17 Key Facts About the Affordable Care Act
Affordable Care Act
Baffled by "Obamacare"? You’re not alone. Polls show few Americans understand the health reform law. And many uninsured adults say they’ve heard nothing at all about the law’s key feature: health insurance marketplaces that opened for business in every state on October 1.
"That’s why we’re working overtime to make sure folks across the country know what’s to come," said Jessica Barba Brown, national communications director for
Enroll America, a Washington, D.C.-based nonprofit coalition dedicated to ensuring that eligible Americans get coverage. If you’re uninsured or lack adequate health insurance, now’s the time to do something about it. Here’s what you need to know to get started:
You must have health insurance
The health reform law requires most U.S. citizens and legal residents to have health insurance in 2014 and beyond or pay a fine. In 2014, the penalty is $95 for an adult or 1% of income, whichever is greater. It’s half of that—$47.50—for uninsured kids, and up to $285 for a family. Fines increase every year. In 2016, it’s $695 per adult, $347.50 for kids, and up to $2,085 per family, or 2.5% of income.
Tip: If you have a religious objection to having health insurance or are experiencing a hardship that prevents you from buying insurance, you may qualify for an exemption from the coverage mandate.
You can shop online
As of October 1, every state will have a health insurance marketplace, or exchange, offering one-stop shopping for health plans in your area. If you’re web-savvy, simply visit your marketplace web site to compare health plans and prices and apply for coverage.
You can go to
Healthcare.gov to find your health exchange and get started. (If the federal government is running the marketplace in your state, you will use healthcare.gov to enroll.)
Tip: For help, try the toll-free hotline: 1-800-318-2596 (TTY: 1-855-889-4325) or click on the "Live Chat" button at Healthcare.gov.
You can enroll "old school"
Don’t worry if you don’t have a computer. You can apply for coverage by mail or in person with the help of a health "navigator," or other individual trained and certified to help you wade through your options and enroll in a health plan.
Tip: Many health clinics, community centers, churches and libraries will have people on hand to assist you. Check with your state marketplace to find a location near you. Go to localhelp.healthcare.gov to find help in your area.
You have a choice of plans
If you buy coverage through the state marketplace, you can choose among health plans in four categories: Bronze, silver, gold and platinum. Platinum plans generally have the highest monthly premiums and lowest out-of-pocket costs. With a bronze plan, premiums are lower but you’ll shell out more when you need care. "People can choose the plan that best fits their family’s needs and budget," Brown said.
People who are under 30 and can't find a plan for less than 8% of their income may be eligible for a
Tip: If you visit the doctor often or take prescription drugs, consider a gold or platinum plan. If you qualify to receive help paying your out-of-pocket costs, you must choose a silver plan.
Cost-sharing subsidies are available, too
You can get help paying your out-of-pocket costs, like your deductible and copayments or coinsurance, if you make less than 250% of the federal poverty level. That’s $28,725 for a single person and $58,875 for a family of four, based on 2013 data.
Tip: You must buy a silver plan to get help paying your out-of-pocket expenses.
You may qualify for free or low-cost care
Twenty-four states and the District of Columbia are expanding Medicaid, the public health program for the poor, in 2014. Eligibility is based solely on your income and family size, not whether you are pregnant, disabled, or have dependent children. People making up to $15,856 a year, or $32,499 for a family of four, in 2013, may be eligible for free or low-cost care.
Tip: Not sure if you qualify? Just fill out an application with your state health marketplace to find out what coverage you and your family may be eligible for.
Young adults have more options
Since 2010, health reform has allowed young adults to stay on their parents’ health plan up until age 26, as long as the plan offers dependent coverage. In 2014, young people will have even more options. Many will qualify for federal subsidies to reduce the cost of private health insurance on the marketplace, while others may be eligible for Medicaid.
If you’re a college student, your university may offer a student health insurance plan. If you work, check with your employer to see what coverage may be available to you.
Tip: For more information on your options, go to health.younginvincibles.org.
