plans during open enrollment time at her company could the new plan refuse to cover the surgery claiming a preexisting condition?

Answer: If as you say the new health plan is a group health plan that has been offered as an option by your sister’s employer, then once enrolled in the new health plan any preexisting condition will be covered. In most states there would be no waiting period either, but just to be safe your sister should check with the new plan to make see if there is a waiting period for any specific conditions.

Question: As an employer with 25 employees, do I have to equally contribute towards health insurance premiums for my employees. Currently I pay for single coverage for all employees. I have some very valuable employees that have been here for over 20 years and I would like to give them employee/spouse coverage without a cost to the employee.

Answer: You may vary your employer contribution to the employees’ premium under your company’s group health plan in several ways. You can contribute different amounts (1) for different classes of employees - hourly vs salaried vs management, for example. (2) for different age groups because rates are higher for older employees, (3) for different locations if rates are higher for some because of ZIP codes, (4) for family status - those with dependents more than single employees. You will have to find another way to provide additional benefits on the basis of length of service alone.

Question: I am planning to retire soon. I been with the same company and on the same insurance plan for 25 years. Can I change my insurance from a company group coverage to an individual coverage. I was told recently that I could not. Can you help.

*Answer: * When you retire (assuming you are not yet 65), you’ll be offered COBRA health insurance. It’s the same coverage you had on the group plan but your employer will no longer be paying for it. It usually comes as a shock to most people when they find out just how much the full premium is. You can stay on COBRA for up to 18 months. Alternatively, you can decide to apply for individual health insurance instead of COBRA. Unlike COBRA, you may choose coverage that’s in line with your budget. Here’s the big obstacle - you must pass the stringent underwriting guidelines to qualify for individual health insurance. It’s been my experience that people of retirement age very often fail to qualify for individual coverage.

One way or another, if you can make it to January 2014, when the guaranteed issue and community rating provisions of the Affordable Care Act (ACA) take affect, you will no longer have to worry about preexisting conditions. You will be able to purchase individual health insurance coverage at the same rate as everyone else in your age and ZIP code demographic. In addition, you may qualify for a federal subsidy that will pay some of your premium. So do what you have to do to get through the next few months. Things will get better.

Question: My 24-year-old son is on my insurance. He gets married and stays on my insurance. His wife is covered on her father’s insurance. She gets pregnant. Her insurance has no maternity coverage. How do they get maternity coverage? How does the baby get insurance for post-delivery?

Answer: Getting maternity coverage for your daughter-in-law is impossible once she is pregnant. The baby is covered for the first 30 days after birth by her insurance coverage. Thereafter, the newborn can be insured under his or her own child-only health insurance coverage within the first month after birth.

Question: I am currently covered by the VA. My benefits will stop in 2013 due to income. I have pre-existing conditions, high blood pressure and cholesterol. My spouse checked with her employer and can get me coverage for around $650/ mo. Will this be the best and most inexpensive choice for me with my conditions?

Answer: When your VA healthcare benefits end in 2013, you probably will not have any other health insurance options than your spouse’s group plan because of your preexisting conditions. Your wife’s employer-sponsored health plan is expensive because it’s probably very comprehensive coverage and that’s why the monthly premium is so high. If you had other coverage options, you would probably choose less comprehensive coverage - a high deductible plan with potentially more out-of-pocket expenses - for a lower monthly premium.

Fortunately, you will not have to pay such a high premium for very long. Thanks to the Affordable Care Act, you will be able to purchase individual health insurance through your state health insurance exchange in January 2014 without being declined or rated-up for your preexisting conditions.

Question: We own a small business and in Alaska and want to have a baby. There doesn’t seem to be any maternity insurance available though. We do not qualify for the state funded Denali Kid Care. Is there any options for us? Thank you.

Answer: You didn’t mention whether you had health insurance or not. If you do not, get some, that would be the first step. Major medical insurance coverage (without maternity) will cover any extraordinary costs connected with having a baby - pretty much everything beyond prenatal tests and normal delivery. Once you are insured against catastrophic loss, you need to start saving for the predictable costs associated with normal delivery, perhaps $10,000.

Question: I have been working for my company for 11 years I went on maternity leave and then my daughter had health problems and I developed post partum and couldn't return back to work, my company said no problem and continued to pay my full premium ever month I am now back to work and the health insurance company is fighting with my boss and wants to drop me from the plan are they allowed to?

Answer: I think I understand what happened and it's really bad luck for both you and your employer. The employer's health plan contract with the insurance company defines a specific length of time employees are to be covered while on maternity leave. Apparently you were out longer than the contracted time. Normally, this is something that would not come to light as long as your employer continued to pay your health insurance premium each month you were out. However, the insurance company will routinely re-certify a health plan and that includes a review of the most recent payroll tax records. If you did not appear on the payroll, you should not have been covered. The insurance company has the legal right not to pay your claim and rescind your coverage. It sucks, but it is what it is.

Question: Would like to quit my job because my mom is ill and need to take care of her. I have bone on bone with both knees and will need surgery down the road. I have been having steroid injections for the past 2 years and have been very helpful. My husband is planning on putting me on his plan what complications do you think we will have with getting me coverage?

Answer: If your husband’s health plan is a group health insurance plan. You will be able to be added to his plan on the month following your employment termination. Your loss of employer-sponsored group health insurance is a qualifying event that will enable your husband’s plan to pick you up without having to wait for his plan’s open enrollment period. If your husband’s health plan is individual health insurance, you will probably be declined. That will leave COBRA coverage as your next option.

Question: After applying for a medical plan and being accepted, then one month later having heart trouble - will policy pay?

Answer: If the insurance company can determine that your heart condition was pre-existing, they will not pay. They will look at your application with a microscope. For example this is the type of general question that should uncover a pre-existing condition.

• “Within the last 5 years have you been advised by a healthcare provider to have, but have not yet had, surgery, treatment, examination, evaluation or test(s) for a medical condition?”

If the insurer can produce medical records or claims history that shows that you did not answer accurately, they will deny your medical claim and rescind your insurance - even if your oversight was not related to a heart condition.

Question: I am a 57 yr old underweight female with a history of controlled asthma and allergies who is mostly healthy. Because of these risk factors, I want to know if underwriting success is higher for a high deductible/low premium plan vs a low deductible/high premium plan. I want to apply for plans with the lowest risk of being declined.

Answer: Generally, the probability of being accepted for coverage is improved by choosing a higher deductible plan. There are some variations to the risk assessment with every carrier. The frequency and number of prescriptions, along with any other risk factors will affect the final underwriting decision regardless of the chosen deductible. I suggest, you call our individual underwriting specialist, Erin, at 800-557-5693 and go over your medical history with her. She can determine where you will be treated the most favorably.

Question: I’m approaching at 65 and my employer is strongly encouraging me to cancel my group coverage and elect Medicare coverage only. Can they do that?

Answer: Yes, your employer can “strongly encourage” you to take Medicare coverage when you become eligible. It’s important that you understand that your employer has been paying at least $500 a month to provide health insurance for you. Medicare will cost $100 per month. Perhaps you could negotiate a reimbursement for the Medicare Part B premium of $100 and an additional $130 - $150 per month for a Medicare Supplement - total cost to your employer is $250 per month and you get virtually 100% coverage. This advice applies only to group health plans with less than 20 employees where Medicare is the primary payor and the group health plan is secondary.

In larger groups, Medicare is the primary payor and there are rules that forbid employers from targeting Medicare-eligible employees by providing incentives (financial or otherwise) for them to drop employer coverage in favor of Medicare. As one of our readers, Chris Anderson of Sylmar, CA, pointed out: “The Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA), has confirmed this prohibition many times, and employers should note that CMS may assess a penalty of up to $5,000 for each violation. An employer cannot offer, subsidize, or be involved in the arrangement of a Medicare supplement policy where the law makes Medicare the secondary payer. Even if the employer does not contribute to the premium, but merely collects it and forwards it to the appropriate individual’s insurance company, the GHP policy is the primary payer to Medicare.”

Question: Can an employer set up an hra with no group health insurance?

Answer: Yes. Companies that want to offer health benefits, but cannot offer group health insurance due to high cost or participation requirements can offer a defined contribution health plan in which they make available monthly contributions that employees can choose how to spend. Employees can use their monthly contribution amount to reimburse their individual health insurance costs and eligible medical expenses. This is just one of many HRA design options.

Question: i am adding a person with a pre-existing medical condition on my group policy…will they be accepted?

Answer: Yes. In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA). This law mandated nationwide, across-the-board guaranteed issue in the small group market - among other things. A small group is defined as an employer group with 2-50 employees. However, insurance companies may charge higher premiums for groups that contain high risks or that have had a history of high claims. In some states, the premium for high-risk groups can be much higher.

