Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition or sign up here to receive it straight from your inbox. Read previous columns here.


Every now and then, I use this space to answer reader questions about how the health-care law works. With lots of people now shopping for coverage on HealthCare.gov, we have lots of questions about Obamacare coming in. So, let's get right to them!

One reader asks: "If I choose the bronze plan, and then a large medical problem comes up such as cancer, a heart attack or gall bladder attack, can I upgrade to the silver plan immediately?"

No: Once you select a health insurance plan on HealthCare.gov, you must wait until the next open enrollment period to switch into a different product. The whole idea here is to prevent the type of plan hopping that the reader describes, where someone jumps to a more robust policy when they know they'll need lots of medical care.

HealthCare.gov does have exceptions to the standard open enrollment period for people who have their insurance situation change, such as those who lose a job or move states. But a big medical expense is not one of those situations.

Another reader writes: "Under Covered California, we meet the requirements to receive "Premium Assistance," which lowers the premium by over $300 per month.  Will we just pay that lower amount, or is this in the form of a tax credit at the end of the year?"

The former guess is right: Anyone who receives premium assistance will receive the lower premium price they see displayed on the HealthCare.gov Web site. They will not have to wait until the end of the year to access their tax subsidy. That's because the tax credit in the Affordable Care Act is advance-able, meaning that (as the name implies) it can be used in advance of tax filings. Each month, then, the federal government will send your premium assistance payment to the insurance plan. You're responsible for whatever amount is not covered by that premium assistance payment.

"My employer offers plans but I prefer the one I have, which is grandfathered through 2014. Am I required to take my employer plan?"

No, you can stick with your grandfathered plan. The Affordable Care Act does require that nearly all Americans carry insurance coverage in 2014. Where they get that insurance coverage, however, is pretty much up to them. While most people tend to prefer employer-sponsored insurance, where the company typically kicks in part of the premium, there's nothing to stop someone from purchasing their own coverage on the individual market.

Another reader: "By what date do you need to obtain insurance coverage to avoid the tax/penalties?"

This is one area where the Obama administration recently changed regulations. The most important thing to know here is that, if you buy coverage by the end of HealthCare.gov's open enrollment period — by March 31, 2013 — you will not be penalized for not carrying insurance coverage.

Initially, anyone who went more than three months without coverage would face a tax penalty. That could leave people who purchased coverage through HealthCare.gov after Feb. 15 — and whose coverage wouldn't start until the beginning of April — would face the penalty. The White House announced a change to that regulation in October that will save anyone who buys coverage by the end of open enrollment from paying a penalty.

Long story short: Get covered by March 31 and you shouldn't face a tax penalty.

KLIFF NOTES: Top health policy reads from around the Web.

Are navigators being steered away from paper applications? "Federal health officials, after encouraging alternate sign-up methods amid the fumbled rollout of their online insurance Web site, began quietly urging counselors around the country this week to stop using paper applications to enroll people in health insurance because of concerns those applications would not be processed in time. Interviews with enrollment counselors, insurance brokers and a government official who works with navigators in Illinois reveal the latest change in direction by the Obama administration, which had been encouraging paper applications and other means because of all the problems with the federal Web site. Consumers must sign up for insurance under the federal health overhaul by Dec. 23 in order for coverage to start in January." The Associated Press

Some HealthCare.gov shoppers might face deductible sticker shock. "For policies offered in the federal exchange, as in many states, the annual deductible often tops $5,000 for an individual and $10,000 for a couple. Insurers devised the new policies on the assumption that consumers would pick a plan based mainly on price, as reflected in the premium. But insurance plans with lower premiums generally have higher deductibles." Robert Pear in the New York Times

Maryland's exchange head has stepped down. "The Maryland official who directly oversaw the rollout of Maryland’s health insurance exchange resigned Friday amid continuing technical problems that have hampered the state’s online enrollment efforts. After an emergency session Friday night, the board of the Maryland Health Benefit Exchange accepted the resignation of Rebecca Pearce, its executive director, and thanked her in a statement for working 'tirelessly and with tremendous dedication'  for more than two years." John Wagner and Lena H. Sun in The Washington Post