Affordable Care Act Issue (November 2013)

Table of Contents

Web Bonus Articles

The basics of Obamacare

By Michelle De Mooy

More than 47 million non-elderly Americans were uninsured in 2012, according to the Kaiser Family Foundation. The Affordable Care Act (ACA)—aka Obamacare—seeks to extend coverage, either through private insurance or Medicaid.

The huge number of people without health insurance and the high cost of medical care created many of the inequities targeted by Obamacare. It was virtually impossible to get coverage on the individual market if the buyer had a pre-existing condition. Many plans excluded ordinary health care needs such as maternity care. With large numbers of people lacking access to primary and preventive care, the nation’s emergency rooms became the everyday medical offices for the uninsured.

As the costs of medical care have continued to skyrocket (a visit to the emergency room averages around $1,265), many uninsured and underinsured people have been unable to pay their medical bills. Health care debt quickly rose to become the number one cause of bankruptcy in the U.S., while hospitals and insurance companies continued to raise premiums, co-insurance and co-pays for everyone, even the adequately insured, in order to cover their costs.

Because it would have been virtually impossible in the U.S. to adopt a socialized (“single payer”) health care system, Congress instead eyed ways to expand public and private health insurance coverage.

Central tenets of the law passed in 2010 are a universal requirement for health care insurance, new policyholder protections, standardized offerings that include preventive care, subsidies for low-income individuals and new competitive health insurance marketplaces. The law does not guarantee access to health care or cap rising health care costs.

Universal requirement

The ACA requires that all Americans have health insurance by 2014, or pay a penalty (the “individual mandate”). You don’t need to do anything if you already have coverage through an employer, retiree plan or federal government program such as Medicare or Medicaid. Plans in existence before March 20, 2010, are considered “grandfathered” and may not be required to provide the benefits prescribed by law. Check with your plan provider to see if this applies. If your current plan is substandard, or has been cancelled because it doesn’t meet current minimum health care requirements, you can seek a new one on the exchanges.

When you file your 2014 income tax return, you will be required to provide evidence (which your insurer should give you) that you have health insurance. Under the ACA, insurance companies cannot:

  • Drop coverage when you or your child becomes sick;
  • Refuse you or your child coverage because of pre-existing conditions;
  • Charge you co-pays for wellness or pregnancy visits; or
  • Limit the amount of lifetime coverage you receive for “essential” health care benefits. (See Financial assistance: Health care cost-sharing for a list of essential benefits.)

Already, many consumers have responded favorably to the ACA provision that allows many young people to remain on their parents’ insurance plan until they turn 26.

Because health insurers under the ACA must spend 80 percent of premiums on medical services rather than on marketing or salaries, many plans have for the past two years been forced to return money to employers and policyholders.

The exchanges

If you do not have coverage, or you cannot afford your employer’s coverage, you will be able to buy individual health care insurance through state or federally run online health insurance marketplaces, or exchanges, that offer a variety of plans. The exchanges are also designed to let individuals know if they qualify for subsidies to pay part or all of their premiums.

In 2015, employers with 50 or more full-time employees will be required to provide health insurance to their workers or pay a penalty.

While not required to do so, small businesses with fewer than 50 full-time employees can purchase insurance for their workers through a broker or a new small business exchange (SHOP).

Low-income plans

Low-income individuals and families may be eligible for Medicaid, the Children’s Health Insurance Program (CHIP), subsidies or other assistance to help with upfront purchase costs. (See Financial assistance: Health care cost-sharing.)

An expansion of the Medicaid program under the ACA is intended to address gaps in coverage for many of the working poor without insurance. States are not required to participate, and have until January 2014 to decide. So far, half the states have said they will not participate in Medicaid expansion.

Lightning rod

Both before and since its adoption, the ACA has been a political hot potato and a lightning rod for criticism. Its detractors have fought the law in courts and in Congress, so far to little avail. Even some supporters question how it can work if the penalties for not having insurance turn out to be cheaper than insurance itself.

