High anxiety? We've got your back.

Here's something you probably never thought you'd hear: Health insurance is about to get interesting.

You have lots of questions about the Affordable Care Act, aka Obamacare. The Sun Journal and the Bangor Daily News want to help you understand what the ACA will mean for you and your family.

  • Glossary: The lingo you need to know.
  • Timeline: How health care coverage has evolved.
  • FAQs: Frequently asked questions and helpful answers

There is more information and coverage in our Affordable Care Act 101 special section

New discounts. New benefits. New rules.

And a new place to buy. 

Come Oct. 1, people can start signing up for health insurance in the new Affordable Care Act marketplace, or exchange. All individuals, families and small businesses can use it, some getting money to do so.

So, are you ready to buy? Maybe? You're not really sure?

Here's what you need to know.

Here's your deadline

The ACA health insurance mandate starts Jan. 1, 2014, requiring almost all Americans to have health insurance or pay a penalty. There's a three-month grace period before the penalty kicks in, however, so if you don't have insurance right on Jan. 1, you're OK. But don't be an April fool.

People who are very poor (those under the federal poverty level) and who live in a state that didn't expand Medicaid (like Maine) are exempt from the penalty. You can also get an exemption if:

  • Your religion prevents you from accepting insurance benefits.
  • You're part of a health care-sharing ministry.
  • You are a member of a federally recognized Indian tribe.
  • You lack insurance for less than three months in a row.
  • You have suffered a certified hardship.
  • You can't afford coverage because you'd have to pay more than 8 percent of your household income for it.
  • You're behind bars.
  • You are not a U.S. citizen, a U.S. national or an alien lawfully present in the U.S.

If you have affordable insurance through your employer, you're all set. Likewise if you get health care through the military, VA, Medicare, Medicaid or some other insurance program.

If you don't have health insurance, the ACA wants you to get some. Like, soon.

Insurance can still be bought and sold the regular way, through agents. But starting Oct. 1, it will also be sold through the marketplace, a virtual shopping center where people and small businesses can compare prices and benefits. Think online shoe shopping — it's all about what fits, what suits your needs and how much you can afford.

Although insurance can still be bought elsewhere, federal subsidies and tax breaks will only be available for insurance bought through the marketplace. (Except for catastrophic plans. No subsidy for those.)

Open enrollment will last from October 2013 to March 2014. In future years it will run from October to January. You can buy individual health insurance only during this time unless you lose your job, get married, have a baby or something else big happens in your life. This is the new rule for insurance bought on or off the marketplace.

How to get started?

So how do you buy insurance from the marketplace? Let us count the ways.

* You can sign up at Healthcare.gov, the official marketplace website. That site will also give the names of "navigators" and certified application counselors — federally designated ACA helpers — who will be able to assist with paper applications.

* You can sign up through the marketplace hotline: 1-800-318-2596 for individuals or 1-800-706-7893 for small businesses.

* Specially trained insurance agents and brokers can sell insurance from the marketplace. Healthcare.gov should be able to provide the names of those people.  

All of those options should be free to you. If someone wants to charge you for helping with an application or signing up for the marketplace, that's a red flag for fraud. More on that later. 

But how much will insurance cost?

Right now, two companies will likely sell to Mainers through the marketplace: Maine Community Health Options and Anthem Blue Cross and Blue Shield.

MCHO is a new nonprofit insurance co-op run by members for members. Anthem is the state's largest health insurer, and it has partnered with MaineHealth, the state's largest health care organization, to offer marketplace plans.

Their prices are based on where you live, how old you are and whether you want a catastrophic, basic (bronze), middle-of-the-road (silver) or high-end (gold) plan. Anthem's prices also increase if you smoke.

In general, if you're a 20-something nonsmoker in Southern Maine, you'll pay the least. If you're a retirement-age (but not quite Medicare-age) smoker in Northern Maine, you'll pay the most.

How much will you pay exactly? The marketplace will tell you once it's up and running Oct. 1 at Healthcare.gov. In the meantime, the Maine Bureau of Insurance has some examples:

* A 21-year-old nonsmoker from Cumberland County will pay $155 a month for Anthem's limited-benefit, high-deductible catastrophic plan.

* A 30-year-old smoker from Oxford County will pay $234 a month for MCHO's basic bronze plan.

* A 40-year-old nonsmoker from Androscoggin County will pay about $325 a month for MCHO's middle-of-the-road silver plan.

* A 50-year-old smoker from Penobscot County will pay about $599 a month for MCHO's high-end gold plan.

* A 60-year-old nonsmoker in Washington County will pay about $754 a month for Anthem's gold plan through a small group, likely his employer.

