J&P
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COBRA etc

COBRA and Healthcare research

 

Contents

General research

Coverage

What we NEED and WANT.

What ACA Plans We Want/Need
10 essential health benefits √
prescription drugs, √ Need
emergency services, √ Want
hospitalization √ Want
laboratory services, √ Want
and mental health and substance use disorder services √
other ###
Free preventive health services
screenings √ Want
Immunizations √ Want

 

Q: annual exams part of aca? (Google)

AI A: “Yes, annual physical exams are considered a covered preventive service under the Affordable Care Act (ACA) and are generally covered at no cost to you when provided by a healthcare professional in your insurance plan’s network. However, this coverage is for the preventive aspect of the visit only; if you discuss or address a pre-existing condition or new medical concerns during the visit, those parts of the visit may result in separate charges.”

COBRA

ChatGPT Conversation(s)

Q: health care insurance – where can I get? Are there are restrictions on when one can sign up? Etc

A:

Here’s a breakdown of how health insurance works in the U.S., how and where to get it, and when you can sign up. If you tell me what state you’re in, I can give more specific details.

Where you can get health insurance

You have several options. What works best depends on your income, whether you’re employed, your age, etc.

Source Who it’s good for / notes
Employer‑sponsored insurance If your job offers health benefits, this is often the easiest / cheapest way, because employers usually pay part of the premium.
Health Insurance Marketplace / ACA (“Obamacare”) If you don’t have employer insurance, you can buy a plan through the Marketplace. You might qualify for subsidies (tax credits) or cost‑sharing reductions depending on your income. Texas uses the federal Marketplace via HealthCare.gov. (healthinsurance.org)
Directly from insurance companies or HMOs You can purchase a plan directly from an insurer. Sometimes the same plans are in the Marketplace, sometimes not. Helps if you want more options or different plan features.
Government programs For people who qualify based on age, disability, income: Medicaid, CHIP, Medicare. In some states, there are sliding‑scale clinics or county programs. (Texas Health and Human Services)
Special programs in your state States often have additional help (premium payment help, children’s insurance, etc.). For example, in Texas there’s CHIP for kids, Medicaid, and a program called HIPP that helps with employer plan premiums under certain conditions. (Texas Health and Human Services)

When you can sign up (“Enrollment Periods”)

You generally can’t just pick up Marketplace or ACA insurance any time—it depends on enrollment windows, unless certain situations happen.

  • Open Enrollment Period
    This is the yearly time window when anyone who doesn’t already have coverage can enroll in or change Marketplace / ACA plans. In Texas, for example, the open enrollment runs November 1 to January 15. (healthinsurance.org)
    If you want your coverage to start Jan. 1, you usually have to pick a plan by mid‑December. If you sign up later in the open enrollment period, coverage starts a bit later. (healthinsurance.org)
  • Special Enrollment Period (SEP)
    Outside open enrollment, you can still enroll if you’ve had a qualifying life event. Examples include:

    • losing other health insurance
    • getting married
    • having a baby
    • moving to a different state or area
    • certain changes in income
      These allow you to enroll outside the open enrollment window. (Planned Parenthood)
  • Government programs (Medicaid, CHIP, Medicare, etc.)
    These typically don’t have strict open‑enrollment windows—you can apply at any time if you meet eligibility criteria. (NerdWallet)

What restrictions and eligibility issues to watch out for

  • Residency: You usually have to live in the state where you buy the plan. Being lawfully present in the U.S. is often required for Marketplace plans. (healthinsurance.org)
  • Income and subsidies: If you want help paying premiums or reducing out‑of‑pocket costs, your income & household size will matter. If your income is above certain levels, you might not get subsidies. (healthinsurance.org)
  • Employer offering “affordable” coverage: If your employer offers coverage that meets certain standards of cost and coverage, that can affect whether you’re eligible for subsidies in the Marketplace. (healthinsurance.org)
  • Medicaid expansion: Not all states have expanded Medicaid under the ACA. That affects eligibility. E.g., Texas has not expanded Medicaid, so some people with moderate incomes may not qualify even if in many other states they would. (healthinsurance.org)

If you tell me your state (or ZIP code) and maybe your income level / employment situation, I can pull up what your specific options are. Do you want me to find that for you?

Q: Pros and cons with COBRA

A:

COBRA (the Consolidated Omnibus Budget Reconciliation Act) gives you the option to keep your employer-sponsored health insurance after leaving a job or losing coverage — but it comes with trade-offs.

