Monday, April 29, 2013

State employees will be forced into Federal Health Exchange plans as they are forced out of their State provided Health insurance!

Hold on a cotton-pickin’ minute! Didn’t Obama say that is you like your health insurance that you can keep it? YES HE DID! Now Washington State has found a way to “PUSH” all of its State’s workers into the federal health exchange. Now the Washington State Workers will be losing the Health Insurance that they enjoy, and be forced into an exchange. That will drive down physician office reimbursements. Patients/Washington State worker’s exchange plan will pay the doctor much less than a private insurance plan would!


Governments may push workers to health exchange
 

OLYMPIA, Wash. (AP) - In a move that would capitalize on provisions under President Barack Obama's health care law but could cost the federal government millions of dollars, Washington state lawmakers have found a creative way to pass a large chunk of their health care expenses along to Washington, D.C. - and analysts say others are likely to follow suit.

The plan threatens to affect the federal budget and the pocketbooks of some part-time workers, as it would push a group of employees out of their current health care plans and into an exchange developed under the Affordable Care Act.

Observers say the shift seems to run counter to the intent of the new health care law. Supporters, however, say it's a viable strategy for governments to pursue as they manage the insurance rules related to part-time staff.

Washington state appears to be the first major government to seriously explore the possibility of pushing workers into the exchange - but it probably won't be the last. Rick Johnson, who advises state and local governments on health care policy at the New York-based consulting firm Segal Company, said he expects it will be an option some governments will look at in the years to come.

"I can see that as one of the solutions out there," Johnson said.

A spokeswoman with the Department of Health and Human Services declined comment, and it's unclear whether the federal government accounted for this possible outcome.

While Democratic lawmakers have expressed concern about the Washington state plan this year, it is drawing growing interest among a bipartisan group of political leaders in the state. Democratic Gov. Jay Inslee, who supported the Obama health care law while in Congress, has reservations about the plan.

But the former congressman said federal rules don't dictate how employers and employees should handle insurance coverage and indicated that he may consider supporting the idea in the future.

"It's one of those ideas that's premature for us to launch this year, but I don't think we should take it off the table," Inslee said Tuesday.

The Washington state proposal has come before lawmakers as governments around the nation are formulating strategies to manage those who don't work 40 hours a week, since the federal law requires employers to provide coverage for those working at least 30 hours.

Virginia, for example, is requiring all part-time employees to work fewer than 30 hours, which will help the state avoid penalties for not providing health coverage. Florida, facing a potential $300 million penalty for not covering workers who have 30 to 39 hours a week, is moving to extend coverage to those employees.

Washington state is in a less common situation, since it already provides coverage for part-timers down to 20 hours a week.

Budget writers in Olympia say their plan would save Washington state $120 million over the next two years. However, it would consequently push more health care costs onto the federal government, since many low-income part-time state employees and education workers would likely qualify for federal subsidies.

Under the proposal, which has been advanced as a way to help deal with a $1.2 billion budget shortfall, Washington state would make policy changes and secure agreements in which staffers who work between 20 and 30 hours a week would get extra compensation but lose state health coverage. They would then be eligible to get health care in the federal plan, without any consequence for the state.

K-12 workers would have to adopt new bargaining agreements to implement the change, though the state would help by offering sweeteners that would be equivalent to as much as a $2 per hour raise.

Rick Chisa, political director at the Public School Employees of Washington, said the union is open to shifting some workers to the exchange but didn't feel that the current proposal - an inducement valued at perhaps $200 a month for someone working 25 hours a week - provided an adequate incentive, especially if it may be taxed as compensation.

He said the change may eventually make sense for cafeteria workers and teacher's assistants who are on the low end of the pay spectrum, but union leaders also want to see what the insurance product will end up looking like in the exchange before making that move.

"We want to make sure that we're not selling workers short and being mesmerized by a shiny $2 bill," Chisa said. He said it was "very unlikely" for such a shift to happen this year.

The shift could be a problem particularly for part-time workers who have larger family incomes.

Steve Hodes, who works 24 hours a week doing policy work for the Employment Security Department, said he would not qualify for insurance subsidies because his wife makes a decent salary working as an attorney.

