Affordable Health Care Act

Information on the Affordable Health Care Act

A major component of the Affordable Health Care Act will go into effect on October 1, 2013. Individuals will be able to explore and compare options of health care plans that are available and enroll in those plans. Here you will find links to the documents that contain some basic information about the Affordable Health Care Act, Medicare and Medicaid eligibility, timelines, a glossary, a Q&A, and important contact information. There are telephone numbers, e-mail addresses, and web addresses so you can find out even more.
 
Affordable Health Care Act: What’s Changing

  • The Health Insurance Marketplace
  • Fee for Individuals Who Do Not Have Health Insurance
  • How does the Affordable Health Care Act Affect Medicare Recipients?
  • How does the Affordable Health Care Act Affect Medicaid Recipients?
  • Timeline

Summary of Benefits & Coverage and Glossary

  • Summary of Benefits and Coverage
  • Affordable Care Act: Working with States to Protect Consumers
  • Uniform Glossary of Health Coverage and Medical Terms

Healthcare Q&A
 
Contact Information: States with Marketplaces

Affordable Health Care Act: What’s Changing

The Health Insurance Marketplace

Fee for Individuals Who Do Not Have Health Insurance

How does the Affordable Health Care Act Affect Medicare Recipients?

How does the Affordable Health Care Act Affect Medicaid Recipients?

Timeline

The Health Insurance Marketplace

States may offer their own options. In the 36 states where the federal government has primary responsibility for the Marketplace, also known as exchanges, consumers will be able to choose from an average of 53 health plans. In most states, health plans will be offered by two or more insurance companies — a high of 13 companies in Wisconsin, but just one apiece in New Hampshire and West Virginia.
 
If you need coverage, you can use the Marketplace. If you have coverage, you gain new protections. If you don’t have coverage, you may have to pay a fee. Open enrollment for Marketplace plans begins October 1, 2013. Coverage begins as early as January 1, 2014.
 
Whether you’re uninsured, you’ve been denied coverage in the past, or you just want to explore new options, the Health Insurance Marketplace will give you more choice and control over your health coverage. The Marketplace will operate in all states, so no matter where you live, you’ll have access to coverage.
 
In the Marketplace, you can compare coverage options based on price, benefits, quality, and other features important to you. You can choose the combination of price and benefits that fits your budget and meets your needs.

  • You can get lower costs on coverage: The Marketplace application will tell you if you’re eligible for a new way to get lower costs on your monthly premiums or out-of-pocket costs for private insurance. You’ll also learn if you can get free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP).
  • Essential health benefits are covered in the Marketplace: All plans must offer a comprehensive set of essential health benefits including doctor visits, preventive care, hospitalization, prescriptions, and more.
  • Pre-existing conditions will be covered: Plans won’t be able to deny you coverage or charge you more due to pre-existing health conditions, including a pregnancy or disability.
  • You can get help in your area: If you need help finding a plan, several kinds of help will be available to give you personalized assistance with the process.

Beginning 2014, most people are required to have health coverage. If they don’t, they may have to pay a fee. People with very low incomes and others may be eligible for waivers.

Fee for Individuals Who Do Not Have Health Insurance

Starting January 1, 2014, if someone who can afford health insurance doesn’t have a health plan that qualifies as minimum essential coverage, he or she may have to pay a fee from:

  • 1% of income (or $95 per adult, whichever is higher) in 2014 to;
  • 2.5% of income (or $695 per adult) in 2016.

Bullets above should be larger for consistency with all the others in the document
 
They also have to pay for all of their health care.
 
The fee for children is half the adult amount. The fee is paid on the 2014 federal income tax form, which is completed in 2015.
 
To avoid the fee in 2014 you need insurance that qualifies as minimum essential coverage. If you're covered by any of the following in 2014, you're considered covered and don't have to pay a penalty:

  • Any Marketplace plan, or any individual insurance plan you already have
  • Any employer plan (including COBRA), with or without “grandfathered” status. This includes retiree plans
  • Medicare
  • Medicaid
  • The Children's Health Insurance Program (CHIP)
  • TRICARE (for current service members and military retirees, their families, and survivors)
  • Veterans health care programs (including the Veterans Health Care Program, VA Civilian Health and Medical Program (CHAMPVA), and Spina Bifida Health Care Benefits Program)
  • Peace Corps Volunteer plans

How does the Affordable Health Care Act Affect Medicare Recipients?

