A Consumer s Guide to the Affordable Care Act

Transcription

1 A Consumer s Guide to the Affordable Care Act

2 The Affordable Care Act was designed to help make health care affordable for everyone. This guide will help you understand how the ACA affects individuals and families. It includes how to get a low-cost health plan, the types of plans you can purchase, what they cover and how to prepare for enrollment. How the ACA protects you Here are some of the ways in which the ACA helps consumers: Young adults can remain on a parent s health plan until the age of 26, even if they live away from home, attend school or are married. Preventive care and women s preventive services are covered with no copays, coinsurance or deductibles. Adults and children with pre-existing conditions can t be denied coverage or pay high rates. Your health plan can t be cancelled if you get sick. There are no lifetime dollar limits on coverage. Out-of-pocket limits also protect you from high medical costs. Your out-of-pocket limit is the most you ll pay for covered services during a benefit period (usually a calendar year). After that, your health plan starts to pay 100 percent of the allowed amount. All copays, coinsurance and deductibles count toward your out-of-pocket limit. How your health care dollars are used Health insurance companies must spend at least 80 percent (80 cents) of every premium dollar they take in on your health care and programs to improve the quality of care. Companies that don t meet this target must pay back the difference in the form of rebates or reduced premiums.

3 When to sign up for a health plan The government sets strict guidelines on when people can enroll in a health plan. The open enrollment period for 2016 coverage is Nov. 1, 2015, to Jan. 31, Outside of these dates, you can only enroll in a health plan or change your current plan if you have a qualifying life event. These events include losing a job, having a baby or getting married. This is known as a special enrollment period. Written proof of the life event must be included with a new application or member change form. It must be submitted within 60 days of the event. Note: If you have health coverage through an employer, your employer sets the open enrollment date. The effective date The date that your health coverage actually starts depends on when you enroll. In general, if you enroll by the 15th of the month, the effective date of your coverage will be the first day of the next month. If you enroll between the 16th and the end of the month, your coverage will start on the first day of the next following month. Example Enroll by Dec. 15: Coverage starts Jan. 1. Enroll between Dec. 16 and 31: Coverage starts Feb. 1. Note: Your coverage won t be effective unless you pay your first month s premium by the due date.

4 Tax penalties The ACA s individual shared responsibility provision otherwise known as the individual mandate requires most Americans to have health insurance. If you don t have health coverage through an individual or employer plan, Medicare or Medicaid, you will face a tax penalty. Other types of coverage will also satisfy this mandate, including: Children s Health Insurance Program (CHIP) Veterans Affairs Indian Health Service TRICARE The penalty for the 2016 tax year is: $695 per person Or 2.5 percent of your yearly household income (whichever is greater) You will be required to pay the penalty on the tax return you file for the year you don t have coverage. Example Pete, his wife and their 18-year-old son do not have health insurance. Their household income is $50, percent of $50,000 = $1,250 $695 x 3 people = $2,085 The family s tax penalty for not having health insurance would be the higher amount $2,085. You won t have to pay a penalty if one of the following is true: You don t make enough money to file a federal tax return. You would have to spend more than 8 percent of your household income on the least expensive health plan available. You show that a hardship prevented you from becoming insured. People who believe they are exempt from this rule can apply for an exemption through the Health Insurance Marketplace at HealthCare.gov.

5 Get ready to enroll An important step before you enroll is to gather information. Think about your family s health care needs and medications. How much can you afford to spend each month on health insurance? When you re comparing plans, be sure to look beyond the monthly premium (the amount you pay each month for health insurance). Find out what your cost would be to see a doctor, fill a prescription, get an X-ray or be hospitalized. Here s a checklist to help you prepare for enrolling in a health plan: Visit choosehap.org to get an idea of your options. Visit choosehap.org/healthinsurance101 to learn how coverage works. Write down a list of any questions you have. Gather household information, such as: Number of people who need coverage Monthly income and expenses Personal information (dates of birth, Social Security numbers, etc.) Set a budget how much you can afford to spend each month on health insurance (premiums and out-of-pocket costs). Have a doctor in mind for you and members of your family, especially if you are enrolling in an HMO and selecting a personal care physician. Make a list of any drugs you or your family members take so you can make sure the health plan s drug formulary includes those drugs. Ours is available at hap.org/prescriptions. Gather the required proof of a qualifying life event if enrolling due to a special enrollment period.