He suspects he and his family might be on the hook for thousands of dollars in new expenses if he was moved to the exchange, though solid numbers are elusive since the exchange doesn't exist yet.

"They don't have a clue how much it is," said Hodes, 63.

Under the federal law, large employers who don't provide coverage to full-time workers will face penalties, but they won't face penalties for not covering employees who work under 30 hours a week. Thousands of part-time government employees in Washington state work between 20 and 30 hours a week and currently qualify for state medical coverage.

Observers have been concerned about how private employers will handle the new health care law and the possibility that some may shed insurance coverage. The owner of Olive Garden and Red Lobster restaurants, for example, began experimenting last year with putting more workers on part-time status.

Virginia is doing something similar, with Republican Gov. Bob McDonnell directing that all part-time state employees work less than 29 hours weekly. That is creating a financially crippling problem for many of Virginia's 9,100 adjunct faculty members at the state's 23 community colleges on 40 campuses statewide.

"I've never anticipated getting rich off being a teacher," said J. Gabriel Scala, an adjunct English professor at J. Sargeant Reynolds Community College in Richmond.

"But the rent has to be paid. And I have to eat. And gas has to be put in the car - and $17,000 a year isn't going to do it," she added.

The efforts appear to be the beginning stages of governments working to manage their costs under the health care law.

Washington Democratic state Sen. Jim Hargrove, one of the budget writers who helped develop his state's plan, said lawmakers were considering the option as a way to help both employees and the state budget.

"We're looking," Hargrove said, "at what the possibilities are."

---
AP Writer Mike Baker can be reached on Facebook: http://on.fb.me/HiPpEV

Monday, April 22, 2013

Obamacare causes a Primary Care Physician Shortage, and ah….they will go broke (like no pay for lots of hours worked) to boot!


 
 
Primary care physicians will be swamped if Obamacare is full enacted! First there will be a crush of Medicaid patients with a low reimbursement insurance (so Primary care docs will lose money). Then these primary Care physicians will have to act as a supervisor to an army of midlevel caregivers like Physician Assistants and Nurse practitioners. Let’s not forget about the pile of new government regulations that will occupy the physicians time when she or he could be treating patients!
Here is what you need to know….Physicians are smart and driven individuals, so they will find another line of work. Many doctors were born to health their fellow human beings, but even they have a tipping point. As that robot on “Lost in Space” used to say…”Danger! Danger!
 
 
Is America running out of doctors?

ObamaCare is set to expand the number of insured Americans, but an apparent shortage of doctors could make it difficult to treat them all

By The Week Staff | July 31, 2012

By the year 2025, the U.S. could have a shortfall of 100,000 doctors.

The primary objective of President Obama's overhaul of the health-care system is to extend coverage to the tens of millions of Americans currently without insurance. "But coverage will not necessarily translate into care," because there may not be enough doctors to treat everyone, say Annie Lowrey and Robert Pear at The New York Times. The U.S. is already facing a severe shortage of doctors, particularly in rural areas of the country, and the problem is only expected to get worse as more Americans gain insurance. Here, a guide to America's dearth of doctors:

Why aren't there enough doctors?
The pool of new doctors hasn't kept pace with
several factors boosting the number of people seeking care: Population growth, the ObamaCare expansion, and an aging Baby Boomer generation that requires additional medical attention. Enrollment in Medicare, the government-run insurance program for the elderly, is expected to swell to 73.2 million in 2025, up from 50.7 million in 2012. Furthermore, the U.S. is facing an acute shortage of primary-care physicians, leaving many patients without access to general practitioners, pediatricians, family doctors, and other providers of basic medical care.

How will the shortage affect patients?
"A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients,"
say Suzanne Sataline and Shirley S. Wang at The Wall Street Journal. The shortage will likely most affect those on Medicaid, the insurance program for the poor and disabled, since Medicaid's rolls are expected to expand significantly under ObamaCare. The shortfall of doctors could reach 100,000 by 2025. (There are currently about 1 million doctors in America.)

