Health Reform

    

         

         

         

 

Health Reform and You

"Health Reform and You" is a series of one-page papers explaining how the Affordable Care Act, also known as “Obamacare,” will affect different groups of people. Click on the right links to learn more.


If You Are Uninsured…

Obamacare creates several new ways to get health coverage. If you are not offered health coverage through your job, you may be able to obtain it through Medicaid or through a new health insurance marketplace (or exchange) in your state.

New Coverage Options

By filling out a single application, you’ll learn your plan options and costs, and whether you qualify for coverage through Medicaid or help purchasing coverage in the new insurance marketplace for your state. You may qualify for Medicaid if you earn less than about $16,000 a year or less as a single individual, even if you are an adult without children at home who previously was not eligible for Medicaid coverage. Other family sizes can qualify at higher income. However, states are not required to expand Medicaid and more than two dozen are unlikely to move forward.

If you earn too much to be eligible for Medicaid, you may still be able to get affordable coverage in the new marketplaces. Whether state-based or federal, these marketplaces will serve as an online store where you can shop for health insurance plans offered by private insurance companies in your area. Insurance plans will come in four levels – bronze, silver, gold and platinum – that will vary in what they cover, what they charge in premiums and what deductibles and other out-of-pocket costs they require. If you are under 30, you may be able to get a “catastrophic” insurance plan that charges lower premiums but requires that you pay more of your own medical bills before coverage kicks in. You cannot be denied coverage because of a pre-existing condition and may need to obtain coverage to avoid paying a penalty.

Financial Assistance

Depending on your income, you may be eligible for federal assistance that will lower the premiums you pay and reduce how much money you must pay out of your own pocket when you seek medical care. In general, a single person with an annual income between about $11,500 and $46,000, or a household with income between $19,500 and $78,000 for a family of three, can get help if coverage is purchased through the marketplace. The range will differ for families of different sizes. Use the Kaiser Family Foundation’s online calculator to get a rough estimate of the premiums and subsidies that may be available to you.

You can start applying for coverage that takes effect in January 2014 during the “open enrollment” period that runs from Oct. 1 through March 31. If you need help with the application there will be people who can assist you. A list of assisters near you should be available on the insurance marketplace website in your state. If you qualify for Medicaid, you can enroll at any time, not just during open enrollment.

If you don’t get coverage you may have to pay a penalty. The minimum penalty will be $95 in 2014, but could reach thousands of dollars depending on your income. Some people won’t have to pay the penalty even if they don’t have coverage. This includes anyone uninsured for less than three months, people who do not have to file a federal tax return, and people who would have qualified for Medicaid but their state decided not to expand the program, among others.

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If You Are Low-Income and May Qualify for Medicaid…

Obamacare creates several new ways to get health coverage. You can learn about your options by filling out a single application. It will tell you whether you qualify for free or low-cost insurance through the Medicaid program or through the new health insurance marketplaces that are being established in every state. You should apply for coverage even if you have been unable to get it in the past from Medicaid or private insurance companies. These are new options under the law.

Medicaid Expanding, But Not In All States

Obamacare expands Medicaid to many low-income adults, including adults without dependent children. However, more than two dozen states have chosen not to expand Medicaid under the law or are still debating the matter. In states that expanded Medicaid, you may qualify for Medicaid as a single individual if you earn less than about $16,000 a year, while other family sizes can qualify at higher incomes. In states that did not expand, you may have few or no options for affordable coverage. In that case, you will not have to pay a penalty for not having coverage.

State Insurance Marketplaces

Even in states that did not expand Medicaid, you may be able to get tax credits to help pay for coverage in new marketplaces if your annual income is between about $11,500 and $46,000 for a single person, or between about $19,500 and $78,000 for a family of three. Whether state-based or federal, the marketplaces will serve as an online store where you can shop for health insurance plans offered by private insurance companies.

You can find out whether you are eligible for federal assistance that will lower the premiums you pay and reduce how much money you must pay out of your own pocket when you seek medical care.

