The Affordable Care Act (ACA):
• All plans sold with effective dates on or after January 1, 2014, must cover 10 Essential Health Benefits (EHBs): Ambulatory patient services, Emergency services, Hospitalization, Maternity and Newborn care, Mental Health and Substance Abuse, Prescription Drugs, Rehabilitative and Habilitative services/devices, Lab services, Preventative/Wellness services and Chronic Disease Management, and Pediatric services (oral and dental).
• Preventative Care are covered with no out-of-pocket costs.
• You cannot be denied coverage because of any pre-existing condition.
• The most in a year you will pay for covered healthcare services from in-network providers (besides your premium) is $6350 for individuals and $12,700 for families.
• Parents can keep their kids on their plans until 26 years old.
Premium Tax Credit and Cost Sharing:
• Tax Credits (called Premium Subsidy) can save individuals and families money by lowering monthly premium payments if the household is between 100% - 400% of the Federal Poverty Level.
• Plans must be purchased inside of the Exchange to access Tax Credits and Cost Sharing.
• Cost Sharing can lower out-of-pocket expenses, such as deductibles and coinsurance payments. The household income must be between 100% - 250% of the Federal Poverty Level. Plans that qualify for Cost Sharing are the Silver Metal Plans inside of the Exchange.
Enrollment Periods and Qualifying Events:
• Next Open Enrollment Period: November 1st to December 16th. The first effective date for these plans is January 1, 2020.
• Special Enrollment Period for a list of qualifying events may allow for individuals to change or enroll in coverage outside of Open Enrollment Period: Marriage, Divorce, Death, Covered Dependent turns 26, Birth or adoption of a child, Loss of employer coverage, New citizenship, Moves to an area with new plan options, member with Catastrophic coverage turns 31, and Change in or loss of subsidy eligibility.
• Special Enrollment Periods last 60 days from the date of the qualifying event.
Penalties for not having insurance:
• Starting 2014 the penalty is $95 for adults and $47.50 for children, with a maximum of $285 per family or 1% of the family income, whichever is greater.
• Starting 2015 the penalty is $325 for adults and $162.50 for children, with a maximum of $975 or 2% of the family income, whichever is greater.
• For the years 2016 and 2017 the fee is calculated 2 different ways--as a percentage of your household income and per person. You'll pay whichever is higher. Percentage of income is 2.5% of household income with a Maximum of the total yearly premium for the national average price of a Bronze plan sold through the Marketplace. Per person is $695 per adult, $347.50 per child under 18 with a Maximum of $2,085.
Exceptions to the Mandate:
• Those with religious objections
• Incarcerated Individuals
• American Indians
• Those whose lowest cost health plan would be more than 8% of the household income
• Those with incomes below the filing threshold
• Undocumented immigrants
