Some readers want to figure out how to become eligible for coverage on the health insurance marketplaces, while others want to figure out how to avoid it. This week I answered questions from both.

I am covered by my employer’s health plan, but I’m not happy with it. My son is 21 and currently covered under my plan. While I realize that I am not eligible for Obamacare, I am curious if I can terminate my son’s policy so that he might be eligible.  

Since the open enrollment period to sign up for coverage on the state marketplaces ended Feb. 15, in general people can’t enroll in a marketplace plan until next year’s open enrollment period rolls around.

If you drop your son from your employer plan, however, his loss of coverage could trigger a special enrollment period that allows him to sign up for a marketplace plan. Whether he’s entitled to a special enrollment period depends on whether his loss of coverage is considered voluntary, say officials at the Centers for Medicare & Medicaid Services. In general, voluntarily dropping employer-sponsored coverage doesn’t trigger a special enrollment period for individuals or their family members. But if you drop your son’s coverage on his behalf without his consent, his loss of coverage wouldn’t be considered voluntary and your son could qualify, according to CMS.

Whether he’ll be eligible for premium tax credits to make marketplace coverage more affordable is another matter, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

If you claim him as your dependent, he generally won’t be eligible. If you don’t claim him as your dependent, he would have to qualify for subsidies based on his own income.

I received a notice from the Pennsylvania Children’s Health Insurance Program that says they are eliminating CHIP coverage for participants who pay full-cost CHIP because it isn’t compliant with the Affordable Care Act. They are forcing us onto the marketplace where the premiums are higher and our deductibles are higher. I believe the state is using the ACA to dismantle its CHIP plan. What can we do?

You should be able to keep your full-cost CHIP coverage after all because state and federal officials reached an agreement on the issue, say consumer advocates in Pennsylvania.

CHIP offers coverage to children in families that earn too much to qualify for Medicaid, the joint federal-state health program for low-income people. But in six states – including Pennsylvania – the program allows families that earn too much to qualify for CHIP under its guidelines to enroll their kids if they pay the full cost of coverage.

The federal government, however, determined that, among other things, the CHIP buy-in program didn’t comply with the health law because plans had annual limits on certain types of coverage, such as behavioral health and physical therapy, that aren’t allowed, says Ann Bacharach, special projects director at the Pennsylvania Health Law Project. That meant that the families of roughly 3,600 kids in the program would face penalties because the kids wouldn’t be considered to have “minimum essential coverage.”

But after notifying families that the full-cost CHIP coverage was ending, Pennsylvania Gov. Tom Wolf this month announced that his administration had reached an agreement with the federal government so that coverage could continue without penalties. Insurers, meanwhile, will work over the coming months to bring the plans into compliance with the health law.

I recently had a disability hearing that went well.  If I receive Medicare later in the year, will I be able to terminate my state marketplace plan?

In general, Medicare coverage doesn’t begin until two years after someone is approved for and begins receiving payments for Social Security Disability Insurance.

Once your Medicare coverage starts, it probably makes financial sense to drop your marketplace plan, says Tricia Neuman, director of the Program on Medicare Policy at the Kaiser Family Foundation (KHN is an editorially independent policy of the foundation.)

“Individuals covered by Medicare are not eligible for marketplace subsidies,” Neuman says.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

For the second time in two years, the state of California has faulted HMO giant Kaiser Permanente for failing to provide patients with appropriate access to mental health care.

Some Kaiser patients still have to wait weeks or even months to see a therapist or psychiatrist, which violates state laws intended to ensure timely access to mental health treatment, the state Department of Managed Health Care said in a report released Tuesday. (Kaiser Health News is not affiliated with Kaiser Permanente.)

In addition, the department, which regulates California’s managed health care companies, found that Kaiser’s informational materials — as well as some providers themselves — improperly indicated to customers that long-term individual therapy was not available to enrollees, even though coverage of treatment for severe mental illness is required under state and federal mental health parity laws.

Tuesday’s report is a follow-up to an inspection released in March 2013, which identified four major deficiencies in the health plan’s delivery of mental health services. Kaiser agreed to pay a $4 million fine — one of the largest ever by an insurer in the state. At the time, the managed health care department said it would follow up on the plan’s progress a few months later. The results were not released until now.

In this follow-up report, the department found that Kaiser had solved two of the four problems by improving the way it collects and analyzes data about access to appropriate mental health care.

“Kaiser has made progress in being able to identify when and where the problems around access are occurring, but they are still not able to address the problems when they arrive,” said department director Shelley Rouillard. “They still have a lot of work to do.”

Kaiser officials say they have made significant strides in bolstering their provider network, including increasing their therapist staff. In addition, Kaiser is working with a separate company called ValueOptions to provide additional mental health care when necessary.

“We are proud of the progress we have made to improve access to mental health care,” Kaiser Permanente officials said in a statement. “We are committed to continuing to improve. We acknowledge there are still some areas where we need to continue making progress and do better for our patients,” including improving access to appointments at some locations.