Last year, the Supreme Court upheld a centerpiece of the law—the individual mandate. This fall, federal budget negotiations were blocked by Republican lawmakers who wanted to defund the ACA—their latest tactic to stop its implementation—which resulted in a 16-day federal government shutdown. In the past month, outcry has risen over glitches on the website. At this point, no one can predict with any degree of certainty the long-term success or failure of Obamacare. A reform this sweeping will need time to play out.

How to apply

  1. Visit
  2. Click the “Apply Online” button and choose your state from the drop-down menu.
  3. Research and compare health care coverage.
  4. Create a Marketplace or state exchange account.
  5. Compare cost of plans, plan benefits and covered providers.
  6. Automatically learn if you qualify for Medicaid or a subsidy.
  7. Complete the application and purchase coverage.

Medicare open enrollment

For those age 65 and older, now is also the time (Oct. 15-Dec. 7) to make changes to health care and prescription drug coverage under Medicare for 2014. Check for changes in coverage, co-pays and other plan options with the Medicare Plan Finder, or call 800-MEDICARE (800-633-4227).

Financial assistance: Health care cost-sharing

By Ruth Susswein

Under the Affordable Care Act (ACA), depending on your income you may be eligible for help paying your health care costs.

The new health insurance exchanges, whether run by your state or the federal government, will provide access to information to help you determine if you are eligible for a subsidy to help pay monthly insurance premiums and a portion of out-of-pocket costs or if you qualify for Medicaid (the government health insurance program for the poor).

There are several forms of financial assistance:

  • Insurance premium tax credits, often referred to as subsidies;
  • Cost-sharing reductions for co-payments (co-pays) and deductibles; and
  • Medicaid coverage.

Once you provide personal information and complete an application form, the health insurance exchange will calculate if you are eligible for a premium tax credit. Insurance premium tax credits are available on a sliding scale to low- to moderate-income individuals to help reduce the cost of coverage. Generally, you will be expected to pay between 2 percent and 9.5 percent of your modified adjusted gross income (MAGI) for health insurance. In general, MAGI is your adjusted gross income plus any tax-exempt Social Security, interest or foreign income you have.

Subsidies are only available for health insurance that’s purchased online through the federal and state exchanges. The subsidies are paid directly to the insurance company, reducing your own monthly premium payment. The Kaiser Family Foundation estimates that about half (48%) of people now buying their own insurance would be eligible for a tax credit that would offset their premium. Among these, the average subsidy would be $5,548 per family, which would reduce their premiums for the second-lowest-cost silver plan by an average of 66 percent.

Subsidy eligibility

Individuals earning up to $45,960 will pay up to 9.5 percent of their income toward health insurance premiums, or up to $364 a month, with the federal government subsidizing the rest. Lower income brackets would receive a larger subsidy. Uninsured individuals earning up to $17,000 will pay $57 a month. Families of four earning up to $94,200 will be eligible for a subsidy. Use the Kaiser Family Foundation subsidy calculator to estimate your eligibility for subsidies and how much you could spend on health insurance.

Cost-sharing reductions

Additional assistance may be available to help pay deductibles and co-payments for individuals earning up to $28,725 and families of four earning up to $58,875 who purchase a silver plan through the federal marketplace. Deductibles are the amount you pay for medical costs before health care coverage kicks in, and co-pays are the $20 or $30 you pay each time you visit a doctor. Cuts to co-pays and deductibles, called cost-sharing reductions, would be in addition to any insurance premium subsidies you’re eligible for.

Spending caps

For people with huge medical bills, new caps on annual out-of pocket health care costs (deductibles, co-insurance, etc.) will come as a great relief. For others, the level of medical spending they could be responsible for will be shocking: Spending caps are $6,350 for individuals and $12,700 for families. (Many individual health insurance policies carried much higher deductibles in the past.) When the out-of-pocket cap is reached, however, the plan pays 100 percent of eligible health care costs.


Some of the nation’s working poor (under age 65) will be eligible for health care coverage under an expansion of Medicaid. Individuals earning $15,800 a year and families of four earning $32,500 now will qualify for Medicaid coverage in some states.

