The Affordable Care Act has so far survived Republican attempts to replace it, but many people still face insurance concerns. Below, I answer three questions from readers.
Q:聽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聽that allow me to see my specialist? I聽cannot 鈥渂reak up鈥� 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鈥檒l have to pay a higher percentage of the cost than if you were seeing someone in your plan鈥檚 network.
But many plans these days don鈥檛 provide any out-of-network coverage. This is certainly true of plans sold on the health insurance exchanges.
The situation you鈥檙e concerned about 鈥� that a specialist you consider crucial to your care isn鈥檛 in a plan鈥檚 provider network 鈥� isn鈥檛 uncommon, said Sabrina Corlette, a research professor at Georgetown University鈥檚 Center on Health Insurance Reforms.
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. (Unfortunately, you probably can鈥檛 get this coverage assurance before you sign up.) 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 would agree that鈥檚 what you鈥檇 be charged to see your out-of-network specialist.
Or not. It鈥檚 up to the plan officials, 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, said Corlette.
鈥淧lans are prepared for this 鈥� the good ones are, anyway,鈥� she said. 鈥淢y understanding is that it鈥檚聽pretty routine to grant exceptions for narrow subspecialties.鈥�
Q: My company has asked employees聽to pay the Cadillac tax聽rather than putting the burden聽 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鈥檚 step back for a minute. The so-called is a 40 percent surcharge on the value of health plans above the thresholds of $10,200 for single coverage and $27,500 for family plans.
A few months ago when it looked as if the ACA 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 , and a lot can happen between now and then.聽With the collapse of efforts to repeal the ACA, however, the tax is on the front burner once again, said J.D. Piro, who leads the health and law group at benefits consultant聽Aon Hewitt. It鈥檚 set to take effect in 2020.
Under the law, insurers or employers would be responsible for paying the tax, but experts say the costs would likely be passed through to enrollees (whether or not you explicitly agree to absorb them).聽So it may not matter how you respond to your employer.
Also, employers who don鈥檛 want to pay the surcharge might聽sidestep the issue by reducing the value of the plans they offer, said Piro. For example, they could increase employee deductibles and other cost-sharing, make coverage less generous or shrink the provider network.
鈥淭hat鈥檚 simplest way to avoid the tax,鈥� he said.
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聽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, and you could have several options through the ACA.
鈥淐overage wouldn鈥檛 necessarily have been cheaper,鈥� said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.
Under the Senate bill,聽for example, the nonpartisan that average 2018 premiums for single coverage would be 20 percent higher than this year鈥檚. In 2020, however, premiums would be 30 percent lower than under current law, on average.聽But deductibles and other out-of-pocket costs would be higher for most people under the Senate bill, according to the CBO.
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 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鈥檚 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.聽Your household income would need to be no more than聽400 percent of the federal poverty level (about ). 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 don鈥檛 have to wait for open enrollment to sign up for Medicaid.
Please visit to send comments or ideas for future topics for the Insuring Your Health column.