Here’s a clear look at the pros and cons of COBRA:

✅ Pros of COBRA

Benefit Explanation
Same coverage You keep exactly the same plan — same network, doctors, benefits, etc. No need to change providers or figure out a new system.
No gap in coverage Coverage continues without interruption if you act quickly (usually retroactive to the day you lost it). This can be helpful if you’re in the middle of treatment.
Covers dependents You can extend COBRA to cover your spouse and/or kids who were on the original plan.
Good short-term option It can be useful while you transition between jobs or wait for new coverage to start.
Avoids needing to re-meet deductibles If you switch to a new plan mid-year, you’d typically start a new deductible. COBRA lets you keep the same one.

❌ Cons of COBRA

Drawback Explanation
Very expensive You pay the full premium (what your employer paid + your portion), plus a 2% admin fee. This can be $400–$1,000+ per person per month depending on the plan.
Limited time Usually lasts up to 18 months, sometimes 36 months depending on the reason for losing coverage (e.g. divorce, death of employee, etc.).
No subsidies COBRA is not eligible for government subsidies like ACA plans. If your income is low/moderate, Marketplace plans are likely far cheaper.
Can be confusing to set up Paperwork deadlines are strict. You typically have 60 days to opt in, and then must pay retroactive premiums going back to when coverage was lost.
Not flexible You can’t change your COBRA plan or coverage level — it’s either the same or nothing.
Doesn’t protect against plan changes If your former employer changes or discontinues the plan for active employees, your COBRA plan changes too, or may end entirely.

Example: COBRA vs Marketplace (ACA) Comparison

Feature COBRA ACA Marketplace Plan
Monthly premium $600–$1,800 (avg family) $0–$500+ (with subsidy)
Doctors/hospitals Same as old job New network, may be different
Deductible Continues from job plan Resets with new plan
Length of coverage Up to 18–36 months Ongoing
Subsidy help? ❌ No ✅ Yes, based on income

When is COBRA worth it?

It might be a good option if:

  • You can afford it and want to keep your doctors/hospital.
  • You’re in the middle of major treatment (e.g. surgery, cancer care, pregnancy).
  • You expect new insurance soon (e.g. starting a new job in a month or two).
  • Your income is too high to qualify for Marketplace subsidies.

If you’d like, I can help you compare COBRA vs Marketplace options based on your situation (e.g. location, income, family size). Just let me know.

Q: So, if get onto COBRA like now, in month of September, and open enrollment for next period starts November 1, what happens then? Do I have choices as an employee or what happens?

A:

Great question — you’re thinking ahead, which is smart. Here’s exactly what happens if you start COBRA in September, and how it intersects with Open Enrollment (OE) starting November 1:

✅ Your COBRA + Open Enrollment Options:

▶️ Now (September):

  • If you elect COBRA now, you’ll stay on your former employer’s health plan.
  • Coverage is typically retroactive to the day you lost employer coverage (e.g., August 31 if your job ended then).
  • You pay the full premium + 2% (no subsidies).

▶️ Starting November 1: ACA Open Enrollment Begins

You now get new choices, regardless of COBRA:

  1. You can stay on COBRA:
    • If it’s working for you and you can afford it, you can continue paying for COBRA through its usual duration (usually 18 months).
    • No action required during open enrollment if you stay.
  2. You can switch to an ACA Marketplace plan:
    • COBRA does NOT lock you out of switching to an ACA plan during Open Enrollment.
    • You can enroll in a new ACA plan from Nov. 1 through Jan. 15 (in most states).
    • That new plan would start January 1, not immediately (important detail).
    • You’ll then drop COBRA as of Dec. 31 and transition to your new ACA plan on Jan. 1.

🚨 Important Things to Know

Question Answer
Can I switch from COBRA to an ACA plan during Open Enrollment? ✅ Yes — Open Enrollment lets anyone enroll or switch, even if you’re on COBRA.
Will I lose COBRA if I shop for other plans? ❌ No — you’re allowed to shop, compare, or switch without affecting your COBRA coverage unless you actively cancel it.
Can I go back to COBRA after leaving it? ❌ No — once you drop COBRA or let it lapse, you cannot get it back. So be sure about the switch.
Can I get subsidies on the ACA plan? ✅ Yes — if your income qualifies, you can get premium subsidies, which COBRA doesn’t offer.
Should I wait until Jan 1 to drop COBRA? ✅ Usually yes — drop COBRA only after your new ACA plan is active to avoid a coverage gap.