Question: I am the fortunate position that I am covered under my spouse’s insurance at a fantastic rate (group health PPO). I’m about to start a fulltime job which offers an HRA “health plan” as a medical benefit option. If I enroll in that plan, will I receive medical care under the PPO as usual and then use the HRA for copays, etc. like I do for an FSA? Or will the HRA qualify as my “primary insurance”? There are levels which are for myself only, myself + spouse, myself + family. My birthday comes first in the calendar year, and will my children also be treated with my insurance as primary if I include my family members?

Answer: HRA plans are very flexible and I’d have to know more about how your employer’s plan is structured to give you a precise answer. But I’ll step out on a limb here and say that you can continue to use your wife’s health insurance coverage primarily and utilize your employer’s HRA plan to reimburse your (and your dependents’ if you add them) out-of-pocket medical expenses. This would be a win-win for both you and your employer, though not for your spouse’s employer.

Question: If you loose insurance coverage due to layoff and you are being treated at the time does company have to cover you?

Answer: Yes. Upon termination, your company is responsible for making COBRA coverage available to you. However, it is your responsibility to make the entire premium payment to maintain that coverage. If you do so, coverage for your ongoing treatment will be seamless.

Question: Why can’t i choose to be the primary health insurance for my children if my coverage is better than my husband’s?

Answer: It’s not up to you to decide which plan is primary. When dependents are covered on both parents health insurance, Coordination of Benefits (COB) rules come into play. Most states have adopted these rules though they can vary some from state to state. In general, when deciding which parent’s health insurance coverage is primary on claims for double-covered dependents, the “birthday rule” applies. That is, the plan covering the parent whose birthday falls earlier in the year pays first, and the plan of the parent whose birthday falls later in the year is secondary. And if these parents have the same birthday, the plan covering the parent the longer period of time is primary.

Question: My husband has a new job. Can I cancel my current health insurance with my company and enroll with his new health insurance plan?

Answer: Your husband’s new job is not an acceptable reason for you to opt out of your own employer-sponsored health plan. You may do that at the next open enrollment period. However, you can’t be added to your husband’s health plan until his plan’s open enrollment period unless you have a “qualifying event” like loosing your coverage through termination. These rules may seem arbitrary are in place to protect employers and insurers against adverse selection.

Question: If i am terminated from my job and have to go onto my husbands insurance will my cancer diagnosis be considered pre existing?

Answer: Your cancer diagnosis is a pre-existing condition for any insurance you would apply for going forward. If your husband’s coverage is group health insurance, your pre-existing condition will not prevent you from becoming insured on his plan. If his coverage is individual health insurance then your cancer diagnosis will cause you to be denied coverage. If that is the case, you have 2 other options COBRA and HIPAA health insurance coverage.

Question: Is an employer responsible for a portion of a terminated individual’s deductible in a group HDHP?

Answer: The employer is not responsible for any part of your COBRA premium, but you asked about the deductible which adds an interesting angle. If your employer was reimbursing some portion of your out-of-pocket medical expenses (below the annual deductible) while you were employed, it’s possible that there is a Health Reimbursement Arrangement (HRA) in place which would spell out whether former employees are to be covered by the HRA while on COBRA.

Question: I have a question about the new health care reform. I have a son that just graduated from college and he was on my health insurance where I work (in massachusetts). He will be accepting a new job in california but his company has a "waiting period" of 180 days. So my question is can he remain on my health insurance under the "age 26" law even if he is moving to another state and the fact that even tho hie employer offers health benefits..he cannot get the insurance till the waiting period of 180 days has been completed? Thank you in advance.

Answer: Health care reform - the Affordable Care Act - allows insured parents to keep their sons and daughters on the their health insurance plan (individual or group) to age 26. Since it's a federal law it affects all states equally. When your son moves to California he can stay on your health plan for a few months until he is covered by his CA employer. However, if you have an HMO in MA it will only cover emergencies in CA. PPO works fine out of state. He can get the in-network coverage in CA if he is careful to select the right provider. If HMO, I recommend he purchase short-term health insurance coverage in CA. It's relatively cheap and easy to qualify.

Question: My husband voluntarily left his job and was offered COBRA for both of us. I am employed by a different company and now want to apply for their health insurance, when do I qualify for coverage. Do I have to wait until the Cobra enrollment period (65 days) runs out?

Answer: Your loss of health insurance due to your husband’s termination of employment is considered a “qualifying event” which allows you to join your own employer’s group health plan on the first of the month after loss of your husband’s coverage. COBRA is an option for people who do not have another employer-sposored option as you do.

Question: My husband works for a large mechanic shop. He was offered insurance and was told that I his wife am ineligible for any plan cheaper than $500 a month. Individual plans are much cheaper than this and I find that amount preposterous and the reasoning even more absurd. The employer stated “26 is a time to have babies and thats why it is so elevated”.I have no inclination of having kids and find this frankly ridiculous. Other employee have family members covered for less and some are not covered at all and are not offered free coverage as my husband was offered (maybe due to the fact his been there 2 yrs?) Is this even legal what he is doing? Putting everyone in different groups and classifications of his morbid idealisms and basing his coverage on this?

Answer: I get a lot of these “is it legal” what my employer is doing and the answer is “yes” in most cases. So it is with your situation. First, the employer is allowed to make a greater contribution some employees’ health plan premium by classification. For example, a greater contribution to salaried workers than hourly workers, or management and non-management. Secondly, it is common for employers to make no contribution to the coverage of spouses and children. Finally, group health insurance is usually more comprehensive - includes maternity coverage for example. On average, group health insurance will cover 80% or more of your average medical expenses (actuarial value) versus 60% or less for individual health insurance. But that’s why individual health insurance can be cheaper and if you don’t need the extra coverage (maternity in your case) why pay for it. Click here to compare rates now. I think you’ll be surprised how much you can save.

Question: Can grandparents cover a baby with insurance?

Answer: If you mean, can you add your grandchild to your individual or group health insurance coverage the answer is no unless you are the child’s legal guardian. You certainly can purchase individual coverage for your grandchild - referred to as child-only health insurance. Unfortunately, due to the law of unintended consequences, child-only coverage is impossible to get in most states. The Affordable Care Act (ACA) legislated that no exclusions of coverage would be allowed for children through age 18. The intent of the law was to make health insurance for children guaranteed-issue - meaning they can’t be turned down because of pre-existing conditions.In most states child-only health insurance is no longer available (California being one of the exceptions) because the insurers refuse to comply with the law’s intent. Quite possible, this stalemate will continue until January 2014, when all health insurance is guaranteed issue.

Question: Does my employer have to pay part of my health insurance in California?

Answer: Yes, but only if your employer already sponsors a group health plan for its employees. If so the law says, they must pay 50% of the employees’ premium for the lowest priced plan available. If your employer does not already have a group health plan for its employees, they are not required to pay any part of your individual health insurance expense.

Question: I have a healthcare reinbursement account. Our son is 24 and on our insurance. We pay for his out of pocket medicine expenses($330 a month after insurance) because he does not make enough money to afford these medications. We do not claim him as a dependant on our tax return. Can I use my reinbursement account for his medical expenses if we are paying for them?

*Answer: * Your health reimbursement arrangement should allow the reimbursement of prescription drugs for your son. The fact that he is covered on your health plan is key in determining his eligibility fro reimbursement. The fact that you do not claim him for tax purposes is not a factor. I can’t say for certain because HRAs are very flexible and it is possible (though highly unlikely) that prescription drugs are not included as a reimbursable expense on your specific plan or that dependents are specifically excluded.

Question: I am in middle management for a large industrial company and pay for a family plan that covers me and my two children. My wife is a teacher whose school board provides single coverage for her (for a fee) that’s nowhere near as good as mine - she can’t opt out. My employer recently announced that effective May 1, if any of us have a spouse with health care coverage, we need to enroll our children on their plan and be covered only as “single” on our own existing plan. No explanation was given although I suspect that in my industry which is predominantly male, the company wants to save costs by not covering child delivery and other costs not directly incurred by the actual employee. Switching to my wife’s plan would be a) more expensive and b) provide less coverage than my children have now. Is this legal?

Answer: Employers increase employee cost-sharing to order to deal with the ever increasing cost of providing health care benefits for its employees. Generally, this occurs after the employer has absorbed much of the cost increases themselves. Usually this cost sharing takes the form of requiring a larger employee premium contribution or a reduction in benefits. As far as I know, your employer has the right to insist that a spouse or dependent must opt out of your coverage if they have access to coverage through their own employer. Requiring you spouse to cover your children on her employer’s health plan doesn’t seem fair. There is not yet (2014) any law that says employers have to provide health insurance at all, but if they do they must follow federal ERISA regulations that among other things govern “fairness” in the administration to the plan. For a more definitive answer, you will have to ask an HR attorney.

Question: I have an individual health insurance policy paid for by my employer. I also have the benefit of being on my husband’s health insurance through his employer. I always thought that MY coverage was primary over the coverage provided by my spouse’s employer. But my carrier said group policies are always primary over individual policies. Is this true? (South Carolina).