You can stick with your employer plan
If you have good, comprehensive health insurance through your job, chances are you don’t need to use the state health exchanges. But be ready to shell out more for that coverage. As health care costs continue to escalate, employers are shifting a greater share of the health plan premium and out-of-pocket expenses to employees.
Tip: Review your options to make sure you have the best plan for you and your family.
No more skimpy benefits
All health plans sold through the health insurance marketplaces must provide, at a minimum, a package of essential health benefits, including basics like emergency services, hospitalization, maternity and newborn care, doctor visits, laboratory services, and prescription drugs.
Tip: Having a standard set of core benefits makes it easier to make apples-to-apples comparisons among health plans and avoids ugly surprises later on when you find the care you received isn’t covered.
You can get coverage even if you’re sick
Beginning in 2014, health plans cannot refuse coverage or charge you more if you have a pre-existing health condition, like cancer, diabetes or high blood pressure. The only exception is for individual health plans with "grandfathered" status. (Individual coverage means a health plan you purchased for yourself or your family. A grandfathered plan is one that has been in place since March 23, 2010 and hasn’t made any major changes since then.)
Tip: If you’re stuck in a plan with a pre-existing condition exclusion, shop around. Plans offered through the state marketplaces will cover you regardless of what health conditions you may have.
Your coverage won’t top out
Health reform ended lifetime limits in 2010, meaning health plans can no longer cap the amount of money spent on essential health benefits during the entire time you are enrolled in the plan. And beginning in 2014, the law prohibits most health plans from imposing annual limits.
Tip: Lifetime and annual limits do apply to non-essential health benefits, such as adult dental care and cosmetic surgery.
Preventive care is free
Most health plans, including private plans offered through the state health insurance exchanges, must cover many preventive health services at no cost to you. In most cases, you won’t pay anything out-of-pocket for flu shots, cholesterol testing or colon cancer screening, for example.
Tip: For free preventive care, you need to see a provider in your health plan network. If a test reveals a problem, you’ll have to pay for any follow-up care.
Contraception is covered
You won’t pay a dime out of pocket for Food and Drug Administration-approved methods of birth control prescribed by your physician.
Tip: Group health plans sponsored by religious employers are exempt from this requirement.
It pays to stay healthy
Employer wellness programs are getting a boost. The law permits employers to sweeten rewards—and step up penalties—from 20% of the total health plan premium to 30% in 2014 and up to 50% for programs designed to prevent or reduce tobacco.
Employers have some leeway in how wellness programs are designed but cannot make unreasonable demands and must give employees fair notice of opportunities to earn rewards for, say, participating in a health screening or lowering their cholesterol.
Tip: Your employer must give you a chance to qualify for a reward at least once a year.
Smokers can get help quitting
The health law added a tobacco cessation benefit for pregnant women on Medicaid in 2010. In 2014, Medicaid must cover tobacco cessation medications, and health plans sold on the health exchanges must cover tobacco cessation services at no cost to you.
Tip: The law also allows health plans on the exchange to charge tobacco users up to 50% higher premiums, but that provision is on hold until at least 2015.
Open enrollment begins October 1
If you buy a health plan on the marketplace by Dec. 15, 2013, your coverage will take effect on Jan. 1, 2014. You can buy coverage up until March 31, 2014, but the effective date will be delayed. If you have a baby, get divorced or lose your job, you can buy coverage after the open enrollment period closes.
For 2015, open enrollment runs October 15 to December 7, 2014.
Tip: If you are eligible, enrollment in Medicaid or the Children’s Health Insurance Program is open all year round.
Scammers are on the loose
Beware of emails, phone calls or visits from people posing as federal government workers, health "navigators" or insurance agents. Con artists are taking advantage of people's confusion over the Affordable Care Act and trying to get their hands on your personal and financial information.
"When enrolling, people should make sure they are talking to a certified application counselor or a federally certified navigator before giving over sensitive information," said
Enroll America's Brown, whose organization in pointing people in the direction of approved, trusted sources for enrollment help.
Tip: If anyone asks you to wire money or hand over your bank account number, it’s a scam.