Can you swap Medicare for Obamacare?

After reading about turmoil in North Carolina's Medicare Advantage program,  85-year-old Marion Meili called with a question: Can I drop my policy and try to find a better deal on the Affordable Care Act exchange?

Short answer:  No.  The exchange,  which offers subsidies for low- and moderate-income people,  was designed to provide new options for people who don't have access to health insurance.  It's not available to those who already have government coverage,  including Medicare and Medicaid, or those who have qualified group plans offered by their employer.

"It's against the law for anyone who knows you have Medicare to sell you a Marketplace plan,"  says HealthCare.gov,  the official ACA exchange site.

Glenn McCoy/Slate.com

Of course,  there's never a simple answer for anything related to health coverage,  so the site follows up with exceptions:  If you're paying a premium for Medicare Part A or if you're eligible for Medicare but haven't signed up you might be able to shop on the exchange  (read details here).

Medicare Advantage is an option that lets senior citizens enroll in a private insurance plan  (get a primer on how the system works here).  Meili's policy is with UnitedHealthcare;  she tells me she got a notice of a rate hike but called the insurance company and "got it a bit cheaper."  That's a good reminder that it's always smart to shop around and ask for a better deal.

It's also smart to get help.  Medicare options and costs change every year.  In North Carolina,  call 1-855-408-1212 or visit the Seniors Health Insurance Information Program website to get advice.

A note if you live in Mecklenburg County:  Shepherd's Center does face-to-face counseling on Medicare enrollment and I have it on good authority  (my 80-year-old mom)  that they do excellent work.  Unfortunately,  they're also booked for the rest of this enrollment period,  which ends Dec. 7.  So if you call the state SHIIP line,  tell them you want your question answered on the phone or you may get referred to Shepherd's Center,  which will just send you back to the phone line.

Don't get double-billed on ACA insurance

I'm hearing from people who are switching plans as they check out their new rates for health insurance on the Affordable Care Act exchange.  I'm working on a story and would love to hear people's experiences,  but in the meantime,  the Kaiser Family Foundation offers an important tip:

Insurers have expressed concerns that if a consumer changes plans, problems with the federal website might keep insurers from learning of the change and consumers could get billed for both plans. “It’s an issue we’re aware of and we’re working with exchange officials to make sure there’s a solution for consumers,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry trade group. Aaron Albright, a spokesman for the Centers for Medicare & Medicaid Services, said insurers will get lists of individuals who have been automatically enrolled into their current plan as well as those who chose to re-enroll. He also said that the agency is "examining options” on how to provide insurers the names of people who picked another plan during open enrollment.

Just in case, keep proof of payment to answer any billing questions and once you’ve cancelled the old policy watch your credit card statements or, if the payment was deducted directly from a bank account, watch those charges to make sure you aren’t paying for two policies. And don’t cancel your current insurance until you have confirmation from your new carrier that you’re covered.

That's among a list of five tips for people enrolling or re-enrolling during the 2015 open enrollment period, which runs through Feb. 15.  Read the other four here.

Reader asks about estimating income

Shortly before open enrollment began Saturday,  a reader who asked to be identified only as Elizabeth logged onto the Blue Cross website to try to estimate the cost of her policy in 2015.  To estimate her subsidy under the Affordable Care Act,  she was asked to enter her modified adjusted gross income.

What,  she wondered,  is that?

I found a one-page explanation of that term created by the University of California Berkeley Labor Center.   And HealthCare.gov,  the official ACA website,  offers a list of tips on what to include and omit in estimating the income that will be used to calculate 2015 tax credits.

Income estimates and tax credits get complicated

Wages,  salary,  tips,  net business income,  unemployment compensation,  alimony,  Social Security,  investment income and rental income all count toward determining how much aid you can get.

Child support,  gifts,  Supplemental Security Income,  veteran's disability payments,  workers comp and loans don't count.

But the biggest challenge,  it seems to me,  is that you're not reporting what you made this year  but predicting what you will make in 2015.  For people with full-time salaried jobs that may be relatively easy,  but for many others it's not.  As John Murawski of the News & Observer reported last week,  a whole lot of people are about to face up to how good their 2014 estimates were as they prepare their taxes.