🎯 Strategy Summary

Timeframe What to Do
Now through October Stay on COBRA (if needed), or start it if you haven’t yet.
November 1 – January 15 Shop ACA plans at HealthCare.gov (or your state exchange). Enroll in a plan to start January 1.
By December 31 Cancel COBRA effective Dec. 31 if you’re switching to an ACA plan.
January 1 New plan starts. COBRA ends. You’re now covered under a new, likely more affordable plan.

If you want, I can help you:

  • Estimate your ACA premiums based on your income
  • Find the best time to cancel COBRA
  • Compare COBRA vs ACA benefits for your situation

Just let me know your state, estimated income, and household size — or whatever you’re comfortable sharing.

Q: When do I have to start paying for COBRA?

A:

When you elect COBRA, you don’t have to pay right away, but there are very specific deadlines to follow. Here’s how it works:

🗓️ COBRA Payment Timeline

✅ 1. You have 60 days to elect COBRA

  • After your employer or plan administrator notifies you of your COBRA rights (usually within 14 days of your coverage ending), you have 60 days to decide whether to sign up.
  • Your coverage is retroactive to the date you lost your employer-sponsored insurance, if you elect it within that time.

✅ 2. **You have 45 more days to make your first payment

  • Once you elect COBRA, you then have 45 days to pay your first premium.
  • That first payment must cover all months back to the date your coverage lapsed.

🔁 3. Ongoing monthly payments

  • After your first payment, you must make payments every month, typically with a 30-day grace period.
  • You’ll get a payment schedule from the COBRA administrator.

📌 Example Timeline

Let’s say you lost your job and health coverage on August 31:

Date What Happens
Sept 1 Coverage ends. COBRA notice sent (by Sept 14).
By Oct 30 (60 days) You must elect COBRA to get retroactive coverage to Sept 1.
By Dec 14 (45 days from election) You must make the first payment, covering premiums for Sept, Oct, Nov (if applicable).
Then monthly Pay each following month, or coverage is canceled after 30-day grace.

💡 Key Points to Remember

Point Details
Coverage is not active until paid Even if you elect COBRA, the coverage doesn’t kick in until you make the first payment. However, it will apply retroactively once you do.
You can wait and see If you’re healthy and not using care, some people wait to see if they need COBRA — and only pay if something happens. But this is risky, especially for prescriptions or ongoing care.
Miss the deadlines = no COBRA If you miss either the 60-day election window or the 45-day payment deadline, you lose COBRA permanently. No second chance.

Do you want help figuring out how much your COBRA premium might be or whether ACA would be cheaper in your case?

Q: Yes, how to figure out our COBRA premium?

A:

To figure out your COBRA premium, here’s how it works and how you can estimate it.

🧾 How COBRA Premiums Are Calculated

Your COBRA premium is:

100% of the total cost of your health insurance plan
+
2% administrative fee

That means you pay both your share and the employer’s share of the premium, plus a small fee.

🧮 Ways to Find Out Your COBRA Premium

✅ 1. Check your last pay stub or HR portal

  • Look for what you were paying for health insurance (your portion).
  • That’s usually just 20–30% of the full cost. Your employer was likely paying the rest.

Example:

Cost Estimate
Your payroll deduction for health insurance $250/month
Employer portion (guess: 75%) ~$750/month
Total plan cost ~$1,000/month
Add 2% admin fee $1,020/month = Your COBRA premium

✅ 2. Wait for your COBRA election packet

  • Your former employer (or their COBRA administrator) must send you a notice within 14–44 days of your coverage ending.
  • This will list:
    • Plan options
    • Premiums
    • Instructions and deadlines
  • If you haven’t received this packet and it’s been more than 2 weeks since your coverage ended, contact HR or benefits ASAP.

✅ 3. Call your HR or benefits administrator

You can ask directly:

“What will my COBRA premium be for my current plan? Can I get a breakdown by medical/dental/vision?”

They should tell you the full monthly cost and help you confirm what’s included.

🧠 Tip: Compare with ACA Marketplace

Because COBRA is often expensive, it’s worth comparing with ACA plans.