How To Apply

You can start applying for coverage during the “open enrollment” period that runs from Oct. 1 through March 31 for coverage to begin on January 1, 2014. If you need help completing the application there will be people who can assist you. A list of assisters near you should be available on the insurance marketplace website in your state. If you qualify for Medicaid, you can enroll at any time, not just during open enrollment. If you have Medicaid today, you continue to have coverage for yourself and your family.

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If You Have a Pre-Existing Condition

If you or someone in your family has a pre-existing health condition – such as heart disease, asthma, or even a pregnancy – you will find it much easier to obtain coverage or change plans starting in 2014. Obamacare bars insurers from denying coverage to people with pre-existing conditions, or physical or mental illnesses or conditions that existed before coverage began. Insurers also can no longer refuse to pay for otherwise-covered medical care and services due to a pre-existing condition or charge you more because of a pre-existing condition in the family.

What’s Covered

If you don’t have insurance or want to change plans, you can shop for a new plan in the individual insurance market or on your state’s new health insurance marketplace (or exchange). These plans will cover doctor visits, hospitalization, prescription drugs and maternity care without any restrictions for pre-existing conditions.  They will cover preventive services like immunizations, screenings and contraception at no expense to you. You will not have to give your detailed health or medical history to apply.  The marketplaces will allow you to compare plans and prices. The open enrollment period for your state’s marketplace will run from Oct. 1 through March 31. Coverage begins on Jan. 1, 2014.

Types of Plans

Plans both in and out of the marketplace will come in four levels – bronze, silver, gold and platinum – that will vary in what they cover, what they charge in premiums and what deductibles and other out-of-pocket costs they require. But these plans cannot charge you more based on your medical history.  Insurers can only vary their premiums based on your age, the number of people in your family covered by the policy and whether you use tobacco.

Help with Premiums

If you buy a policy through your state’s marketplace, you may also be eligible for financial assistance to help cover the cost. In general, you may be eligible if you are a single person with an annual income in the range of $11,500 to $46,000, or if your household income is in the range of $19,500 to $78,000 for a family of three. The range will differ for families of different sizes. Use the Kaiser Family Foundation’s online calculator to get a rough estimate of the premiums and subsidies available to you. People with lower incomes who buy coverage through the marketplaces also may have their deductibles and other out-of-pocket costs reduced. If your income is lower, you may be eligible for coverage through Medicaid.

Other Options

Obamacare established a temporary program in 2010 to offer coverage to people with pre-existing conditions. If you have coverage through the Pre-existing Condition Insurance Plan in your state, you can remain enrolled through the end of January 2014, but are encouraged to get coverage in your marketplace as soon as possible.

If you currently have insurance you purchased on your own (and not through an employer), then the plan may be exempted from the law’s requirements about pre-existing conditions.  However, you can still drop that coverage and buy one under the new rules.

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If You Buy Coverage in the Individual Market

 

If you buy your health plan on your own now (rather than getting covered through an employer), you will have new options for getting your coverage, but the law requires you to stay covered or be penalized.

What’s Covered

Under Obamacare, health plans must cover doctor visits, hospitalization, prescription drugs and maternity care without restrictions for pre-existing conditions, or physical or mental illnesses or conditions that existed before coverage began. These plans are generally more comprehensive than those on the individual market now and must cover any pre-existing conditions. They cover preventive services like immunizations, screenings and contraception at no expense to you. All plans must cover maternity care and childbirth without any extra coverage costs. You can no longer be required to give your detailed health or medical history to apply for coverage.

Where to Get Coverage

The law establishes new health insurance marketplaces (or exchanges) in every state that will allow you to compare plans and prices. Enrollment in such plans begins on Oct. 1 of this year and coverage takes effect on Jan. 1. Plans both in and out of the marketplace will come in four levels – bronze, silver, gold and platinum – that will vary in what they cover, what they charge in premiums and what deductibles and other out-of-pocket costs they require. If you are under 30, you may be able to get a “catastrophic” insurance plan that charges lower premiums but requires that you pay more of your own medical bills before coverage kicks in. Insurers cannot charge you more based on your medical history or if you are a woman. Insurers can only vary premiums based on your age and the number of the people in your family covered by the policy and whether you use tobacco.