Answer: Coordination of Benefit Rules were codified by the National Association of Insurance Commissioner in 1986 and each state uses this model with some modifications. The rules cover how the primary payer is determined when an insured employee or dependent has double coverage. For example the rules state that the group plan covering the insured as an employee pays first. To determine who pays first on dependent children’s claims, the plan covering the parent whose birthday is earlier in the calendar year is primary.

The Coordination of Benefits endorsement on group health policies does not apply to individual health insurance policies so they generally pay their full benefits regardless of other group health policies in force. But there are variations between states, it is important that you review the provisions of your individual health insurance policy because they will sometimes include their own provisions about other insurance.

Question: I’m 9.5 months pregnant and currently covered under my husband’s group insurance policy. It’s very expensive, but we obviously needed the maternity coverage, so we opted for adding me to his rather than me getting individual insurance. We’d planned on just adding the baby to our plan, but just found out that the cost of this with our current plan is prohibitive and we can’t downgrade the plan for another 9 months (during open enrollment). I have done some research and think the best bet is for him to drop me from his plan 1 month after the baby is born (so my postnatal visits are covered) and for me and the baby to get individual insurance (which is still substantially cheaper than the family plan through his work) as soon as she’s born. My question is about the timeline with the birth and insurance. Since we wouldn’t be adding the baby to our existing plan and instead starting a new plan (which it looks like I can’t do till she’s born and we have her birth certificate), will we have trouble getting coverage? I know we have 30 days to add her to our group plan, but if we’re opening up a new plan, how does that work? I know it can take up to a few months to get new coverage and obviously can’t go without coverage for my child. We’re in Florida and I have no health concerns (other than currently being pregnant!). I’m nervous since we don’t have much time to sort this out. Thanks for your help!

Answer: I’m guessing at 9.5 months pregnant you don’t have much patience for a long-winded answer so I’ll get right to the point. You can apply for individual health insurance - both you and the child together - about 2 weeks after the baby is born. You will need a copy of the initial physical exam for the baby. If the baby has no health issues, you should be able to get coverage starting within 30 days of the baby’s birth. Your group health insurance will cover the baby for the first 30 days after birth. If you have the energy, click here to start shopping for a health plan now - just enter a birth date of a month ago for your child.

Question: My company pays for half of my premium and I pay the other half along with full coverage for my three year old daughter...the deduction for my health insurance had increased...I told my employer that I would like to opt out of the company policy and purchase individual insurance, because I could get a better policy at a cheaper rate and they advised me that I cannot cancel my insurance until open enrollment in November. I was never advised that my premiums were increasing, there was not a meeting, email, nothing letting me know. Can my employer force me to stay on their company plan until November?

Answer: Yes. Apparently your employer did a lousy job of communicating the increase in your health insurance contribution back in November when you could have opted out. Employees should have the option to decline medical coverage or to purchase individual health insurance as long as their decision does not affect the medical rates of those remaining in the plan. Opt-Out provision are restricted to open-enrollment periods because it was determined that about 20 percent of a plan's participants generate 80 percent of the claimed costs in any given year. In most cases, those who opt out of a medical plan are the healthier population; employees expecting high expenses prefer the extra coverage. Since employees with more medical needs tend to stay in the plan, when employees opt out there are fewer premium dollars coming into the plan, but claim and administrative costs do not go down in the same proportion. This results in higher premiums for those remaining in the plan. That's why restrictions are in place for right to opt out.

Question: My employer offers health insurance to me at no cost to me. My husband also has me covered through his insurance at his place of employment. I have been told that my insurance through my employer has to be my primary. I want to opt out of my insurance through my employer and only have my husband insurance, but my employer is telling me that I can not opt out and that I have to take the insurance. Is this right? The board pays our insurance, but I would rather them put my board paid money into and annuity.

Answer: The responsible thing to do would be to take the coverage your employer is offering and cancel the coverage being offered through your husband’s employer. Your sense of entitlement is especially astonishing at a time when many people lack good health care and some can’t get it at all.

Question: My employer has just sent me an email stating he will no longer cover the insurance premium for my spouse and my cost for myself will increase. He states this is effective in March. Is this legal? This is a small Colorado employer.

Answer: Yes. Your employer was never required to cover your spouse and did so voluntarily. If an employer offers a group health plan, he or she is required to be fair. For example, it the employer offers coverage for spouse or other dependents, he or she must offer like coverage to all employees of that class, e.g. hourly, salaried, management, etc..

From what you say, your employer is making a choice to no longer contribute to dependent coverage for all enrolled employees effective on the March 1 plan renewal date. That is his right and probably a necessity for the health of the business. Employer sponsored health insurance costs have increased by 50% over the last 5 or 6 years.

Question: I moved my family from Virginia to Alaska last week. We have an individual family policy (not group) from Anthem BCBS Virginia. My intention was to keep the Virginia policy and apply for a new policy when we got here. Since arriving I have not been feeling well. It may be nothing but my concern is that if I visit a doctor and there is something wrong I may not be able to get a new policy. Is this a ligitimate concern and what if any recommendations do you have? Thank you!!

Answer: Your Anthem Blue Cross Blue Shield of Virginia policy covers you in Alaska. As long as you get medical services from a provider who is in the Premera Blue Cross of Alaska network, your coverage in Alaska will be the same as they would have been in Virginia. If you have something wrong, get treatment. It could be something that would become serious if not treated now. Go see a doctor!

Normally, your current policy will cover you in Alaska for months (six months is probably the limit). You should apply for coverage with Premera Blue Cross in Alaska if you live there on a more permanent basis. If you have developed a serious medical condition in the meantime and do not qualify for individual health insurance with a new carrier, there are other options like HIPAA and PCIP.

Question: Why can’t employer reimburse individual insurance premiums?

Answer: Employers can reimburse individual health insurance premiums, but the reimbursement is not tax deductible for the employer and is taxable as income for the employee. The employer would have to establish a Health Reimbursement Arrangement (HRA) in order to enjoy the same tax advantages of group health insurance - deductible premiums and pre-tax income for the employee.

Question: Can you opt out of mandatory maternity coverage in California if dont want it?

Answer: Not if you are covered by a group health insurance plan. California law requires all employer sponsored group health plans to include maternity coverage. While it seems illogical for a single male or an older female to be required to pay the extra costs associated with insuring for maternity coverage when they will never use the benefit, it is one of the basics that makes insurance work, that is: those with no claims finance those with claims. It makes the maternity benefit affordable for all those who need it.

In the individual health insurance market, many plans are available without the maternity benefit. This makes those non-maternity plans more affordable, but also makes those plans with a maternity benefit very expensive for the few who require it.

Question: Does Obamacare provide maternity for married dependents?

Answer: The Affordable Care Act (ACA) includes several categories of essential benefits to set a benefits floor for all health insurance plans from 2014 going forward and maternity and newborn care is one of those categories.

But I think you may be asking another question. It sounds like your married son or daughter is covered under your health insurance policy and you have a grandchild on the way. We don’t know yet how that situation will be covered in 2014, but today, the maternity and delivery costs will not be covered by your health insurance.

Question: If you are treated for an illness in the last few days of December and have to have additional treatment in January of the following year for the same illness do you still have to meet your deductible again.

Answer: Generally, the annual deductible resets on January 1st. But you may want to contact your health insurance company to ask about “fourth-quarter roll over.” Some health insurers will allow dollars paid toward your deductible in the final months of 2011 to “roll over” or count toward your 2012 annual deductible. This can give you a head start toward meeting your deductible in the new year.

Question: We purchased a private plan through Golden Rule / United Health Care in 2009. They excluded coverage for my 7 year old son’s ears for life. Anything at all to do with his ears. Is this considered a grandfathered plan and can they still deny coverage for his ears?

Answer: The Affordable Care Act (ACA), or Obamacare depending on your politics, legislated that no exclusions of coverage would be allowed for children’s (through age 18) health insurance. Most sane individuals would see the intent of the law was to make health insurance for children guaranteed-issue - meaning they can’t be turned down because of pre-existing conditions. The insurance industry chose to interpret the law differently with the result that in most states child-only health insurance is no longer available (California being one of the exceptions) because the insurers refuse to comply with the law’s intent. I guess your son’s health insurance carrier will keep doing what they want until forced not to.

Question: I am turning 65 and work half-time. I am not eligible for health benefits, so I am on my wife’s policy. It is at a state university and it is through Anthem. Will I be able to continue on her policy, or will Anthem kick me out?

Answer: When you turn 65 you have health insurance available. It’s called Medicare. Your wife’s employer is no longer obliged to offer you coverage as a dependent on her employer-sponsored policy. Medicare is excellent coverage and it’s available to you for less than $100 per month. Anthem will not “kick you out” because they collect a nice piece of change from your wife’s employer as long as you remain on the group plan. Do the right thing and opt for Medicare.

Question: Do you have to have a cafeteria plan for health premiums to be pre-tax?

Answer: Yes. A version of the Section 125 “cafeteria plan” can be designed for premiums only. This single purpose plan is referred to as a Premium Only Plan or POP plan. With a POP plan in place employers may deduct the employee’s portion of the company-sponsored group health insurance premium directly from said employee’s paycheck before taxes are deducted. POP plans cannot be used to pay individual health insurance premiums.

