PPACA- Patient Protection and Affordable Care Act -Explained!
Open Enrollment Period for 2017 ended January 31st 2016-
NEW Enrollment Period opens 1st November, 2017 for
1st January 2018 health insurance coverage.
Check out now whether you have a Special Enrollment Period and your likely Tax Credit and cost sharing information on our Insurance page .
Also detailed information about PPACA at our blog site: http://www.azhealthinsuranceblog.com
NOTE: If you do not need or qualify for any Tax Credit, we can possibly still get you covered outside of any Enrollment Period- ask me how!
Eric – Cell: 602-616-1660
New procedures took effect Jan. 1, 2014, ( subject to any new or other legislative actions) which made shopping for health insurance a completely different experience for those who buy it on their own—or are uninsured BUT only during Enrollment or Special Enrollment Periods.
These are the main changes:
This is the most popular part of health reform: Health plans must sell coverage to everyone, regardless of pre-existing conditions, and can’t charge more based on health or gender.
By 1st October 2013 , every state had to have an insurance marketplace — an organized exchange where individuals and small-business owners can view, compare, and purchase qualified private health plans.
Arizona uses the Federal exchange system at healthcare.gov.
It’s expected that most consumers would shop on their state’s exchange online, but they can also shop by phone or through qualified insurance brokers/agents.
States had the option of setting up marketplaces/exchanges themselves or allowing the federal government to do the job.
From 1/1/2014 everyone (applicable individuals) will be required to have health insurance or pay a penalty. Almost any sort of legitimate coverage will satisfy the mandate: private insurance obtained on your own or through a job, Medicare, Medicaid, CHIP, Veterans Affairs, or Tricare,etc.
A U.S. citizen is an “applicable individual”unless he or she is religiously exempt, a member of a health care sharing ministry or in jail.
Some people will be exempt from the payment of any penalty -if they make too little money to file a federal tax return; have to spend more than 8% of the household income on the cheapest qualifying plan, even including any subsidy; are an American living abroad or are in prison.
Further if you have existing coverage either as an individual or through an employer which was basically in place 3/23/2010 when PPACA became law you are “grandfathered” and do not have to change your coverage nor pay any penalty even if it is not “Essential Coverage” nor “affordable”.
The government granted a six-week extension until March 31 2014 for Americans to sign up for coverage and avoid new tax penalties under the then president’s health care overhaul law.
If you don’t have health insurance( “minimum Essential Coverage”), you’ll have to pay a tax penalty, starting at the highest of 2.5% of household income or $695 per individual, $2,085 per family. percent of income in 2017.)
Afraid you won’t be able to afford insurance? If you buy from the insurance companies on a marketplace/exchange as an individual, you may qualify for a subsidy in the form of an advance tax credit if your household income is between 100 percent and 400 percent of the federal poverty level.
(The tax system already subsidizes people who have coverage through a job by excluding the cost of their health plan from income taxes.)
For instance, a family of four with an income of 200 percent of poverty, or about $46,000 in 2012, will pay no more than $235 a month for health insurance. People with household incomes of less than 250 percent of poverty will also get subsidies to reduce their out-of-pocket costs, such as deductibles and coinsurance. You’ll learn whether you qualify for a subsidy when you shop on the exchange.
Marketplace health insurance plans
There are 5 different basic health plans in the marketplaces including SHOP for small employers– which will offer plans created and offered by the usual health insurance companies like Humana,Aetna, Healthet,UHC,etc.- run by either the state or federal authorities:-
1) A Catastrophic plan for anyone age up to 30 which will have limited physicians and specialists office visits and catering to young people who do not want or won’t pay for a fully fledged medical plan- they all believe themselves to be invulnerable of course.
B) -4 different full health metal designated plans:
Platinum 90% (Actuarial Value),
Gold 80% (AV),
Silver 70% (AV)
Bronze 60% (AV).
Actuarial Value is not the same as the % or Coinsurance we usually see when talking about health insurance plans -like 80/20, 70/30, etc.but are fairly close to it but of course as the % of coinsurance or AV goes up the premiums will also increase and as it goes down, so goes down the premium.
The health care law was intended to expand the government-run health program for low-income Americans to cover up to 16 million more people with household incomes up to 133 percent of the poverty line ($14,856 for an individual and $30,657 for a family of four). That includes many at or below the poverty line who are not currently eligible.
Governor Brewer persuaded the Arizona legislature to expand the Medicare (AHCCCS) program in Arizona!
Nearly 12 million Americans received more than $1.1 billion in rebates in August, 2012, from insurers who didn’t spend enough of their 2011 premium income on health care.
Insurers must spend at least 80 percent of premiums on medical care and quality improvements for customers in their individual and small-group (under 50 employees) plans. The cut-off is 85 percent for large group plans.