Why do so few doctors choose to go into primary care?
The main reason is money. Medical school graduates can expect to make an average of
$3.5 million more over the course of their careers if they choose to enter a specialized field, such as anesthesiology or radiology. The difference in pay is enough that primary-care physicians carry a stigma within the medical community of being less talented and intelligent. The trend has huge implications for ObamaCare: "It is no exaggeration to say that the success of the health-care law rests on young doctors choosing to do something that is not in their economic self-interest," says Sarah Kliff at The Washington Post.

What can we do about it?
ObamaCare contains modest
provisions increasing Medicaid primary-care payments and incentives for medical students to become primary-care physicians. The number of primary-care residencies climbed 20 percent between 2009 and 2011, but it's still not enough. Communities have been encouraged to create more walk-in clinics, and to allow more nurses to provide primary care. In addition, the U.S. could alter its immigration policies to attract doctors from overseas, "which should be very easy to do since doctors in the U.S. earn on average about twice as much as their comparably trained counterparts in Western Europe and Canada," says Dean Baker at Business Insider.

Friday, April 19, 2013

Obamacare will take my private health insurance from me...why...because I cannot pay a 62% increase in my private healthcare premium


Bottom line…There will be a huge increase in premiums for those of us that pay for our own Health Insurance. Where do I come up with a 26%, or 32%, or a 60% increase in my insurance premium. Patients that do not have insurance do not see the doctor. Obamacare will be a mess, and why should I be filed into some second rate Government sponsored health plan…I deserve better as an American, a Veteran, and a tax payer! We all do!

 Health Actuaries: Obamacare Rates Will Soar

But health law supporters are pushing back, noting close ties between the actuaries making the forecasts and an insurance industry that has been complaining about taxes.

By Jay Hancock, Kaiser Health News Staff Writer

THURSDAY, April 18, 2013 (Kaiser Health News) — Few aspects of the Affordable Care Act are more critical to its success than affordability, but in recent weeks experts have predicted costs for some health plans could soar next year.

Now health law supporters are pushing back, noting close ties between the actuaries making the forecasts and an insurance industry that has been complaining about taxes and other factors it says will lead to rate shock for consumers.

"Most actuaries in this country -- what percentage are employed by insurance companies?" Sen. Al Franken, a Minnesota Democrat, asked an actuary last week at a hearing of the Committee on Health, Education, Labor and Pensions.

The committee was discussing a study published last month by the Society of Actuaries (SOA) predicting that, thanks to sicker patients joining the coverage pool, medical claims per member will rise 32 percent in the individual plans expected to dominate the ACA exchanges next year. In some states costs will rise as much as 80 percent, the report said.

The witness was unable to answer Franken's question, but the senator made his point. Insurance is why actuaries exist. The industry and the profession are hard to separate. 

Using predictive math, actuaries try to make sure insurers of all kinds don’t run out of money to pay claims. Many actuaries also work for consultants whose clients include insurance companies.

Undisclosed in the SOA report was the fact that about half the people who oversaw it work for the health insurance industry that is warning about rate shock. The chairman of society committee supervising the project was Kenny Kan, chief actuary at Maryland-based CareFirst BlueCross BlueShield.

Others on the committee work for firms with insurer clients. The report included committee members’ names but not their affiliations.

The SOA "portray themselves as this nonpartisan think tank when in fact everything about the study is by people who have a vested interest in the outcome of the study," said Birny Birnbaum, executive director of the Center for Economic Justice, a Texas group that advocates on behalf of financial and utility consumers.

To perform the research, the society hired Optum, sister company of UnitedHealthcare, the country’s biggest private health insurer.

Society spokeswoman Kim McKeown said the project was overseen by credentialed actuaries "from a cross-section of industry organizations" and was "exposed for review and comment to the broad health care actuarial community."

Even supporters of the health act worry about premium increases next year, when many of its provisions take effect. But the debate fits into a larger discussion about actuaries’ public role. Actuaries are self-regulated, which some say makes them unaccountable.

Their associations set conduct standards and investigate malpractice in confidential proceedings. During the previous two decades the Actuarial Board for Counseling and Discipline, which works with the Society of Actuaries, has recommended public disciplinary measures for fewer than two people a year, according to its annual report.