But like anyone who's ever used health insurance knows, you don't just pay the monthly premium. There are also co-pays, deductibles and a host of other checks to write. That monthly price can be the least of your worries if you go to the doctor a lot or wind up in the hospital with third-degree burns after saving a house full of orphans and kittens from fire.

The federal government has designated official "navigators" to help people and small groups, well, navigate. In Maine, navigators will come from Western Maine Community Action and a partnership between the Maine Lobstermen's Association and the Massachusetts-based Fishing Partnership Support Services. 

Those navigators are getting trained now. Come Oct. 1, they'll be able to explain the marketplace and differences between insurance plans. However, they won't be allowed to recommend a plan or tell you which one you should chose.

Certified application counselors will also be available to help through various groups, likely community health centers, hospitals and social service agencies. Like navigators, they won't be able to tell you which plan to choose.

So which plan will, ultimately, give you the best coverage for the lowest cost? Depends on your needs and how you'll use your insurance. That's something you'll have to decide.

You may be eligible for a subsidy

If you're concerned about cost (and, really, who isn't?), the federal government may give you money to help pay for your health insurance. AKA, a subsidy.

If you need to buy your own insurance (because an affordable plan isn't offered through your job) and you earn between 100 percent and 400 percent of the federal poverty level, you can get a subsidy as a tax credit or have it paid directly to the insurance company to lower your monthly premium.

Right now, poverty level is $11,490 a year for one person (modified adjusted gross income). For a family of four it's $23,550. 

Also, if you earn less than 250 percent of the poverty level, you can get a subsidy to cap your out-of-pocket expenses at a discounted rate. That means you'll ultimately spend less when you see a doctor after saving those orphans and kittens.

How big are the subsidies? It's a sliding scale, so it depends on your salary. But a family of four can earn up to $94,200 a year and still be within 400 percent of the federal poverty level. According to the Kaiser Family Foundation's subsidy calculator, that family's subsidy could be about $920 a year, or about 9 percent of the premium for the middle-of-the-road silver plan. (The subsidy is always based on the silver plan.)

That family could earn up to $58,875 a year and still be within 250 percent of the federal poverty level. According to the subsidy calculator, that could entitle them to an out-of-pocket expenses cap of $12,700 a year.

Keep in mind . . .

* Anthem's Southern and Central Maine plans are HMOs that have a narrow network. That means you can't go to any doctor or hospital you want and expect  insurance to pay for it. That has been controversial.

* When you apply for insurance on the marketplace, you will automatically be considered for Medicaid. If it turns out you're eligible, you will be signed up for that instead.

* Catastrophic plans, which are available only for people under 30, aren't eligible for subsidies. It might be cheaper to use a subsidy to buy a more comprehensive plan with a higher regular sticker price.   

* Beware of fraud. Red flags: Someone who wants to sign you up for marketplace insurance before Oct. 1. Someone who wants to charge for helping with an application or getting you insurance from the marketplace. Someone who calls, asks for your personal information and says it's for the marketplace or part of new ACA regulations. (Community groups may ask current clients about their health insurance status and ask for permission to contact them about the marketplace after it opens. That's OK.)

Never give out personal information to a caller. Don't pay anyone to sign you up for the marketplace. If you want local, in-person help, look for the list of navigators and certified application counselors at Healthcare.gov and other official resources at www.enroll207.org in the coming weeks. 

So what happens if I don't get insurance?

Unless you apply for and get an exemption, you'll have to pay a penalty.

For 2014, that penalty will be 1 percent of family income or $95 per adult and $47.50 per child (up to $285 per family), whichever is more. In 2015 the penalty jumps to 2 percent of income or $325 per adult and $162.50 per child (up to $975 per family), whichever is more. And in 2016 the penalty will be 2.5 percent of income or $695 per adult and $347.50 per child (up to $2,085), whichever is more.

The IRS is in charge of that.


What do you think of this story?

Login to post comments

In order to make comments, you must create a subscription.

In order to comment on SunJournal.com, you must hold a valid subscription allowing access to this website. You must use your real name and include the town in which you live in your SunJournal.com profile. To subscribe or link your existing subscription click here.

Login or create an account here.

Our policy prohibits comments that are:

  • Defamatory, abusive, obscene, racist, or otherwise hateful
  • Excessively foul and/or vulgar
  • Inappropriately sexual
  • Baseless personal attacks or otherwise threatening
  • Contain illegal material, or material that infringes on the rights of others
  • Commercial postings attempting to sell a product/item
If you violate this policy, your comment will be removed and your account may be banned from posting comments.