Twenty-four states and the District of Columbia are taking the federal government up on its offer to fund expanded Medicaid eligibility; 26 states are not. Alarmingly, the decision not to expand coverage in more than two dozen states still leaves many poor people without coverage.

For those who fall within this coverage gap, there will be extra federal funding for community health care centers that provide medical services on a sliding (income) scale.

To find out if your state is expanding Medicaid coverage, click here to go to and use the “Get State Information” menu.


If you don’t purchase insurance next year, you will be required to pay a penalty—either $95 per adult and $47.50 per child (up to $285 per family) or 1 percent of annual household income, whichever is higher.

In 2015, the penalty jumps to $975 per family ($325 per adult) or 2 percent of household income, and the penalties increase each year by the rate of inflation, to a maximum of 2.5 percent of your income in 2017. You pay the penalty when you file your income tax return.

Insurance must be obtained by January 2014 to avoid the fee, although you are allowed a coverage gap of three months in a year and will be exempt from the fee for these months.

Some people will qualify for hardship exemptions, meaning they will not have to purchase coverage, nor pay a penalty fee. Qualifying reasons for exemption include:

  • Unaffordability (if coverage would cost more than 8 percent of income);
  • Inability to qualify for Medicaid (since your state did not expand coverage);
  • Bankruptcy; and
  • Religious objections.

For a full list of hardship exemptions, visit

Affordable Care Act: What’s in it for you?

By Ruth Susswein

All Americans and legal immigrants are required to have health insurance as of Jan. 1, 2014.

Those who are uninsured and not eligible for coverage through Medicare, Medicaid, Tricare or an employer (as well as those who can’t afford employer-based coverage) can enroll through the new federal or state health insurance exchanges.

While exchanges are government-run, health care coverage is purchased from and provided by private insurance companies.

Plan tiers

Eligible consumers can choose from four tiered health care plans—bronze, silver, gold and platinum—bronze being the least expensive. Monthly insurance premiums are stepped up with each higher tier, but the more you pay in premiums, the lower your out-of-pocket expenses. Out-of-pocket costs include co-payments (the $20 or $30 you pay at the time of service) and deductibles (the amount you must pay before insurance kicks in).

After deductibles, bronze plans cover about 60 percent of eligible health care costs; silver plans, about 70 percent; gold, about 80 percent; and platinum, about 90 percent. Most plans have annual out-of-pocket maximums—when you reach the maximum, the plan covers 100 percent of eligible health care costs.

What’s covered

Insurance policies must cover “minimum essential benefits” in order to be certified and offered on the exchanges: emergency room care, hospital care, doctor visits, maternity and newborn care, prescription drugs, preventive/wellness care and chronic disease management, mental health and substance abuse treatment, rehabilitative services, pediatric care (includes vision, and sometimes dental) and laboratory services.

Preventive services, such as annual checkups and vaccinations, will be provided for free (no deductible, no co-pay) under all plans.

Other services, such as blood pressure, HIV and diabetes screenings, will be available for free to people in certain age groups or risk categories. Certain recommended health screenings for women, such as mammograms, will also be covered without a co-payment.

Beyond premiums

When shopping for a plan on the exchanges, look beyond the premiums. Deductibles, co-insurance and out-of-pocket maximums can have a big effect on your overall costs.

A deductible is the amount you pay before your insurance benefits kick in. The average deductible for a silver plan will run about $2,000 a year, and about $5,000 a year for a bronze plan, the least expensive insurance option. Co-insurance is your share of eligible health care costs. For example, if your plan pays 80 percent and you pay 20 percent, your co-insurance is 20 percent of the health care cost.

Out-of-pocket maximums—when you have reached this level of spending, benefits are payable at 100 percent. Office co-pays usually do not count toward this figure.

Help navigating

Although there have been serious technical snags during start-up of the exchanges, help from trained individuals is available via online chat at or by phone at 800-318-2596 (24 hours a day, seven days a week, in up to 150 languages).

Those with the most training, called Navigators, help consumers—at no charge—obtain impartial information about health insurance plans, create a health insurance exchange account, determine subsidy eligibility and apply for coverage. While this varies somewhat between states, in-person assisters and certified application counselors help consumers determine eligibility for public benefits, such as coverage under Medicaid and CHIP (the Children’s Health Insurance Program). Some states also allow insurance agents and brokers to help register people for the health insurance exchanges.