Medicare isn’t part of the Health Insurance Marketplace, so you don’t need to do anything. If you have Medicare, you are considered covered.
 
The Marketplace won’t affect your Medicare choices, and your benefits won’t be changing. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan, you’ll still have the same benefits and security you have now. You won’t have to make any changes.
 
Note: The Marketplace does not offer Medicare supplement (Medigap) insurance or Part D drug plans.

How does the Affordable Health Care Act Affect Medicaid Recipients?

In certain states, the Marketplace doesn't provide the final decision on Medicaid eligibility. Instead, the Marketplace conducts an assessment and passes the application to the State Medicaid agency to conduct a final eligibility determination. Check with your state for information on health care coverage.

Timeline

The Affordable Care Act is a set of health insurance reforms that started in 2010 and will continue to roll out in 2014 and beyond. There are important changes in the law from 2010 through 2015.

2010

  • March 23, 2010: President Obama signs the Affordable Care Act
  • Coverage for children with pre-existing conditions
  • Coverage for young adults under 26
  • No more lifetime limits on coverage
  • No more arbitrary cancelations or rescissions
  • Right to appeal health plan decisions
  • Consumer Assistance Program
  • Small business tax credit
  • Temporary coverage for people with pre-existing conditions
  • Community Health Centers

2011

  • Prescription drug discounts for seniors
  • Free Medicare preventive services for seniors
  • The 80/20 Rule (Medical Loss Ratio)
  • Rate Review

2012

  • New preventive services for women
  • You have the right to get an easy-to-understand summary about a health plan’s benefits and coverage.

2013

  • October 1: Open enrollment in the Health Insurance Marketplace begins

2014

2014 is an important year. The Health Insurance Marketplace will offer a new way for people without insurance to get coverage and to find out if they can get lower costs for private insurance. They can also find out if they qualify for Medicaid or the Children’s Health Insurance Program (CHIP).

  • People who do not have health coverage may have to pay a fee.
  • January 1: Coverage begins in the Health Insurance Marketplace
  • Coverage for pre-existing conditions
  • Savings on monthly premiums and out-of-pocket costs
  • Medicaid expansion
  • No more yearly limits on coverage
  • Expanded small business tax credit
  • March 31: Open enrollment closes

2015

Employer Shared Responsibility Payment

Summary of Benefits & Coverage and Glossary

Summary of Benefits and Coverage

Working with States to Protect Consumers

Uniform Glossary of Health Coverage and Medical Terms

Introduction

Under the Affordable Care Act, health insurers and group health plans will provide the 180 million Americans who have private insurance with information about their health plan benefits and coverage. Specifically, the regulations will ensure consumers have access to two forms that will help them understand and evaluate their health insurance choices. The forms include:

  • An easy-to-understand summary of benefits and coverage
  • A uniform glossary of terms commonly used in health insurance coverage such as "deductible" and "co-payment"

Summary of Benefits and Coverage

Under the law, insurance companies and group health plans will provide consumers with a document detailing, in plain language, information about health plan benefits and coverage. This summary of benefits and coverage document will help consumers better understand the coverage they have and, for the first time, allow them to compare different coverage options. It will summarize the key features of the plan or coverage, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. People will receive the summary when shopping for coverage, enrolling in coverage, at each new plan year, and within seven business days of requesting a copy from their health insurance issuer or group health plan.
 
This summary of benefits and coverage will include a new, standardized health plan comparison tool for consumers called “coverage examples,” much like the Nutrition Facts label required for packaged foods. The coverage examples would illustrate how a health insurance policy or plan would cover care for common benefits scenarios. Plans and issuers will simulate claims processing for each scenario so consumers can see an illustration of the coverage they get for their premium dollar under a plan. The examples will help consumers see how valuable the health plan will be at times when they may need the coverage.

Working with States to Protect Consumers

The Affordable Care Act establishes common-sense consumer protections and requires insurers to operate in a more transparent manner.  Fair rules and transparency help create a more level playing field between consumers and insurers. The law also empowers States by putting them in the driver’s seat in implementing many of these new consumer protections.
 
