Do I have to pay the health law’s so-called “Cadillac tax” because I have good health insurance? When can I get Trumpcare plans for my kids? And what can I do if my insurance plan choices don’t include a specialist who is the only doctor in the area that can treat my cancer? Here are the answers to some recent questions about health insurance from readers.
Q: My company has asked employees to pay the Cadillac tax rather than putting the burden on the company. They are also telling us not to worry because it will never happen, but want us to agree that if it does, we will take on the cost. Can they do that?
Let’s step back for a minute. The Cadillac tax is a 40 percent surcharge on the annual cost of health plans above $10,200 for single coverage and $27,500 for family plans. While these plans are sometimes considered the health plans for well-to-do professionals, some union plans and other group plans with a pool of older, sicker enrollees may also fall into this category.
A few months ago when it looked as if the Affordable Care Act was going to be replaced, many employers believed, as yours apparently still does, that the Cadillac tax would never become effective: Both the House and Senate bills would have delayed the tax until 2026. But with the collapse of those efforts to repeal the ACA, the tax is on the front burner once again, says J.D. Piro, who leads the health and law group at benefits consultant firm Aon Hewitt. Unless Congress addresses it, the tax will take effect in 2020.
By law, insurers or employers would be responsible for paying the tax, but analysts say the costs would likely be passed through to enrollees, whether or not employees like you explicitly agree to absorb them.
So it may not matter how you respond to your employer in this case.
Also, employers who don’t want to pay the surcharge might sidestep the issue altogether by reducing the value of the plans they offer, says Piro. For example, they could increase employee deductibles and other cost-sharing, make coverage less generous, or they could shrink the provider network.
“That’s simplest way to avoid the tax,” he says.
Q: I have a rare disease, and there is literally only one specialist in my area with the expertise needed to treat me. I am self-employed and have to buy my own insurance. What do I do next year if there are zero insurance plans available that allow me to see my specialist? I cannot “break up” with my sub-specialty oncologist. I must be able to see the doctor that is literally saving my life and keeping me alive.
If the plan you pick covers out-of-network providers, you can continue to see your cancer specialist, although you’ll have to pay a higher percentage of the cost than if you were seeing someone in your plan’s network.
But many plans these days don’t provide any out-of-network coverage. This is certainly true of plans sold on the health insurance exchanges.
The situation you’re concerned about — that a specialist you consider crucial to your care isn’t in a plan’s provider network — isn’t uncommon, says Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. And, unfortunately, you probably can’t get any coverage assurance before you sign up.
If this happens, you can contact your plan and make the case that this particular provider is the only one who has the expertise to meet your needs.
Then ask your plan to make an exception and treat the out-of-network specialist as if she were in-network for cost-sharing purposes. So, if in your plan, an in-network specialist visit requires a $250 copayment, for example, the plan could agree that’s what you’d be charged to see your out-of-network specialist.
Or not. It’s up to officials who administer the health plan, and they may argue that someone in-network has the expertise you need. If you disagree, you can appeal that decision.
But it may not come to that, says Corlette.
“Plans are prepared for this — the good ones are, anyway,” she says. “My understanding is that it’s pretty routine to grant exceptions for narrow subspecialties.”
Q: I need to purchase affordable health insurance for my two daughters who are 19 and 17. Is Trump insurance available yet? I need something I can afford and everything is so expensive.
President Donald Trump never put forward a proposal to replace the ACA. Instead, he backed the House and Senate replacement versions, which ultimately failed. But those versions might not have addressed your concerns, anyway, and you may have several options through the ACA.
“Coverage wouldn’t necessarily have been cheaper,” says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.
Under the Senate bill, for example, the average 2018 premiums for single coverage would have been 20 percent higher than this year’s, according to an analysis by the nonpartisan Congressional Budget Office. In 2020, under the Senate bill, premiums would have been 30 percent lower than under current law, on average. But deductibles and other out-of-pocket costs would have been higher for most people, the CBO predicted
Premiums for young people would generally have declined. The bill would have allowed insurers to vary rates to a greater degree based on age, resulting in lower premiums for young people. In addition, premium tax credits generally would have increased for young people who have incomes above 150 percent of the poverty level.
Your current coverage options under the ACA depend on your family situation. If you have coverage available to you through your employer, you can keep your daughters on your plan until they turn 26. For many parents, this is the most affordable, comprehensive option.
If that’s not a possibility, assuming the three of you live together and you claim them as dependents on your taxes, you may qualify for subsidized coverage on the health insurance marketplace next year. Your household income would need to be no more than 400 percent of the federal poverty level (about $82,000 for a family of three). You can apply for that coverage in the fall.
If you live in one of the 31 states plus the District of Columbia that have expanded Medicaid coverage to adults with incomes below 138 percent of the poverty level (about $28,000 for a family of three), you could qualify for that program. You can sign up for Medicaid anytime.
Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter @mandrews110.