These assigned helpers will have identification and will not appear at your door uninvited, except in limited cases where they have been dispatched by trusted local organizations helping with outreach to hard-to-reach communities. New programs often attract fraudsters looking to capitalize on consumers’ vulnerabilities, so check IDs and don’t invite strangers into your home. Your insurance payments should be made through the exchange directly to the insurer, not to an assister, counselor or other individual.

What your state offers

State health insurance exchanges are available in 16 states (CA, CO, CT, HI, ID, KY, MA, MD, MN, NM, NV, NY, OR, RI, VT, WA) and Washington, DC. Cost and coverage will vary by state. Each state program has its own name (for example, Covered California and Maryland Health Connection).

Consumers in the remaining states are covered by the federal exchange. The federal exchange is called the Health Insurance Marketplace. By choosing your state at, you will learn where to apply.

Depending on your income, you may be eligible for a tax credit, also called a subsidy, to help offset the cost of monthly insurance premiums, and other cost-sharing reductions to help with co-payments and deductibles.

(For details on subsidies, see Financial assistance: Health care cost-sharing.)

Comparing options

A key benefit to the new health insurance exchanges is the ability to compare various plans’ costs and coverage. It is also where consumers will need to invest the most effort, especially in the early stages of this system. Some state exchanges (CA, MD, OR and RI) are adding search tools to allow direct comparison of doctor, drug and hospital coverage, but most states currently rely on links to insurers’ provider directories, which can make the search more cumbersome if insurer listings are not user-friendly.

Consider your prior year’s medical expenses (insurance premiums, co-pays, deductibles, co-insurance and prescription drugs) to estimate the medical costs you’ll want coverage for in the coming year.

Check to see if your doctors, hospitals or other medical providers are part of network coverage. Some insurance plans will require all health care services to come from in-network providers (except for emergencies), while others will offer out-of-network coverage at a higher cost-share.

All cost and coverage choices should be considered carefully, because once you sign up for a plan, you are locked into that coverage until the next open enrollment period each fall.

Enrollment deadlines

For this first year, open enrollment runs through March 31, 2014. Future open enrollments will run from Oct. 15 through Dec. 7. For health care coverage to start by Jan. 1, 2014, it must be purchased by Dec. 15.

People with certain changes in circumstances, such as those who’ve lost insurance, have a new family member or have moved to a new state, can enroll when those changes occur. This is called a qualifying life event.

(Click here for a complete list of qualifying life events.)

Small business, Medicaid and CHIP applicants may enroll at any time.

How to pay your health insurance premiums

By Monica Steinisch

The Affordable Care Act (ACA) goes a long way toward making health insurance more affordable for all Americans, in many cases slashing monthly premiums for those who qualify for subsidies. But most consumers purchasing coverage through the health insurance exchanges will have to shoulder part—if not all—of the cost of coverage, which means making monthly premium payments to a private health care plan.

Mandated payment options

Federal rules require insurers to accept various forms of payment, but leave some payment choice to the insurer’s discretion. Insurers must accept money orders and cashier’s checks (both of which can be expensive and inconvenient), personal checks, electronic funds transfers and prepaid cards. Acceptance of other forms of payment, such as cash and credit cards, is optional.

Electronic funds transfers (EFT), or automated bank account transfers, are one of the easiest payment options for consumers with a checking account and are welcomed by businesses because they’re inexpensive and efficient. Consumers can add the insurance account to their online bill pay system and have the monthly insurance premium automatically debited from their checking account on a pre-determined date every month.

However, recurring bill payments carry potential disadvantages. First, you need to make sure you have enough money in your checking account to cover the automatic payments. An error could be very expensive, triggering multiple overdraft fees.

If you use your bank’s online bill pay system, pay close attention to how your payment is being submitted to the insurer. If the payments are being sent electronically from your bank account, you should have the payment made at least 48 hours before the due date, but if the insurer can only accept a check from your bank, you should allow as much as five business days. Carefully monitor when your bills are due so that you can change a payment date if necessary.

