Q&A: Affordable Care Act

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Posted: Sunday, September 15, 2013 6:10 am | Updated: 4:20 pm, Fri Sep 20, 2013.

How do I learn more?

You can learn about insurers’ rates and enroll in coverage Oct. 1 through HealthCare.gov or call 1-800-318-2596 toll free to speak with a customer service representative.

How will it work?

If you need health insurance or want better and/or cheaper insurance, you will shop for it in online marketplaces, also called exchanges. These are set up to help you compare the cost of private insurance, determine if you qualify for financial help and buy insurance. The marketplaces will open Oct. 1, 2013, for coverage that kicks in Jan. 1, 2014.

How do I know if I qualify for help with premiums?

You may qualify for subsidies to help pay for premiums if your income is from $11,500 to $46,021 for an individual and $31,155 to $93,700 for a family of four. But if your employer offers an Affordable Care Act-compliant plan that the government deems affordable for your income, you may not qualify for a subsidy.

How is the law changing for those with pre-existing conditions?

Insurers can’t deny coverage to anyone regardless of pre-existing conditions. And they cannot charge you more because of your gender or more than they charge a healthy person your age.

How are the plans categorized?

There are four types of plans available under the law: bronze, silver, gold and platinum. Bronze plans will cover 60 percent of expected medical costs; silver plans will cover 70 percent; gold plans will cover 80 percent, and platinum plans will cover 90 percent of medical costs.

All plans cover the same benefits, but bronze has the lowest premiums, coupled with higher deductibles and co-payments. Platinum plans have the lowest out-of-pocket costs and the highest premiums.

Is there a difference between what an older person can be charged versus a younger person?

The ACA allows insurers to charge older adults up to three times more than younger ones.

Can more people be eligible for Medicaid under the new law?

Medicaid expansion assists low-income Americans. States that choose to do so can expand their Medicaid programs to residents under age 65 earning less than $11,500 for an individual and $31,155 for a family of four. States that do this will get federal funding to cover 100 percent of the costs for the first three years, then 90 percent for the following years. New Jersey has opted in. Pennsylvania has not.

Can some people be too poor to get help?

Yes, in a way. In Pennsylvania and other states that have refused Medicaid expansion, some residents may earn too little to buy their own insurance – even with government subsidies — and too much to qualify for Medicaid.

How will the law affect drug costs for those on Medicare?

Older adults who have Part D drug coverage and reach the “doughnut hole”— the point at which they must start paying the full prescription drug expenses themselves — get a 50 percent discount when buying brand name drugs and a 14 percent discount on generic drugs covered by Medicare Part D. The prescription drug coverage gap continues shrinking until disappearing completely in 2020, when only the usual drug co-pays will apply.

Is dental coverage included?

In the health insurance marketplace, you generally can get dental coverage as part of a health plan or by itself through a separate, standalone dental plan.

What is the individual mandate?

This part of the ACA requires most Americans to buy health insurance starting January 1, 2014, or pay a fine if they don’t comply. This mandate will likely only affect about 2 percent of the population because most Americans already have insurance, are exempt under the law, would qualify for Medicaid, or would use subsidies to buy policies in the marketplace, according to an analysis by the Urban Institute, a Washington think tank.

What’s the penalty for not having insurance?

For an individual, the tax penalty starts at $95 a year or up to 1 percent of income, whichever is greater. By 2016, it rises to $695 per individual or 2.5 percent of income. For a family, the penalty is capped at $285 in 2014 and rises to $2,085 or 2.5 percent of income in 2016.

How will it be collected?

The Internal Revenue Service will collect the penalty through your tax returns. In 2014, federal returns will include a new form to list your source of health insurance.

What are the “essential health benefits” that all plans must provide?

The law stipulates that plans must include: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services; laboratory services; preventive and wellness services; chronic disease management, and pediatric services, including oral and vision care.

What if I’m a part-time employee without coverage?

If you’re a part-time worker without job-based coverage, you may be able to buy health insurance in the marketplace and get lower costs, based on your income.

Can I keep my own doctor?

Depending on the plan you choose in the marketplace, you may be able to keep your current doctor. Different plans have different networks and providers. When comparing plans in the marketplace, you will see a link to a list of providers in each plan’s network. If staying with your current doctors is important to you, check to see if they’re part of the network before choosing a plan.

What percentage of Americans are covered by insurance from their jobs?

According to the Kaiser Family Foundation, almost 60 percent of American adults under age 65 — 149 million in all — are covered by employer-sponsored plans.

Sources: U.S. Department of Heath and Human Services, Kaiser Family Foundation, Consumer Reports, Urban Institute, Healthcare.gov.

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