A helpful guide for those not sure of how the Affordable Care Act might affect their family.
Understanding the Affordable Care Act can be more difficult than untangling your kids’ double-knotted shoelaces or getting gum unstuck from their hair. But we’ve got you covered. Read our ABCs below and learn about the monumental law, its impact and the common terms you and your family should know. Don’t worry. You won’t be quizzed afterward.
A: Affordable Care Act (ACA)
The comprehensive health care reform law, also referred to as Obamacare. Enacted in March 2010, it overhauls the existing American health care system, gives people with limited income new options for getting health coverage, and requires most Americans to have qualifying health insurance starting in January 2014, according to Dr. Joel Cantor, distinguished professor, Center for State Health Policy at Rutgers University.
B: Benefits of ACA
Among the benefits is that insurance companies are no longer allowed to discriminate or charge you more because you have a preexisting medical condition or illness, Cantor says. They must also cover treatments for these conditions, and plans cannot charge women more than men for the same plan.
Marketplace insurance plans include five categories: Bronze, Silver, Gold, Platinum or Catastrophic. The category you choose affects the total amount you'll likely spend for premiums and essential health benefits annually, according to Dr. Mary Campagnolo, a family and geriatric physician and immediate past president of the New Jersey Medical Society.
Marketplace open enrollment ends March 31, 2014. If you enrolled by Dec. 23, 2013, coverage can begin as soon as Jan. 1, 2014, according to Cantor.
E: Essential health benefits
Marketplace insurance plans must now offer essential health benefits, including ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services.
If you do not have minimum essential coverage by March 2014, you may have to pay a penalty, Cantor says, adding this year, it will be a flat amount (estimated at $95 per adult), or 1 percent of household income, whichever is greater. In several years, when the law is fully phased in, the fee will increase to $695 or 2.5 percent of the annual income, whichever is greater.
With the ACA, it means an exemption from certain provisions of this law. This often comes into play with job-based health plans.
H: Health marketplace exchange
New Jersey residents will use HealthCare.gov to access the marketplace, which is a new way to find and compare coverage options based on price, benefits, quality and other features important to you.
I: Insurance plans
Medicaid and Medicare are two commonly discussed insurance plans. Medicaid is a state-administered health insurance program for low-income families and children, pregnant women, the elderly and people with disabilities. Medicare is a federal health insurance program mainly for people who are age 65 or older.
J: Job-based health plan
It’s estimated that at least 50 percent of Americans will have employer or job-based health coverage, Campagnolo says. If you have access to an affordable, job-based health plan, you can review plans in the health care marketplace exchange, but you might not be eligible for premium tax credits available to help pay for the coverage. Campagnolo adds it’s also best to check with your employer to ensure the law has not affected your current health benefits.
K: Kaiser Family Foundation
The Kaiser Family Foundation’s website, KFF.org, provides a comprehensive, non-partisan overview about the ACA. You’ll find FAQs, an ACA Fact of the Day, a calculator to estimate costs, and a clever YouToons video that explains the law and its impact on families.
L: Law, and what it will do
This law will do four things: help people who can’t afford coverage get it; change the rules under which private health insurance is sold to make it more available and dependable for people; add a variety of mechanisms within the law to make health care better; and add provisions to reduce the rise of health care costs, according to Cantor.
M: Minimum essential coverage
Everyone is now required to have minimum essential coverage or else pay a penalty fee, unless you qualify for an exemption. Coverage includes individual marketplace policies, job-based coverage, union plans, COBRA, student health plans, retiree health plans, veterans’ health plans, Peace Corps volunteer plans, grandfathered health plans, Medicare, Medicaid, The Children’s Health Insurance Program (CHIP) and TRICARE military health coverage.
N: New Jersey
New Jersey is among the states that will expand its Medicaid program in 2014 to cover households with incomes up to 133 percent of the federal poverty level. That equals $15,800 a year for one person or $32,500 for a family of four. There have been an estimated 21,000 new enrollees in Medicaid, which includes CHIP, and 79,000 phone inquiries about the program since October 2013, Campagnolo says.
O: Out-of-pocket estimate
An estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.
P: Premium tax credits
In New Jersey, an estimated 400,000 residents are eligible for premium tax credits, which help you afford health coverage purchased through the marketplace based on your income and household size. If you have access to an affordable, job-based health plan, you might not be eligible for premium tax credits to help pay for the coverage, and you generally won’t qualify if your estimated 2014 income is above $45,960 for an individual and $94,200 for a family of four.
If you have questions or want to apply for coverage, call Healthcare.gov’s 24-hour hotline at 1 (800) 318-2596.
For more information, visit AARP.org; Healthcare.gov; and New Jersey Family Care’s website, NJFamilyCare.org.
In most states, insurers are allowed to increase premiums by up to 50 percent more if you smoke. The tobacco surcharge is not covered by the health care marketplace’s premium tax credits (if you qualify), and states are allowed to limit tobacco surcharges.
T: Total cost estimate
The total amount you may have to pay for health plan coverage in the marketplace. It’s estimated before you actually have the coverage and have health expenses under the coverage.
The new Health Insurance Marketplace helps uninsured people find health coverage. New Jersey residents will use HealthCare.gov to apply for coverage, compare plans and enroll. The website will explain if you qualify for a private health plan, Medicaid or Medicare.
V: Value-based purchasing
Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers.
W: Ways to apply
There are four ways to apply for coverage in the health care marketplace exchange: a paper application, online, by phone, or in person with an assister.
Examples, including infographs and polls, of how the law could impact you and your family are available on AARP.org and the Kaiser Family Foundation’s website, KFF.org.
Y: Young adults
ACA allows you to keep or add your children on your policy until they are age 26, even if they no longer live with you, have graduated from college or are married. However, you will not be able to include their spouse or their children on your policy.
Z: Get some Zzzs
Meaning, sleep on it before making a major decision about insurance plans, Campagnolo urges. Families must determine what’s best for them, she says, so think about the health care needs of your household.
Health & Wellness Resources
1 (888) OUR-AARP
Dr. Mary Campagnolo
Medical Society of New Jersey
Dr. Joel Cantor
Center for State Health Policy
Kaiser Family Foundation
U.S. Centers for Medicare & Medicaid Services
1 (800) 318-2596
Published (and copyrighted) in Suburban Family Magazine, Volume 4, Issue 10 (December, 2013).
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