Wondering what the Affordable Care Act, commonly known as the ACA or health care reform, means for you? Many of the changes help to expand access to health care coverage and will likely affect you and your health care benefits. To help you prepare we’ve compiled a simple list of the top 10 facts you need to pay attention to in order to better understand and meet the requirements of the law.
1. Required coverage: Most people are now required to obtain Qualified Health Coverage (QHC) or to pay a penalty. Compliant coverage may include, but is not limited to, employer-provided insurance, coverage you buy on your own or coverage under Medicare or Medicaid.
2. Health insurance marketplaces: You can buy health insurance directly through the health insurance marketplace in your state, which can be accessed at healthcare.gov. Keep in mind if you purchase health insurance through these marketplaces you will lose any contribution your employer provides towards equivalent health insurance benefits offered at your workplace.
3. Summary of benefits and coverage: Health insurance issuers and group health plans are now required to provide you with an easy-to-understand summary about your health plan’s benefits and coverage. For an even deeper understanding of your health plan, be sure to take advantage of opportunities to meet with a benefits advisor or broker if offered by your employer.
4. Dependent coverage: Private insurers must continue dependent coverage of children until age 26. If you have children under age 26, you can insure them even if they are married, are no longer living with you, are not dependents on your tax return or are no longer students. The only exception applies prior to 2014 for employees covered under certain grandfathered plans. In this case, if your children can get their own job-based coverage, your plan may not extend coverage to them. Additionally, private insurers aren’t required to offer spouse coverage.
5. Pre-existing conditions: Major medical plans cannot exclude you from coverage or charge a higher premium for a pre-existing condition, including a disability. Additionally, the law provides protections for children with pre-existing conditions. As of September 23, 2010, insurers cannot deny coverage to any child under age 19 based on health conditions, including babies born with health problems.
6. Preventive care: Except for certain grandfathered plans, you will not have to pay a copayment, co-insurance or deductible to receive certain recommended preventive health care. These services may include screenings, vaccinations, and counseling such as:1
7. Doctor choice: Now you are guaranteed to be able to choose any primary care doctor or pediatrician you want from your health plan’s provider network. For example, you can see an OB-GYN doctor without needing a referral from another doctor. For emergency care, you can go to a hospital outside your plan’s network without prior approval from your health plan.
8. Tax credits and premium rates: Individuals with household incomes between 100 percent and 400 percent of the federal poverty level may be eligible for tax subsidies to help offset the costs of health care coverage.2 To be eligible one of the following must be true for you:
a. You don’t qualify for public coverage, including Medicaid, the Children’s Health Insurance Program, Medicare, or military coverage.
b. You don’t have access to affordable, minimum value health insurance through an employer. This occurs if the cost of individual coverage exceeds 9.5 percent of your household income and/or the plan pays less than 60 percent of covered benefits.3
9. Flexible spending accounts (FSAs): The ACA limits FSA contributions to $2,500 per year and prohibits the purchases of over-the-counter medications through a FSA, Health Reimbursement Account (HRA) or Health Savings Account (HSA) without a prescription. These limitations and caps will likely create more out-of-pocket expenditures that aren’t eligible for individual reimbursement.
10. Voluntary insurance coverage: Voluntary insurance benefits, also known as supplemental benefit options, work with major medical coverage to help provide you with financial safety net for out-of-pocket expenses not covered by your major medical plan. As health care costs continue to rise, these benefits help to provide a layer of financial protection. Unlike major medical insurance, voluntary insurance pays cash benefits directly to its policyholders, unless otherwise assigned, if they get sick or injured.
This material is intended to provide general information about an evolving topic and does not constitute legal, tax or accounting advice regarding any specific situation. Aflac cannot anticipate all the facts that a particular employer or individual will have to consider in their benefits decision-making process. We strongly encourage readers to discuss their HCR situations with their advisors to determine the actions they need to take or to visit healthcare.gov (which may also be contacted at 800.318.2596) for additional information.
Coverage is underwritten by American Family Life Assurance Company of Columbus. In New York, coverage is underwritten by American Family Life Assurance Company of New York.
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1 Healthcare.gov, (2014). Free preventive care, accessed September 17, 2014, from https://www.healthcare.gov/how-does-the-health-care-law-protect-me/free-preventive-care/.
2 Congressional Research Service (2013). Health Insurance Exchanges Under the Patient Protection and Affordability Care Act (ACA), accessed on September 17, 2014, from fas.org/sgp/crs/misc/R42663.pdf.
3 For more information on the tax subsidies, visit www.irs.gov.