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ObamaCare Clusterfuck: If you're not a US resident, you're on your own

I thought I'd try out the Chat feature on healthcare.gov, not least because it provides a transcript, unlike voice. I encourage others of us who have questions -- I'm sure Katiebird does -- to try chat too, and post transcripts here, because you don't have to identify yourself with an email address (granted, they know everything anyhow, but then, they always did). So let's smoke out some of the inconsistencies! I am "CALLER":

[11:55:46 am]: Thanks for contacting Health Insurance Marketplace Live Chat. Please wait while we connect you to someone who can help.
[11:55:50 am]: Please be patient while we're helping other people.
[11:55:55 am]: Welcome! You're now connected to Health Insurance Marketplace Live Chat.

Thanks for contacting us. My name is Susan. To protect your privacy, please don't provide any personal information, like Social Security Number, or any other sensitive medical or personal information.
[11:56:12 am]: Susan
Welcome to the Health Insurance Marketplace Live Chat, my name is Susan, how may I help you? To better assist you; please include the name of the state you reside in with your inquiry. Thank you.

[11:57:31 am]: CALLER
Hi-- I'm from Maine. I'm thinking of moving to a foreign country for an extended period. Will ObamaCare cover me if I do? What are the residency requirements? Thank you!

[11:59:34 am]: Susan
Thank you for your question today. One moment while I research information regarding where the coverage is extended to. I am happy to assist.

[12:00:09 pm]: CALLER
Thanks!

[12:01:40 pm]: Susan
To buy health coverage through the Health Insurance Marketplace, you must live in the United States, be a U.S. citizen or lawfully present, and cannot currently be incarcerated. Residents of a U.S. territory are not eligible to apply for health coverage through the Marketplace. U.S. territories can decide whether to create their own Marketplace or expand Medicaid coverage.

If you are a U.S. citizen living in a foreign country, you are not required to get health coverage under the Affordable Care Act. If you're uninsured and living abroad, you don't have to pay the fee that other uninsured U.S. citizens may have to pay. Generally, health coverage in the Marketplace covers health care provided by doctors, hospitals, and medical services within the United States. If you're living abroad, it's important to know this before you consider buying a Marketplace plan.

[12:02:51 pm]: CALLER
So, in essence, I'm on my own but don't have to pay the penalty, either.

[12:03:18 pm]: Susan
In addition to this, there is also the following information regarding citizenship. To be eligible to purchase and use coverage through the Health Insurance Marketplace, you must be a U.S. citizen or be lawfully present. If you are not a citizen, you must be considered "lawfully present" in the United States for the entire time you plan to be covered by a Marketplace plan.

The citizenship and immigration status of each member of your family is determined separately. When open enrollment begins on October 1, 2013, you may need to provide some documents depending on your citizenship and immigration status to complete the Marketplace application.
[12:03:40 pm]: Susan
One moment while I look into the penalty portion of your inquiry.

[12:03:52 pm]: CALLER
I'm a citizen of the US. That's not an issue for me.

[12:08:04 pm]: Susan
Thank you for your patience. An uninsured person will pay the fee for 2014 in 2015, when he or she files a federal income tax return. If you don't pay the fee, the Internal Revenue Service will hold back the amount from any future tax refunds. There are no liens, levies, or criminal penalties for failing to pay the fee.

But, you are correct, as mentioned before, if you are a U.S. citizen living in a foreign country, you are not required to get health coverage under the Affordable Care Act. If you're uninsured and living abroad, you don't have to pay the fee that other uninsured U.S. citizens may have to pay.

[12:09:15 pm]: CALLER
I'm not sure what you're saying. Are you saying that if I am a US citizen living abroad:
[12:10:14 pm]: CALLER
1. No requirement to purchase coverage, no penalty OR
[12:11:31 pm]: CALLER
2. No requirement to purchase coverage, penalty, but no enforcement of the lien?

[12:14:14 pm]: Susan
I apologize, I don't mean to be confusing. The information I have regarding general eligibility requirements is:

To buy health coverage through the Health Insurance Marketplace, you must live in the United States, be a U.S. citizen or lawfully present, and cannot currently be incarcerated. Residents of a U.S. territory are not eligible to apply for health coverage through the Marketplace. U.S. territories can decide whether to create their own Marketplace or expand Medicaid coverage.

