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Affordable Care Act Q & A: Medicare And Medicaid


I'm Michel Martin and this is TELL ME MORE from NPR news. Later in the program, the author of "Queen Bees and Wannabes" will be with us. That provocative best-seller changed the way many people think about social relationships among teen and preteen girls. Now author Rosalind Wiseman is trying to be same for boys. She'll tell us about her new book "Masterminds and Wingmen" and our parenting roundtable will chime in.

That's later in the program, but first, we're going to have another installment in our series about the Affordable Care Act. In a few weeks, states will launch new online exchanges where you'll be able to shop for and buy health insurance if you need it. Over the course of this summer, we've been trying to answer some of the most common questions people have had about the new law.

Today, in our weekly Money Coach conversation, we want talk about how the new program could affect those already using programs like Medicare and Medicaid. Here to help us once again is Mary Agnes Carey. She's senior correspondent at Kaiser Health News. That's a nonprofit news service. It is not affiliated with Kaiser Permanente. Welcome back. Thanks so much for joining us once again.

MARY AGNES CAREY: Thanks for having me.

MARTIN: Could you give us just a quick reminder about how these health exchanges are supposed to work and who they're for?

CAREY: They're online marketplaces where everyone can shop there. Only certain individuals could get financial help, but they're really designed for people that buy their own coverage right now in the individual market and small businesses with 50 or fewer workers. As you mentioned, some states are setting them up, some states are partnering with the federal government and the federal government is doing the exchanges in some states.

MARTIN: So no matter where you live - I mean, I know people will have read coverage of some states not wanting to cooperate with this. There - some of the leaders of some states are politically opposed to this. No matter where you live, should you be able to participate in an exchange somewhere?

CAREY: Absolutely. If your state government isn't doing it, the federal government will do for them.

MARTIN: So let's go to some of the questions we received from listeners. Let's start with Medicare. Now this is a program that American seniors - it's to help American seniors so they can get health insurance or health coverage. This question is from Greg Shutske (ph) of Pittstown, New Jersey.


GREG SHUTSKE: I'm turning 65 next year and so I have questions about how Medicare is going to be impacted by the Affordable Care Act, in particular, the Medicare Advantage program.

MARTIN: Mary Agnes, what about it?

CAREY: Medicare Advantage is the part of Medicare that - where private insurers offer coverage, and about 27 percent of beneficiaries are right now enrolled in the program. What the Affordable Care Act does is reduce payments to Medicare Advantage over time to equalize them with the same payments given for beneficiaries that are in fee for service, and that's where about three quarters of beneficiaries are. The point here is that, for years, Medicare Advantage plans received more money per beneficiary, rather, from the government than what the government spent on those in traditional fee for service. So they want to equalize those payments.

That has brought some concerns that Medicare Advantage plans will either leave the program or they'll cost more. And according to the Department of Health and Human Services, since the ACA was signed into law in 2010, Medicare Advantage premiums have fallen by 10 percent and enrollment has increased by 28 percent. But one thing to watch here is these Medicare Advantage plans, often, are more generous. They might cover a gym membership, hearing aids, eyeglasses - things traditional Medicare doesn't. As those reimbursements are reduced, maybe those benefits - those extra benefits might go away.

MARTIN: So what should you do? Should you compare what your coverage is now?

CAREY: You should. Exactly. You should look at the Medicare Advantage plan, - what does it offer and what would you pay for a Medicare Advantage premium compared to traditional Medicare? What would you pay on part A, part B and then part D.

MARTIN: If you're just joining us, this is TELL ME MORE from NPR News. We're talking about the Affordable Care Act, and today we're focusing on how it may affect people who are already participating in programs like Medicare and Medicaid. We're joined by Mary Agnes Carey, senior correspondent at Kaiser Health News. It's not affiliated with Kaiser Permanente. What if you're a couple years away from being 65 - that's when most people are eligible for Medicare - but you don't have insurance? What should you do?

