The case of a Presque Isle man’s mysterious health insurance plan

When Wilbur Clark of Presque Isle originally sent in a letter to the editor, published in the BDN in November, about signing up for health care coverage, he was frustrated. He had been laid off from his work as a mechanic for the Maine Military Authority in Limestone the previous month. At the age of 59, he was worried about his employment prospects and his options for health care.

Under the Affordable Care Act, he had tried signing up for a health insurance plan on HealthCare.gov but was floored at the price the website quoted him: He would have to pay a premium of more than $700 per month. He had used a subsidy calculator online to figure out what he’d owe, he said, and it wasn’t anything close. His letter described how such a high monthly premium would leave Mainers with nothing else to live on, once other living expenses were considered.

The problem, of course, is that someone earning Clark’s income — or, now, lack of income — should pay far less. We talked. He emailed screenshots of some of his selections and results online and described his steps: The site verified his identity and his eligibility; it gave him a confirmation ID number; he reported a 2012 federal adjusted gross income of $21,468; he reported he is single with no dependents; he estimated his 2014 income would be similar to 2012, given unemployment benefits.

He sent me a copy of his tax return to verify his income; and the site, which connects to the Internal Revenue Services to determine an applicant’s eligibility for subsidies, also verifies income.

He looked at four different plans, including a $735-per-month “silver” plan and a $657-per-month “bronze” plan. Yet in the spot after “premium tax credit,” the amount totaled “$0.00/mo.” He apparently wasn’t eligible for a subsidy. Still, he selected bronze.

When he sought clarification from both the Aroostook County Action Program, which is the local navigator to help people sign up, and the federal help line, he was told he should qualify for a subsidy. A representative at ACAP also confirmed to me at the end of November that someone with his income should receive a subsidy. That was one thing everyone clearly agreed on.

We wondered whether it could be a technical glitch. A representative from the U.S. Department of Health and Human Services, however, told me the agency wasn’t aware of any problems with premiums being displayed inaccurately. She couldn’t speak about Clark’s specific situation but said it was possible he hadn’t presented a full picture of his estimated 2014 income, as “income” doesn’t just include wages but items such as unemployment compensation and Social Security payments. Or, perhaps, he had elected to not apply the tax credit to his monthly premium but instead collect it during the tax filing process.

By that time, Clark had already submitted his application and couldn’t go back to review the steps he’d taken along the way. It was a possibility, he said, that he hadn’t estimated his 2014 income correctly. He didn’t remember requesting to receive the subsidy all at once.

“I was told repeatedly not to trust the calculators, that the estimate I got, the premium I got on the website, was accurate,” he said.

To make matters urgent, on Dec. 2, Clark received a bill. HealthCare.gov had processed his insurance selection and sent him an invoice via insurer Maine Community Health Options. He sent it to me. It said he owed $657 by Dec. 15 for coverage during the month of January.

He filed an appeal with the federal government and, after some back and forth communication, was ultimately able to delete his application and start over. He said he filled out the application for a second time — correcting his expected 2014 wages to account for updated unemployment and displaced worker benefits, lowering the total to $18,000 — and got a similar result: no subsidy.

He got in touch with Maine Community Health Options, which organized a conference call with HealthCare.gov, and they figured out the application with him over the phone. He said he didn’t answer questions differently over the phone.

He emailed me Dec. 30 to describe it: “Had a conference call with Maine Health Options and HealthCare.gov this morning. They redid my application a third time and got a subsidy this time. I have health insurance now for thirty six dollars a month, with a 500 deductible and a 10 dollar co-pay.”

That’s right: His premium is $36 per month.

He printed out his health insurance ID card on Thursday, and his first payment of $36 has been deducted from his bank account.

He is happy to finally have coverage and said he didn’t get discouraged along the way. “I’m in a position where I have nothing to lose and everything to gain. So every attempt that I made and every time I came up against a brick wall with technical problems and problems on the telephone and having to redo things, I was in a position where I had nothing to lose and everything to gain. Now that I have a subsidy and affordable health care, it’s made it worth it,” he said.

And the reason why he didn’t get a subsidy in the first place? The two main possible explanations are human error or technical glitches, but there’s no way to know for sure. It will remain a mystery for now.

The only error he could have made, Clark said, was when the website asked whether he wanted a subsidy. “I am positive that I clicked on ‘yes’ both times,” he said.

He questioned why that step was in place. “Why would someone applying for health care have to make a decision on whether they want to be considered for a subsidy or not? Wouldn’t entering the information of your income level tell them immediately whether you were eligible for a subsidy or not, and who would turn it down?”

Kevin Lewis, chief executive officer of Maine Community Health Options, said he couldn’t speak about Clark specifically. “But I can say that we’ve worked successfully with hundreds or thousands of people to ensure that they have the advantage of the ACA’s advanced premium tax credit.”

The lesson, of course, is to be vigilant. If you’re quoted a price that doesn’t make sense or you think is wrong, get help. Call the federal hotline, a local navigator or the insurer, and don’t give up.

Clark didn’t, and he won’t anytime soon. After working as a mechanic his whole life, he’s going back to school. He’ll pursue a master of business administration degree from Husson University in Bangor. Classes start Jan. 21. It’s a new year.

Erin Rhoda

About Erin Rhoda

Erin Rhoda is a writer and storyteller. As editorial page editor of the Bangor Daily News, she writes the newspaper's opinion on matters from Kittery to Fort Kent.