At the risk of sounding like a broken record:  When in doubt,  get help.  You can make an appointment for free personal advice from someone trained to navigate the ACA exchange by calling 1-855-733-3711 in North Carolina and 1-888-998-4646 in South Carolina  (I've heard you may get a busy signal,  but that should ease after the first few days.)  Insurance agents and brokers can also help with the exchange.

And remember to check the source of your information.  There are a lot of folks with official-looking websites and mailings trying to sell products,  push agendas and maybe even rip you off.  When I googled the ACA and  "modified adjusted gross income,"  the first link that came up was a detailed explanation on ObamacareFacts.com.  The page contains a note that it's  "privately owned,"  and if you click around a bit more you'll learn that it's  "run by two guys, we have no ties to any political party or organization and don’t receive funding from anyone."  This unnamed duo may be as unbiased as they repeatedly profess to be and their information may be solid.  But I wouldn't stake my health or money on it.

Read more here: http://charobshealth.blogspot.com/#storylink=cpy

Bell House demise brings painful lesson

I visited Greensboro's Bell House in September to meet adults with cerebral palsy and related disorders who had been told their longtime residence was being closed because government guidelines deemed it too big to be a home.  Medicaid rules designed to get people out of institutions dried up money for the nonprofit facility,  but residents insisted Bell House was far from institutional.

The final day was supposed to be Oct. 31,  but relocation has spilled into this month.  It's not that people weren't eager to help,  but finding new homes for people with good minds but severely impaired bodies isn't easy.

Doris Lentz in her Bell House room

"It’s certainly been much, much more difficult than we expected (and we knew it would be difficult)," director Jeni Kirk emailed me recently, as she worked to find a place for the last few residents to live. 

The funding system provides extra support for people with disabilities to live independently or in group homes with no more than three residents.  But people like Doris Lentz,  who lived at Bell House since 1979,  wanted to stay with the residents and staff who had become family.  Lentz,  who had a bad experience living in a nursing home as a young adult after her mother died,  also feared trading the independence she had at Bell House for a more restricted setting.

The closing drew extensive coverage,  and offers to help came in from nursing homes,  assisted living facilities and people with  "accessible"  apartments to rent.  But Kirk says frustrated residents and staff learned over and over that the label didn't mean a facility was ready to handle people in motorized wheelchairs who need help with bathing and other daily activities.

"We had residents go visit  'accessible'  houses and discover that they couldn’t even get into the building because there were steps,  not a ramp,"  Kirk said.  "We even had someone visit a place where the resident's room would have been on the second floor – without an elevator, and the caregivers told them that they would carry the person up and down the stairs  These kind of findings were the norm,  not the exception."

Likewise,  assisted living and skilled nursing centers would offer to take residents,  only to conclude later that they couldn't handle someone with such extensive physical needs.

Christenbury

Rhonda Christenbury of Charlotte,  a member of Lentz's family,  said one assisted living center in Greensboro had accepted Lentz and a handful of other residents in late October.  They had started moving in possessions and changing phone numbers when the facility backed out,  Christenbury said.

Lentz moved last week to a skilled nursing home in Burlington,  Kirk said this week.  "Though moving to Burlington was not what she or her family wanted, the facility is apparently quite nice and  (Doris)  and her family felt okay about the move,"  Kirk reported.  Another Bell House resident and friend will join her this week,  though Kirk said she had to fight  "bureaucratic rigamarole"  to get her in. 

"The final resident is slated to move to an apartment on Thursday of this week,  but again,  the bathroom is not accessible and he will likely have to get by with sponge baths until an accommodation can be made to retrofit the bathroom,"  Kirk concluded.  "This experience has really opened my eyes to the crisis that exists for provision of accessible housing for the disabled."

Hidden costs: A personal postscript

I recently made my first venture into the world of consumer cost control in health care.

As a baby boomer,  I grew up trusting my doctors to tell me what was needed,  with insurance picking up the tab.  In recent years I've joined many of you in seeing my premiums and out-of-pocket costs rise;  my family is now on a very high-deductible plan.

