PITTSFIELD

In most ways, it's the best of times for Massachusetts residents in terms of health insurance coverage -- at 2 percent, the state has the lowest level of uninsured citizens in the nation.

Yet it can be the worst of times when one's income edges above the maximum allowed for the state's Commonwealth Care subsidy program. The difference can mean monthly premiums that are hundreds or thousands more when the open market is the only option.

"We talk to a lot of people every year who are right over the limit -- we call it ‘the cliff,' ‘' said Kate Bicego, who manages a help-line service for Health Care For All, a nonprofit that advocates for an improved health care system and assists residents with information about coverage.

Kate Bicego, who manages a help-line service for the nonprofit Health Care For All, says her organization talks with several people each year who are
Kate Bicego, who manages a help-line service for the nonprofit Health Care For All, says her organization talks with several people each year who are ‘right over’ a federal poverty benchmark. (David L. Ryan / Boston Globe)

Over the past seven years, the help line has fielded some 40,000 calls.

"When people were paying $118 a month [on their premium], oftentimes it is shocking," Bicego said, referring to the steep increases some face.

Commonwealth Care provides subsidized insurance for those up to 300 percent above the federal poverty level, which means $34,470 for a single person and $58,590 for a family of three, with the figures adjustable depending on the number of dependents. (See income chart.)

The premiums for Commonwealth Care coverage range from zero for those closest to the poverty line to $118 a month for the lowest-priced plan for those near the limit. But go a fraction of a percentage point above that limit and a notice could arrive saying your subsidized coverage is being terminated.

"They could then lower their income or purchase on the private market," Bicego said.

"People have what I would call sticker shock," she added. "They earn a few bucks more, get a raise, and they receive a termination notice."

'Fighting it'

Lenox resident Deborah Alecson, a widow with a son in college, unexpectedly faced "the cliff" recently and said she isn't sure what she'll do if her Commonwealth Care coverage expires -- as expected -- in a few months.

Alecson, a member of the adjunct faculty at Excelsior College in Albany, N.Y., where she teaches in the School of Health Sciences, said she has qualified for the lower Commonwealth Care premiums for several years. But last year she withdrew some money from a retirement savings account to help her son with college expenses, and the funds were counted as income -- pushing her over the eligibility limit.

Local health care nonprofit Advocates for Access "is fighting it on my behalf," arguing this is a "one-time deal," not continuing income, she said. But if her appeal is unsuccessful, Alecson said she's thinking: ‘Do I really want health insurance?' "

Considering that she also could lose her affordable coverage by getting a pay raise, she added, "This really is a system designed to keep people impoverished."

The option of simply going without health insurance also could prove costly, as state residents who can afford private insurance but don't purchase it are subject to a fee when they file an income tax return.

The option of simply going without health insurance also could prove costly, as state residents who can afford private insurance but don't purchase it are subject to a fee when they file an income tax return.

There is, however, some good news on the horizon for those on the income borderline and facing much higher premiums: Provisions of the federal Affordable Care Act, otherwise known as "Obamacare," will take effect Jan. 1 and are expected to ease the guidelines to allow incomes of up to 400 percent of the poverty line.

Enrollment for the ACA program will begin Oct. 1.

Coverage options

Income eligibility for Commonwealth Care insurance rates is determined by a person's weekly gross pay and monthly average, and by projecting that out over a year. Soon after a person's salary increases, the change will become apparent to the state, and a notice then could be expected.

In addition to subsidized Commonwealth Care plans, the state program provides a comparison of costs (Commonwealth Choice) for residents shopping for insurance on the open market. Commonwealth Care and the Commonwealth Choice comparison services are run by the Health Insurance Connector Authority, which was created as part of the Health Care Reform Act of 2006.

The authority's website (www.mahealthconnector.org) displays various insurance plans offered in Massachusetts and has an interactive feature to determine the open-market monthly cost per person or family for coverage. Premiums depend on factors such as annual deductibles and co-pays -- showing Bronze, Silver and Gold options, with Gold providing the maximum coverage and lowest deductibles and co-pays but also costing more.