If you are a U.S. citizen living in a foreign country, you are not required to get health coverage under the Affordable Care Act. If you're uninsured and living abroad, you don't have to pay the fee that other uninsured U.S. citizens may have to pay. Generally, health coverage in the Marketplace covers health care provided by doctors, hospitals, and medical services within the United States. If you're living abroad, it's important to know this before you consider buying a Marketplace plan.

[12:15:14 pm]: CALLER
Right, but that doesn't explain about the penalty ("individual responsibility payment"). That's the difference between #1 and #2.

[12:16:32 pm]: Susan
One moment while I research more specific information regarding the penalty for you. Thanks again for your patience.

[12:17:01 pm]: CALLER
Am I going to be putting myself in a position where (1) I can't purchase insurance through the Marketplace but (2) have to pay a penalty for not purchasing insurance even though I'm forbidden from doing so? (I should say that I'm somebody who needs a subsidy; that's exactly why I'm thinking of moving abroad, because the cost of living can be so much lower.) Thanks for your help.

[12:20:04 pm]: Susan
My pleasure. Great questions. I previously pulled just the last paragraph earlier in regards to the penalty, but actually the whole of this may better answer your question.
[12:20:09 pm]: Susan
The Affordable Care Act requires most people to maintain health insurance. You can get insurance through your job, through the Health Insurance Marketplace, or directly from an insurance company. After open enrollment ends on March 31, 2014, you cannot get Marketplace coverage until the next annual enrollment period, unless you have a qualifying life event such as a birth or marriage. If you do not get health insurance in 2014, you may have to pay a fee.

The fee in 2014 is 1% of your yearly income or $95 per person for the year, whichever is higher. The fee for uninsured children is $47.50 per child. The most a family would have to pay is $285. Amounts go up after 2014.

In 2015, the fee per person rises to $325 per person or $975 per family, or 2% of income, whichever is higher. For 2016, the fee per person will increase to $695 per person or $2,085 per family, or 2.5% of your household's income, whichever is higher. The fee for children will be half that amount, and there will be an overall cap for family payments. From 2017 on, the fee will rise each year with inflation. You will also have to pay the entire cost of all your medical care if you do not get health insurance.
[12:21:04 pm]: Susan
And then again, the end of that portion was: An uninsured person will pay the fee for 2014 in 2015, when he or she files a federal income tax return. If you don't pay the fee, the Internal Revenue Service will hold back the amount from any future tax refunds. There are no liens, levies, or criminal penalties for failing to pay the fee.

[12:23:24 pm]: CALLER
OK. Suppose I purchase insurance abroad in the foreign country (not through the Marketplace). Am I now "insured" in the eyes of ObamaCare, and does that avoid the penalty? I want to avoid the penalty even if there is no lien or levy. After all, that could change at some future date, or even be applied retroactively. Thanks again!
[12:24:00 pm]: CALLER
(By "penalty" I mean the $95/1% of income thing.)

[12:26:07 pm]: Susan
Wouldl you filing U.S. income taxes for the time you are away?

[12:26:21 pm]: CALLER
Yes, I would be filing US income taxes.

[12:27:10 pm]: Susan
Thank you. One moment please while I look that up.
[12:29:58 pm]: Susan
Thank you for your patience. I am still researching that information.

[12:30:22 pm]: CALLER
That's fine. I knew it was an oddball question.

[12:33:30 pm]: Susan
I apologize, the only information I have regarding that is that if you are a U.S. citizen living in a foreign country, you are not required to get health coverage under the Affordable Care Act. If you're uninsured and living abroad, you don't have to pay the fee that other uninsured U.S. citizens may have to pay. Generally, health coverage in the Marketplace covers health care provided by doctors, hospitals, and medical services within the United States. If you're living abroad, it's important to know this before you consider buying a Marketplace plan.

[12:35:43 pm]: CALLER
Well, that doesn't really answer the question, but that's not your fault. Maybe you can forward this conversation up the line...