On July 23, 2010, the Departments of Health and Human Services, Labor, and the Treasury issued an interim final rule regarding internal claims and appeals and external review processes for group health plans and health insurance issuers offering coverage in the group and individual markets.  This rule works to give people in most plans better information about what their rights are and why their claims were denied or coverage rescinded. Under the rule, consumers have the:

  • Right to information about why a claim or coverage has been denied.  Health plans and insurance companies have to tell you why they’ve decided to deny a claim or chosen to end your coverage – and how you can appeal that decision.
  • Right to appeal to the insurance company.  If you’ve had a claim denied or had your coverage rescinded, you have the right to an internal appeals process, a process in which you ask your insurance company to conduct a full and fair review of its decision.  If the case is urgent, your insurance company must speed up this process.
  • Right to an independent review.  Often, insurers and their policyholders can resolve disputes during the internal appeals process.  If you can’t work it out through the internal appeals process, you now have the right to take your appeal to an independent third-party for review of the insurer’s decision.  This is called “external review.”  This way, the insurance company no longer gets the final say regarding your benefits, and patients and doctors get a greater measure of control over health care

These protections and standards are an important step forward in reforming the health care system to make sure it works for consumers, not just insurance companies.

Uniform Glossary of Health Coverage and Medical Terms

This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs.

Appeal

A request for your health insurer or plan to review a decision or a grievance again.

Balance Billing

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Co-insurance

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Complications of Pregnancy

Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren’t complications of pregnancy.

Co-payment

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Deductible

The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Durable Medical Equipment (DME)

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

Emergency Medical Condition

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergency Medical Transportation

Ambulance services for an emergency medical condition.

Emergency Room Care

Emergency services you get in an emergency room.

Emergency Services

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

Excluded Services

Health care services that your health insurance or plan doesn’t pay for or cover.

Grievance

A complaint that you communicate to your health insurer or plan.

Habilitation Services

Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Insurance

A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

Home Health Care

Health care services a person receives at home.

Hospice Services

Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care:

Hospital Outpatient Care

Care in a hospital that usually doesn’t require an overnight stay.

In-network Co-insurance

The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.

In-network Co-payment

A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.

Medically Necessary

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Network

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

Non-Preferred Provider

A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

Out-of-Network Co-insurance

The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.

Out-of-Network Co-payment

A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.

Out-of-Pocket Limit

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.

Physician Services

Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

Plan

A benefit your employer, union or other group sponsor provides to you to pay for your health care services.

Preauthorization

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary, called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Preferred Provider

A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

Premium

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Prescription Drug Coverage

Health insurance or plan that helps pay for prescription drugs and medications.

Prescription Drugs

Drugs and medications that by law require a prescription.

Primary Care Physician

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Primary Care Provider

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Provider

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

Reconstructive Surgery

Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.

Rehabilitation Services

Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Skilled Nursing Care

Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

Specialist

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

UCR (Usual, Customary and Reasonable)

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Urgent Care

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Healthcare Q&A

Q. What is the Marketplace?
 
A. In the Marketplace, also called the exchange, you can purchase health care coverage. See our document that gives you links to and telephone numbers for those individual states that have chosen to offer their own options.
 
Q. If I have health insurance, how does the health care law protect me?
 
A. Whether you need health coverage or have it already, the health care law offers new rights and protections that make coverage fairer and easier to understand.
 
Q. How does the Affordable Care Act help people like me?
 
A. If you need coverage, you can use the Marketplace. If you have coverage, you gain new protections. If you don’t have coverage, you may have to pay a fee.
 
Q. Can children stay on a parent’s plan until age 26?
 
A. If a plan covers children, they can be added or kept on the health insurance policy until they turn 26 years old.
 
Q. What if I currently have COBRA coverage?
 
A. If you have COBRA continuation health coverage, you keep it or decide to buy a Marketplace insurance plan instead at any time starting January 1, 2014.
 
Q. What if I want to change individual insurance plans?
 
A. If you have an individual insurance plan and want to change it, you can use the Marketplace to explore your options and enroll in a new plan.
 
Q. What if I have job-based insurance?
 
A. If you have job-based health insurance you like, you can keep it. You're considered covered. You may be able to change to Marketplace coverage if you want to.
 
Q. What if I have a grandfathered health insurance plan?
 
A. If you are covered by a plan that existed March 23, 2010, your plan may be "grandfathered." You may not get some rights and protections that other plans offer. Grandfathered plans are those that have stayed basically the same, but they can enroll people after that date and still maintain their grandfathered status. In other words, even if you joined a grandfathered plan after March 23, 2010, the plan may still be grandfathered. The status depends on when the plan was created, not when you joined it. How to find out if your plan is grandfathered?

