Are you covered?

INDIVIDUAL MANDATE
Beginning in 2014, the Affordable Care Act requires most individuals and their dependents to have health insurance or pay a penalty. Although a key factor in reducing the number of uninsured Americans, the mandate is the most unpopular part of the law. But its necessary to make the laws insurance market reforms work properly. The ACA bars insurers in the individual and small-group markets from denying coverage to people with pre-existing health problems, charging higher premiums based on their health and placing annual and lifetime limits on covered benefits. Without the individual mandate, these new consumer protections would cause sharper premium hikes because they would encourage older, sicker people to get coverage, while healthy people would wait until they get sick to buy insurance. The mandate is designed to discourage this behavior and promote a mix of healthy and less-healthy people to enroll for coverage. That diversity of new enrollees is designed to help keep premium costs in check.

AFFORDABLE CARE ACT

On Oct. 1, Americans can begin enrolling for health coverage next year on the new state insurance marketplaces. The Affordable Care Act becomes fully operational three months later in 2014. Thats when most people must have health insurance or face a fine for noncompliance. Most of the roughly 260 million Americans with job-based, individual or government coverage probably have nothing to worry about. But if youre unsure or among the nearly 49 million uninsured Americans weve prepared a guide to bring you up to speed.

Essential health benefits

All insurance plans, both in and out of the marketplaces, must cover these 10 essential health benefits Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health services Prescription drugs Rehabilitation services Laboratory services Preventive and wellness care Pediatric services

Insurance industry reforms

Rules designed to make new policies more generous, affordable and transparent Accessibilty Guarantees access to individual coverage regardless of current or past health problems Value of coverage must cover at least 60 percent of costs Out-of-pocket limits must limit annual out-of-pocket costs such as co-pays, deductibles Rating requirements amount older plan members may be charged, no annual benefit-spending limits, rates cant vary based on gender, occupation or claims history

Online, telephone resources

HealthCare.gov: http://www.healthcare.gov The YouToons get ready for Obamacare video: http://kff.org/health-reform/video/youtoons-obamacare-video/ CuidadoDeSalud.gov (resource for Spanish speakers): http://www.cuidadodesalud.gov Business.USA.gov/healthcare (federal ACA information website for business owners): http://business.usa.gov/healthcare HHS Affordable Care Act hotline: 1-800-318-2596 HHS ACA hotline for hearing-impaired callers with TTY/TTD technology : 1-855-889-4325

families earning roughly between about $23,550 and $94,200 annually. The amount of the tax credit is based on the price of the benchmark plan, which is the second-lowest cost silver plan in your area.

Do I have to buy coverage?

No if ...
... you have insurance through Your employer Medicaid or CHIP (Childrens Health Insurance Program) Tricare or veterans health program Medicare Private insurance you bought thats at least the bronze coverage level A grandfathered plan from before ACA was enacted

INSURANCE MARKET CHANGES

No if ...

... youre a member of one of the following exempt groups Part of religious group opposed to accepting health insurance benefits An undocumented immigrant In prison Part of an Indian tribe Too poor to file a tax return ($10,000 single, $20,000 family) Paying more than 8 percent of income for health insurance, minus employer contribution or tax credits

Penalties for the uninsured

2014
Adult Child

2015

2016
695.00 347.50

$95.00 325.00 47.50 162.50

Family* 285.00 975.00 2,085.00

Penalties will increase yearly by cost-of-living adjustment after 2016

*Family penalty is whatever is greater: $285 or 1 percent of family income for 2014; $975 or 2 percent, 2015; $2,085 or 2.5 percent, 2016

MEDICAID EXPANSION
Hoping to reduce the ranks of nearly 49 million uninsured Americans, the Affordable Care Act allows states to expand the number of people eligible for Medicaid, the state/federal health insurance program for the poor and disabled. This so-called Medicaid Expansion will extend coverage in 2014 to an estimated 8 million nonelderly adults who earn up to 138 percent of the federal poverty level. Thats about $15,900 for an individual in 2013 or nearly $32,500 for a family of four. The federal government has pledged to pay all medical costs for the newly eligible Medicaid enrollees in 2014, 2015 and 2016 and no less than 90 percent of their costs