Yet actuaries play many public roles. By calculating the adequacy of employer pension contributions they affect the retirement of millions. And they’ll act as virtual referees for important aspects of implementing the health act.  

"I have a great deal of respect for actuaries," said Timothy Jost, a law professor at Washington and Lee University and health law expert. "But I do think they often end up in … situations where the interests of the public and of their employers might be in conflict."

While the Obama administration has developed a calculator plans must use for determining whether insurance plans meet the health act’s standards for benefits and value, recently finalized regulations give insurer-employed actuaries the power to override it by substituting one benefit for another.

Insurance company actuaries calculate rates when plans file with states, which act as the industry’s primary regulators. Charged with making sure the prices are justified, state insurance departments often have far less actuarial expertise at their disposal than the insurers.

The Vermont Department of Financial regulation "does not have actuaries on staff," a spokeswoman said. "We outsource our review of rate filings."

The situation in 2011 was the same in a dozen other states, according to information compiled by the National Association of Insurance Commissioners.

Health-act supporters complained that that the actuary society's study predicting a 32 percent increase in claims didn't account for key factors, including the potential for competition to lower prices, the subsidies people will receive to buy the coverage and the fact that next year’s plans will be more generous than this year's.

Often actuaries' predictions are not significantly better than, say, those of the Weather Channel. Recent premium increases of 50 percent and higher for nursing home insurance reflect a previous under-calculation of costs by actuaries. Actuarial models didn't work especially well at calculating subprime mortgage risk a few years ago, either.

A settlement in New York last month revealed cases in which actuaries overestimated liabilities and a mortgage insurer paid out as little as 20 percent of collected premiums in claims.

Jost and Birnbaum want representatives of consumers and state insurance departments to be included on the actuaries’ discipline board. In proceedings at the insurance commissioners’ group, consumer advocates also want the board to state that actuaries' first duty is to the public whenever they furnish calculations to state or federal regulators and to tighten conflict-of-interest standards for firms producing work relied on by both insurers and regulators.

"There is always room for improvement in everything," said Karen Terry, an actuary for State Farm and the vice president of professionalism at the American Academy of Actuaries, an umbrella group that works with the discipline board and groups such as the SOA that represent professional subspecialties such as health or pension actuaries. "We're open to that dialogue."

Monday, April 15, 2013

Obamacare will double patients wait to see their Physician! What...don't believe me? In Massachusetts patients wait from 33 days to 55 days under Mass-Care (same thing as Obamacare).


The patients wait to see a Physician will double under Obamacare (Massachusetts patients wait an average of 55 days to see a Primary Care doctor). 45% of Physicians are over the age of 55, and they will not work for free under the Obamacare lower reimbursements! So…now what?


Behind the coming physician shortage

Michael Tanner

Posted: 11:01 PM, April 30, 2011

NEW YORK POST

The doctor is not in.

The United States already faces a growing physician shortage. As our population ages, we require more and more intensive health care. At the same time, enrollment in medical schools has been essentially flat, meaning we are not producing new physicians at anywhere near the rate we need to. In fact, according to the American Association of Medical Colleges, we face a shortfall of more than 150,000 doctors over the next 15 years.

And it could get a whole lot worse.

The health reform bill signed into law last year is expected to significantly increase the number of Americans with health insurance or participating in the Medicaid program. Meanwhile, an aging population will increase participation in Medicare. This means a greater demand for physician services.

But at the same, the bill may drive physicians out of practice.

Existing government programs already reimburse physicians at rates that are often less than the actual cost of treating a patient. Estimates suggest that on average physicians are reimbursed at roughly 78% of costs under Medicare, and just 70% of costs under Medicaid. Physicians must either make up for this shortfall by shifting costs to those patients with insurance — meaning those of us with insurance pay more — or treat patients at a loss.

As a result, more and more physicians are choosing to opt-out of the system altogether. Roughly 13% of physicians will not accept Medicare patients today. Another 17% limit the number of Medicare patients they will see, a figure that rises to 31% among primary care physicians. The story is even worse in Medicaid, where as many as a third of doctors will not participate in the program.