Punching in data for a fictional 30-year-old Pittsfield resident just above the income limit, and selecting an annual $1,000 deductible and some co-pays, the plans displayed had premiums ranging from $343 to $351 per month. For a family of three, the cost ranged from $689 to $734 per month.

Under the subsidized plans for people just under 300 percent of the federal poverty mark, the lowest monthly cost available is $118 a month for a single person earning up to the maximum -- currently at $34,470.

About 16 percent of the approximately 200,000 residents enrolled in the Commonwealth Care program are between 250 and 300 percent of the poverty level, or closest to the income cutoff.

But those guidelines are expected to change significantly in 2014.

Charles "Chip" Joffe-Halpern, executive director of Ecu-Health Care in northern Berkshire County, an organization that assists people with health care cost and selection issues, said the federal program is expected to increase the maximum income for subsidy eligibility for an individual adult from $34,470 to $45,960. Eligible income for a household of three will rise in 2014 from $58,590 to $78,120.

"We are very excited about this," Joffe-Halpern said. "This will be very helpful."

'Nine ways to Sunday'

Ecu-Health Care is one of two local nonprofits that counsel people on health care insurance issues; Advocates for Access is in central and southern Berkshire County.

"We run into them every day," Cheryl Thomson, manager of Advocates for Access, said in reference to people near or over the income limit. "We try to work with the families nine ways to Sunday."

However, both Thomson and Joffe-Halpern said the income limits are a solid wall in many cases, and they are eager to see the new, higher income levels.

In 2014, the federal program will begin to supersede aspects of the Massachusetts program, which was a model for the national Affordable Care Act. There also are aspects of the state program that are more generous for residents -- including the expected premium rates -- according to Suzanne Curry, health reform policy coordinator with Health Care For All.

She said that during ongoing discussions concerning the changeover, "We are advocating that [costs and benefits] are kept as close as possible under the ACA."

In fact, Curry said, the state stands to receive a much larger infusion of federal funds for health care through the ACA, which could allow Massachusetts to add to the programs and "kind of make whole" any subsidy or benefit reductions for state residents.

However, she added, "I don't foresee it going much higher," referring to the 400 percent of poverty maximum coming in 2014. Curry said a shift in the political climate in Washington toward increasing ACA funding would have to come first.

Affordability schedule

With the federal program due to launch on Jan. 1, Ecu-Health Care and Advocates for Access will undertake the same role as today in assisting residents in making enrollment and health care insurance choices.

Joffe-Halpern said all those now in Commonwealth Care or purchasing health insurance on the market should determine whether they are eligible for subsidized coverage. Even some of those who are offered insurance through an employer might qualify, he said, depending on how much they are required to pay and the level of coverage provided.

As for financial penalties possible under the state system (and under the ACA) for those who can afford health insurance but do not purchase it, Bicego said residents should not assume they will pay a fee.

In truth, she said, there are exemptions a resident can apply for in the Schedule HC income tax form. Bicego said an "affordability schedule" is used to determine whether a person is able to purchase insurance and isn't eligible for Commonwealth Care, programs such as Medicare or Medicaid, or an employer-offered plan that meets the state's definition of affordable.

The most important consideration, according to those interviewed, is that residents ask questions and become aware of where they land within an evolving health insurance system -- and take advantage of the assistance available to find the most affordable option.

To reach Jim Therrien:
jtherrien@berkshireeagle.com,
or (413) 496-6247
On Twitter: @BE_therrien 

Commonwealth Care: Key numbers

Income eligibility

Family: 2013 / 2014

Single: $34,470 / $45,960

Two: $46,530 / $62,040

Three: $58,590 / $78,120

Four: $70,650 $94,200

 

Lowest monthly premiums compared to poverty level (2013)

Up to 150%:   $0

150-200%:  $40

200-250%:   $78

250-300%:   $118

Source: HealthConnector

Help with health care issues

Advocates for Access

(413) 445-9480 / Pittsfield

(413) 854-9608 / Great Barrington

 

Ecu-Health Care

(413) 663-8711

Mass HealthConnector

www.mahealthconnector.org/portal/site/connector

(877) 623-6765

 

Health Care For All

www.hcfama.org

Help line: (800) 272-4232