Consumers also can arrange to have payments taken from their bank account by the insurer. However, this type of “auto debit” can be difficult to change or undo, in some cases requiring notification in writing to both the bank and the insurance company, and then monitoring the account to ensure the change takes place on time.

In an effort to meet the needs of the millions of “unbanked” Americans—those who do not have a traditional banking relationship—the Obama administration recently decided that insurers participating in the exchanges must accept general-purpose reloadable prepaid cards.

Prepaid cards can be used in many of the same ways as a credit card, but since you are using money you have already “loaded” onto the card rather than borrowing, you don’t have to have a good credit history to get one. (Learn more about prepaid cards in the 2012 Prepaid Card Survey issue of Consumer Action News.) Paying with a prepaid card is significantly more convenient than buying and mailing a cashier’s check or money order. If it’s a low-fee prepaid card, it even could be less expensive.

At the insurer’s discretion

Insurers don’t have to accept cash, although individual insurers are free to do so. A system in which you pay your premium in cash at a storefront, such as Western Union or Walmart, for example, could become a reality at some point in the future. Never mail cash!

Credit cards are not a required option either, and might not be accepted by the insurance company you choose because of the fee merchants have to pay for every transaction.

While the 16 states that run health insurance exchanges can make their own policies about payment types, they are likely to follow the federal government’s lead. That includes accepting recurring prepaid card payments if the federal government decides to adopt such a policy. Learn more about insurance premium payments on your state’s exchange or directly from your health care plan.

Twenty-somethings eligible for ‘catastrophic’ coverage

Under the Affordable Care Act (ACA), low-cost “catastrophic” policies are available for young people under age 30. Catastrophic plans are designed to protect account holders from very high medical costs—medical catastrophes. These plans come with a high annual deductible of $6,350 ($12,700 for a family) before insurance kicks in, but premiums are low—as little as $50 a month. For people under 30, catastrophic coverage satisfies the health insurance requirement. Despite the catastrophic label, the plans include three primary care visits per year and preventive care without a co-pay.

The ACA also allows young people to remain on their parents’ health care plan until they turn 26. This is true even if the young people are:

  • Not living with their parents,
  • Not financially dependent on their parents,
  • Married,
  • Students, or
  • Eligible to enroll in their employer’s plan.

When choosing to remain on your parents’ plan, check that in-network health care providers are conveniently located, because using out-of-network providers can be very costly.

A wealth of resources for learning more about Obamacare

Consumer Action’s staff found some great resources to help you with the new requirements of the Affordable Care Act (ACA). If you have others to suggest, email them to our .(JavaScript must be enabled to view this email address) and we’ll consider adding them online.

AARP Health Law Answers

AARP Health Law Answers offers a customized report on how the Affordable Care Act applies to you—you provide personal information, including age, state, income bracket, number of family members and current health insurance coverage. The website also offers an extensive array of educational fact sheets and videos.

Click here for materials in Spanish.

Click here for fact sheets in Chinese, Korean, Vietnamese and Tagalog.

Asian & Pacific Islander American Health Forum

The APIAHF posts The Health Care Law and You, a PowerPoint presentation developed by the U.S. Department of Health and Human Services to educate communities about the benefits of the Affordable Care Act.

The presentation, available in Chinese, Korean, Vietnamese, Tagalog, Hindi, Bengali, Hmong, Khmer, Laotian, Samoan and Tongan, was originally translated by the Office of Public Engagement at the Centers for Medicare & Medicaid Services.

Health Law Helper

The Health Law Helper online tool from Consumer Reports helps narrow down your health insurance options. To customize the report, you provide information about the region you live in, your household and current health insurance coverage. (Click here for the Spanish site.)

Get Covered America

Get Covered (run by non-profit Enroll America) estimates your monthly health insurance costs based on region, household size and income. The site’s Help Center offers FAQs (frequently asked questions) that answer basic questions about the ACA and a glossary to navigate legal terms. (Click here for the Spanish site.), created by the U.S. Department of Health and Human Services, is designed to help consumers find and compare private insurers’ health insurance plans and provide links to state exchanges. (Click here for the Spanish site.)