6 Qualified health plans All qualified health plans cover essential health benefits that include the following 10 types of services: 1. Ambulatory patient services (outpatient care you receive without being admitted to a hospital) 2. Emergency services 3. Hospitalization 4. Maternity and newborn care (care before and after your baby is born) 5. Mental health and substance use disorder services, including behavioral health treatment including counseling and psychotherapy 6. Prescription drugs 7. Rehabilitative and habilitative services and devices (to help people with injuries, disabilities or chronic conditions gain or recover mental and physical skills) 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric vision and dental services If you don t currently have health coverage, you ll need to get a qualified health plan or face tax penalties. There are three ways to buy a health plan: 1. Directly through an insurance company such as HAP 2. Through the Health Insurance Marketplace 3. Through a licensed insurance agent

7 The metal tiers All qualified health plans are grouped into metal levels or tiers: Platinum Gold Silver Bronze These tiers are based on the percentage of health care costs the plan covers. They allow people to compare plans with similar coverage value (also called actuarial value). They are not ranked by any quality measures. Bronze plans usually have the lowest premiums and highest out-of-pocket costs (copays, deductibles and coinsurance). Platinum plans usually have the highest premiums and the lowest cost sharing. It is also possible that lower-tier plans offered by one insurer may cost less than another s higher-tier plans. Insurers selling plans to individuals may offer several different options within each metal level. They are not required to offer plans in all four levels. To learn more about HAP Personal Alliance health plan for families and individuals, visit choosehap.org.

8 Lower-cost eligibility There are several factors that affect the cost of health care under the ACA. These include: Rating rules Federal and state taxes and fees Essential health benefits Depending on your income and the number of people in your household, you may qualify for a lower-cost health plan. These plans are available through the Marketplace, Healthy Michigan Plan or other Medicaid programs. Lower-cost eligibility at a glance Number of people in your household Your estimated total household income for Up to $16,243 $16,244 to $47,080 2 Up to $21,983 $21,984 to $63,720 3 Up to $27,724 $27,725 to $80,360 4 Up to $33,465 $33,466 to $97,000 5 Up to $39,206 $39,207 to $113,640 6 Up to $44,947 $44,948 to $130,280 7 Up to $50,687 $50,688 to $146,920 8* Up to $56,428 $56,429 to $163,560 You may qualify for the Healthy Michigan Plan or another Medicaid program. You may qualify for lower costs through the Health Insurance Marketplace. *Add $4,160 for each additional person in a household of more than eight. Lower costs through the Health Insurance Marketplace If you buy a health plan through the Marketplace, you may be eligible for cost savings based on your family size and income. The lower your income, the higher your savings may be. If eligible, you will receive a cost savings (called an Advance Premium Tax Credit) that can be applied directly to your monthly premiums. You may also be eligible for lower out-of-pocket costs.

9 Lower costs through the Healthy Michigan Plan If you have a limited income, you may be eligible for the Healthy Michigan Plan. This plan provides coverage for Michigan residents who: Are age 19 to 64 years Make up to 133 percent of the federal poverty level (about $16,000 a year for individuals or $33,000 for a family of four) Do not qualify for or are not enrolled in Medicare or other Medicaid programs Are not pregnant when applying You may apply for the Healthy Michigan Plan at any time. Online: michigan.gov/mibridges By phone: (855) In person: Visit a local Department of Human Services office. For more information, visit choosehap.org/help-paying-your-premiums. Help is always available Health insurance companies and licensed health insurance agents are friendly and knowledgeable. They re great at helping you learn about health insurance and how to choose the right health plan. If you have any questions, call us at (855) WITH-HAP ( ).

10 Health Plans for Everyone Individual Group Medicare Medicaid hap.org Subsidiaries Alliance Health and Life Insurance Company ASR Health Benefits HAP Midwest Health Plan HAP Preferred Inc. HAP does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations Health Alliance Plan of Michigan A Nonprofit Company 0M 7/