  • Check your plan’s materials: Health plans must disclose if they are grandfathered in all materials describing plan benefits. They must offer contact information.
  • Check with your employer or your health plan's benefits administrator.

What grandfathered plans do and don't have to cover. Here's a quick look at the consumer protections that do and don't apply to grandfathered plans. All health plans must:

  • End lifetime limits on coverage
  • End arbitrary cancellations of health coverage
  • Cover adult children up to age 26
  • Provide a Summary of Benefits and Coverage (SBC), a short, easy-to-understand summary of what a plan covers and costs
  • Hold insurance companies accountable to spend your premiums on health care, not administrative costs and bonuses

Grandfathered plans DON'T have to:

  • Cover preventive care for free
  • Guarantee your right to appeal
  • Protect your choice of doctors and access to emergency care
  • Be held accountable through Rate Review for excessive premium increases

In addition to the above, grandfathered individual health insurance plans (the kind you buy yourself, not the kind you get from an employer) don't have to:

  • End yearly limits on coverage
  • Cover you if you have a pre-existing health condition

Note: Some grandfathered plans offer protections they're not required to. Check with your insurance company or benefits administrator to learn if your grandfathered plan offers the rights and protections listed above.
 
Health plans that don't meet minimum essential coverage don't qualify as coverage in 2014. If you have only these types of coverage, you may have to pay the fee. Examples include:

  • coverage only for vision care or dental care
  • workers' compensation
  • coverage only for a specific disease or condition
  • plans that offer only discounts on medical services

Q. What if I'm losing job-based insurance?
 
A. If you lose your job-based health insurance, you have two primary options for health insurance coverage: a Marketplace plan or COBRA continuation coverage.
 
Q. How do I appeal a health plan decision?
 
A. If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party
 
Q. How can I get consumer help if I have insurance?
 
A. Many states offer direct help with problems or questions about health insurance through Consumer Assistance Programs. Other help resources are available too.
 
Q. Can I use a Flexible Spending Account (FSA) to pay some medical expenses?
 
A. You can use a Flexible Spending Account (FSA) to pay for co-payments, deductibles, some drugs, and other health care costs. FSAs are limited to $2,500 per year.
 
If you have further questions, call 800-318-2596, 24 hours a day, 7 days a week.

Contact Information: States with Marketplaces

If you live in one of the following states, call or click on the link to contact the Health Insurance Marketplace in that state that can serve you. Instead of HealthCare.gov, you’ll use that website to find and apply for coverage, compare plans, and enroll. If you live in any other state call or click to contact HealthCare.gov to find information.
 
HealthCare.gov: 800-318-2596 (24/7); https://www.healthcare.gov/
 
California: Covered California; 800-300-1506; www.coveredca.com/
Colorado: Connect for Health Colorado; 855-752-6749; www.connectforhealthco.com/
Connecticut: Access Health CT; 855-805-4325; www.accesshealthct.com
District of Columbia: DC Health Link; 855-532-6465; http://dchealthlink.com/
Hawaii: Hawai’i Health Connector; 877-628-5076; www.hawaiihealthconnector.com
Idaho: Your Health Idaho; 855-944-3246; info@YHI.org; www.yourhealthidaho.org
Kentucky: Kynect, Kentucky’s Health Connection; 855-459-6328; http://kynect.ky.gov
Maryland: Maryland Health Connection; 855-642-8572; www.marylandhealthconnection.com
Massachusetts: Commonwealth Care Health Connector; 877-623-6765; www.mahealthconnector.org/portal/site/connector
Minnesota: MNSure; 855-366-7873; http://mn.gov/hix
Nevada: Nevada Health Link; 855-768-5465; contact@exchange.nv.gov; www.nevadahealthlink.com
New Mexico: Be Well; info@bewellnm.com; www.bewellnm.com
New York: New York State of Health; 855-355-5777; www.nystateofhealth.ny.gov
Oregon: Cover Oregon; 855-268-3767; www.coveroregon.com
Rhode Island: Health Source RI; 401-222-5192; www.healthsourceri.com
Vermont: Vermont Health Connect; 802-654-8854; http://healthconnect.vermont.gov
Washington: Washington Health Plan Finder; 855-923-4633; www.wahealthplanfinder.org