Traditionally, most doctors have been willing to take some Medicare patients either out of altruism or as a “loss leader,” to reach other family members outside the Medicare program. Others try to get around Medicare’s low reimbursement rates by unbundling services or providing care not covered through the program. (Nearly 85% of seniors carry supplemental policies to cover these additional services). With many office and equipment costs fixed, even a low reimbursement patient may be better than no patient at all for some doctors. This is even more true for hospitals where Medicare patients may account for the majority of people they serve. And doctors can take some comfort in the fact that Medicare is pretty much guaranteed to pay and pay promptly. The same is not always true of private insurance.

But if reimbursements fall much more, the balance could be tipped.

The government’s own chief actuary says that reimbursement cuts could mean “reductions in access to care and/or the quality of care.” Once the cuts hit hospitals, they too will be in trouble. Medicare’s actuaries estimate that 15% of hospitals could close. Inner-city and rural hospitals would be hardest hit.

Nor is the pressure on reimbursement rates likely to be felt solely in government programs. The health care law contains a number of new regulations that are already driving up insurance premiums. The government is responding by cajoling and threatening insurers. If insurers find their ability to pass on cost increases limited, they too may begin to cut costs by cutting reimbursements.

For a lot of older physicians, retirement in Florida may begin to look like a very good option. Roughly 40% of doctors are age 55 or over. Are they really going to want to stick it out for a few more years if all they have to look forward to is more red tape (both government and insurance company) for less money? Those that remain are increasingly likely to join “concierge practices,” limiting the number of patients they see and refusing both government and private insurance.

And, at the same time, fewer young people are likely to decide that medicine is a good career. Remember, the average medical school graduate begins their career with more than $295,000 in debt.

A 2010 IBD/TPP Poll found that 45% of doctors would at least consider leaving their practices or taking early retirement as a result of the new health care law. And, an online survey by Sermo.com, a sort of Facebook for physicians, found that 26% of physicians in solo practices were considering closing. Of course, not every doctor who told these polls that he or she would consider leaving the field will actually do so. But if even a small portion depart, our access to medical care will suffer.

In fact, we have already seen the start of this process in Massachusetts, where Mitt Romney’s health care reforms were nearly identical to President Obama’s. Romney’s reforms increased the demand for health care but did nothing to expand the supply of physicians. In fact, by cracking down on insurance premiums, Massachusetts pushed insurers to reduce their payments to providers, making it less worthwhile for doctors to expand their practices. As a result, the average wait to get an appointment with a doctor grew from 33 days to over 55 days.

Promising universal health coverage is easy. But what does universal coverage mean if you can’t actually see a doctor?

Michael Tanner, a Cato Institute senior fellow, is co-author of “Healthy Competition: What’s Holding Back Health Care and How To Free It.”

Monday, April 8, 2013

Here comes Obamacare, and doctors are starting to declare bankruptcy!


 
Doctors going broke, and declaring bankruptcy? If lowered third party reimbursements, and cash paying patients becoming extinct is not enough….Here comes Obamacare! It’s going to be ugly! Physicians will make less and less, patients will have longer waits and higher premiums, and malpractice lawyers will be laughing all the way to the bank!
 
Doctors driven to bankruptcy

By Parija Kavilanz @CNNMoney April 8, 2013: 6:00 AM ET

NEW YORK (CNNMoney)

As many doctors struggle to keep their practices financially sound, some are buckling under money woes and being pushed into bankruptcy.

It's a trend that's accelerated in recent years, industry experts say, with potentially serious consequences for doctors and patients. Some physicians are still able to keep practicing after bankruptcy, but for others, it's a career-ending event. And when a practice shuts its doors, patients can find it harder to get the health care they need nearby.

Chapter 11 bankruptcy filings by physician practices spiked in March, noted Bobby Guy, co-chair of the American Bankruptcy Institute's health care committee. "Eight filings in three weeks is very unusual," said Guy.

