Frequently Asked Questions about Healthcare

Yes.  By October 1, 2013 all employers, large, small, those offering health insurance, and those not offering health insurance, must notify all employees of their options.  The US Department of Labor has created 2 forms, one for employers offering and one for employers not offering coverage. Here are links to the forms;

Notice for employers with plans

Notice for employers without plans

We can assist you in completing the forms. Just send us an email.

Yes. One of our Marketplace certified agents had the wonderful opportunity to have a presentation recorded.  You may watch it here http://youtu.be/gnl5lSMAPnc

Subsidies will be calculated at the time you apply through a government exchange.  On July 5, 2013 the Federal government has relaxed the rules that exchanges must verify income levels on individuals for the 2014 year.  This means that exchanges can only conduct random checks of income levels for 2014.

A household with an income level of less than 400% of the federal poverty level may qualify for a subsidy.

On July 2. 2013, the Obama Administration announced that it is delaying the employer mandate until January 1, 2015.  This means that employers that employ 50 or more employees will not be subject to providing affordable insurance or paying a penalty.   This does not however, delay the start of the individual mandate that will become effective January 1, 2014.  The individual mandate requires that individuals must carry insurance as defined in the law or pay a penalty in 2014 of the greater of 1% of income or $95.  This amount increases in the following years.

The health insurance reforms adopted as part of the Patient Protection and Affordable Care Act (PPACA), and the subsequent reconciliation bill, are phased-in over 5 years. Most provisions will not take effect until January 1, 2014. There are also modifications to certain provisions that will change in the years after 2014. However, there are some new protections that have already been implemented:

• Lifetime limits are prohibited and annual limits are restricted
• Enhanced appeal procedures are available to consumers
• Children under 19 years of age cannot be denied coverage
• Children up to age 26 may remain on a parent’s policy
• Preventive services must be coverage and cannot have cost-sharing
• New rate review transparency requirements are in place
• Medical loss ratio standards limit insurers’ overhead
• A standardized summary of benefits must be used by all insurers, allowing for easier comparison of plans

We have three ways to explore the law;

1. Read the entire law (4.27MB 2409 pages)

2. Read the law section by section.

3. Use the interactive timeline.

The key goal of the health care reform law is to ensure that nobody can be denied coverage or be priced out of coverage due to a health problem. However, if you allow people to wait until they have a health problem to purchase insurance, then the market simply will not work. There would be few choices available to consumers, and those choices would be expensive for everyone. So, the law requires everyone to have minimum coverage, thus creating a pool of both sick and healthy individuals.You are not required to purchase coverage, however you may be subject to a penalty if you do not.

Visit our insurance and coverage finder page to get quote from several different insurance companies. Provide some simple information and you'll find a whole range of options available to you.

Yes. Health plans in effect as of March 23, 2010, are grandfathered under the law and will be considered “qualified coverage” that meets the mandate to have health insurance that begins January 2014 as long as the issuer continues to offer it without substantial changes.

Unfortunately, the grim fact is that health care spending is likely to continue rising faster than general inflation well into the future, resulting in higher premiums. While some individuals and families with health problems may see their premiums decrease significantly under the new rating rules, for most Americans premiums will continue to increase from year to year.

All plans sold or renewed in 2014, must limit the out-of-pocket exposure of consumers to approximately $6,000 for individual and $12,000 for families. These limits will be indexed to average premium growth in future years. In addition, the deductible for plans in the small group market will be limited to $2,000 for individuals and $4,000 for families in 2014, also indexed to average premium growth in future years.

Also, all plans must design their cost-sharing (deductibles, copays, coinsurance) to fit into specific levels of coverage. The levels of coverage are defined as follows:

• Bronze Level – The plan must cover 60% of expected costs for the average individual
• Silver Level – The plan must cover 70% of expected costs for the average individual
• Gold Level – The plan must cover 80% of expected costs for the average individual
• Platinum Level – The plan must cover 90% of expected costs for the average individual

Yes, though they may not charge older individuals a premium that is more than 300% of the premium charged a younger individual. Currently, rates can vary based on age as much as 700% in some cases. In addition, insurers may not vary rates based on health, claims, genetic information, or any other health-related factors. Insurers may only vary rates in a state by age (within limits), tobacco use, geography, and the number of family members covered.

