Q&A with Susan Gustafson - Health Insurance Marketplace

Susan Gustafson is a Health Insurance Specialist with the Centers for Medicare & Medicaid Services

Ask the Experts is a series of educational talks and presentations on a variety of topics designed to provide you with important information about living with lupus. To listen to and download the original presentation, and to see other topics, please visit www.lupus.org/ask.


1. What medications for lupus are being covered in the Marketplace formularies? Are biologicals and Benlysta covered on any of the 3 tiers? Long Beach, CA

To find out which prescriptions are covered through your new Marketplace plan, you can do one of the following:

  • Visit your insurer’s website to review a list of prescriptions your plan covers
  • See your plan’s Summary of Benefits and Coverage
  • Call your insurer directly to find out what is covered. Have your plan information available. The telephone number is on your insurance card, the insurer's website, or you can find it by logging into your account in the Marketplace.
  • Review any coverage materials that your plan mailed to you.

2. I can’t work due to my lupus and currently am covered under my parent’s insurance plan. I will be 26 soon and will be kicked off of my parent’s insurance plan. What do I need to do? Arlington, VA

On your 26th birthday, your coverage on a parent’s plan ends. You may switch to employer coverage or get a Marketplace health insurance plan. When your coverage ends you'll qualify for a special enrollment period so you can enroll outside of open season. You can use the Health Insurance Marketplace to compare health insurance plans based on what’s important to you. When you apply for coverage in the Marketplace, you'll find out if you can get lower costs on your monthly premium and if you qualify for lower out-of-pocket costs. You’ll also find out if you qualify for free or low-cost coverage available through Medicaid or the Children's Health Insurance Program (CHIP). When enrolling you need to select your plan by the 15th of the month if you want your coverage start by the 1st of the following month. If you enroll or change plans between the 16th and the last day of the month your coverage will start the first day of the second following month.

If you’re under 30, you may be able to buy a special kind of health insurance plan that protects you from very high medical costs. These “catastrophic” plans usually have lower premiums and protect you from worst-case scenarios. In the Marketplace, catastrophic plans cover 3 doctor visits per year at no cost and free preventive benefits.

3. Where does a college student apply for coverage if he/she goes to school in a different state from where they usually reside? Dallas, TX

The student should use the college address on their application.

4. I am a college student, will my tuition cover my health insurance or do I need to apply for insurance outside of college? Oklahoma City, OK

Please check with your college/university.

5. Does insurance under the marketplace cover alternative therapies such as acupuncture or chiropractic? Kansas City, MO

Specific health care benefits may vary by state and by plans. Even within the same state, there can be small differences between health insurance plans. When you fill out your application and compare plans, you’ll see the specific health care benefits each plan offers.

6. Lupus can affect your dental health. Is dental covered under the marketplace? Denver, CO

Under the health care law, dental insurance is treated differently for adults and children 18 and under.

  • Dental coverage for children is an essential health benefit. This means if you’re getting coverage for someone 18 or younger, dental coverage must be available as part of a health plan or as a stand-alone plan.
  • This is not the case for adults. Insurers don’t have to offer adult dental coverage.

Under the health care law, most people must have health coverage or pay a penalty. But this isn’t true for dental coverage. You don’t need to have dental coverage to avoid the penalty.

Dental coverage is available 2 ways

  • Health plans that include dental coverage. In the Marketplace, dental coverage is included in some health plans. You can see which plans include dental coverage when you compare them. If a health plan includes dental coverage, you’ll pay one monthly premium for everything. The premium shown for the plan includes both health and dental coverage.
  • Separate, stand-alone dental plans. In some cases separate, stand-alone plans are offered. You may want this if the health coverage you choose doesn’t include dental coverage, or if you want different dental coverage. If you choose a separate dental plan, you’ll pay a separate, additional premium.

7. If I lose my job, can I maintain the same insurance plan that I was offered through my employer? Scottsdale, AZ

If you lose your job and with it your job-based health insurance coverage, you may buy an individual plan through the Marketplace. You may also have the option of keeping your health insurance for a limited time through a program called COBRA continuation coverage.

  1. Get an individual Marketplace plan - If you leave your job for any reason and lose your job-based coverage, you can choose to buy coverage from the Marketplace. This is true even if you leave your job outside the Marketplace open enrollment period. By using the Marketplace, you’ll learn if you qualify for lower costs on your monthly premiums on private insurance. You could also qualify for lower out-of-pocket costs. Through the Marketplace you’ll also learn if you qualify for free or low-cost coverage from Medicaid or the Children’s Health Insurance Program (CHIP).
  2. Get COBRA coverage - You may also be able to keep your job-based plan through COBRA continuation coverage. COBRA is a federal law that may let you pay to keep you and your family on your employee health insurance for a limited time (usually 18 months) after your employment ends or you otherwise lose coverage.

If you buy COBRA continuation coverage, you won't be able to get any of the lower costs on premiums and out-of-pocket costs that people may get using the Marketplace. You’d also have to pay the full monthly premium, including any part of the premium that your employer had contributed.

8. If I want to meet a navigator in person to apply for health insurance, where do I go? Reno, NV

In all states, there will be people trained and certified to help you understand your health coverage options and enroll in a plan. They will be known by different names, depending on who provides the service and where they are located. All will provide similar kinds of help:

  • Navigators
  • Application assisters
  • Certified application counselors
  • Government agencies, such as State Medicaid and Children’s Health Insurance Program (CHIP) Offices

Insurance agents and brokers can also help you with your application and choices.