Five years ago, Plantation, Fla.-based bankruptcy attorney David Langley didn't have a single doctor as a client. Since then he's handled at least six bankruptcy cases involving doctors. Two current clients -- an orthopedic surgeon and an OB/GYN -- also are in bankruptcy.

None of his physician clients had malpractice lawsuits that landed them in dire financial straits. All are "top-notch doctors," he said.

The weak economy has taken a toll on doctors' revenue, as consumers cut back on office visits and lucrative elective procedures, said Guy, a bankruptcy attorney in Nashville with Frost Brown Todd LLC.

Doctors also blame shrinking insurance reimbursements, changing regulations, and the rising costs of malpractice insurance, drugs and other business necessities for making it harder to keep their practices afloat.

Oncologist Dr. Dennis Morgan had a profitable solo practice in Enfield, Conn., for years. Revenues began to fall, he said, when reimbursements for treatment and drugs to oncologists started shrinking. He made cutbacks, but he began having trouble meeting expenses, and his business debt grew. Critical chemotherapy drug and medical supplies providers "eventually cut me off," Morgan said.

In June 2011, his practice, in a medically underserved area, filed for bankruptcy. It had hundreds of chemotherapy patients at the time.

For the next two years, his role became "that of a captain of a sinking ship managing the allocation of life boats until rescue arrived," he said. He redirected patients to other doctors and area hospitals. Early last year, he stopped practicing medicine.

Having a cancer practice close can be "debilitating" to a community, said Morgan. "If you have to travel one or two hours to get treatment and you have no one to go with you, it becomes a matter of getting care or not getting care," he said.

Primary care doctors face similar challenges. Langley recounts one client, a solo practitioner in an underserved area of Broward County, Fla., whose patients were mostly on Medicare or lacked insurance.

As the economy worsened in the wake of the recession, fewer patients could afford to come in. Cash payments and reimbursements dropped. To come up with money to keep the practice going, she took a second job at a hospital. Still, her debt ballooned. She fell behind on state tax payments.

Two years ago, Florida tax officials showed up at her door to shut the clinic down. She quickly called Langley and he was able to file an emergency bankruptcy for her online while the officials were still in the waiting room. He gave them the bankruptcy case number, and they left without closing the clinic. Langley eventually helped the doctor restructure her debt and the clinic is still open, he said.

Dr. Morgan Moor was on the brink of bankruptcy in 2011. An internist with a solo practice in Brentwood, Tenn., Moor said the recession badly hurt her once-thriving practice. By 2010, she had lost almost half of her active patients, her annual revenue had dropped nearly 30%, and she had to lay off half her employees.

"We were told that bankruptcy was our only option," she said. So she hired Guy. Luckily, Moor said, she was able to restructure her debt and her business without filing.

Every day since has been a struggle, though. "Every payroll, I wonder if we will be able to keep doing this," she said. "I try not to think about it because it paralyzes me with fear”.

Wednesday, April 3, 2013

Obamacare raises taxes on middle income tax payors! Or something! Who knows?


Ok, so you will be made to purchase something you may or may not want! Then you will be made to pay a tax on something you may or may not want. Or something! Who knows? Where is all this money going? Not to the doctors!

 

Millions Could Get Surprise Tax Bills Under ‘Obamacare’ If They Don’t Accurately Project Their Income

April 2, 2013 1:31 PM

Related tags


 

WASHINGTON (AP) — Millions of people who take advantage of government subsidies to help buy health insurance next year could get stung by surprise tax bills if they don’t accurately project their income.

President Barack Obama’s new health care law will offer subsidies to help people buy private health insurance on state-based exchanges, if they don’t already get coverage through their employers. The subsidies are based on income. The lower your income, the bigger the subsidy.

But the government doesn’t know how much money you’re going to make next year. And when you apply for the subsidy, this fall, it won’t even know how much you’re making this year. So, unless you tell the government otherwise, it will rely on the best information it has: your 2012 tax return, filed this spring.

What happens if you or your spouse gets a raise and your family income goes up in 2014? You could end up with a bigger subsidy than you are entitled to. If that happens, the law says you have to pay back at least part of the money when you file your tax return in the spring of 2015.