CAREY: I would take a look at the exchanges and see if there's any way you can get some help with either your subsidy, your co-pays or your deductibles. For example, the health law provides subsidies to individuals up to 400 percent of poverty to help with their premiums. If you're at 100 percent of poverty, you're making around $11,500. Up to 400 percent to just under $46,000. The Medicaid expansion - if your state is allowing this Medicaid expansion to go through - it's optional for states - that allows individuals with incomes up to about 16,000 to get coverage under Medicaid. A key area there are single, childless adults that may not have coverage now. And so the other thing to think about is could you get help with your co-pays and deductibles? That goes up to about 250 percent of the poverty line, which is around $29,000. The thing here to remember is as you look on the exchanges, it's just not the premium that you've got to pay. You've got co-pays. You've got deductibles. You need to look at your total out-of-pocket cost as you're comparing.

MARTIN: Speaking of Medicaid - and for those who don't know that, this is a program to assist low income Americans so that they have access to medical care - I want to play this next question because I think this is a situation that a lot of people are in. They're kind of on a blended situation, like one part of the family has access to coverage and other parts don't. So we received this question from Melanie Yoklie (ph). She is from Greensboro, North Carolina.


MELANIE YOKLIE: My husband is eligible for insurance through his employer, but we do not subscribe due to cost. I am an unemployed, stay-at-home mom. So what I need to know is can my husband get insurance through work while myself and my children get insurance on the exchange? Our children are currently enrolled in Medicaid. So if we can find something that's at our budget, could we get a policy through the exchange and include them?

MARTIN: So there are a couple questions in there, so maybe we should unpack them. What about the first question about the kids? The kids are already in Medicaid, but does it make sense to leave them or move?

CAREY: You could, but I would advise Melanie to run the numbers first. As much as I understand, as a mother with two kids myself, you want everybody on the same policy. It's hard enough to understand one, let alone more than one policy. But Medicaid might be a better deal economically for the family to keep her kids there. So those are the - she's got to compare and contrast that with exchange coverage.

MARTIN: And then what about the question of whether her - if her - they're not participating in their husband's plan due to cost, and she doesn't seem to have insurance at all. What do they do?

CAREY: Well, they could look at, for example - there's a couple of options. Her husband has an offer of coverage. I don't know if it's individual or family coverage, but the only way that they'll qualify for a subsidy is if two things happen. Number one, that her husband's coverage is deemed to be unaffordable. That means it costs more than nine and a half percent of the family's income, or that it doesn't cover 60 - it doesn't pay for 60 percent of the covered benefits. So if either one of those conditions pertain to her husband's coverage, then they could look into the exchanges and possibly qualify for a subsidy for coverage.

MARTIN: So, overall - you know, we've got about a minute and a half left - this is complicated and people shouldn't feel bad about the fact that they have to kind of wade through some homework, but you got to do it. Now the exchanges are open for enrollment on October 1st. So if you're interested in possibly purchasing coverage or if you're in a situation where you're telling people, you should research this, what should people be doing now?

CAREY: I think that they should determine what they're looking for in health insurance and how much they're willing to pay for it. There are going to be four different levels of coverage - premium, gold, silver and bronze - and they vary by co-pays and deductibles. They should find out, do you qualify for a subsidy? You can go to healthcare.gov to determine that. You can use a subsidy calculation - calculator, rather, at the Kaiser Family Foundation - KFF.org. So start looking at it and be ready to go when the exchanges open on October the 1st.

MARTIN: And is there any place you can go for somebody to kind of sit with you? I know that maybe that's a ridiculous question, but a lot of people, you know, just going to a website or something like that is - doesn't really help matters. So is there any human being you can talk to to help you walk through your options, in the same way that people used to get that kind of help from a corporate benefits office?

CAREY: The federal government has funded something called a navigator program. There are grants throughout the states where you need boots on the ground. They may be at a senior service center or a community center. That's going to be done on a local basis. You could try to find that out at healthcare.gov or find out through your local church, maybe your school, maybe another community group. But there are navigators and assisters throughout the country to help you.

MARTIN: Well, thank you for helping us.

CAREY: I enjoyed it. Thank you.

MARTIN: Mary Agnes Carey is a senior correspondent at Kaiser Health News. That's a nonprofit news service. It's not affiliated with Kaiser Permanente, and she was kind enough to join us here in our Washington, D.C. studios. Mary Agnes, thanks again. Transcript provided by NPR, Copyright NPR.