If you give me:

  • Your ZIP code
  • Household size
  • Estimated income for 2025

I can:

  • Show you approximate ACA premiums after subsidies
  • Help you decide whether to keep COBRA short-term or switch during Open Enrollment (Nov. 1)

Let me know if you want to run that estimate.

Q: 78758, 2 adults, $150,000    (limit how much we take out in INCOME, a test to see what will happen)

A:

If two adults in ZIP code 78758 (Austin area, Texas) have a household income of $150,000 per year, here’s a breakdown of what your ACA Marketplace (HealthCare.gov) plan costs might look like — and how that compares to what a COBRA premium could be.

🔍 ACA Marketplace Estimate for $150,000 & 2 Adults in 78758

Here are relevant facts & likely premium ranges:

  • Texas uses the federal Marketplace. (healthinsurance.org)
  • To qualify for premium tax credits (subsidies) under the ACA, your income must be up to a certain level relative to the Federal Poverty Level (FPL). With $150,000 for two people, you very likely are above the range where subsidies are available. (Subsidies phase out generally once income is above ~400% of FPL, though recent changes/temporary expansions have affected that. (The Texas Tribune))

Given that, here’s what you’ll probably see:

Plan Tier Approx Monthly Premiums (without subsidy) for 2 adults in this income range*
Bronze ~$700‑$1,000+
Silver ~$800‑$1,200+
Gold ~$1,000‑$1,500+
Platinum (if available) even higher

*These are rough guesses based on available ACA Texas market data. Deductibles, provider networks, and plan details will affect this a lot.

⚠️ Why ACA Costs Likely Higher for You

Because your income at $150,000 for two people is almost certainly above the cutoff for receiving any premium tax credit or subsidy (or very little if partial), you’d be paying the full price of the plan. That means no discounts, so you bear the full monthly premium + deductibles + out‑of‑pocket costs.

⚡ COBRA vs ACA Given Your Situation

Since your income is high, ACA plans are likely fairly expensive for you. COBRA premiums—though high— might sometimes be competitive depending on what your employer’s plan cost is and how much the employer was subsidizing.

Here’s how to compare:

  1. Find out your employer’s total plan cost (employer + your share) and multiply by COBRA’s 102% (includes the 2% admin fee). That’s your COBRA cost.
  2. Get quotes for ACA plans for your age(s), ZIP code, etc. (with no subsidy assumed if you’re over the subsidy threshold).
  3. Compare monthly costs + your expected healthcare usage (how much you think you’ll pay out‑of‑pocket for doctors, etc.).

If you like, I can pull up real plan quotes for two adults in 78758 with your income, so you have exact numbers to choose from. Do you want me to do that?

Q:  Timeline for enrollment et c for COBRA if last day of coverage is Oct 3.  (2025-09-15)

A:

If your last day of coverage under your group health plan is October 3, here’s a detailed timeline of your COBRA rights and key dates:

🔹 1. Qualifying Event Date

  • October 3, 2025 – This is your last day of coverage, so your COBRA qualifying event date is usually considered October 4, 2025 (the day after coverage ends).

🔹 2. Employer Notification to Plan Administrator

  • The employer has 30 days from the qualifying event to notify the plan administrator.
  • Deadline: November 3, 2025

🔹 3. Plan Administrator Sends COBRA Election Notice

  • After being notified, the plan administrator has 14 days to send you the COBRA election notice.
  • Deadline: November 17, 2025

🔹 4. You Have 60 Days to Elect COBRA

  • You have 60 days from the later of:
    • The date your coverage ended (October 3), or
    • The date the COBRA election notice is sent.

⚠️ Usually, it’s the notice date that controls.

  • If the notice is sent on November 17, 2025, your deadline to elect COBRA would be:
    • January 16, 2026

🔹 5. You Have 45 Days to Pay First Premium

  • Once you elect COBRA, you have 45 days to make your first payment (which may include retroactive premiums back to the date coverage ended).
  • For example, if you elect COBRA on January 10, 2026, your payment deadline would be:
    • February 24, 2026

🧾 Summary Timeline

Event Date
Last day of coverage October 3, 2025
COBRA Qualifying Event Date October 4, 2025
Employer notifies plan admin By November 3, 2025
COBRA notice sent to you By November 17, 2025
COBRA election deadline Likely by January 16, 2026
First premium payment due 45 days after election

Would you like a printable version or reminder calendar for these dates?

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