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Be Out, Be Healthy, Get Covered: Answers To 10 Queer Questions About Obamacare

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"Be Out, Be Healthy, Get Covered: Answers To 10 Queer Questions About Obamacare"

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Today is National Coming Out Day. And no matter who you are, being proud to be yourself means taking care of your health – and that’s much easier with health insurance coverage.

That’s why a new initiative called Out2Enroll wants to encourage LGBT community members and their allies to celebrate National Coming Out Day by “coming out” for coverage.

The Out2Enroll campaign, which aims to connect LGBT community members and their families with new coverage options available through Obamacare, was officially launched on September 12 at the White House. Today is the unveiling of the campaign’s new website, where LGBT community members can get answers to their questions about what Obamacare means for them.

So here are the answers to ten questions LGBT community members may have about Obamacare:

1. What do I really need to know about Obamacare?
2. Why does health insurance matter for LGBT community members?
3. Will there be financial assistance available to help me afford coverage?
4. There are a lot of questions about my household income – is my same-sex partner in my “household”?
5. Can I enroll in family coverage with my same-sex spouse or partner?
6. Will all of the services that I need be covered under Obamacare?
7. What if I have a preexisting medical condition, such as HIV?
8. What if I’m transgender?
9. Who can help me if I experience discrimination when applying for or enrolling in coverage?
10. What if my plan refuses to cover the services that I need?


1. What do I really need to know about Obamacare?

Here are four things you need to know about the new Health Insurance Marketplaces that are available in every state. More information is available in this fact sheet, but here are the highlights:

  • You will be able to shop online, over the phone, or in person for a plan that fits your budget.
  • Every plan will have to cover a core set of benefits.
  • LGBT people will have the same access to health insurance coverage through the Health Insurance Marketplaces as anyone else.
  • The Health Insurance Marketplaces will help you navigate your options and enroll in coverage that’s right for you.


2. Why does health insurance matter for LGBT community members?

Many LGBT community members have long been left out when it comes to health coverage. It has been too hard to find coverage that treats LGBT families fairly, that covers the care LGBT people need, and that doesn’t break the bank.

And the health of LGBT communities suffers as a result. LGBT communities continue to face significant disparities such as higher rates of tobacco use, abuse and violence, mental and behavioral health issues, and HIV infection.

That’s where Obamacare comes in. For the first time, there are new affordable options, protections against discrimination based on sexual orientation and gender identity, and coverage even if you have a preexisting medical condition. The law may not be perfect – but this is an unprecedented opportunity for LGBT community members to take the steps they need to stay healthy and to protect themselves and their families. And getting covered is the first step.


3. Will there be financial assistance available to help me afford coverage?

Yes, Obamacare helps make coverage more affordable! How? Premium tax credits and cost-sharing reductions can help make private coverage more affordable. Or you may be eligible for public coverage under Medicaid. This financial help is based on your income and is determined on a sliding scale basis, which means that individuals with lower incomes will get more help. You can learn more about the premium tax credits and what assistance you may be eligible for at Out2Enroll and through your state’s Health Insurance Marketplace.


4. There are a lot of questions about my household income – is my same-sex partner in my “household”?

Your “household” includes the individuals that you claim on your federal tax return. This includes you, your spouse, and your dependents. What about your same-sex spouse? Well, if you claim them on your federal tax return (i.e., you file as a married couple), they are included in your household for purposes of financial assistance through the Marketplaces.

But this is not true if you are in a civil union or domestic partnership. If you are not legally married, you and your partner will be considered two separate households when determining whether you are eligible for financial assistance and Medicaid. In other words, you will each be considered as your own household with your own individual income. In some states, you may be able to combine your tax credit with your partner’s tax credit to buy family coverage, but you should ask your Marketplace directly if that’s an option you’re considering.


5. Can I enroll in family coverage with my same-sex spouse or partner?

There is no single standard for defining a “family” under Obamacare. As a result, states have different rules about family coverage, and insurance companies may have discretion in how they define “family” for their plans.

As you compare plans through your Marketplace, you can look for plans that cover you and your spouse or partner together. This will depend on the way that the plan defines “family.” You can usually find this information by looking at the detailed plan documents available on your Marketplace website (these are often called a “Certificate of Coverage” or an “Evidence of Coverage”). If the plan won’t cover you and your spouse or partner together, you may be able to enroll as individuals.