[12:38:34 pm]: Susan
Due to the nature of your question and/or concern, I would advise you to contact a representative at our call center. We are available to help you 24 hours a day, 7 days a week. You can reach us toll free at 1-800-318-2596. Hearing impaired callers using TTY technology can reach us at 1-855-889-4325. In addition to English and Spanish, we can provide assistance in a number of languages through an interpretation service. We are closed on Memorial Day, Independence Day, Labor Day, Thanksgiving Day, and Christmas Day.

[12:38:34 pm]: CALLER
Are you still there? I don't want to sign out if you have more information to come.

[12:39:22 pm]: Susan
Thanks again you for your patience.

[12:40:09 pm]: CALLER
No problem. Can I sign out, or do you have more to come?
[12:40:53 pm]: Susan
You are free to leave the chat. Thank you for your questions. Have a great day.
[12:41:07 pm]: CALLER
Thanks. Bye!

So, summing up (and readers, please correct me if I am confused):

1. US citizens living abroad cannot use the Exchanges, and hence are not eligible for subsidy but are not fined.

2. If a US citizen living abroad purchases insurance abroad, it's unknown whether ObamaCare considers them "insured" or not.

Not happy about this! In essence, ObamaCare's eligibitly requirements are built around residence, and not citizenship. It's almost like they want to do everything possible to keep us in the clutches of the heatlh insurance companies....

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Alexa's picture
Submitted by Alexa on

That is the same information that I got calling my local County Health Office months ago.

We've planned for 8 years now, to relocate outside of the US (in retirement).

We've narrowed it to two countries--both of which offer excellent medical care at VERY low costs.

If anything, we are concerned that it will soon become a "MT" country--which would drive health care costs up considerably (we fear).

So, depending upon one's circumstances, this "confirmation" can be good news. (Obviously, for Americans not looking at expatriating to a country with excellent medical care at low costs, I suppose this is not very good news).

Just another glaring example of ObamaCare's "buckets."

The PPACA needs to be "repealed and replaced," but only with "enhanced" Medicare For All.

Several commenters at NC had it right when they said that, with all of the "hits" the the Medicare program has already taken due to the PPACA (not to mentioned the major cuts that are included in PBO's 2013-2014 Budget), "standard" Medicare, while MUCH BETTER than the PPACA, will not be sufficient coverage to keep the masses of Americans "out of the poorhouse," in the future.

Thanks, Lambert, for using the "live chat" feature.

If Mr. A weren't so "security conscious," I would try it out on another topic. ;-)

Alexa's picture
Submitted by Alexa on

is a bit more confusing.

Would be interested in hearing if anyone finds out about the requirement for this coverage (while living abroad).

When we checked a year-and-a-half ago (so the PPACA was law), it was indeed optional--since the Medicare program was not fashioned around "a mandate."

And we were told that one could live outside of the US permanently, and still participate in Medicare.

Only hitch--you have to come "stateside, or at least to a US territory"--in order to "use" your coverage.

This may be correct only "Pre-ObamaCare"--dunno.

I'm still searching for "regs" to clarify this information, but haven't had any luck so far.

Submitted by mgmonza on

Very curious as to which two countries? If this is too public a forum to publish that, I'll understand.

If I make it the few years left until minimum retirement, I'd love to be able to live outside the U.S. but it would have to be very, very cheaply. Social security retirement at 62 is well below poverty level.

Alexa's picture
Submitted by Alexa on

if I gave out that kind of personal (detailed) information on a blog. And please don't take that in any way "personally."

But, hey, I don't mind saying that in the "final cut" we looked at several Latin American countries.

[We reluctantly eliminated Mexico--and I've lived and studied there--because of today's "drug violence."]

So whereas I won't pinpoint "the two," don't mind saying that our broader list was comprised of Costa Rica and Nicaragua in Central America, and Brazil, Argentina, Paraguay, and Uruguay in South America.

Actually, we looked at all but one South American country (Columbia), but reluctantly eliminated the others for various reasons--not all of which had to do with the quality of life, or the cost of living, both of which were obviously major considerations.

If we were to retire to Europe, France would be our pick.