The health care law engineers a complete makeover of individual and small group coverage next year through a series of changes designed to make newly issued policies more Marketplace plans will thereafter. The June 2012 generous, accessible, be divided into four Supreme Court decision Who will use marketplaces? People purchasing individual and affordable and transparent. categories based on the allows states to decide small-group coverage portion of medical whether to participate in The individual, or How the coverage levels vary expenses they cover: the Medicaid expansion. nongroup, market has Percent of health care costs covered by: Bronze plans cover 60 As of July 1, 23 states and long been problematic for the District of Columbia are percent; silver plans cover consumers. Its known for Insurers You 70 percent; gold plans moving forward with high customer 20 10 cover 80 percent and expansion, 21 states are dissatisfaction and 30 40% platinum plans cover 90 not and six others are still turnover, high coverage percent. Plan members debating the issue, denial rates, lean benefits 90 80 pay the remaining portion. according to the and premiums subject to 70 nonpartisan Kaiser Family frequent increases. The marketplaces will 60% Foundation, which studies also offer catastrophic The new rules health care issues. coverage for people under guarantee access to age 30 and those age 30 individual and small-group INSURANCE and over with low incomes coverage regardless of MARKETPLACES Bronze Silver Gold Platinum who cant get affordable current or past health insurance or who have a As part of broad problems. Catastrophic plans typically have lower premiums than a hardship exemption from changes to the way health comprehensive plan, but individuals are usually responsible They also require each the individual mandate. insurance is bought and for initial health costs often up to $6,000 before coverage plan to cover at least 60 Catastrophic plans protect kicks in. Tax credits cannot be used to purchase catastrophic sold, the Affordable Care percent of medical costs, coverage. against high medical costs Act creates new online and limit annual from accidents or a major health insurance out-of-pocket costs, like illness. marketplaces where Low-income people will co-payments and TAX CREDITS individual and small-group Small employers and get larger tax credits than deductibles. The new Nearly 26 million lowcoverage can be their workers will also be those with higher incomes. consumer protections also and moderate-income purchased from qualified able to purchase coverage The amount of the tax limit the amount that older people will be eligible for health plans. Each state through the marketplaces, credit is revealed after plan members may be tax credits to help pay for will have a marketplace using the Small Business submitting an online charged; outlaw annual coverage on the new that will launch in October Health Options Program, application through the benefit-spending limits; marketplaces, according to with open enrollment for or SHOP. Some small marketplace. The money is and no longer allow Families USA, a coverage in 2014. employers with less than sent directly to the insurers to vary rates nonpartisan patient 25 workers will be eligible applicants insurance An estimated 7 million based on gender, advocacy group. The tax for a tax credit worth up to company to be applied to people will purchase occupation or medical credits are structured to 50 percent of their the premiums. insurance on the claims history. protect people from premium contribution. marketplaces between Individuals and families spending more than a set The law requires all October and March 2014, In states with who earn between 100 portion of their income on individual and small-group according to the federally-operated percent to 400 percent of coverage. The amount of health plans in 2014 to Congressional Budget marketplaces, employers the federal poverty level the tax credit depends on cover a list of essential Office. can only offer worker will be eligible for the tax the applicants income and health benefits, including coverage through one credits. In 2013, that would substance abuse services, The marketplaces will the cost of coverage. The SHOP plan in 2014, but be individuals who earn either be federally tax credits could range pediatric dental and vision multiple plans in 2015 and roughly $11,500 to operated, state-run or from a few hundred dollars care, mental health thereafter. $46,000 annually, or administered jointly. to more than $10,000. treatment and others often four-person excluded from current policies. Medicaid Expansion Where the states stand (as of Sept. 16, 2013) Maine Just 15.4 million people N.H. purchase individual coverage, according to the Vt. Wash. In states that participate, N.D. Mont. Kaiser Family Foundation. Minn. Mass. more people will be covered by But that number is Ore. N.Y. Medicaid, the state/federal health Wis. R.I. expected to increase S.D. Idaho insurance for the poor and disabled Mich. Conn. substantially next year, Wyo. Pa. N.J. Iowa when premium tax credits Ohio Policy by state Neb. Del. Nev. Ill. Ind. W. become available to help Utah Expanding Not expanding Va. Va. Md. people buy individual Colo. Kan. Ky. Mo. Calif. D.C. Debate ongoing coverage through the new N.C. Tenn. online insurance Okla. S.C. The annual income cutoff Ariz. Ark. marketplaces in October. N.M. for Medicaid will rise to: About 24.5 million people Miss. Ala. Ga. Individual $15,900 have small-group coverage La. Texas Family (4) $32,500 through companies with 50 Fla. or fewer employees, About 138 percent of the federal Alaska according to federal poverty level** Hawaii estimates. **Federal poverty level in 2013:

Insurance marketplace coverage

Help for the uninsured

individual, $11,490; family (4), $23,550

NOTE: Alaska and Hawaii are not to scale

Source: Kaiser Family Foundation, Alevere Health, acaexplained.org, MCT illustration Graphic: Tony Pugh, Judy Treible, Eric Goodwin,

2013 MCT