The health reform law requires that insurers and employers that provide dependent coverage to children make that coverage available to adult children of enrollees up to their 26th birthday. This requirement became effective for “plan years” beginning September 23, 2010, so parents will be able to enroll a child in group coverage during the next open enrollment period. Children can be added to an individual policy when it is renewed.

Of course, adding an adult child to the plan will likely increase your premiums. If the child is 19 or older, the insurer may exclude coverage of pre-existing conditions for a period of time, as allowed by existing state and federal law, until the prohibition on preexisting condition exclusions takes effect in 2014.

Starting in 2014, most Americans will be required to have health insurance and could face federal penalties if they do not. Taxpayers will be required to indicate on their tax returns whether they have health insurance that meets minimal benefits standards. If consumers do not have insurance by 2014, they would owe $95, or 1 percent of taxable income, whichever is greater. The penalty rises to $325, or 2 percent of taxable income in 2015, and then $695, or 2.5 percent of taxable income in 2016, up to a maximum of $2,085 per family.

A private health insurance exchange is an exchange run by a private sector company or nonprofit. Health plans and carriers in a private exchange must meet certain criteria defined by the exchange management. Private exchanges are designed to help consumers find plans personalized to their specific health conditions, preferred doctor/hospital networks, and budget. They are sometimes called marketplaces or intermediaries, and work directly with insurance carriers, effectively acting as an extension of the carrier.

Public health insurance exchanges are state-run marketplaces where individuals and small business can purchase private insurance policies. These public exchanges will begin operation in 2014.

Prices for policies sold in Affordable Insurance Exchanges (Public Exchange) have not been established yet. Public Exchanges—state-run marketplaces where individuals and small businesses can purchase private insurance policies—will begin operation in 2014. Insurers will offer plans with a certain guaranteed set of benefits at a range of prices. Members of Congress will purchase their health insurance through the new Exchanges, and you will be able to as well. The law makes clear that insurers won’t be able to charge more based on your gender or your health status, and there will be limits to how much premiums can vary based on your age. Private Exchanges are available and have their own rates established. Our exchange can be accessed through our insurance and coverage finder page.

There are a number of things you can do to make sure that a plan is legitimate. If you have questions about a plan, one of your best options is to contact your state’s Consumer Assistance Program or your state’s Department of Insurance.

Also, you may want to review the suspected plan to make sure it is comprehensive. Some insurance may not really be health insurance. Read this guide to learn more about different kinds of insurance.

The Small Business Tax Credit has been available since the 2010 Tax Year. Businesses with fewer than 25 full-time equivalent employees (FTE) and average annual wages less than $50,000 per employee may qualify. To receive the tax credit, an employer must have a group health plan and must pay at least 50% of the premium.

The tax credit is equal to a percentage of what the employer pays and is based on the average premium in the small group market in the State. For Tax Years 2010 through 2013, the maximum credit in each year is 35% of the employer’s contributions (25% for nonprofit employers). Beginning Tax Year 2014, the maximum credit is 50% of the employer’s contribution (35% for nonprofit employers). The full 35% tax credit (50% in future years) is available for a business with 10 or fewer full time equivalent workers and average annual wages of $25,000 or less. The tax credit phases out completely for employers with 25 workers (FTEs) or average wages of $50,000.

Every plan sold or renewed in the individual and small group market after January 1, 2014, must include all the benefits in a “benchmark” plan – a plan chosen for the state based on coverage currently available in the state – and will cover services in the following categories:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance abuse disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

For people with individual or job-based health insurance plans that are not grandfathered, the Affordable Care Act makes certain preventive services available without a copayment. An annual physical exam is not one of those services, however. See what’s covered and find out what this means for you.

The law imposes tax changes that would affect some people who are covered through their employers, especially those in higher tax brackets. Beginning next year, the law increases the Medicare tax by 0.9 percent on earnings over $200,000 for individual taxpayers and $250,000 for married couples filing jointly. It also imposes a 3.8 percent tax on unearned income for high-income households.

If you are covered by VA health benefits, you are considered covered under the Affordable Care Act.