We didn't really consider Asia, but it would probably be a "good fit" for many folks. And I'm thinking that some parts of Asia are relatively inexpensive (IIRC).

I haven't seen the figures lately, but if I'm not mistaken, the numbers of American expats really began to increase during the mid-2000's.

We think it's a great option. And no one is going to denounce their American citizenship, or anything like that. We look at it as just "having a second home." ;-)

If you have an interest in this topic, you might want to start with some of the "Yahoo Expat Forums." We did get books from the library on various countries (including travel guides for some details like weather, etc). We also wrote to various embassies, and even some local governments for information.

We are lucky to have several very good "acquaintances" [if not close friends] who've relocated outside of the continental US. (And having lived so many years in Alaska, the idea doesn't seem foreign, or odd, or uncomfortable to us, at all.)

Hope you check out some of the forums. Doing so won't commit you to anything. And you just might find the idea very appealing. ;-)

Submitted by lambert on

For reasons that i assume are. obvious?

Rainbow Girl's picture
Submitted by Rainbow Girl on

So what the Susan's script gives us includes a gap, namely, if you are a US citizen residing overseas and have no health coverage, you may or may not be fined a penalty under the ACA mandate. I guess from an Insurance-Actuarial-Privatized Government perspective once you're overseas you get to be some other country's actuarial problem.

However, since the ACA seems to say clearly (at least according to Susan's script) that a US citizen residing overseas is specifically NOT ALLOWED to purchase ACA insurance products, a logical reading would be that nothing you do or don't do ONCE YOU LIVE OVERSEAS, implicates the ACA penalty payment issues.

I know. Logic is not the first aspect that comes to mind with ObamaCare.

Alexa's comment re Medicare being available to expats IF they come back "stateside" to get their medical services is consistent with what I know to be the case for a friend who now lives in East Asia but comes to the US about 4 times a year for major medical care issues (she's covered under Medicare).

Alexa's picture
Submitted by Alexa on

difficulty finding anything "in writing" on this policy.

If the Administration doesn't "gut" Medicare, it would probably be well worth keeping. And the beauty of it would be, that will so much lower medical costs, a supplemental Medigap policy would not be essential for financial security, etc.

I just hope that the PPACA does not change this policy.

Best of luck to your friend . . .

Rainbow Girl's picture
Submitted by Rainbow Girl on

It's just not in the news and under the radar. (I can't hear any howling from AARP, just crickets... hmm, wonder why? Oh, they sell Medigap policies! Duh!)

For example, it now costs $104 per month in premiums. * It has been going up every year. I'm not sure these increases don't swallow up any COLA increase in the SS monthly payments either. Plus, there's a deductible -- it's now about $150 -- and then it's only an 80/20 policy. So if you have major surgery, you're on the hook for 20%. And from what I've been reading, more and more doctors are opting out of Medicare because of decreased reimbursement.

This is a silent coup that is occurring under the radar of the hoopla about the Exchanges.

It's getting to be time to Occupy Medicare and CMS and HHS. Medicare should be free, period. No "premium," no co-pays, no deductibles. We've paid for it already for chrissakes.

* And if you don't enroll exactly when you become eligible, they slap a $27.00 penalty on you, i.e., your monthly premiums once you join are 104 (or whatever it will be in the year it happens) plus the penalty of $27. Medicare is looting Americans and is being looted by Kleptocrats and Grand Bargainers.

Alexa's picture
Submitted by Alexa on

Medicare."

I did realize that the RX insurance (Part D?) had "late penalties," but never realized that it also applies to the basic Medicare plan.

Sometime this fall, I plan to post a short "blurb" about some of the cuts that are included in the Administration's current budget. They are awful. And of course, they also go after "Medigap" beneficiaries--can you believe that!

So here's a situation where individuals and couples are trying their best to "act responsibly," and the PtB want to "penalize them financially" for doing so.

It's getting almost surreal . . .

Alexa's picture
Submitted by Alexa on

From all that I've read and heard, "serious" cuts to Medicare are just beginning.

This Spring, I heard a NPR program on the "rollout of the ACA" which got pretty detailed about the need to (and plans to) implement very deep cuts to our public programs, as soon as the ACA is fully implemented.