Question: I own a small business and have a health insurance plan for myself and 6 employees. Most of us have elected high deductible insurance coverage - over $1000 deductible. If I choose to reimburse the employees for their health insurance deductible, what would be the best way to do it?

Answer:To do it right you will want to create a Health Reimbursement Arrangement or HRA. If you reimburse employee out-of-pocket medical expenses without a proper HRA in place, you’ll be reimbursing with after tax-dollars. The HRA makes the reimbursements tax deductible to the business and pre-tax for the employee.

Question: My husbands insurance was cancelled for the year because he did not have enough hours due to unemployment. What can we do for insurance. His union is offering us coverage for $7000. we can’t afford that! We are hoping to stay healthy and get through the year. Any advice?

Answer: Staying healthy will definitely make thing easier, but if you need medical care, here are some other ideas:

1. Check out your local free clinic (if you are lucky enough to have one in your area). Generally, there is little paperwork and good doctors, dentists, and nurses who volunteer their time.
2. Read my article, 7 Ways to Pay Less for Hospital Care
3. Read Maggie’s article, 7 Ways to Get Cheaper Prescription Drugs

Good luck.

Question: I am 9 weeks pregnant and recently qualified for PCIP (for people with pre existing conditions without insurance 6 months). It is ONLY maternity coverage. Coming up in February, I am eligible for my work health insurance to kick in. I am confused. Can I keep my maternity with PCIP and enroll in work (anthem blue cross for Dental, vision, and medical come February? I am concerned because before applying for PCIP, I turned to anthem and they denied me because it was a pre-existing condition. Can I have both insurances? Please help. Thank you.

Answer: You are very fortunate to be pregnant and have 2 options for coverage. Let me start by saying that you can’t have both PCIP and employer-sponsored group health insurance. You need not be concerned about selecting the employer-based coverage with Anthem Blue Cross as you cannot be declined due to preexisting conditions with group health insurance as you were when applying for individual health insurance.

Question: I have a pre existing condition and my health insurance has gone up considerably every year. We now pay over $2000 a month and I'm 32 years old. I have 3 questions: (1) I'm thinking of moving from New York to California- can I keep my Aetna plan and stay insured even though I'm moving states or can they drop me? (2) The other question is I'm getting married and would hope that I could join my husbands plan however would they accept me with a pre existing condition? (3) And will Obama's law help me in any way? Thank you.

Answer:

(1) You must have a group or employer-sponsored health plan as Aetna not sell individual plans in NY. If you remain employed with the same employer and move to another state, you can continue with Aetna group coverage and they cannot drop you.

(2) If you get married, you can be added to your husband's health insurance plan without consideration of your preexisting condition if you remain in NY state as NY has guaranteed issue laws albeit at very high rates as you point out, If you move to California (married or not) and apply for an individual health insurance plan, you will have to qualify through the underwriting process and your preexisting condition may cause you to be declined for coverage.

(3) The main provisions of the Affordable Care Act (what you referred to as Obama's law) are scheduled to go into effect in January 2014. Insurance companies in every state will not be able to use preexisting medical conditions to deny coverage or charge more for coverage. That would pretty much solve both issues you raised above. You will then be able to buy an affordable health insurance plan anywhere in the country. So, yes, I would say it will help you big time.

Question: If a person is in the process of addressing a health problem at the end of the year and his insurance changes in January which is responsible for the health coverage?

Answer: It sounds like your employer-sponsored health insurance coverage has changed insurance carriers. It you have ongoing treatments that continue from 2011 into 2012, the old insurance is responsible for all medical services received in 2011 even though you may not be billed until 2012. Conversely, the new insurance plan will be responsible for all medical services with dates of service in 2012.

Question: My wife lost her job and the medical insurance was through her employer. My job offers it but they are making me wait 6 months in my new position before I can sign up. Is that legal in Minnesota? Thank you, Jason.

Answer: Yes. Employers can set the new-hire waiting period up to 6 months before becoming eligible for the company’s health plan. Suggest you take your COBRA health insurance option for 6 months until you are covered under your employer-sponsored group plan.

Question: Do California employers have to provide health insurance to their employees?

Answer: The is currently no requirement for California employers to provide health insurance for their employees. Health care reform places no requirement on small business employers (less than 50 employees) to provide employer-sponsored health insurance in 2014 and beyond.

The Affordable Care Act (ACA) mandates that larger employers (50 or more employees) provide health insurance starting in 2014 or pay a penalties called the play-or-pay tax. The play-or-pay tax is one of the most significant tax consequences of health care reform. The tax will take effect in 2014, and it will have a significant impact on large employers subject to it. Both applicable large employers that offer coverage, and those who do not offer coverage to their employees will be subject to this tax. Employers will face another big decision due to this tax. Their question will be, “Should we offer healthcare coverage to our employees at all, or just simply pay the applicable tax?”

Question: How can I get health insurance for a newborn child when mother is unmarried.

Answer: The marital status of the mother is not a factor. You can purchase child-only health insurance coverage for this newborn baby. If you are a grandparent or other interested party, you can be responsible for paying the premiums. Health insurance rates for infants under 1 year old are higher and this is understandable, because all health insurance plans now include well-child baby visits and routine exams that include blood tests and other diagnostic tests. Start by getting a health insurance quote now.

Question: I have insurance through my job. My kids are under my husband’s job insurance. I just received information that my job’s insurance is going to change the plan … It is way too expensive for just one person. My question is, do you think that my husband’s insurance would insure me?

Answer: Your husband’s employer has the option of not adding you on your spouse’s coverage if you have coverage offered by your own employer. You should ask your husband to inquire with his employer if you can be added. If so, you may have to wait until his next open enrollment period.

Question: I have recently been diagnosed with breast cancer. I am currently on COBRA. What happens to me when it expires.

Answer: I’m so sorry about your bad news. At least your ability to remain insured is protected by federal laws. However you must take the right steps to protect your rights. First and foremost, stay on COBRA until your coverage expires. If you do that you will qualify for HIPAA guaranteed coverage after your COBRA coverage expires. Most health insurance companies who market individual health insurance offer HIPAA qualified coverage. HIPAA guaranteed plans are usually high deductible plans at a substantial rate-up over the standard rate for a “healthy” applicant. You may be able to purchase a HIPAA plan from your current insurer, but can shop for HIPAA plans from any other carrier in your state. Contact them directily about 60 days before your COBRA expires.The PCIP plan will not work for you because they require an applicant to be uninsured for 6 months prior to enrollment. In January 2014, your preexisting condition will no longer be a consideration in obtaining health insurance thanks to the Affordable Care Act. I wish you the best of luck.

Question: I am very confused by the deductibles on my family’s health insurance. Does the whole family meet the deductible or just one person?

Answer: I don’t blame you for being confused. There are differences in how health plans work for families versus individuals. The main difference between individual and family coverage is how the annual deductible is computed.

Individual Deductible Family Plans: Some family insurance has separate deductibles for each individual and then a family deductible limit. For example. a plan might have a $5000 deductible for each family member and a $10,000 deductible limit for the whole family. What that means is that any given individual in the family must reach $5000 in covered medical expenses before the health plan begins to pay. Also, let’s say that this family has 3 individual members and that the total in family expenses exceeds $10,000, from this point on through the end of that calendar year all family members will have been deemed to have met their deductible. Statistically, only one family member usually has major medical expenses in a given year, so the individual deductible plan is generally recommended.

Aggregate Deductible Family Plans: Some family health plans have one deductible for the whole family. For instance, a plan might have a $10,000 deductible for the family and each family member’s covered medical expenses are combined to meet the $10,000 family deductible. Statistically, only one family member usually has major medical expenses in a given year, so the $10,000 family aggregate deductible is usually harder to reach. We generally recommend family health plans with this type of family deductible, but there are situations when an aggregate deductible is preferable, for instance a large family would have a greater chance of meeting the family deductible with no single individual accounting for $5,000.

Question: Should i put my baby on my work insurance or a private plan?

Answer: If your employer pays a substantial portion of the cost for your baby’s coverage and the portion that you have to pay is affordable for you, then go with the employer-sponsored plan. But you may find that your employer does not contribute toward an employee’s dependent coverage. If that is the case you should shop for a child-only health insurance for your baby. Child-only health insurance is a health plan for a child, or children, without an adult on the same policy. Health insurance rates for infants under 1 year old are higher and this is understandable, because all health insurance plans now include well-child baby visits and routine exams that include blood tests and other diagnostic tests. Once beyond the toddler stage, children’s health insurance is more affordable.

Question: Do you have a list of insurance companies in California that offer HRA plans?

