A Closer Look at Obamacare's Marketplace

People have reported confusion resulting from subsidy audits of the Marketplace (the administrative entity behind www.healthcare.gov). Recently, some clarification has emerged.

Cliff Eserman (Incompas Financial Inc.) reported that the Marketplace conducts ongoing audits to ensure correct subsidy calculations. The law requires the consumer to report to the Marketplace anything that could affect the subsidy calculation, such as changes to income. When the Marketplace conducts an audit, it notifies the consumer and specifies the additional documentation needed. Depending on the audit type, the consumer has 60 to 90 days to respond. The consumer can respond by sending the documents through the mail or by uploading them through healthcare.gov.

The consumer chooses how the Marketplace communicates with them, Eserman reported. The consumer has the responsibility to update the Marketplace of any changes involving their preferred communication choice. For example, a consumer had chosen their email address. Later, that consumer changed their email address, but did not notify the Marketplace. The Marketplace would be unable to communicate with the consumer in a timely manner, but would continue with other methods of communications. The consumer, however, would still be liable for failure to respond in a timely manner.

A Marketplace subsidy audit can determine if the consumer's subsidy should increase, decrease, or remain unchanged. The marketplace cannot cancel health insurance because of a subsidy audit, Eserman reported. The pre-audit subsidized premiums remain unchanged until the audit concludes or the deadline for response has passed. When an audit changes the net premium, the Marketplace notifies the consumer and the insurance company.

Mara Burger (Florida Department of Health) reported that the Marketplace does not communicate with AIDS Drug Assistance Programs (ADAPs). The Marketplace has the responsibility to notify the consumer, but the consumer can appeal its decision (full link at end of article). A Marketplace Blog, "The Marketplace Might Need More Information from You," has more information. Most importantly, if consumers mail the requested documents but fail to include the identifying barcode from their notice, the Marketplace may not be able to identify them (full link at end of article).

Examining Health Insurance

At the Men's Health and Wellness Conference in July, Eserman proposed two ways of looking at health plans. As health insurance lowers costs for people with serious health issues, they should see it as an asset. Appropriate health insurance policies must cover current drugs, and ideally should not require a referral to see a specialist. The plan's network should include the preferred primary and specialist physicians, as well as the preferred and closest hospitals.

When comparing costs between appropriate plans, the consumer should calculate the "worst case" financial scenario for each plan. First, they should multiply the monthly premium by 12 months in year. Then, they add the maximum out-of-pocket expenses to the total premiums. This will yield the maximum yearly in-network covered cost for each plan.

"As a comparison, a person might look upon health insurance as a liability if they rarely use their policy," Eserman said. They should examine monthly premiums, as well as copays for generic drugs and visits to their primary physician. They should also check to see if the plan's network includes their primary physician. As health conditions can change suddenly, consumers now in good health have to consider costs for Urgent Care and Emergency Rooms.

Paying for healthcare requires attention to detail. People will have to remain actively engaged.

For more information, please visit the websites below.

For Eserman's blog on insurance, please visit Incompasins.com/cliffs-notes