IOW, Phase One was implementing the individual mandate, THEN the PtB will tackle the serious cuts to Medicare and Medicaid.

When I have more time (by November), I will try to locate a brief synopsis that I transcribed of one of the forum members who spoke to all these cuts. (One dude is a Vanderbilt University professor and so-called expert on healthcare management. This guy was downright "scary.")

I do believe that they intend to phase (very slowly) both programs out.

(Can't prove it, Hipp--just what I take away "reading between the lines," and because of Geithner's Congressional Testimony about raising the Medicare eligibility age--hinging on the SCOTUS ruling that the ACA is constitutional, etc.)

IOW, this process will likely be VERY incremental. First the Medicare eligibility age will continue to rise. Then, after the implementation of the ACA ropes enough Americans into the Health Exchanges (or Marketplace), the REAL cuts will be proposed and implemented.

I'm sure that you know about the Medicare premium "surcharge" that this Administration has included in their current Budget (for be levied against beneficiaries of decent Medigap policies--regardless of their income--it is an across-the-board cut that will devastate many lower income Americans, IMO.

But, it could be that aside from the looming cuts to our public programs, the practice of "Boutique" or "Concierge" Medicine may further weaken our healthcare system (especially if cuts to providers are greatly reduced at some point) for lower and moderate income Americans.

Here an interesting link and excerpt (I thought):

What Is Boutique Medicine (a Concierge Doctor Practice) ?

Question: What Is Boutique Medicine (a Concierge Doctor Practice) ?

More and more doctors are practicing concierge medicine, opening boutique practices in an effort to avoid dealing with insurance and reimbursements. What do those terms, concierge practice and boutique medicine, mean? Are these forms of practice beneficial to patients? What are the pros and cons to consider in deciding whether to choose a doctor who participates in this form of practice?

Answer:

There is a third adjective used to describe concierge or boutique medical practices, too, and it is really more descriptive -- "retainer medicine."

In a concierge/boutique/retainer medical practice, a doctor has made the determination that she will no longer accept insurance for her services. Patients who choose this doctor pay a retainer, in the form of cash, for the care they receive from her.

Why are these types of practices becoming so popular? . . .

I believe that it would greatly behoove us all to keep an eye on the machinations of this Administration (and frankly, those to come) when it comes to further Medicare, Medicaid and/or Social Security "reform."

I'm convinced that "we ain't seen nothing yet." ;-)

[Apologize for typos, etc., in advance. In a "time crunch."]

Submitted by lambert on

... to replace social insurance.

The same will be be done with Social Security, which will become the "public option" for retirement, and gradually gutted.

I wish I could go away somewhere with no distractions for three days and write all this stuff up. This is all "market state" stuff and it's killing me I can't complete that series of posts. But now I have to go paint... And stack the wood... And so on and on and on....

Submitted by hipparchia on

1. I agree with you that the end game Obama and crew have in mind is something resembling the swiss system - everybody is mandated to buy private insurance all their lives, with the govt providing some premium support depending on your income.

2. I repeat: the "doctors are dropping out of medicare" meme is a fear-mongering tactic, aimed at getting people to stop trusting medicare right now (thus making it easier to gut medicare in the future). for now, it's still an outright lie, but it could morph into a truthful statement if we let the neoliberals and technocrats ruin medicare.

3. concierge practices only accept cash-only patients. those doctors don't want to deal with any insurance intermediary at all - not medicare, not Medicaid, not insurance companies. I can't blame them, but most of us are never going to have enough cash to pay all our own medical bills, so if you see headlines along the lines "more doctors opening concierge practices" keep in mind that that's just one more tactic being used by the medicare-destroyers to get people to distrust medicare.

I believe that it would greatly behoove us all to keep an eye on the machinations of this Administration (and frankly, those to come) when it comes to further Medicare, Medicaid and/or Social Security "reform."

Medicaid is left up to the states to administer, with not much in the way of federal guidelines. my preference would be for Medicaid to go away entirely.

alternatively, instead of "going swiss" I can see the neoliberals destroying medicare and dumping a bunch of us into Medicaid, because the states are "laboratories of democracy!" donchaknow.