The rule does not apply to self-insured plans offered by employers who pay employee health expenses on their own. The only way to know if you are self-insured is to ask your employer. You can’t tell just by looking at your insurance card.
Standard disclosure forms.
Beginning in September, 2012, all health plans had to use a standardized, consumer-friendly form to provide a uniform summary of benefits and coverage, including information on co-payments, deductibles, and out-of-pocket limits. Insurers also had to calculate and disclose a patient’s typical out-of-pocket costs for two medical scenarios: having a baby and treating type 2 diabetes.
Caps on Flexible Spending Accounts (FSAs).
Employers could still set their own limits (usually $2,500 to $5,000) on FSAs in 2012. But in 2013, the most that could be set aside tax-free for medical expenses not covered by insurance was $2,500, with the cap increasing by the annual inflation rate in subsequent years. Plus you can no longer use FSAs to pay for over-the-counter drugs unless you have a doctor’s prescription. The cap took effect January 1, 2013.
Flexible Spending Account change for 2014!
The US Treasury Department has modified its FSA “use-it-or-lose-it” provision to allow rollover of FSA funds. Effective in plan year 2014, employers that offer FSA programs will have the option of allowing participants to roll over up to $500 of unused funds at the end of the plan year.
“This policy development is fantastic news for everyone involved with FSAs – but especially for participants themselves”
FSAs allow employees to contribute pre-tax dollars to pay for out-of-pocket healthcare expenses – including deductibles, copayments, and other qualified medical, dental or vision expenses not covered by the individual’s health insurance plan.
Small Employers- > 50 employees
Effective -1/1/14 small employers do not have to offer any benefits to their employees and do not have to pay any penalties if they do not!
HOWEVER, if a small employer does offer benefits to the employees which are PPACA qualified and affordable then while their employees can go to the marketplaces to get a policy they CANNOT get any Tax Credits or cost payments with respect to those plans.
Any small employer can use a qualified insurance broker/agent to advise and assist them obtain their health insurance PPACA approved /affordable plans from the SHOP marketplace or any private marketplace/exchange!
Small employers can also go to a different marketplace called SHOP where they are able to also get tax credits on their health insurance premium contributions (of up to 50% ) and also plans for their employees health insurance benefits. .
Other items to be taken into account when calculating the Tax Credit will be- the average Annual Wage and the total number of employees!
Large Employers-(50 plus employees)
For large employers their requirements (The Employer Mandate or PAY OR PLAY ) were delayed to 1/1/2015 but are now effective !!
1)- if they do not offer any health insurance plans to at least 95% of their employees which meet the PPACA Essential Elements they will have to pay a fine of $2,000 per employee (minus the first 30 employees) .
2) if they do offer PPACA compatible plan and its NOT affordable OR its affordable and an employee still goes to the marketplace and gets a tax credit etc then the employer pays a fine of $3000 per employee who gets the tax credit. FT employees only= 30 hour per week.These penalties are not tax deductible!!
The large employer can get their health insurance PPACA approved /affordable plans from any broker, insurance company ,etc.
More young adults with insurance.
All health plans must allow young adults to remain as dependents on their parent’s health plan until they turn 26, whether or not they live at home or can be declared as dependents on the parent’s income tax return.
Free preventive care.
New private health plans must cover and eliminate cost-sharing (co-payment, co-insurance or deductible) for proven preventive measures such as immunizations, Pap smears, and screening colonoscopies.
Beginning August 2012, private health plans had to provide additional preventive measures to women, including free well-woman visits, screening for gestational diabetes, domestic violence screening, breastfeeding supplies, and contraception.
Workplaces run by religious organizations that object to birth control are to receive a special accommodation: their health plans must still offer the coverage, but the cost of it will be borne entirely by their insurance companies.
People on Medicare are also now entitled to the same free preventive coverage, and in addition get a free annual “wellness visit.”
More consumer protections.
Health insurers can’t set lifetime limits on your coverage or cancel if you get sick. .
For more detailed information: –Detailed PPACA blog site:
Individuals and families- Check out your Tax Credit eligibility,etc at our ACA blogsite: http://www.azhealthinsuranceblog.com
Small Employers– Check out your eligibility for Tax Credit using the SHOP marketplace , and how much, on your employee contributions you are paying at our blog site: http://www.azhealthinsuranceblog.com
Get your individual /family insurance quote: Healthcare.gov
Don’t forget to include our FFN ID-EWALTERS37 and NPN:- 8594684 when asked if anyone is helping you set up your account!!
For a No Cost, No Risk, review of your coverage and for more information contact:
NOTE: New legislative changes to the ACA are being proposed nearly every day and the above information may be out of date by the time you read this page, please call Eric Walters- 602-616-1660 to get the latest update!
Eric Walters Insurance Services
14482 N 100th Place,
SCOTTSDALE AZ 85260