By Randy Dotinga
WebMD Health News
Reviewed by Lisa Zamosky
March 19, 2014 -- The big deadline -- the final, no-more-extensions, we-mean-business-this-time deadline -- is almost here. After March 31, Americans -- with a few exceptions -- won't be able to buy health insurance for 2014.
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And unlike the previous deadlines, there seems to be no chance of a last-minute reprieve.
It's a good time to take a look at the state of health care reform. Here are seven things we know now about it.
1. The March 31 Deadline Is Firm
Don't expect this enrollment deadline to get extended. Most uninsured people will need to buy insurance by then to avoid facing a penalty.
How come they mean it this time? There have been lots of extensions and delays to the law, partly because of the botched launch of Healthcare.gov.
"But if you continuously push [the deadline] back, it will look like the policy is a failure, and you're not doing what the law intended, which is to force people to buy coverage," says John Bowblis. He's an assistant professor of economics at Miami University of Ohio who studies health insurance.
Could there be one more delay? Possibly. If there are technical glitches in the final days of enrollment, federal officials are working on a plan to approve sign-ups for everyone who tries to enroll before the deadline.
People with low income can apply at any time for Medicaid or the Children's Health Insurance Program, though.
2. You May Be an Exception to the Rules
What if you want to get insurance after the March 31 deadline? You'll only be able to if you have what's known as a "life event." That includes getting married or divorced, giving birth to or adopting a child, or losing your job. A life event qualifies you for a special enrollment period.
If you didn't have a life event, will have to wait until the fall -- Nov. 15 in almost all states -- when enrollment opens for coverage that takes effect in 2015.
There are exceptions to tax penalties, too.
You'll be penalized if you don't have health coverage this year, unless you fall in certain exempted groups of people like most prisoners, those who were uninsured for fewer than 3 months of 2014, and those in certain religious groups. People who have faced hardships like bankruptcy, homelessness, and domestic violence (among several other types of hardship) may also be exempt. You're also exempt if you were found to be ineligible for Medicaid because your state didn't expand the program, or if you can't find a plan that costs less than 8% of your income.
3. Can You Keep Your Old Insurance? Maybe Not
After an outcry from people who feared cancellation of their insurance would force them to lose their doctors or pay higher rates for a health plan, the Obama administration said it would allow people to keep the policies for 1 year -- even though they might not meet the law's minimum coverage standards. Earlier this month, officials extended that another 2 years for a total of 3.
But there's still one catch: States don't have to allow those extensions, and insurance companies don't have to offer them. Washington state, for example won't allow those policies that don't meet "Obamacare" standards to be offered.
4. Those Penalties Can Add Up
The tax penalties won't kick in until you file your 2014 taxes in 2015, but they can add up, and they'll grow over time.
The penalty for not having health insurance in 2014 will be 1% of your annual income or $95 per adult, whichever is higher. If you pay $95 per person, you'll also have to pay a penalty of $47.50 for each uninsured child under 18 in 2014, up to a maximum amount per family of $285. In practical terms, though, most people who have to pay a penalty will fall into the 1% category. That's 1% of your household income above the tax filing threshold of $10,150 for an individual.
In the next 2 years, that penalty gets stiffer: In 2015 it will be 2% of income or $325 per person. In 2016 it will be 2.5% of income or $695 per person, whichever is higher.
5. Premiums May Not Tell the Whole Story
Are those Marketplace policies a good deal? It's hard to say. A January report from PriceWaterhouseCoopers found that premiums for Marketplace policies are cheaper, on average, than those offered through employers. PriceWaterhouseCoopers's Ceci Connolly told Marketplace.org that even when you factor in all the out-of-pocket costs, the average top-tier gold and platinum plans are similar to employer plans.
But why are deductibles so high, rising into thousands of dollars a year in some cases?
"An insurance company needs to collect more money in terms of premiums than it expects to pay out," Bowblis says. "One way to make sure this happens is to either have low premiums and high cost sharing, or high premiums and low cost sharing." The Obama administration pushed for lower premiums, he says. "But low premiums equal high deductibles."
6. You May Fall Through the Medicaid Gap
An estimated 5 million low-income people aren't getting financial help to buy insurance coverage, because their incomes aren't high enough to earn a subsidy from the federal government. But if their state hasn't expanded Medicaid, they may make too much to qualify for that program.
It's an unusual situation, to make too little to get help from the feds but too much to get help from the state. That's the way things stand, though, in the 25 states that have declined to expand Medicaid.
"We need to take the long view," says Aaron Katz, a principal lecturer at the University of Washington who studies health care expenses. "It took 17 years after original enactment of Medicaid for all 50 states to join in. I expect the vast majority of states to adopt the expansion in the next 5-10 years. The pressure from hospitals, doctors, and businesses, already evident in some of the 'no' states, will grow as they realize how much they're paying for their states' denials."
7. Dental Coverage Isn't Guaranteed, Except for Kids
If you get insurance through a federal or state Marketplace, it likely won't include dental care. Insurers aren't required to offer dental care -- except for policies that cover children -- and you won't pay a penalty if you go without dental coverage for yourself or for children. Public health advocates pushed hard to have pediatric dental care included. The efforts were fueled in part because of a Maryland boy, who died in 2007 from a bacterial infection that spread from an abscessed tooth. His family had lost their Medicaid coverage.
Why is dental coverage treated differently from other kinds of medical coverage? The law's framers stayed away from universal dental coverage because they feared losing the battle in Congress if costs got too high, says Jeff Album. He is vice president of public and government affairs with Delta Dental, a dental insurance company.
Historically, about 99% of dental plans are sold separately from medical plans, Katz says.
SOURCES: Kaiser Family Foundation: "Status of State Action on the Medicaid Expansion Decision, 2014." Healthcare.gov: "How do I qualify for an exemption from the fee for not having health coverage?" "What if someone doesn't have health coverage in 2014?" Kaiser Health News: "FAQ: Dental And Vision Care Part Of 'Essential Benefits' For Kids." Wall Street Journal: "Health Site Plans Deadline Leeway." Marketplace.org: "Americans who have bought Obamacare are getting a good deal."
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