What Clients Need to Know About ACA Changes

Susan Polk, a health insurance agent in San Luis Obispo, issued an advisory to help her clients sort out the Affordable Care Act (ACA), “Some people think that, come January 2014, a new insurance card will magically appear in their mailbox. This is most certainly not true. Enrollment will not be automatic, except in certain circumstances when you participate in an employer group plan of more than 200 employees, and you must make choices among various options, choose a plan, and enroll yourself and family members,” Polk says. She outlines the following key points:

 Individual health insurance – All insurance is guaranteed issue, meaning you are guaranteed to get coverage. There are no waiting periods for pre-existing conditions. Higher premiums cannot be charged for any health conditions, although an individual can be charged up to 50% more for smoking. California has decided not to implement this option.

 Free or low-cost health insurance – Individuals and families making less than 138% of the Federal Poverty Level (also known as the Federal Income Guidelines) will be eligible for MediCal in California (133% will be eligible for Medicaid in most other states). There is no longer an asset test, so people can now hold onto their retirement plans and other property and still qualify for free or greatly reduced medical care.

• Health Plans Offered – Insurance companies can offer four plans of insurance. Bronze plans must provide at least 60% coverage. Silver plans must provide at least 70% of coverage. Gold plans must provide at least 80% of coverage, and Platinum plans must provide at least 90% coverage. Deductibles and co-pays may vary from company to company. The only requirement is that they can prove that the actuarial value of the coverage meets the minimum percentages.

• Premium subsidies – Individuals and families making between 138% and 400% of the Federal Poverty Level will be eligible for premium subsidies. Your eligibility in 2014 will depend on your income in 2012. Each subsequent year, the eligibility will be based on your income in the calendar year two years prior, for example, in 2015 your subsidy would be based on your 2013 income. By purchasing insurance through the Health Benefit Exchange, they will be subsidized for the difference between the second lowest cost Silver Plan and the amount they are expected to pay, which varies from 2% to 9.5% of the Modified Adjusted Gross Income. For those who make over 400% of the Federal Poverty Level, there is no subsidy. However, they will be able to purchase any of the same products outside of the Exchange with no underwriting.

• Individual Mandate – Individuals will be required to purchase medical insurance starting in January 1, 2014. This is called the ìIndividual Mandate. Those not enrolling will pay a penalty along with their income taxes annually to the Internal Revenue Service, beginning in 2015. The penalty for not participating in 2014 will be the greater of 1% of Modified Adjusted Gross Income or $95, whichever is greater. This will increase each year, until it is the greater of 2% or $295.

• When to Enroll – The first open enrollment will start on October 1, 2013, and will continue until March 31, 2014. After that, open enrollments will occur each fall between October 15th and December 7th. There will be no enrollment into individual insurance outside of open enrollment except for certain qualifying events, including losing other coverage, birth, divorce, death, and a few other life events.

• Grandfathered Plans – If you have present individual insurance, you may be able to keep it, if your original effective date was before March 23, 2010, and you have not made substantial changes to your policy. In this case, your plan is said to be grandfathered and you can keep the plan even after ObamaCare is fully implemented. President Obamaís message to Americans in January of 2010 was that if we liked our health plans, that we would be able to keep it. He makes good on that promise if your plan is grandfathered. If your plan is not grandfathered, it will go away on December 31, 2013. You will then have a choice of any health plan offered by any health insurer in your county.

• Why enroll through a broker? – Private insurance brokers will go through a formal training process to be eligible to enroll folks in the Health Insurance Exchange (in California, this is known as Covered California). Health insurance brokers are qualified to assist people. Their training and experience with health insurers will make them the optimal choice for your enrollment needs. They can help you choose the best plan for your circumstances and help you with the tools youíll need to find a doctor and access care.

Polk offers the following advice for 2013:
• Know your income and optimize the results. Falling above the 400% threshold will mean paying 100% of the cost of your health insurance with no subsidy. Some individuals may not want to fall below the 138% (in California, 133% in other States), as that would mean eligibility in MediCal or Medcaid and could restrict access to personal physicians.

• If your plan is grandfathered, don’t make any changes until after the summer or fall. A synopsis of plans will be available later in 2013. At that time, you will be able to preview plans and see how the premiums compare to your present plan. It is expected that once the Affordable Care Act is fully implemented, grandfathered plans will see much lower premium increases.

• Make your appointment early. We will begin making appointments in August for the October enrollment.

• Keep your records handy. You may be asked to bring your 2012 tax return to your appointment, and other important records. This information will help insurance agents quickly determine your eligibility for subsidies and help you get the best result. All personal information is kept strictly confidential.

Last Updated 11/25/2020

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