Help with Premiums

If you choose to buy a new policy through your state’s marketplace, you may also be eligible for financial assistance based on your income to help cover the cost.  In general, you may be eligible for federal assistance if you are a single person and your annual income is between about $11,500 to $46,000, or if your household income is between about $19,500 to $78,000 for a family of three. The range will differ for families of different sizes.

If you choose to buy new coverage outside of your state’s marketplace, your plan will still offer the same protections that plans offered through the marketplace do — but you won’t be offered financial assistance.

If your current plan continues to offer coverage next year, you may be able to remain in that plan. However, you would not be eligible for tax credits for that coverage. You may want to compare your current premiums and benefits to what you might be able to get through the new state marketplaces before deciding which option is best for you.

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If You Have Job-Based Coverage

If you are now covered by job-based health benefits through your (or a family member’s) employer, then you likely can keep that coverage and will not have to make any changes.  In most cases, your employer coverage will satisfy the law’s requirement that you obtain insurance.

Changes to Employer Coverage

Some features of your employer coverage may already have changed as a result of the law.  For example, if you are a parent, your children may now stay on your policy until they reach age 26.

Your plan also now likely covers preventive services like immunizations and screenings at no cost to you, though some employer plans in place in 2010 are exempted from this requirement.

Beginning in 2014, your plan cannot set an annual dollar limit on your benefits that could leave you without coverage if you get seriously ill.  Your plan also can no longer limit anyone’s coverage for pre-existing conditions. Your plan also can no longer limit the total dollar amount of benefits you may receive over your lifetime.  Employer plans are also required to limit the amount of cost sharing (such as deductibles and co-pays) that you are required to pay for covered services to $6,350 per person per year.  This provision will take full effect in 2015.

In some cases, your employer may need to change your health benefits to meet the law’s requirements.  For instance, if you currently get only bare-bones coverage through your employer — such as help paying for routine doctor visits, with little or no coverage for hospitalization of other serious illnesses — that coverage can no longer be offered in 2014.  Your employer may decide to offer more comprehensive coverage, as most employers already do, or your employer may decide not to offer any coverage to its workers.

Employer Mandate

The law encourages employers to offer health insurance. Large employers — those with at least 50 full-time workers (or the equivalent in part-time workers) may face penalties if they do not offer affordable coverage to full-time workers.  These penalties will begin in 2015, a year later than originally called for in the law.  Smaller employers — those with 50 or fewer full-time workers — are not required to offer coverage, but may get tax credits if they do.

If your employer offers coverage that is too costly for you to afford based on your income, you may want to buy coverage through the new health insurance marketplace (or exchange) in your state instead.  The marketplaces are like an online store for people buying their own health insurance and would allow you to compare plans based on price and other factors.  You may qualify for tax credits to purchase this coverage if your employer does not offer you coverage that meets the law’s requirements and your household income falls below a certain level — about $46,000 for an individual or $78,000 for a family of three.   If your income is very low (less than about $16,000 for a single individual) you might also qualify for coverage under Medicaid.

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If You Have Medicare…

If you have Medicare, you will not have to make any changes to your health insurance coverage as a result of Obamacare.  You can continue to rely on Medicare to help pay your hospital, physician and other medical expenses.

You will still have the option to choose between traditional Medicare or a Medicare Advantage plan (such as a Medicare HMO) offered in your area, and among Medicare prescription drug plans.  If you are on Medicare, and low income, you may also qualify for extra help with premiums and cost sharing.  The law did not change these options.  For more information about your Medicare coverage options, you can visit http://www.medicare.gov or call the 1-800-MEDICARE help line.