Answer: HRAs are usually offered by third-party administrators like 105 Concepts, TASC Benefits, and Zane Benefits. In the past, some of the major insurance carriers in California have tried offering fully-insured high deductible health insurance plans packaged or "wrapped" with an HRA plan, but they really were not equipped to handle the medical expense reimbursement part of the arrangement. Typically, third-party administrators will charge a set-up fee to create the documentation and a monthly administration fee to handle the employee reimbursement. In addition, year-end tax-reporting documents are prepared as part of the service. Annual costs for a for a fully administered HRA start at about $1,000 for a small business. Self-administered or document-only HRA plans are available starting at $200.

Question: Will I be able to keep major medical insurance if i am not employed or being offered group insurance after the age of 65 if i only have an individual policy?

Answer: Yes. You can keep your individual health insurance after age 65. However, you would be wiser to take Medicare coverage (assuming you qualify). Medicare coverage is more comprehensive than most individual health insurance plans and the cost of Medicare coverage would be a small fraction of the cost of a private plan post 65.

Question: What is the minimum employer contribution per employee for group health plans in California?

Answer Employers must pay at lease 50% of employees’ premium for lowest cost plan offered by the plan’s carrier(s). There is no requirement for the employer to make any contribution to the employees’ dependents.

Question: Do you have to be an “uninsured” resident of Utah for 12 months? I am uninsurable but currently have cobra through my husband. When it runs out how much would the premium be for the high risk insurance? What is it based on?

Answer: That is correct. The HIPUtah Major Risk Health Insurance plan requires that you be uninsured for 12 months before applying. So that’s not for you. When you have exhausted your COBRA benefits, you will qualify for federal HIPAA coverage. That’s high deductible coverage offered through the insurance carriers in each state by federal law.You may be able to purchase a HIPAA plan from your current insurer, but can shop for HIPAA plans from any other carrier in your state. It’s more expensive than regular individual health insurance, but they must cover you. Remember you only have to get to January 2014 - two years form now - when you will no longer have to worry about being “uninsurable” and can buy health insurance without regard to your pre-existing medical conditions at the same price as everybody else. Hang in there. It will get better.

Question: Our company health insurance is only offered as high deductible, What can i do with costs that I can’t afford?

Answer: Your dilemma is very common nowadays. On the one hand, your employer is probably doing the best he or she can by providing health insurance coverage of any kind. On the other hand, you, the employee do not perceive it as much of a benefit because the high deductible means high out-of-pocket expenses for covered medical expenses. Expenses your are afraid that you cannot afford.

It’s understandable that you feel like you are not getting much of a benefit, but here’s are couple things to remember: First, high-deductible health insurance is a whole lot better than no insurance at all. Even though you may never reach your deductible amount, you still get a big discount on covered medical expenses within your network, in some cases the negotiated amount that your end up paying is less that half the original billed amount. Secondly, if you were to have a catastrophic medical expense, say $50,000, the maximum out-of-pocket amount on your policy, probably no more that $10,000, would at least set a limit on what you owe that you could reasonably expect to pay off over time. So that high deductible insurance could make the difference between having to file for bankruptcy or not.

Question: What are the tax implication if my employer offers a health insurance plan and I decided to delcine and purchase my own? They do not offer an FSA.

Answer: If you opt out of your employer's group health plan in favor of your own personal health insurance plan, your health insurance premiums will be lumped together with your medical expenses and listed on your federal 1040 form as itemized deductions. You may deduct only the amount by which your total medical care expenses for the year exceed 7.5% of your adjusted gross income. Usually, only people with unusually high expenses and low income will find premiums to be tax-deductible.

I understand, that many employers are reacting to ever increasing group health insurance costs by asking employees to make greater contributions to the premium. Even though your share of the premium is a lot more than it used to be, it's usually a better deal to take the group coverage than to purchase personal health insurance. That's because state laws require the employer to pay a substantial percentage of the premium - usually at least 50% - for each employee. So even though you can find individual health insurance plans at lower premiums, they don't cover as much. The average group health plan has an actuarial value of 80% or more. That means the plan will cover 80% 0f the typical medical costs. Individual plans can have an actuarial value as low as 55%. Dependents are a different matter. Employers are not required to pay anything toward coverage of an employee's dependents and smaller employers typically do not.

So, bottom line, take another look at the employer sponsored health plan for yourself, but shop for personal coverage for your spouse and kids. Families do not all have to be on the same plan.

Question: Husband company not insuring divorced spouse who is uninsurable

Answer: Your ex-husband’s employer no longer has an obligation to offer coverage to the ex-wife under the company’s group health insurance plan. In fact, the insurance company would not allow it even if the employer wanted to. However, the ex-wife does have some coverage options even if she is “uninsurable” due to pre-existing conditions. My first suggestion would be the Pre-Existing Condition Insurance Plan (PCIP), one of the early benefits of health care reform. It’s very good coverage at a fair price.

Question: Can infants be insured with their own health insurance?

Answer: Yes. An infant can be insured on their own health insurance policy. A parent or guardian must complete an application for child-only health insurance.

A provision of the Affordable Care Act already in effect requires that children under 19 years of age in are eligible to enroll in an health plan without regard to any preexisting medical conditions. Enrollment guidelines vary by state. The California guidelines are listed below.

1. Annual Open Enrollment Period during the month of the child’s birth date.

2. Late Enrollment Period, within 63 days of any of the following conditions:

   • Loss of group health coverage because of termination or change in employment,
   • Loss of employer contribution,
   • Death of primary insured,
   • Legal separation or divorce of primary insured causes loss of coverage,
   • Loss of Healthy Families, AIM, or Medi-Cal coverage.
   • Recently became a resident of California,
   • Newborn in California but did not enroll in birth month,
   • Coverage of child mandated by court order,
   • Child is newly adopted.

Question: If a medical condition was over 15 years ago, is it considered pre-existing?

Answer: The underwriting guidelines for most individual health insurance carriers will usually draw the line for serious preexisting conditions at 10 years. That is to say, if you’ve had no treatment or symptoms for that previous condition in over 10 years, that previous condition will not cause your application to be declined automatically. However, your overall health risks will be evaluated, however you could still be refused coverage. The outcomes of individual health insurance underwriting are very difficult to predict right now.

Question: Can an HRA reimburse employees for Medicare premiums?

Answer: Yes. In 2002, the IRS issued Notice 2002-45 and Revenue Ruling 2002-41 that opened the door for employers to legitimately reimburse non-group health insurance premiums to their employees as a tax-free fringe benefit. When an HRA is combined with non-group health insurance, including MediCare, the HRA can reimburse the employees’ premiums. The HRA and high deductible individual health insurance combination is absolutely the cheapest health plan available today.

Question: If I am covered by group heath insurance, should I pay more for my wife?

Answer: Yes. In employer-sponsored group health plans, employees pay more to cover their spouse or children than they do for themselves. There are 2 reasons for that. First, the insurance companies set dependent rates higher than employee rates. Secondly, employers must pay a substantial portion of the employees’ premium (varies by state), but no such requirements exist for dependent premiums.

If your spouse can qualify for individual health insurance, you’ll probably find that you can insure her at less cost outside the group. Get a quote now.

Question: I have been offered a job that only offers HRA insurance and I don't understand it fully, so I am hesitant to accept the job. What should I do?

Answer:: One of my group clients is in the game business. Most of the employees there are young people - under 30 for the most part. The company was providing a defined contribution per month for each employee to pay for group health insurance coverage but found that many of the employees did not value the benefit. We quickly found that the "young invincibles" were healthy and they felt the insurance was too expensive. They believed that they'd never meet the deductibles required before they could get medical expenses paid for. Moreover it wasn't even medical services that they needed. Rather it was treatment for that nagging toothache that the health plan didn't even cover.

So the employer initiated an HRA plan that reimburses medical, dental and vision expenses as well as health insurance premiums. The employees love it and the employer is actually spending less than before.

Question: I read in the newspaper that the Preexisting Conditions Health Insurance Plan was a bust. What happened?

Answer: It's not a failure by any means, however enrollment is less than expected so far.

Several months ago, the special insurance pools became one of the earliest facets of the new health-care law to take effect. They are intended as a temporary coping mechanism for people with preexisting medical conditions that traditional insurance companies do not want to cover. The program is temporary, because, starting in 2014, the law will forbid insurers to reject customers based on whether they are healthy or sick.

One must be a resident of California, have a pre-existing condition as shown by a
Rejection letter from a health insurance company in the last 12 months, or coverage offered with premiums higher than those of the state risk pool, be a U.S. Citizen, U.S. National or lawfully present foreign national, and have been uninsured for 6 month prior to application for the plan.

A fundamental problem is that insurance for people with existing medical problems remains too expensive for many. Monthly premiums range from $350 to $600 for a middle-aged individual in California.

Another hurdle is the requirement that an applicant must have been uninsured for 6 months prior to applying for the special risk pools. The thinking behind this requirement is to prevent a wholesale migration of insureds from existing state major risk pools to the new pools where rates and coverage are better. HHS needs to take a look at removing that requirement.

Question: Obama claims health reform will lower health insurance rates. The Republicans say they'll go up. Who's right?