Data showing all of the plans available to people by county or parish is available and downloadable in a variety of formats (click here). You don’t need to create an online account to access the information.

Kaiser Family Foundation

The Kaiser Family Foundation’s Subsidy Calculator estimates health insurance premiums and subsidies for people purchasing insurance through the new health insurance exchanges.

The site also features answers to questions about the ACA, as well as “one-pagers” explaining how the law will affect specific populations (the uninsured, low-income, those with employer-based coverage, pre-existing conditions, women, etc.). (Click here for a video in Spanish.)

National Association of Insurance Commissioners

The site’s special Health Care Reform section provides FAQs for consumers and a brief video about the ACA created by the Kaiser Family Foundation.

The site’s health insurance exchange preview tool allows users to compare health plan costs by region and by tier (platinum, gold, silver, bronze, catastrophic). Results, based on the user’s household and income, show possible health care providers, estimated monthly costs and subsidies (if eligible).

Its Subsidy Calculator helps consumers determine the amount of subsidies their household may receive.


WebMD features a short video explaining the ACA, as well as a cost calculator and health insurance plan checklist.

Young Invincibles

Young Invincibles' website FAQ page and informative flow charts explain the impact of the new health laws for people under 35. A smartphone app is also available to help consumers find free and paid health care options. The site’s events page lists informational sessions around the country.

The Young Person’s Guide to Health Insurance

The Young Person’s Guide to Health Insurance is an overview written by U.S. PIRG with twenty-somethings in mind, this downloadable document explains health coverage options and the financial elements involved in purchasing an individual plan.

Resources for advocates

The following resources are suggested for community advocates who are seeking to educate others on health care reform.

Centers for Medicare & Medicaid Services (CMS)

The CMS website offers resources for professionals to learn about the ACA’s health insurance exchanges in order to help people apply. (Click here for Spanish language resources.)

Click here to find forms and reports in Chinese, Navajo, Spanish and Tagalog.

Click here to find Health Insurance Marketplace resources in languages including Arabic, Portuguese, Farsi, French and Korean.

Families USA

Families USA offers a clearinghouse for information about the health care system and a grassroots network for community health insurance and health care educators, as well as reports and analysis about health care reform.

Stand Up for Health Care is a project of Families USA, a national nonprofit, non-partisan organization dedicated to the achievement of high-quality, affordable health care for all Americans.

U.S. Dept. of Health and Human Services (HHS)

The HHS’ Health Resources and Services Administration (HRSA) offers resources for community-based organizations to educate patients about their new health care options and spur enrollment for the uninsured, isolated or medically vulnerable.

Click here to find HHS ACA resources in Spanish and for other targeted audiences, including American Indians and Alaska Natives

Scammers target consumer confusion around health care reform

By Michelle De Mooy

Confusion surrounding the rollout of the Affordable Care Act (ACA) has led to a rise in scams and swindles intended to cash in on consumer uncertainty about the new health care law, according to the Federal Trade Commission.

One popular scam focuses on seniors. Thieves, typically claiming to be from Medicare, tell elderly consumers that they must give updated information for the new health insurance law, including their Social Security numbers, dates of birth and other personal information that, in the wrong hands, could be used to steal people’s identities. Other scams tell seniors that in order to continue receiving benefits, they need to verify bank account and routing numbers and Medicare ID card information.

Obamacare scams

In a variation on these scams, the National Consumers League reports that scammers in Massachusetts set up fake websites claiming to sell Obamacare policies, using them to gain personal financial information from consumers. Other bogus websites advertise themselves as health care markets or exchanges, even using a state seal in an effort to appear legitimate. The best source for health care information, and to locate state and federal exchanges, is

The National Association of Insurance Commissioners (NAIC) details another common con. Crooks call individuals claiming to have the person’s new “Obamacare” insurance card and request personal information before sending it out. Other “phishing” schemes offer discount plans that aren’t actually available through the health insurance exchanges, and fraudulent offers that promise inexpensive health care to undocumented immigrants. Currently, undocumented immigrants are not eligible to participate in the exchanges. All legitimate plans are detailed on the government’s health insurance marketplace,

Criminals tend to use the same techniques to get people ensnared in their rip-offs. Here are few red flags to look for:

Fear tactics.