Improvements to Medicare Benefits                                                

The health reform law made some significant improvements to Medicare’s benefits that may help you:

  • Medicare no longer requires you to pay a fee for an annual checkup from your doctor.
  • Medicare no longer charges a fee for many preventive screenings for cancer, depression, diabetes, cholesterol, obesity, and other conditions.
  • Medicare is gradually reducing the amount of money  people who have very high prescription drug costs have to pay each year, by closing a gap in coverage, sometimes called the “doughnut hole.”

Other Medicare Changes

Most of the other changes to Medicare affect how Medicare pays health insurance companies, hospitals and other health care providers for the care received by people on Medicare.  For example, the law reduced what Medicare pays HMOs and other private Medicare Advantage plans.  Other changes are designed to get hospitals, doctors and other health care providers to improve the quality of care they provide for people on Medicare, such as by encouraging providers to work more closely together to coordinate care for patients when they are discharged from the hospital and by taking steps to prevent unnecessary hospital readmissions.  Most of these efforts are in the early stages, and it will take time to see what kind of impact they have.

The law also includes new fees for people on Medicare with relatively high incomes.  If you are single and your income is more than $85,000 annually or you are married and your income is more than $170,000 annually, you may pay higher Medicare premiums.

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If You Are a Woman…

 

As a woman, it is especially important for you to understand how the Affordable Care Act (ACA) will change healthcare in 2014.  Your healthcare needs differ from men’s and you are often the main healthcare decision maker for your family.  Obamacare broadens the range of many services that are important to women that health plans now must cover, some without any co-pay.  In addition, it expands access to coverage through Medicaid and the new state health marketplaces. Changes important to women include:

No More Pre-Existing Condition Limits

Plans will no longer be allowed to deny coverage to pregnant women or those who have been diagnosed with depression or experienced domestic violence.

Equitable Insurance Pricing for Men and Women

If you get your insurance on the individual market or through the new insurance marketplaces, your plan can no longer charge you a different premium than it would charge a man of the same age.   This practice was called gender-rating and is no longer permitted.

Preventive Services

If you have private insurance and you or your family needs a vaccine, a health screening, or a number of other recommended preventive services– deemed “highly effective” in preventing health problems–your insurance plan probably covers it without any cost sharing. These include mammography, Pap smears, HPV vaccines, STI screening, and annual well woman visits.

Contraceptives

If you need birth control, you probably no longer have to pay anything out of pocket for it if you have private insurance. The new law requires most private plans to cover all forms of prescription birth control (but not all brands) without any co-pay. Women with Medicaid also get birth control covered without cost-sharing.

Maternity Care

Obamacare requires that plans in the individual market and the new state marketplaces cover maternity services including childbirth, prenatal visits, and well-baby care.   Most employer plans were already required to cover maternity care, but now you will also get prenatal visits and screenings, breast pump rentals, and breastfeeding counseling without any co-pay because they are considered preventive services.  All state Medicaid programs cover maternity care as well, but the specific services may vary from state to state.  If you are nursing and work for a large employer (50 or more employees), you now have access to a private room and break time to express milk for your baby.

Abortion

Many private insurance plans cover abortion.  If you’re signing up in your state’s new marketplace, your coverage for abortion services will depend on where you live and the plan you choose.  Some states have banned abortion coverage from all plans in the marketplace while some allow it.  You’ll have to check the details of your policy to see if it covers the procedure.  State Medicaid programs typically limit abortion coverage to pregnancies that are a result of rape or incest or in cases when the pregnancy is a threat to a woman’s life.  Some state Medicaid programs may cover abortion under other circumstances.

Direct Access to Ob-Gyns

If you have private insurance, most plans now must allow you to choose an ob-gyn as your primary provider or see an ob-gyn for basic care without a referral.


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Health Care Marketplace

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Publicly recognized as an official “Champion for Coverage,” we can help consumers looking for health coverage options through the Marketplace, including the completion of this application.

You can ask to see certification showing he or she is authorized to perform this work. He or she can help you complete the section in the application where we ask for their information.

 

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