Question: The Health Reform law is very unpopular among voters. It looks like the Republicans could successfully block funding for health care reform. What do you think?

Question: My broker has presented an HRA option that will save me quite a lot of money on my company's group health benefits next year. Is it worth the change? What are the pitfalls?

Question or concerns about HRAs? Ask Phil Now!

Answer: The advantages are great and the disadvantages small. However, I will caution you that communicating the benefits to your employees is perhaps the most important step in making an HRA strategy pay off for your company. Here's a list of pros and cons:

Advantages of HRAs for employers include:

Reimbursements of qualified claims are tax-deductible for the employer.

Employers know their maximum expense related to their health care benefit.

Advantages of HRAs for employees include:

Contributions that employers make can be excluded from employees' gross income.

Reimbursements may be tax free if the employee pays qualified medical expenses.

Unused funds in the HRA can be rolled into future years for reimbursement.

HRAs may be offered in conjunction with other employer-provided health benefits including Flexible Spending Accounts (FSAs).

Employees do not have to be covered under any other health care plan to participate, unlike (for example) a Health Savings Account (HSA) which requires a High Deductible Health Plan.

Employees can be reimbursed for a health care plan that meets their or their families' specific needs, as opposed to a standard company plan.

Disadvantages of HRAs

HRAs must follow "a variety of statutory rules and provisions" including the COBRA continuation coverage requirements, ERISA, and HIPAA.

HRA plans are considered "Primary Payers" subject to Medicare Secondary Payer (MSP) mandatory reporting requirements.

Self-employed persons are ineligible.

Highly compensated participants may be subject to certain limitations.

Question: How does the health reimbursement account work for the employee?

Answer: A HRA fund or account is money that is set aside by your employer and is used toward medical expenses for some your out-of-pocket medical expenses. For example, if you have an annual deductible of $2,500 and a $1,000 fund, up to $1,000 of your medical expenses is paid out of that account. You are then responsible for your remaining expenses up to $2,500, when the high-deductible health insurance coverage kicks in. Health Reimbursement Arrangements (HRAs) get preferential tax treatment - you are not taxed on the amount reimbursed.

Question: I have been diagnosed with breast cancer and I am covered under my husband's current COBRA coverage. What happens to me when the COBRA coverage ends in November?

Today, the six month anniversary of the enactment of the Affordable Care Act, some of the law's key provisions go into effect. Here's a look at how the law affects people who get their health insurance at work, people who buy their own individual health insurance or are enrolled in Medicare.

Q: I get my coverage through work and the "open enrollment" period for next year is approaching. I'd like to keep my current health plan. Will it be affected by the new law?

A: Your plan will feature some new consumer protections. For example, your plan won't be able to set a lifetime limit on coverage. And if you have an adult child up to age 26 who can't get health insurance at a job, you'll be able to keep him or her on your health plan. These changes kick in for plan years beginning on or after Sept. 23. If your employer makes significant changes - like cutting benefits or raising your out-of-pocket costs beyond a specific amount - the plan is considered a new plan (rather than an existing "grandfathered" one) and must include a wider set of consumer protections.

Q: Like what?

Patients will get, for example, certain preventive services such as breast cancer screenings and cholesterol tests without paying deductibles or co-payments. In addition, they'll be able to see obstetricians and pediatricians without getting prior authorizations. Recommended immunizations also must be provided at no cost.

Q: What if my employer offers a new plan and I want to switch to that?

A: In that case, your coverage would include the wider set of protections.

Q: Will my health insurance cost less?

A: Probably not. Health insurance premiums have been increasing steadily over the last decade and that trend is continuing. According to a new report from the Kaiser Family Foundation and the Health Research & Educational Trust, workers nationwide on average are paying 14 percent, or $482, more for family health insurance coverage in 2010 than in 2009. Employers, struggling with the recession, aren't increasing their share. Instead, they're shifting more costs onto employees, according to the survey. A recent study by the National Business Group on Health found almost two-thirds of employers planned to ask employees to contribute more toward their premiums.

Q: I'm a small business owner. Do I have to offer coverage to my workers this fall? And if I do, will the government help me pay for it?

A: No business owner - small or large -- is required to offer coverage. But small businesses with 25 or fewer full-time employees who earn an average yearly salary of $50,000 or less will qualify for a tax credit up to 35 percent of the cost of premiums. The credit increases to 50 percent in 2014 for most small employers. To qualify for the credits, businesses must cover at least 50 percent of the cost of workers' insurance. Starting in 2014, businesses with 50 or more employees that don't provide health care coverage and have at least one full-time worker who receives subsidized coverage in the health insurance exchanges will have to pay a fee of up to $2,000 per full-time employee. (The firm's first 30 workers would be excluded from the fee.) Businesses with 50 or fewer workers would be exempt from the requirement.

Q: I buy my own health insurance coverage. How will the health law affect my coverage?

A: For policy years starting after Sept. 23, all health insurance policies in the individual market will be barred from cancelling coverage once you get sick -- a practice known as "rescission" - unless you committed fraud when applying for coverage. Insurers will be prohibited from setting lifetime limits on your coverage. The plans must allow you to keep an adult child up to age 26 on your health plan. New policies can't deny coverage for children up to age 19 based on a pre-existing medical condition. But "grandfathered" plans can; they can also set annual dollar limits and require cost-sharing for some preventive services. Most people in the individual market are expected to move to a new plan by 2014. Other provisions of the law will kick in later. For example, as of 2014 insurers won't be able to refuse to cover adults with pre-existing medical conditions. That same year, individuals whose incomes are up to 400 percent of poverty -- $88,200 for a family of four at the current poverty level - will qualify for subsidies to help purchase health insurance on exchanges, marketplaces where consumers can shop for coverage. At that point, most people will have to have health insurance or pay a fine.

Q: I'm on Medicare. Will my benefits change?

A: Your basic package of Medicare benefits won't shrink and in fact will expand under the law. But if you're in a Medicare Advantage plan - a private plan that offers Medicare benefits - you might lose some extra benefits at some point. In terms of the overall Medicare program, let's start with prescription drugs. As of late August, one million Medicare beneficiaries received a $250 check to help cover prescription drug costs in what's known as the doughnut hole. That's the gap in coverage where beneficiaries must pay the full cost of their prescriptions until catastrophic coverage kicks in. Starting next year, beneficiaries will receive a 50 percent discount on brand name drugs and a 7 percent discount on generic drugs while they are in the coverage gap. The health law closes the gap entirely by 2020. In addition, beginning next year, Medicare beneficiaries won't have to pay co-payments or deductibles on many preventive health care services, including diabetes and cervical cancer screenings. Medicare will also pay for an annual wellness visit to the doctor. To help pay for the health overhaul, Congress is cutting payments to Medicare Advantage plans, beginning the year after next. Beneficiaries won't lose any of their basic Medicare benefits as a result of the reductions but some Medicare Advantage insurers could decide to stop offering additional benefits, such as coverage for eyeglasses or gym memberships.

Q: Many Republicans have criticized the health care law as too intrusive and too expensive. If they pick up seats in the November election, how could the law be affected?

A: Some Republicans have threatened to block funding for the implementation of the law; others have called for its outright repeal. But accomplishing either would be tough unless they win large majorities in both the House and Senate. President Barack Obama would likely veto any legislation to gut the law, so Republicans would need a veto-proof majority - two-thirds of both chambers - to override such an action. Also, some Republicans might be reluctant to repeal provisions of the bill that are popular with the public, such as keeping a child up to age 26 on their parents' health care plan or outlawing rescissions and lifetime and annual limits.

QUESTION: I am a juvenile type 1 diabetic, have a heart condition called Torsades de Pointes, and I have celiac sprue. I dont get Medicaid anymore and I have a child. I'm not able to afford my diabetes supplies nor my other supplies for the other problems. I need an affordable insurance company to get coverage through.

Many questions continue to come in about covering young adults to age 26 on their parents' health insurance coverage. Officially, the regulations governing this issue go into affect on September 23rd, 2010. I've taken the liberty of including an excellent Q&A page from the U.S. Department of Health & Human Services website - www.hhs.gov. It's very comprehensive and covers all the bases.

Question: My daughter will finish her MBA in Ohio, and plans to stay from October to December (3 months),in CALIFORNIA,and maybe extend the residence for a longer period. We would like us to suggest what health insurance she should take and the cost.

Question: I just read your blog post about the new free preventive care ruling. Who does it apply to?. For instance, I am insured on a group plan through my employer, will I get the free benefits in September?

Question: I'm male, age 63. I had bariatric surgery. COBRA recently ran out. Applied to several reputable insurance companies, most won't insure us and those who will want $800+ per month. I don't understand underwriters adversity to bariatric surgery whereby I lost 100 lbs. and got rid of my diabetes and medical insurance paid for it. Looking for affordable Major Medical and I can afford to pay $400.

Question: What is the low income insurance program with pre-existing illness that the gov.has now besides medicaid or Medicare. Heard on the news and they said you must sign up on 7-1-2010.