In Kaiser’s Northern Region, the managed health care department found 22 percent of patients did not have timely access to either an initial or follow-up appointment. In one case, a sexual assault victim diagnosed with post-traumatic stress disorder and major depression was prescribed an antidepressant in an initial visit, but no follow-up appointment was scheduled.

The patient tried to schedule both individual and group therapy visits, but her psychiatrist responded by “offering psychotherapy in the community at the patient’s expense and suggested that the patient investigate appropriate group therapy in the community because weekly individual therapy was not available in the Plan, and Plan group therapy did not address sexual assault,” according to the report.

The patient was eventually able to schedule an appointment with a Kaiser therapist — five months after her initial visit, the report said.

According to another case cited by the department, a psychiatrist wrote an email to a patient saying that, “No one ever sees a therapist once a week in the Kaiser Health Plan. Not a covered benefit for the past 20-something years and will not be a benefit in the future.”

Based on Tuesday’s report, the managed health care department’s Office of Enforcement will consider whether Kaiser Permanente should face further disciplinary action, which could include another fine.

Kaiser Permanente is one of the largest not-for-profit health plans in the country, with an operating revenue of $56.4 billion and almost 7.5 million members in California.

The company has been in a protracted labor dispute with the National Union of Healthcare Workers, which represents the plan’s therapists. Union leaders have accused the health plan of a “chronic failure to provide … quality mental health care.” In its written statement, Kaiser blamed the union for continued problems in providing timely access to mental health care.

“We need union leadership to work constructively together with us to remove obstacles and solve problems more quickly …” the statement said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The sleek hospital tower that Johns Hopkins Medicine built in 2012 has the frills of a luxury hotel, including a meditation garden, 500 works of art, free wi-fi and a library of books, games and audio.

As Dr. Zishan Siddiqui watched patients and some fellow physicians in Baltimore move from their decades-old building into the Sheikh Zayed Tower, the internist saw a rare opportunity to test a widespread assumption in the hospital industry: that patients rate their care more highly when it is given in a nicer place.

For decades, hospital executives across the country have justified expensive renovation and expansion projects by saying they will lead to better patient reviews and recommendations. One study estimated $200 billion might have been spent over a decade on new building. Hopkins’ construction of the tower and a new children’s hospital cost $1.1 billion. Patient judgments have become even more important to hospitals since Medicare started publishing ratings and basing some of its pay on surveys patients fill out after they have left the hospital.

Siddiqui’s study, published this month by the Journal of Hospital Medicine, contradicts the presumption that better facilities translate into better patient reviews. Siddiqui examined how patient satisfaction scores changed when doctors started practicing in the new tower, which has 355 beds and units for neurology, cardiology, radiology, labor and delivery and other specialties.

Siddiqui discovered that for the most part, patients’ assessments of the quality of the clinical care they received did not improve any more than they did for patients treated in the older Hopkins building, which had remained open. Units there were constructed as early as 1913 and as late as 1980, Hopkins officials said. They functioned as the control group in the study, since a hospital’s satisfaction scores often change over time even when a hospital’s physical environment remains constant.

The study used the responses both to Medicare-mandated surveys and private ones from Press Ganey, a consulting company that administers surveys. In the study, Hopkins patient ratings about the cleanliness and quiet in new tower’s rooms — elements Medicare uses in setting pay — soared, as did views on the pleasantness of the décor and comfort of the accommodations. But patient opinions about their actual care — such as the communication skills of doctors, nurses and staff — did not rise any higher than they did in the older building.

“Despite the widespread belief among health care leadership that facility renovation or expansion is a vital strategy for improving patient satisfaction, our study shows that this may not be a dominant factor,” Siddiqui and his fellow authors wrote.

The study’s results were startling because previous studies have found that patients in older hospital buildings give lower scores on the quality of their care. Hospital executives have noticed it anecdotally as well; for instance, when NYU Langone Medical Center relocated its cardiology unit to a renovated floor, its patient experience scores rose.

Newer buildings allow for some medical benefits, such as better organized nursing stations and private rooms that protect against the spread of infectious bacteria and diseases. But the Hopkins researchers said “hospitals should not use outdated facilities as an excuse for achievement of suboptimal satisfaction scores.”

A nationwide survey from 2012 conducted by the consultants J.D. Power and Associates reached similar conclusions to the Hopkins paper about the influence of the physical environment on satisfaction scores. That survey found that communication by doctors, nurses and other staff was most important, while the facility accounted for a fifth of patient satisfaction.

After reading the Hopkins study, Dr. Bradley Flansbaum, a physician at Lenox Hill Hospital in Manhattan wrote on the blog of the Society of Hospital Medicine that “it just might be that what doctors do and say matters, and a first-class meal and green gardens cannot paper over, or in the converse, sully our evaluations.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Since 2010, 9.4 million people with Medicare have saved over $15 billion on prescription drugs.