Alexa's picture
Submitted by Alexa on

program as Medicaid has become (and a "racket"--considering MERP), I wish they would eliminate it, and put all the folks into Medicare.

Actually, I wish that our Medicare program would be greatly expanded and enhanced (benefit-wise).

We are pretty certain that we will have much better medical care and outcomes, if we relocate. As a matter of fact, we didn't realize until we started looking into retiring outside of the continental US, just how many countries DO have much more superior health care systems.

It's a cryin' shame, really . . .

Alexa's picture
Submitted by Alexa on

Just heard Yahoo News reporter Olivier Knox report on "The Press Pool," that on August 21, 2013, the WH conducted a major ObamaCare meeting in the "highly secure war room, or Situation Room."

This room is normally used for national security emergencies, etc.

Does this portend well for the kickoff of the ACA?

I wonder . . .

Rainbow Girl's picture
Submitted by Rainbow Girl on

We need a transcript or a leaked power point stack from this meeting.

Submitted by hipparchia on

interesting question. and it's even more complicated than you thought it was...

http://www.dol.gov/ebsa/faqs/faq-aca13.html

with some caveats, through 2015, if you're covered by expat insurance in the other country, the us will apparently consider you to be properly insured.

the issues the dept of labor mentions in that link may be partly why businesses get another year to comply with their part of the mandate.

Submitted by hipparchia on

it appears to be directed at multinational employers, whose us employees living in other countries may be covered by employer-sponsored group plans that are unique to those countries.

many of the countries that have universal healthcare, whatever the type, require anyone living there for more than a few weeks or months, including expats, to acquire health insurance, usually by paying into that country's health system in some way. given that most of these are more comprehensive than what you get here in the us, then yes, in a sane world you would have aca-approved insurance. of course, because aca is all about giving your money to the insurance companies (and not about providing you with actual care), then in practice aca-approved is probably going to turn out to be "those marvelous plans in the exchanges!"

Alexa's picture
Submitted by Alexa on

several sources (including embassies, etc.).

many of the countries that have universal healthcare, whatever the type, require anyone living there for more than a few weeks or months, including expats, to acquire health insurance, usually by paying into that country's health system in some way. given that most of these are more comprehensive than what you get here in the us, . . .

Alexa's picture
Submitted by Alexa on

for articles and info related to "Expat Insurance."

We've been gathering information for years (there are many helpful online expat forums, etc.), but of course, the ACA greatly complicates the "health insurance" issue.

Unless something changes (and you never know), we will not have access to "group insurance" when we relocate. Only federal employees who take "immediate" retirements qualify to participate in FEHBP as retirees.

So, our only choice is to obtain expat insurance, or self-fund our medical expenses, until we reach the Medicare eligibility age of 65 (if it stays at that--and I seriously doubt that it will).

It will be interesting to see how the cost of health insurance compares to the US Health Exchanges. Quotes we obtained a little more than three years ago, were less than our group health (monthly) premiums, so we are hopeful that it will be a manageable situation.

Anyhoo, I appreciate the info very much--every bit helps. ;-)

Submitted by lambert on

Ecuador might be a more congenial political environment. Cost of living about half, I'm told Cuenca is a lovely city. Internet connection not so good. Stuff like banking and visas seems more straightforward than some Asian countries.

Alexa's picture
Submitted by Alexa on

We're actually considering having a major surgery there. Mr A's company (which is self-funded) is greedy enough to consider the possibility, or so we were told several months ago. We shall see. ;-)

Certainly medical costs there are very reasonable. So much so, that "medical tourism" (MT) has become a pretty big industry there. Of course, that can have a tendency to raise medical costs. (Not to say that they would not still be substantially lower than the Lower 48).

If it were not for the fact that there has been such a substantial influx of expats over the past several years, we might still be considering Ecuador. Much like Panama and parts of Mexico (and to some extent, some locations in Costa Rica), it got to be such a popular expat destination, that the cost of living has steadily been on the rise.

We think it's wonderful that Correa has managed to avoid another coup. According to many expats there, a successful coup would not affect their community that greatly. I hope they are right.

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