QUESTION: My husband's job does not provide health insurance. We had regular insurance for him until COBRA ran out. He went to a limited benefit health plan but the plan has gone under. Is there a plan, any plan, that would cover my husband? Indiana does have a high risk insurance pool - We'd have to pay about $800.00 per month for it - we can't afford it.

Question: I have prescription drug coverage under Medicare and will be hitting the "doughnut hole" pretty soon. What will the new healthcare bill help me pay for my drugs?

I'm signed over my Medicare to Secure Horizons, which I like. I heard these type plans are to be cancelled by the new healthcare reform?

I have a preexisting condition and recently lost my job -- and with it, my health benefits. What does this law do for me?

I have a great insurance policy through my employer, and I don't want it to change. But my friends at work say that the government will be taxing our plan. What's up with that?

Question: I can't afford any of the plans that my company offers me. What does Obama Care do to help?

Question: So what's to stop my insurer from raising my health insurance rates between now and 2014?

Question: Is anything being done to control skyrocketing health care costs?

Question: What options do I have for getting individual health coverage. I am 59 5'3" and weigh 175. I have HBP under control with medication. My COBRA ends 8/25/2011. Got any suggestions?

Question: My older son will be 23 on July 4th. He's now on our family insurance because he's a student. We have received notice that he will he have to get his own coverage. Also, my daughter will be 19 on October 16th. She will not be a full time student at that time. Can she stay on our insurance?

Question: I'm in the California high risk pool because of preexisting. conditions. Can I switch to the federal plan when it comes out?

Question: How do you think all this health insurance reform change will impact our premiums? I do understand that you can only give me an opinion, and please allow yourself to speculate if you have to, but the bottom line is that most people I know are just worried about the economical impact of this change in their budgets, and we would like to know what possible scenario are we going to be confronting. From HealthcareShopper customer, Renee Sanudo

How do I sign up for my new insurance?

Question: I have a high deductible health insurance plan. I recently found out I am pregnant (We've been trying). I also found out that my insurance does not cover maternity--at all. Out-of-pocket payments do not go towards my deductible. I've looked into Medicaid. I make too much. What are my options?

Question: I hear that most of the Health Reform changes won't happen until 2014. What, if anything, changes right away?

Qustion: I can't get health insurance because of my pre-existing conditions. Will I be covered by the new healthcare plan next year?

Question: Hi, first thank you for this great q&A. second, i last applied for health insurance about 5 years ago and i am currently still overweight. (5'7" 258lbs). bp is undercontrol as is cholesterol with the use of caduet 10/10. no diabetes, hx of asthma as a child, recent xray showed a small rough area of the socket in my hip, not really an issue according to my chiropractor. i need some relief from the premiums i'm paying currently, any chance of some cheaper insurance?

thanks again for the help

Question: Hello. My maternity rider became effective March 1 but I found out I am pregnant and based on my last period and the ultrasound I got at the free clinic it looks like I might have conceived the third week in February (just a week shy). Since it is so close to my effective date and there is no way to be 100% sure, how will the insurance company determine my conception date? If they go by the due date then what if the baby ends up being late? How is all this determined? Please help!

Question: My son has bipolar and was in an auto accident a few months ago and hasn't been able to work. He was on his company insurance but lost his coverage. He is looking for a new job but needs health insurance for his monthly therapy and prescriptions. We were going to put him on an individual policy until he gets a job with employer insurance again. The companies we looked at will not cover the bipolar, what can we do? With so many people suffering from mental health issues , it is amazing to me that they don't consider it like any other physical condition.

QUESTION: My wife is 12 weeks pregnant, and her COBRA insurance expires in July (7 mos. into pregnancy). My COBRA insurance also expires in July. Will she be able to get a different insurance policy?

Question: My Cobra will expire on 4/30/09 and I will not turn 65 until Aug of 2010. Can I contact someone to continue Cobra or an Individual plan? Should I contact the current carrier I have had for the past 15 months?

Question: My husband was laid off from his job. We are offered the COBRA coverage from his previous employer. I will be electing the COBRA coverage because I am 8 months pregnant. My husband and son are going to look into getting an individual family plan instead of electing COBRA through his prior employer.

Is this an option for our family? Can my husband and son get an individual family plan while I am on COBRA along with our newborn (once he is born)? After the birth, and if everything is fine with both myself and newborn would we be able to also change to an individual family plan?

Question: My husband has been offered a job with a good company.They have offered to pay for cobra for the 90 day waiting period until his new insurance kicks in. My question is, my husband is in pain managment where he gets steriod shots and is administered medications from a previous back surgery over a year ago. I myself have high blood pressure.This new insurance company United Health Care, has told me that he must be evaluated by the underwriters to see if they will cover these preexisting conditions,if he denied we will be out of luck. Is there anything that we can do, or any resouce that we can contact to get information. Thank You

Question: I am retired and on Medicare with a BC/BS Medigap policy which continues to be administered by my former employer. I pay about $100/month for this coverage. If my previous employer discontinues this insurance, will I have the same COBRA-HIPPA options for continuation of the MediGap coverate that apply in layoff situations to persons who are not yet eligible for Medicare?

Question: A number of years ago, we had a layoff from my long time employer; only one of the senior staff remained. That person has an autistic child. Recently, I have been told that he could not be terminated because he had an uninsurable dependent. Is that true?

Question: I have recently changed jobs where the health insurance is very cheap for me but very expensive to add my wife. I'd like to get a private plan for her, but she takes several medications that could make it prohibitive. Is there some obvious option for this situation? She's otherwise healthy and I would consider high deductibles.

Question: I am a single parent with a job that does qualify my children for all kids coverage under the guidelines, however, when you add my child support into our income, we have too much. My shopping around is getting us nowhere fast, insurance comparable to bcbs is ranging from $590.00-$900.00 a month. What can you suggest? I really had hoped that bcbs all kids would cover them.Thank you.

Question: My mom is currently insured under COBRA/CAL-COBRA (which expires Oct. 1, 2008). She applied for the Kaiser Permanente Individuals and Families" health care coverage and was denied coverage. The reasons being: she has High Cholesterol, was diagnosed with tendonitis of the shoulder and bursitis of the hip (she gets steroid injections to relieve the pain) and was diagnosed with bilateral carpal tunnel syndrome with surgery performed on the left hand in April 2007. Can you please suggest an affordable health insurance plan that will not deny her? She is 64 and will be 65 in 2009.

Question: I'm 21, and just moved out of state and am not on my moms health insurance anymore because im taking a semester off school. Is there anyway I can get health insurance so I can afford cheaper birthcontrol?

QUESTION: I am required by court order to provide insurance for my child. Do I have to go on my group's policy or can I just enroll my child?

Two questions: I had a sarcoma cancer removed 7 yrs. ago and have tried to get life insurance (additional to my small policy with my employer) but have been denied. Will I ever be insurable? I'm a state employee of 20+ yrs. with 2 children and the possiblity of a layoff, which would cancel my current health and life insurance. Would we as a family (children & husband) be eligible for health insurance? And would we be required to have physicals as I did with the life insurance application? Thank you...

Question: BCBS of Illinois only covers dependent children until 19 years of age. I need to find health coverage with bi-polar, personality disorder, PTS and takes meds. She currently is not employeed.

Question: My parents keep telling me that they are uninsurable because my mom has diabetes and my dad has high blood pressure. They are 58 and 62 and would like to retire, but need health coverage. Other they would both like to lose a few pounds, I don't think either would be considered overweight.

Question: my question is bcuz of my weight which I have no health problems. I was denied health insurance. Thank you Tina

Question: My daughter was covered under my health insurance until she turned 23 years old. I elected to buy Cobra, hoping that she would eventually get insurance when she graduated from college & found a job. She is working full-time for the federal government, but doesn't receive health benefits (she is considered a seasonal employee). Because Cobra is so expensive, I contacted PacifiCare directly for insurance. (We signed up with Cobra and simply continued with PacifiCare as the provider).
She was just denied coverage because she has been taking Lexapro since she was a teenager. I never that it would be an issue. She saw a psychiatrist 5 times when she was 17 years old. The psychiatrist told me that my daughter has a chemical imbalance and may need to always take meds to regulate the imbalance. My daughter is not bio-polar or suicidal. She graduated cum laude from college and has an active social life. As I said, I never thought in this day and age a drug for depression would keep her from obtaining insurance. Is it considered a pre-existing condition even though she has been covered by PacifiCare for 10 years? (The last 1 ½ years through Cobra, but her health carrier is PacifiCare).
Would it have been better for her to lie and cover the drug expense herself? I know you don't recommend lying, but what will happen in the future if she is offered employment? She is being responsible and taking care of a chemical imbalance and yet she'll be penalized for being truthful.

Question: What are the guidelines for privacy when applying? Is information submitted for application of Insurance protected?

Question: Three years ago I was denied BCBS coverage. Can I ever get coverage again?

