Second Opinion is a weekly Q&A series that answers questions from San Diegans on the Affordable Care Act. Ask yours here.
The Question: What is an employer's responsibility if one of its workers opts out of its group plan?
Sylvia Hampton is an advocate. She was entered into the San Diego Women's Hall of Fame in 2008 for her work protecting women's rights. She's a member of the League of Women Voters. And she pushes for improved access to health care through San Diegans for Health Care Coverage, a nonpartisan coalition of nonprofits, businesses and health care provders.
This week, she's advocating for a friend. Her Second Opinion question is really for him.
He recently switched jobs and his new company doesn't offer coverage through his preferred provider, Kaiser. It says his only option is to leave his Kaiser doctor and find a new one through the company plan.
Here's Hampton's question:
"They are consumers who want to keep their doctor. And the employer is saying, 'Sure, keep your doctor, keep Kaiser, but we're not going to pay for it.' What is the responsibility of the employer to pay that share, or the normal share of the cost that they would pay for another employee who is going on the plan that they have contracted?"
Hampton called the situation "unfair," especially for people undergoing a special course of treatment or who have a chronic illness.
"These are problems we've had all along with health care. It's one of the reasons we needed reform," Hampton said. "But this is an area where reform is not happening for the consumer the way it should."
The Takeaway: Choices are limited for individuals with access to employer-based plans.
Under the Affordable Care Act, a large employer's responsibilities start and stop when it offers affordable coverage. The law defines that as plans with premiums falling within 9.5 percent of an individual's income and covering at least 60 percent of his or her medical expenses.
The company is not obligated to offer a stipend if its employees seek coverage elsewhere, nor will it be fined by the federal government, said Linda Keller, the executive vice president of San Diego-based insurance brokerage Intercare.
And if the employees go on to the state's insurance market, Covered California, to shop for alternative coverage, they will not qualify for subsidies. Covered California doesn't offer premium assistance to people who have affordable coverage options elsewhere – whether its through work, Medi-Cal or Medicare.
The Orders: Start looking for a new doctor.
The subsidy rule for people with access to a group plan doesn't mean they can't buy a plan through Covered California. But it means they'll be paying the full premium without help from the federal government or an employer.
Check out last week's Second Opinion: Does Obamacare reduce costs for people with pre-existing conditions?