That could result in smaller tax refunds or surprise tax bills for millions of middle-income families.

“That’s scary,” says Joan Baird of Springfield, Va. “I had no idea, and I work in health care.”

Baird, a health care information management worker, is far from alone. Health care providers, advocates and tax experts say the vast majority of Americans know very little about the new health care law, let alone the kind of detailed information many will need to navigate its system of subsidies and penalties.

“They know it’s out there,” said Mark Cummings, who manages the H&R Block office where Baird was getting her own taxes done. “But in general, they don’t know anything about it.”

A draft of the application for insurance asks people to project their 2014 income if their current income is not steady or if they expect it to change. The application runs 15 pages for a three-person family, but nowhere does it warn people that they may have to repay part of the subsidy if their income increases.

“I think this will be the hardest thing for members of the public to understand because it is a novel aspect of this tax credit,” said Catherine Livingston, who recently served as health care counsel for the Internal Revenue Service. “I can’t think of what else they do in the tax system currently that works that way.” Livingston is now a partner in the Washington office of the law firm Jones Day.

There’s another wrinkle: The vast majority of taxpayers won’t actually receive the subsidies. Instead, the money will be paid directly to insurance companies and consumers will get the benefit in reduced premiums.

Health care providers and advocates for people who don’t have insurance are planning public awareness campaigns to teach people about the health care law and its benefits.

Enroll America, a coalition of health care providers and advocates, is planning a multimillion-dollar campaign using social media, paid advertising and grass-roots organizing to encourage people who don’t have insurance to sign up for it, said Anne Filipic, a former Obama White House official who is now president of the organization.

The Obama administration says it, too, is working to educate consumers.

“On Oct. 1, each state will have a marketplace up and running where consumers can choose a private health insurance plan that fits their health needs and budget,” said Treasury spokeswoman Sabrina Siddiqui. “The premium tax credits will give middle-class Americans unprecedented tax benefits to make the purchase of health insurance affordable for everyone, and we will continue to work with consumers, community health organizations and other stakeholders to raise awareness and understanding of these tax benefits.”

The subsidies, which are technically tax credits because they are administered through the tax code, will help low- and middle-income families buy health insurance through the state-based exchanges. Under the new law, nearly every American will be required to have health insurance starting in 2014, or face penalties.

The enrollment season starts Oct. 1.

The subsidies are available to families with incomes up to 400 percent of the poverty level. This year, four times the poverty level is about $62,000 for a two-person family. For a family of four, it’s $94,200.

About 18 million people will be eligible for subsidies, according to the Congressional Budget Office.

If families get bigger subsidies than they are entitled to under the law, the amount they have to repay is capped, based on income and family size. If they get less than they qualify for under the law, the government will pay them the difference in the form of a tax refund.

There are also special rules that protect people who marry or divorce from being required to pay back subsidies just because their marital status changes.

There are four thresholds for repaying the subsidies:

–A family of four making less than $47,000 would have to repay a maximum of $600.

–If the same family makes between $47,000 and $70,000, the amount they have to repay is capped at $1,500.

–If the same family makes between $70,000 and $94,200, the amount is capped at $2,500.

–Families making more than four times the poverty level have to repay the entire subsidy.

“It’s potentially going to come as a shock to individuals who meet that criteria where their income hits a point where they owe money back,” said Rep. Charles Boustany, R-La., chairman of the House Ways and Means oversight subcommittee. “The fact is, with variations in income, people could end up owing money back and that will create consternation and problems for them.”

The total amount of money that taxpayers will have to repay is unclear, but congressional estimates offer some clues.

Twice since the health care law was passed Congress has increased the caps for how much people will have to repay. Combined, the two measures are expected to raise more than $40 billion over the next decade, according to Congress’ Joint Committee on Taxation.

“I think people will get there,” said Livingston, the former IRS official. “They will develop instincts about it the way we all do about any process we go through multiple times. But when it’s new, in the early years, this will be a real learning curve.”

(© Copyright 2013 The Associated Press. All Rights Reserved. This material may not be published, broadcast, rewritten or redistributed.)