Fear mongering from those opposing the ACA often creates concern about the consequences of not purchasing insurance. Some scammers are calling consumers and telling them that they will go to jail unless they purchase a plan immediately. In fact, if you don’t have insurance by the deadline of January 2014, the most that can happen is that you will pay a fine when you file your 2014 tax return (due April 15, 2015).

Time and rate pressure.

Some thieves make it sound like premiums and fees on insurance plans will change and that they can “freeze” your rate or give you a cheaper price if you purchase a plan with them immediately. The current open enrollment period for health insurance plans is in effect through March 31, 2014, and current plan premiums are listed at and on state health insurance exchanges. If your plan premium does increase, it will be on an annual basis, and you are free to switch plans each year during open enrollment, which will be from Oct. 15-Dec. 7.

Fake cards and credentials.

Unlike Medicare, there is no ID card associated with the ACA for consumers, and government agencies rarely call consumers, preferring to use the U.S. Postal Service for their communications. State health insurance exchanges also won’t contact consumers via telephone. If you do get a call from someone wanting to help sign you up, get their name and ID number and confirm their identity with or your state Medicare or Medicaid office. Call to verify identities of people who say they represent local community groups, as well.

Fakers ‘phishing’ for personal info.

Be wary if someone calls you asking for personal information, such as your Social Security or bank account number, with regard to the ACA. Never give out personal information unless you are absolutely certain there is a legitimate reason for doing so (and even then, verify the identity of the person asking for it). According to a survey by Javelin Strategy and Research, 12.6 million Americans were victims of identity theft last year and the numbers keep rising, so closely guard your personal information.

Report scams

Some state exchanges, such as Covered California, are posting health care fraud alerts to prevent scams and direct consumers to legitimate assistance. You can report a scam or file a complaint with your state exchange, or with the Federal Trade Commission (FTC) at or 877-FTC-HELP (382-4357).

You can also report scams to at 800-318-2596 (TTY: 855-889-4325), or contact the U.S. Department of Health and Human Services Fraud Hotline at 800-447-8477. Visit the U.S. Department of Health and Human Services website for more information.

When you and your health plan disagree: Appealing your insurer’s decision

By Monica Steinisch

The Affordable Care Act (ACA) gives you the right to appeal private health plan decisions to deny your claim or cancel your coverage. While many policyholders already had this right under state law, it now applies nationally to all policyholders. The process includes an:

  • Internal appeal—the insurer’s review of the health plan’s decision, and
  • External review—an independent third party’s review if the insurance company continues to deny payment or coverage.

Here are steps for dealing with a health plan decision you don’t agree with:

  1. File an internal appeal with your health plan within 180 days of receiving notice that your claim was denied or coverage was terminated. Submit all required forms, and any additional information (e.g., a physician’s letter) that supports your claim. An internal appeal must be completed within 30 days for a service you haven’t received yet, and within 60 days if you’ve already received services. You can file an expedited appeal if the standard timeline would jeopardize your health. Some group plans in certain states may require more than one level of internal appeal before you can request an external review.
  2. Request an external review as soon as possible after receiving an appeal denial. (Deadlines vary, but you should make your request within 60 days of the denial to avoid missing the cutoff date.) Follow the instructions included with the health plan’s decision. The external review process has to meet federal consumer protection requirements. If your state’s review process provides even greater protections, your insurer must follow that. If your health insurance company uses the Department of Health and Human Services (HHS)-administered external review process, there’s no charge for filing. If your issuer contracts with an independent review organization or uses the state’s review process, there could be a fee of up to $25. (Learn more about the HHS-administered process at the HHS-Administered Federal External Review Process website.) The review should be completed within 45-60 days of your request; an expedited review can take just a few days. If your health situation is urgent, you can request an external review at the same time you file an internal appeal.