6. Will all of the services that I need be covered under Obamacare?

People in the LGBT community have not always been able to access the services they need. For example, transgender people have often been denied coverage outright for the care they need to stay healthy and to live as who they know they are inside. Many other members of the LGBT community have also been left high and dry by plans that didn’t cover important benefits such as prescription drugs, reproductive health care, or mental and behavioral health care services.

Although Obamacare may not address all of these issues, the law goes a long way towards ensuring that every American has access to comprehensive coverage. In fact, most health insurance plans will have to cover a minimum set of “essential health benefits,” which includes ten categories of benefits and services that must be covered:

  • Ambulatory patient services, which is care you get without being admitted to a hospital
  • Emergency services
  • Hospitalization, including surgery
  • Maternity and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment, counseling, and psychotherapy
  • Prescription drugs
  • Rehabilitative and habilitative services and devices, which help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including dental and vision care for children

Your specific benefits will vary depending on which state you live in and how much flexibility insurers have to modify coverage under state law. For example, plans in every state have to cover prescription drugs, but the actual drugs that are covered may vary. Similarly, plans in some states will cover assisted reproductive technologies such as in vitro fertilization as part of their maternity care benefits, while others will not. You should check with the Marketplace in your state to make sure you are considering plan options that cover the benefits you need.


7. What if I have a preexisting medical condition, such as HIV?

Great news! Beginning in 2014, most health insurance plans, as well as Medicaid and the Children’s Health Insurance Program, can’t refuse to cover your treatment or charge you more just because you have a preexisting condition such as HIV, cancer, or asthma. This is true even if you have been refused coverage in the past. (The only exception is for grandfathered health plans, which means a plan that you bought for yourself before March 23, 2010. These plans do not have to cover preexisting conditions, but if you have one of these plans, you can switch to a new plan through your Marketplace and get the coverage you need.)

In addition, plans sold through the Marketplace will have to cover a minimum set of “essential health benefits,” such as prescription drugs and chronic disease management. Obamacare also prohibits insurers from placing lifetime and annual dollar limits on essential health benefits, meaning you can no longer “max out” of care that you need.

These protections increase access to care that people need, especially for individuals with preexisting conditions, such as HIV. If you have specific questions about getting covered as someone living with HIV, please check out the HIV Health Reform website as well as this Marketplace health plan assessment workbook, which can help you find coverage that works for you.


8. What if I’m transgender?

Being transgender is no longer a preexisting condition – and insurance companies cannot deny you coverage or charge you more based on your gender identity. If you are a transgender person, you have the right to expect that your plan will cover the services you need as long as those services are covered for other people on your plan. These services include preventive screenings such as mammograms, Pap tests, and prostate exams; hormone therapy; and mental health services. Depending on your plan, these services may also include surgical procedures related to gender transition.

When you are shopping for plans through your Marketplace, you’ll be able to compare each plan side-by-side to see what is covered by looking at detailed plan documents (usually called a “Certificate of Coverage” or an “Evidence of Coverage”). If coverage for care related to your gender transition is part of what is important for you in insurance, keep a close eye out for the “exclusions” and “limitations” on coverage. Exclusions for things like “services related to sex change” or “sex reassignment surgery” indicate that a plan may not offer the kind of coverage you need.


9. Who can help me if I experience discrimination when applying for or enrolling in coverage?

Obamacare includes new nondiscrimination protections – and they’re extensive. First, nobody who works with the Marketplaces, including employees and insurance companies offering plans for sale, is allowed to discriminate against LGBT people. Second, insurers can’t treat you differently or charge you more if you have a condition such as HIV, cancer, or any other preexisting condition. Third, insurers can’t offer plans with benefits that discriminate based on sex, gender identity, sexual orientation, or health condition.

If you feel you’ve been treated unfairly when trying to apply for or enroll in coverage, you can make a complaint directly to your Marketplace, your state’s insurance department, or with the Office for Civil Rights at the U.S. Department of Health and Human Services.


10. What if my plan refuses to cover the services that I need?

If your plan refuses to cover services that should be included and are medically necessary, you have the right to appeal this decision and have it reviewed by a third party. What are your rights? Among others, you have the right to:

  • Ask the insurance company to reconsider its decision.
  • Know why an insurance company denied your claim or ended your coverage.
  • Know how to challenge the insurance company’s decision.

There are two ways to appeal a plan’s decision: internal appeals and external review. To learn more about this process, check out this resource. And if you need help filing an internal appeal or external review, contact your state’s Consumer Assistance Program or insurance department.

For more questions and answers, visit Out2Enroll

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