Question: What is available for the family who makes to much for low cost health insurance, but still is unable to afford health insurance for children

Question: I was informed that Medicare would no longer cover my grandson (age 3) because I'm not his legal guardian anymore- but he and his father live with me and (father) cannot afford health insurance. Will this insurance cover my grandson?

Question: I recently applied and was declined for a condition that I have had for over 10 years and that no underlying cause has been found. When the condition does occur, which could happen once or twice in a year or not at all, the prescription used is of minimal cost. Should I appeal the decline?
Thank you.

Question: My husband and I are self-employed and need to purchase insurance. We applied to Unicare and while he was accepted, I was denied due to my "build" (their term). I have no history of high blood pressure or any other health issues often assumed to be linked to a bigger "build." In fact, I lead a healthy lifestyle, walking several miles everyday.

What is my best next step? Shall I apply to another company and simply fudge my height/weight? 10lbs less or 1/2 inch taller and I am within "desired" BMI levels.

Question: I am suffering from metastatic breast cancer and have been treated for several months. Now I am being told that my insurer will only pay for 4 office visits and 300.00 of lab work a year. Can they suddenly change my coverage like this after my deductibles have been met?

Question: Can I pay my insurance premiums from my hsa account?

Question: >> I'd would like to pay a certain amount into my United Healthcare servings account. I understand the monthly minimum amount is $25 but are you flexible to allow my deposit to fluctuate each month as long as I do not deposit less than $25 a month? I mean, would you allow me to deposit, for instance, $50 in one month, $38, in the next, $100 in the following, and so on?

Question: is it ok to make lump sum deposits in my hsa accout.

Question: What happens to the money in my health savings account if I havent used it by the end of the year? Is it like a caffeteria plan and I lose it if I dont use it?

Question: I recently bought a HSA PPO health plan but the insurance doen't have an actual health savings account to go with it. do you have any recomendations?

Question: Can i continue to have the same insurance plan ,even if i change the employer?

Question: I'm looking around for another plan because my insurance company keeps raising th e price - twice this year already and I have not cost them a dime! Is there a company out there who recognizes a good customer when it sees one?

Question: I have some questions -
1. I have two cards. Golden Rule and FACT. I believe that FACT is a route to discount services for Dental and Vision. However, on the cover of the document it is stated that the Policyholder is Fact. Could you clarify for me FACT vs Golden Rule?
2. I will need to visit an orthopaedic specialist. Do I select a specialist from www.goldenrule.com (to get a preferred supplier) and make my own appt, or do I need to go through my Primary Care Physician first?
3. When I get medical treatment, should I simply present my Golden Rule card, have them bill Golden Rule, and then pay when they invoice me (i.e. to ensure that applicable discounts are applied)?

Thanks and sorry for the bother.

Question: I take Lomectol for bi-polar. I was denied coverage by blue cross blue shield nevada. Dont you think thats insulting? I thought it was mean.

Question: What do I do about this? The court says I have to get insurance for my son in Houston Texas but I live in Wisconsin. I tried to do a application on teh computer but its asking for all kinds of infomation I dont have about him. I didnt even know I had a son until last week.

Question: I'm over 50 which means that I need a bone scan. My doctor says its not necessary but will give me an Rx if I really think I cant live without it. How do I know if its covered on my plan?

Question: When I ran a quote on the website it wasn't clear about bills that the insurance company would pay and what bills I pay . What happened the last time I had insurance was I went for some blood work and I ended up paying for the whole thing! The plan I was looking at was the Unicare performance 2000 in Texas. I can afford it ok. but does it cover the things I need?

Question: I have to have a breast lump removed because my doctor is not sure if its cancerous or not. I tried to schedule the surgery but the hospital wanted my deductible up front. I was shocked. Do I have bad insurance?

Question: I get confused between what a copayment is and what a coinsurance is. Can you tell me the difference? Thanks!

Question: I never see a doctor but consider myself fairly healthy. My wife on the other hand takes really good care of herself and sees her doctor for regular maintenance. Over the past year she has had trouble getting her thyroid levels right, which gave her a bit of high blood pressure but her doctor says their ok now and the blood pressure also. She is 5 ft 3 in tall and weighs 172 pounds. She was declined by Blue Cross 18 months ago and now we want to try and add her on to my plan because she's not covered at all right now. We live in Shasta County, CA which means we can only to apply Blue Cross or Blue Shield. I guess no other companies operate out here.

Question: My wife is completely healthy and takes premarin for menopause. I have high blood pressure and take a low dose of Mavik to keep this controlled. I've been told by Aetna that they charge an extra 25% on top of the standard premium for this. This doesn't seem fair with my wife being so healthy -- why is she being penalized? She goes to curves and stays fit, eats well and takes good care of her self.

Question: I live in Texas and my wife and children are currently in Oklahoma and will be there through the end of the year. I'd like to be covered when I visit them and vise versa. Is there such a thing as an insurance plan that will cover all of us?

Question: Is it possible for me to get medicare supplement insurance? I am 62 and had lukemia which is why i have medicare in the first place.

Question: I spoke to another angent about getting some insurance. He talked about a deductible and I got so mixed up. What does deductible mean, is it a yearly amount that I to pay? Im a student so I can't afford $5000. Thanks for your help!!!!

Question: My broker told me to get travel insurance for my vacation to spain next month. Do I really need this? Seems a bit overkill.

Question: My wife and I run a small business selling greetings cards. A friend told me that a small group policy is totally the better way to go and that his insurance covers everyting. Would it be a good thing for us my wife is 52 and doesn't smoke. I'm 55 and smoke about a pack a day.

Question: I was told by the insurance company I'm with now that I was allowed to go to any doctor. I went to see a holistic practitioner and the bill was almost $400. I have now found out that they won't cover any of this and quite honestly I cant afford a big bill like this. I saw a normal doctor and only had to pay a co pay. What can I do to get the insurance company to pay up like their supposed to?

Question: I need a dental plan for myself (aged 42) my wife (also 42) and my two children 12 and 8. Is this possible or would I have to buy health insurance as well?

Question: I need your help to know what to do. I have the option of taking Cobra but its super expensive. First off why? Is my former employer taking a cut or what? Next is it a good idea to take the Cobra even though itcosts so much? I have a new job starting soon but I don't want to go uncovered.

Question: I applied for my 5 year old son for the Blue Cross Tonik plan and they denied him which was a huge surprise to me. He's a healthy young boy with no health problems whatsoever. He gets a flare up of excema now and then and I use a cream and it calms down right away. Is it right that they denied him for something so simple or is this just the insurance company being all about the money?

Question: Can I make an application for my two daughters without me having to be on the plan? I have insurance from my employer but Its too much to add my kids on.

Question: My ex wife and son live in Texas and I've been told by the court to get health insurance for my son. he has PDD NOS so I cant get regular insurance for him. What are my options or maybe I should ask do I have any options at this point?

Question: I have an application for United Healthcare and it's asking for so much information that I'm way overwhelmed. What do I include and what do I leave off? I'm completely healthy other than I'm taking HRT meds for hot flashes. I had a summer cold last year but I'm not sure of the date - do these two things need to be on there? Their asking for 10 years back.

Question: My wife and I are in the process of adopting a baby girl from China.We live in Escondido, California. We need to get her some health insurance but the application form for Blue Cross is asking for all kinds of information we just don't have. We don't even know her height and weight at this point! What do you suggest?

Question: I need health insurance but I dont know if I can get it because I have a couple of health issues and you know how insurance companies are. Is it ok to put applications in with a couple of companies at the same time?

Question: How long will it take for my application to go through? I did it online a few day's ago and need coverage to start on the 1st of next month.

Question: I live in Florida and I'm moving with my wife and two sons to Colorado when I start my new job in September. My new employer doesn't offer benefits so I need to get my own insurance. I don't want to be without insurance. My question is how can I get insurance in Colorado when I'm still living in Florida?

Question: I applied for health insurance with Unicare and they turned around and told me they couldn't cover me. Can they do this? I was covered with them for years through my employer and paid them thousands of dollars in premiums. I only have a little acid reflux and use one prescription called Nexium!! Are they allowed to do this? How do I get them to change their minds about this?

Question: I think I might well be pregnant and I want to get insurance to cover the birth etc. Is it okay if I apply and say I'm not pregnant seeing as I'm only about 3 weeks in? How would an insurance company know I'm pregnant if I haven't seen a doctor yet? Help!

Question: I work for a small company that doesnt have benefits like health insurance so my employer will be paying. When I called Unicare and they told me that I couldnt have health insurance with them if my employer is paying for it. Why??? Is there another company out there that will cover me?

Question: I was declined insurance and they said it was because of a previous claim that I made while I had employer coverage with the same insurance company. I called them to find out why and they said I was treated for high cholesterol while I had the group plan. I have never had high cholesterol, in fact I'm completely healthy!!! What do you think I should do about this?

Question: I have been denied insurance due to a pre-existing condition. Are there any insurance companies that will cover me? I have a cyst on my ovary that needs to be removed. I live in California.