Keep a file of all information related to the appeals process, including notes from phone conversations. Send the original request for an appeal or review and keep a copy for yourself. Otherwise, send copies of documents and keep the originals in your file, unless an original is required.

If you need help filing an appeal or requesting an external review, contact your state’s Consumer Assistance Program, if it has one, or your state’s Department of Insurance. Or call at 800-318-2596 (TTY: 1-855-889-4325).

Medical debt installment plans

By Monica Steinisch

As out-of-pocket medical costs increase, many hospitals and physicians are employing the services of companies that offer no- or low-interest payment plans for patients who owe them money. Payments can start as low as $25 per month and last for just a couple of years, but they can also go much higher and last for much longer.

Patients using such a service can stretch payments out over time and avoid costly finance charges, heavy-handed collection tactics and negative marks on their credit report—as long as they continue to make payments as promised. You might even have the option to have your consistent monthly payments reported to the credit bureaus, which is a real benefit if you need to improve your credit record.

But even with no-interest payment plans from companies with reassuring names such as CarePayment and ClearBalance, medical bill installment plans aren’t the best option in every situation. In some cases, a bill might be so huge that it would be unrealistic and financially devastating to attempt to pay it off.

Before agreeing to an installment plan for a large medical bill, consult with a financial adviser or bankruptcy attorney to understand all your options. A credit counselor can give you general information about bankruptcy and possible alternatives so that you can make an informed decision about next steps—and counseling services typically are free or inexpensive. (Find a reputable credit counseling agency at the National Foundation for Credit Counseling.)

Consider these steps before entering into a debt installment agreement:

  • Compare prices for medical procedures using free online tools such as Healthcare Blue Book and New Choice Health. (See Consumer Action’s Pre-purchase Resource Guide.)
  • Try to negotiate lower amounts for each service (surgery, hospitalization, X-rays, etc.), or ask for a flat percentage off the entire bill.
  • Ask your hospital’s patient advocate, or ombudsman, if you qualify for financial assistance through a hospital program, government agency or charitable organization.

Some health care providers will automatically enroll you in a medical installment payment plan if your bill is not paid within a few months. If the plan doesn’t work for you, try to negotiate payment terms that fit your budget.

Other tips:

Even if your health care provider does not use an outside service to administer patient payment plans, many allow patients to make payments and avoid having the debt reported as unpaid to the credit bureaus. Ask your provider directly if this is an option and what the terms would be.

About Consumer Action

Consumer Action is a non-profit organization that has championed the rights of underrepresented consumers nationwide since 1971. Throughout its history, the organization has dedicated its resources to promoting financial and consumer literacy and advocating for consumer rights in both the media and before lawmakers to promote economic justice for all. With the resources and infrastructure to reach millions of consumers, Consumer Action is one of the most recognized, effective and trusted consumer organizations in the nation.

Consumer education

To empower consumers to assert their rights in the marketplace, Consumer Action provides a range of educational resources. The organization’s extensive library of free publications offers in-depth information on many topics related to personal money management, housing, insurance and privacy, while its hotline provides non-legal advice and referrals. At, visitors have instant access to important consumer news, downloadable materials, an online “help desk,” the Take Action advocacy database and nine topic-specific subsites. Consumer Action also publishes unbiased surveys of financial and consumer services that expose excessive prices and anti-consumer practices to help consumers make informed buying choices and elicit change from big business.

Community outreach

With a special focus on serving low- and moderate-income and limited-English-speaking consumers, Consumer Action maintains strong ties to a national network of nearly 7,500 community-based organizations. Outreach services include training and free mailings of financial and consumer education materials in many languages, including English, Spanish, Chinese, Korean and Vietnamese. Consumer Action’s network is the largest and most diverse of its kind.


Consumer Action is deeply committed to ensuring that underrepresented consumers are represented in the national media and in front of lawmakers. The organization promotes pro-consumer policy, regulation and legislation by taking positions on dozens of bills at the state and national levels and submitting comments and testimony on a host of consumer protection issues. Additionally, its diverse staff provides the media with expert commentary on key consumer issues supported by solid data and victim testimony.


Affordable Care Act Issue (November 2013)   (CA_News_Nov_2013.pdf)




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