When my husband got a screening colonoscopy early this year,  we grumbled about being stuck with a $708 bill for anesthesia and pathology ($1,370 before the insurance discount),  but we weren't shocked.  We were mostly grateful to get more than $2,200 covered for the rest of the procedure.

It wasn't until I did an article on hidden costs for procedures that are supposed to be fully covered that I realized we should have asked more questions.  Dr. Rig Patel,  president of the N.C. Society of Gastroenterologists,  offered details on how and why patients can end up with big bills for a cancer screening that's supposed to be covered by all policies.

So when I got my reminder email,  I was ready.  First I followed Patel's suggestion to ask the questions in advance,  rather than making an appointment and quizzing the doctor as the procedure is about to begin.

When I got a scheduling staffer,  I asked about sedation/anesthesia.  She said the gastroenterology practice had changed its approach since the last time my husband and I did this.  Then patients were given Demerol/Versed,  known as conscious sedation.  Now they're put under with propofol,  which our policy doesn't cover,  unless they specifically ask for the old form of sedation.

I also asked about timing.  I'd been told to expect a follow-up in five years.  She said the recommendation was  "four to five years,"  and the practice was giving me the opportunity to do it at four.

Yeah  ...  no thanks.  When I make an appointment next year I'll ask for Demerol/Versed,  which worked fine the first time.  My father,  a surgeon,  always emphasized the slim but serious risks of anesthesia.  Never be put under unless it's a medical necessity,  he told me.  So skipping the propofol seems like a wise medical approach,  as well as a money-saver.

Some would cite this as an illustration of the value of shifting costs to patients:  With more skin in the game,  we stop being  "passive consumers."  I was pleased that the staffer got back to me quickly and had good answers.  But I can't help wondering why it falls to those of us with no medical training to figure out what to ask.  Wouldn't it make sense for the gastronterologist's office to lay out the medical and financial implications of a new approach and give all patients an informed choice,  rather than waiting to see who speaks up?

North Carolina's advantage: Easy access to personal help

Mary Gibson was frustrated.  I had run an article listing a number North Carolinians could call to get in-person help enrolling for health insurance, but what about South Carolina?  The HealthCare.gov link I had listed to look up local options provided little help.

My first try at finding a central contact for South Carolina had failed,  but I told her I'd keep looking and call her back.  I eventually found one  (888-998-4646)  by posting a query on the Facebook page of a friend who works for The Columbia State.  But the challenge illustrates a key finding of a recent study by the Robert Wood Johnson Foundation.

The foundation,  a New Jersey-based group that pushes for health care access,  set out to determine why North Carolina enrolled a significantly higher percent of its uninsured residents in the Affordable Care Act exchange than South Carolina did,  despite similar demographics and politics.  (The report also compares Wisconsin,  which also had relatively high enrollment,  with Ohio,  which did not.)

Get Covered Mecklenburg coalition hosted sign-ups Saturday

The conclusion:  North Carolina tapped longstanding partnerships between health care and consumer groups,  worked together to create a strong message promoting enrollment and created a central scheduling system that made it easy for people to get help signing up.

"The scheduling system tracked data on appointments,  sometimes enabling organizations to deploy additional Navigator support in areas with high demand,"  the report says. "...The establishment of a central toll-free number helped brand the Marketplace and create a unified message about where to go to obtain enrollment information."

The system wasn't perfect,  it continues,  but is serving as a national model for Enroll America,  a nonprofit group described as playing a central role in North Carolina's success.

"In contrast to the collaborative atmosphere in North Carolina,  there were notable conflicts in South Carolina,"  the report says.  "To the shock of many community-based organization,  the largest Navigator grant went to an out-of-state,  for-profit agency"  (DECO Recovery Management of Maryland).  As reports at the time indicated,  the results were fragmented and confusing.

This year the Charleston-based Palmetto Project scrambled to put together a statewide system for scheduling personal assistance after it got a federal grant in September.  I'll be curious to hear what upstate residents experience as enrollment begins.