Visit LocalHelp.HealthCare.gov to find help in your area. You can search by city and state or zip code to see a list of local organizations with contact information, office hours, and types of help offered, such as non-English language support, Medicaid or CHIP, and Small Business Health Options Program (SHOP). These organizations can assist you in finding the kind of help that works for you.

9. If I haven’t signed up for health insurance by March 31st and have to pay a fee, how is that fee administered? And, how do I ensure security/that the bill is not a scam?  Lansing, MI

The penalty in 2014 is calculated one of 2 ways. You’ll pay whichever of these amounts is higher:

  • 1% of your yearly household income. The maximum penalty is the national average yearly premium for a bronze plan.
  • $95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285.

The fee increases every year. In 2015 it’s 2% of income or $325 per person. In 2016 and later years it’s 2.5% of income or $695 per person. After that it is adjusted for inflation.

If you’re uninsured for just part of the year, 1/12 of the yearly penalty applies to each month you’re uninsured. If you’re uninsured for less than 3 months, you don’t have a make a payment.

The individual shared responsibility provision goes into effect in 2014. You will not have to account for coverage or exemptions or to make any payments until you file your 2014 federal income tax return in 2015. Information will be made available later about how the income tax return will take account of coverage and exemptions. Insurers will be required to provide everyone that they cover each year with information that will help them demonstrate they had coverage beginning with the 2015 tax year.

The IRS routinely works with taxpayers who owe amounts they cannot afford to pay. The law prohibits the IRS from using liens or levies to collect any payment you owe related to the individual responsibility provision, if you, your spouse or a dependent included on your tax return does not have minimum essential coverage. However, if you owe a shared responsibility payment, the IRS may offset that liability against any tax refund you may be due.

10. I live in a small town with one rheumatologist. Is he/she obliged to accept my insurance and see me? If not what are my options? Fort Bragg, CA

Different plans have different networks and providers. Most health insurance plans offered in the Marketplace have networks of hospitals, doctors, specialists, pharmacies, and other health care providers. Networks include health care providers that the plan contracts with to take care of the plan’s members. Depending on the type of policy you buy, your care may be covered only when you get it from a network provider. A provider has a choice to join a network and is not obligated to accept insurance.  Some plans have an exception process that will allow members to see non-network doctors. When comparing plans in the Marketplace, you will see a link to a list of providers in each plan’s network. If staying with your current doctors is important to you, check to see if they are included before choosing a plan.

11. If I’m traveling between states and need to see a doctor, will my insurance carry over to that state? Sanford, ME

Each plan establishes a service area. This is a geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it's also generally the area where you can get routine (non-emergency) services.

If you live in one state and work or spend a lot of time in another state, carefully check the provider directories of the plans you’re thinking about buying. See if their networks have doctors, hospitals, and other health care providers in the places you’ll be. Also check out the plan’s payment policies for out-of-network care.

  • Some plans have networks that cover only part of one state. Other plans have networks that cover much of the country.
  • If you use a doctor or facility that’s not in your plan’s network, you may have to pay more for the services you get.

Marketplace plans must have a link to a provider network directory on their website – and the directory must have the most current listing of in-network providers. You can also contact the plan to confirm your doctor or facility is part of the network.

In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance. Your insurance company can't charge you more for getting emergency room services at an “out-of-network” hospital.

12. If I have insurance through the marketplace will I still be eligible to receive help through co-pay or prescription assistance programs? Chicago, IL

You would not be eligible for state assistance prescription programs if you have drug coverage from a Marketplace plan.

Health plans will help pay the cost of certain prescription medications. You may be able to buy other medications, but medications on your plan’s “formulary” (approved list) usually will be less expensive for you.

To find out which prescriptions are covered through your new Marketplace plan:

  • Visit your insurer’s website to review a list of prescriptions your plan covers
  • See your Summary of Benefits and Coverage, which is also available in See Plans Before I Apply
  • Call your insurer directly to find out what is covered, and have your plan information available. The number is on your insurance card, the insurer's website, or you can find it by logging into your account in the Marketplace.
  • Review any coverage materials

13. What would be the implication of being insured through a state based marketplace vs a federally run marketplace? Jacksonville, FL

No matter what state you live in, you can use the Marketplace. Some states operate their own Marketplace. In some states, the Marketplace is run by the Federal government. Find the Health Insurance Marketplace in your state.

  • State Based Marketplace – State creates and runs its own Marketplace. There will be a dedicated web-site and call center that will vary by state.
  • Federally Facilitated Marketplace – State has a Marketplace established and operated by the Federal government – known to consumers as The Health Insurance Marketplace. HealthCare.gov is the website for the Federally Facilitated Marketplace.

14. Would the tier level (bronze, silver, gold, platinum) affect the quality of care I will receive and or affect what doctors are available to me? Washington, DC

When you compare Marketplace insurance plans, they're put into 5 categories based on how you and the plan can expect to share the costs of care:

  • Bronze
  • Silver
  • Gold
  • Platinum
  • Catastrophic

All Marketplace insurance plan categories offer the same set of essential health benefits. The categories do not reflect the quality or amount of care the plans provide.

The category you choose affects how much your premium costs each month and what portion of the bill you pay for things like hospital visits or prescription medications. It also affects your total out-of-pocket costs —the total amount you’ll spend for the year if you need lots of care.

15. How are emergency room visits and hospital coverage addressed under the marketplace? Brooklyn, NY

Every health insurance plan sold in the Marketplace will offer 10 essential health benefits. Emergency room visits and treatment in the hospital for inpatient care are essential health benefits.  In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance. Your insurance company can't charge you more for getting emergency room services at an “out-of-network” hospital.