Exchanges are the central mechanisms created by the health reform bill to help individuals and small businesses purchase health insurance coverage. On October 1, 2013, an Exchange in every state will begin enrolling individuals and small businesses into qualified health plans. The Exchange, operated by the federal government or by the state, will provide information to consumers about their coverage options and what assistance is available to them. The Exchanges will also administer the new health insurance subsidies and facilitate enrollment in private health insurance, Medicaid, and the Children's Health Insurance Program (CHIP). The federal law does not require anyone to purchase health insurance through the Exchange, though subsidies will only be available for plans sold through the Exchange. You will be able to purchase this coverage right on the Exchange’s website or through your agent if he or she is approved to sell Exchange plans. If you would rather buy other health insurance through an insurance agent or broker, you will be free to do so.

Beginning with the 2010 tax year, tax credits are available to qualifying small businesses that offer health insurance to their employees. Your business qualifies for the credit if you cover at least 50 percent of the cost of health care coverage for your workers, pay average annual wages below $50,000 and have less than the equivalent of 25 full-time workers (for example, a firm with fewer than 50 half-time workers would be eligible).

The size of the credit depends on your average wages and the number of employees you have. For tax years beginning in 2010 through 2013, the maximum credit is 35 percent of the employer's premium expenses that count toward the credit. The full credit is available to firms with average wages below $25,000 and less than 10 full-time equivalent workers. It phases out gradually for firms with average wages between $25,000 and $50,000 and for firms with the equivalent of between 10 and 25 full-time workers.

You can see a general overview of the preventive services covered or read a more detailed list of covered services.

A Health Savings Account (HSA) is a special account that lets individuals in Qualified High Deductible Health Plans (QHDHP) set aside money, tax-free, to pay for health-related expenses. They are only available as part of a health plan. HSA’s will still be available if you have a QHDHP.

A large group is considered 50 or more Full Time Equivalent (FTE) employees. An FTE is any employee working on average 30 hours per week or more. The total number of hours worked by part-time employees is divided by 30 hours per week (or other comparible time period) to determine the FTE of part-time employees. Example: 10 part time employees each work 24 hours per week which adds up to 240 hours. 240 hours divided by 30 hours is 8 FTE.

The law and subsequent regulations prohibit insurers from denying coverage for children based on health status or excluding coverage of their pre-existing conditions if otherwise covered under the policy. This protection became effective after September 23, 2010. A child can be added to an existing policy under the enrollment rules of the policy. If you are seeking a child-only policy, you will need to inquire whether child-only coverage is available in your state. If you are covered under a group plan, you may add your child to your policy at the next open enrollment period.

The federal law specifically states that neither businesses nor individuals are required to purchase through a government Exchange. You may still purchase through your agent.

The health care law does not require small employers to provide insurance. However, there may be tax credits if they choose to provide insurance to their employees.

A new small business health care tax credit provides a 35% tax credit on health premiums, with the credit increasing to 50% in 2014. Information for small employers is available here.

The employer responsibilities under the health reform bill do not apply to employers with fewer than 50 “Full Time Equivalent” employees.

Yes. The tax credit is designed to both support those small businesses that provide coverage today as well as those that newly offer such coverage.

Yes. An employer that fails to offer “minimum essential coverage” to its employees will be subject to a penalty of $2,000 for each of their employees beyond the first 30. In your case, this penalty would be $2,000 x (75-30) = $90,000. Employers that do offer minimum essential coverage will be assessed a penalty of $3,000 per employee that is eligible for, and receives, a subsidy through the Exchange because their share of the premium for the employer’s group health plan exceeds 9.5% of their household income. This penalty may not exceed $2,000 times the number of employees, disregarding the first 30 employees.

Starting in 2014, new plans sold to individuals and small businesses have to include coverage for pediatric vision and pediatric dental services. Additional detail will be available as we approach 2014. Subscribe to our “E-Newsletter” to receive updates when more information becomes available.

The law and regulation is not clear on how to manage this situation. Subscribe to our “E-Newsletter” to receive updates when more information becomes available.

These employers are subject to a penalty of $3,000 for each full-time employee that receives subsidized coverage through an exchange. The maximum penalty is the amount equal to $2,000 times the number of full-time employees, excluding the first 30 employees.