The report also suggests that Blue Cross and Blue Shield's dominance of the North Carolina market may have proven an advantage in getting the word out.  Last year and again in 2015,  Blue Cross is the only company selling ACA marketplace policies statewide  (Coventry and UnitedHealthcare are competing in many counties).  The report suggests that dominance created an incentive for Blue Cross to market heavily statewide,  with such efforts as mobile units and events at retail outlets to reach the uninsured and newly insured.

Readers ask about glitches, immigrants and renewal

During the 2014 enrollment period,  Jacqueline Smith’s son bought health insurance through the Affordable Care Act exchange  –  or so he thought.

Smith says he never got any kind of confirmation, bill or policy and remained uninsured.  Now the Charlotte woman is wondering:  How can he do it this year and make sure it’s right?

The simplest answer is to get help.  Insurance agents and ACA exchange counselors offer guidance at no charge.  For an appointment with health insurance navigators,  call 1-855-733-3711 in North Carolina and 1-888-998-4646 in South Carolina.

If you decide to go it alone, look for a bill from the insurance company you chose.  Enrollment isn’t complete until the buyer has made the first payment, says Madison Hardee, a Legal Services of Southern Piedmont lawyer who is a health care navigator.

"However, we encourage consumers to be proactive and contact their insurance company a day or two after selecting a plan,"  Hardee added.  "That way, they can confirm coverage and go ahead and pay the first month’s payment over the phone." 

Other reader questions:

My wife and I got on the affordable care plan last year. Do we have to do anything to renew it?

No.  If you do nothing by Dec. 15,  the plan will automatically renew.  But look at the statement from your insurance company detailing any changes in the plan or premium.  Experts say it’s smart to go online, update your information and see if there are better deals this year.

In fact, the reader who sent this question followed up later that day saying he had just gotten a letter from Coventry saying his old policy was cancelled and offering a new one at three times his current premium, with a higher deductible.

How long do immigrants have to be in the country to qualify for insurance on the exchange?

Eligibility is based on legal status, not length of residence. Those who have become citizens, hold a green card or have been granted asylum or refugee status are eligible. People who are not in the United States legally can’t participate, regardless of how long they’ve been here. See www.healthcare.gov/immigrants/ for details.

Will Supreme Court snatch subsidies?

A recent U.S. Supreme Court decision to hear a challenge to the Affordable Care Act raises new questions as 2015 enrollment gears up.   The challenge involves the 34 states that refused to set up their own exchanges for offering subsidies,  including North and South Carolina.

Most rulings from lower courts have sided with those who say the federal exchange those states use is valid, but the review raises the prospect that it could be deemed illegal.  There's a lot at stake:  The first time around,  more than 325,000 North Carolinians got tax credits to reduce the cost of health insurance.

“Is there a guarantee that the subsidy won’t be revoked by the Supreme Court and you’ll be stuck having to pay the bill yourself?” a blog reader asked earlier this week. “... Would they have to pay for the rest of the year without a subsidy? For the previous parts of the year?”

Brandon

The consensus seems to be that there's no risk to signing up.  Asking people to repay assistance would be unheard of,  two experts I spoke with said.  A ruling would be unlikely before summer,  and both Washington and Lee's Timothy Jost and UNC Charlotte's William Brandon say it's doubtful that the court would leave millions of Americans suddenly stranded without the aid they're counting on.

“People should go ahead and sign up, and the Supreme Court will hopefully go the right way,”  said Jost,  a law professor who's the author of a health law casebook.  “Why would (Congress) have created the federal exchange if it can’t do anything?”

Brandon,  a professor of political science and health policy,  agrees:  “People would be making a big mistake if they hold off on enrollment thinking it may not be there next year.”

An enrollment Q&A by Margot Sanger-Katz of The New York Times reached the same conclusion: "Ultimately, the case could mean that people in those states  (using the federal exchange)  who are getting subsidies to help pay for health insurance will no longer be able to receive them.  But the case is a long way from being decided and won’t take money away from people who sign up for insurance now."