So, you've got my back! I

So, you've got my back! I doubt it. ObamaScare is the brainchild of our fearless leader, our "elected" government reps, and the insurance and healthcare businesses. They will benefit the most from this fiasco along with anyone else with stock investments in these companies. Meanwhile, US citizens without insurance and not able to afford it, will try to scramble to pay the premiums or pay a penalty which, as I understand it, will be over $600 by 2016. The Sun Journal and so-called experts talk about how ObamaScare will be so affordable and beneficial for all of us. Now, let's see--do I pay a premium of possibly up to $600 a month for health insurance that will pay benefits of maybe up to 70%, or do I buy food and heat?

FRANK EARLEY's picture

Why isn't there more to choose from???????

Wasn't the idea behind creating insurance pools, to create competition thus reducing the cost. Is two the norm when it comes to insurance plans to choose from nation wide. Especially when one of the two is shafting a good chunk of the population. I'm still curious how expanding Medicaid, would have helped in the long run. If everyone who qualifies is put on MaineCare, how is that going to work without government subsidies?
What about the thousands being kicked off of MaineCare Jan.1st? Won't they just be put back on the system? This whole program has been trashed by stupid Republican loyalties. I think they should hang a big portrait of the Governor in the lobby of every emergency room in the State. So those with no where else to go, will know who to thank.................

MARK GRAVEL's picture

"This whole program has been

"This whole program has been trashed by stupid Republican loyalties."

Let's go back to the root locus, Obamacare!

How can something so complicated be well thought out in a handful late night congressional meetings? It cannot.

What do you expect from legislation that needs to be passed before the details are defined?

Now why are you surprised it is a cluster F?


A handful of late night meetings?

I don't know what country you were in at the time but I remember months and months of debate. I remember Republicans refusing to participate one after the other except for Snowe and Collins. I remember all of Palin's pithy remarks especially the one about "death panels" As far as I can tell the only Republican contribution was to force the omission of end of life counseling which would have saved millions in tax dollars. That and their fight against the tax imposed on those who refuse to get life insurance which ended up as an expensive Supreme Court case. So if Republicans refused to read the bill before they voted on it whose fault is that? There was never any secret about what was in it. And the same details that are in there now were in there then before the vote. And as for the origin of the law, look to Massachusetts and Mitt Romney.

MARK GRAVEL's picture

The final 2,400 page bill was

The final 2,400 page bill was introduced by the senate via reconciliation and open to only 13 hours of debate. Remember the House speaker's words - "You have to vote for it to read what is in the bill." Wow, that was really a reflection of her motives.

Not sure if anyone can read 2,400 pages in 13 hours.

BTW, The bill was not challenged in the Supreme Court, the LAW was. Law meaning a bill signed by the president. Law meaning the bill can no longer be debated.

To give you further proof ACA is bad legislation and law makers had no clue of the details:

"Unpublished CRS Memo: Obama Administration Has Missed Half Of Obamacare's Legally Imposed Implementation Deadlines"

How can a well crafted bill miss so many key deadlines? It cannot.




She has explained her remark many times but once the Republicans get ahold of a bone they have to chew it to death. She was referring to one specific change and she misspoke made that remark because she was impatient and tired. It did not refer to the whole bill. As for the delays that is very inconsequential when you consider the size of the task. Most of the people affected have already complied and it will not affect the eventual outcome. Again an often repeated mantra that means nothing except to people who would vote 39 times to repeal the same bill for nothing.. They probably missed a few deadlines when they were building the pyramids too. As for law makers having no clue well what else is new.

MARK GRAVEL's picture

Wouldn't have been a simple

Wouldn't have been a simple task to put 3-days between reconciliation and the vote to give people time to digest the contents and respond to their representative?

There was a motive behind the 13-hour debate, then vote. It was precisely not to allow time to digest the bill's contents. No, I think Nancy meant what she said.

FRANK EARLEY's picture

I'll use my favorite phrase.............

If your not part of the solution, your part of the problem.

OK that being said. Mark, what is your idea on a different type of plan????????????


I noticed Mark suddenly has left the building??? Cat cut your tongue Mark?

MARK GRAVEL's picture

I thought I saw Elvis leave

I thought I saw Elvis leave the building, so I followed him. It was just Obama in Elvis garb.

My solution is to treat primary care like cosmetic surgery, where the customer pays out of pocket for most routine services.

Insurance is reserved for catastrophic coverage, not designed to pay for all expenses.

Doctors, labs, and hospitals need to compete for customers. One can see the affects competition in the graph below.


Stay informed — Get the news delivered for free in your inbox.

I'm interested in ...