LaWana Mayfield

At an enrollment kickoff Wednesday,  Charlotte City Council member LaWana Mayfield talked about  "fear tactics"  being used to deter the people who are most likely to lack health insurance  --  young people,  African Americans and Latinos  --  from signing up.  She said people are "being told it will be taken away."

"We cannot let fear stop us from gaining access to health care,"  Mayfield said.

One thing seems certain:  The political strife over  "Obamacare,"  approved in 2010 with no Republican votes,  will rage on in 2015,  as the GOP gains a majority in the Senate as well as the House.

ACA window-shopping: What are you seeing?

The 2015 rates were posted on HealthCare.gov today,  allowing people to start preparing for Saturday's start of the open enrollment season.  I plugged my info in and quickly got a menu of plans.  But because I have workplace insurance and didn't do this last year,  I don't have much sense of how rates and plans are changing.

So if you already have insurance through the exchange,  please take a peek and let me know what you see.  You can let your current plan renew automatically,  but experts say it's smart to check the 2015 options to see if you can get a better deal.

Update:  I'm hearing from people who went to their personal account and couldn't get anything new.  What you have to do is go to the general HealthCare.gov page and enter general info  (zip code,  income  and age/smoking status of those who will be insured)  to get rates for 2015.  I don't think you'll be able to get an official individual quote until Saturday.

Image: TheTakeaway.org

A few reminders:  The Mecklenburg  branch of Get Covered America will hold an opening day enrollment and information event at the Children and Family Services Center,  601 E. Fifth St.,  from 10 a.m. to 4 p.m. Saturday,  Nov. 15.  If you plan to apply,  bring your Social Security number,  date of birth,  employer information,  proof of household income and policy numbers for any existing coverage.

While you can't sign up for subsidized insurance until Saturday, you can schedule an appointment for in-person assistance in North Carolina now by calling 1-855-733-3711.

And you can get a lot of helpful tips by downloading HealthInsurance.org's  "Insider's Guide to Obamacare's Open Enrollment."

On a separate but related note:  I've heard from several people distressed about big increases in Blue Cross and Blue Shield of North Carolina's rates for Medicare Advantage or Medicare Part D insurance.  I plan to follow up,  but got sidetracked last week when I made a temporary return to the education beat to help cover the departure of Charlotte-Mecklenburg Schools Superintendent Heath Morrison.

Read more here: http://charobshealth.blogspot.com/#storylink=cp

Get answers as enrollment time nears

How much will you pay at tax time if you still don't have health insurance?  How can you minimize hassles when the Affordable Care Act exchange opens for 2015 enrollment on Nov. 15?  Is there anything you need to do if you got insurance on the exchange this year?

"The Insider's Guide to Obamacare's Open Enrollment,"  a 38-page free e-book produced by healthinsurance.org,  provides some of the clearest answers I've seen to these and other questions.  To get a copy,  go to this link and provide your email address  (you're signing up for a newsletter,  but you can unsubscribe if you're not interested).

Enrollment billboard on Wilkinson Boulevard

A couple of crucial points:  If you want your 2015 insurance to be in effect on Jan. 1,  you have a short window  --  Nov. 15 to Dec. 15  --  to shop on HealthCare.gov.  And if you're among more than 357,000 North Carolinians who bought 2014 plans on the exchange,  there are good reasons to check whether your plan is still the best deal,  rather than letting this year's plan automatically renew.

The guide predicts the website will work better than it did last year  --  and even explained why I've had so little luck getting any insurance folks to talk to me about the testing:  "Insurers (who have tested the 2015 site) are bound by a confidentiality clause that prohibits them from discussing the results of their testing with the media."

But with a three-month window this year,  compared with six last year,  the authors still suggest starting early and doing groundwork in advance.  For those who are so inclined,  you can call 1-855-733-3711 now to make a post-Nov. 15 appointment for in-person assistance in North Carolina.

Get Covered Mecklenburg plans a big opening day enrollment and information event at the Children and Family Services Center,  601 E. Fifth St.  It will be from 10 a.m. to 4 p.m. Nov. 15.  If you plan to apply,  bring your Social Security number,  date of birth,  employer information,  proof of household income and policy numbers for any existing coverage.