Despite the State Farm commercial, you can’t believe everything you read on the internet.
Although I have over 30 years in the healthcare/insurance industry, I urge you to use this post as a guide only.
I’ve been known to be wrong – shocking as that may be.
I have three goals.
- To simplify health reform’s Affordable Care Act (ACA)
- To relate information to you — the freelancer/sole proprietor
- To provide you with helpful resources
In Part 1 of this 3-Part series, we helped get you started and looked at what you should do first.
In this second post, we’ll review What You Need to Know about ACA. We’ll close the series with a post on When To Do What.
Terms of Exception
There are some plans that may have exceptions to required benefits – at least for now.
Grandfathered plans are health insurance plans that were in place on March 23, 2010. These plans are exempt from some of ACA provisions.
However, plans can lose the grandfathered status if they make certain changes.
If you have health insurance now ~
- Find out if you have a grandfathered plan (your broker or insurance company can help)
- You can ask for a policy that complies with all ACA provisions
- But, that does not mean your insurance company cannot raise your rates
Trust me – they probably will.
Healthcare.gov has additional information about what grandfathered plans can and cannot do.
If you have health insurance (or did in the past), there may be changes to benefits that are required by the ACA.
Some changes took place already and others occur in 2014. The following is not an exhaustive list of changes – exhausting – but not– exhaustive.
ACA requires full coverage for certain preventive services.
- Specified preventive care is covered with no out-of-pocket cost to you
- No copays or coinsurance, (the amount you pay) and no deductible applied
Grandfathered plans are not required to do this, but some insurance companies do anyway.
Adult Child Coverage
One of the first provisions put in place was the coverage expansion for dependent “children.”
- Insurers must cover dependent children up to age 26
- The child does NOT have to be a full-time student
- He or she does NOT have to be unmarried, living with parents or claimed as a dependent on the parents’ tax form
Most insurance companies added this provision even before the date required.
Most plans had exclusions for pre-existing conditions.
The following is an example of a typical exclusion.
- You had asthma before you were covered under the plan
- You continue to be treated for asthma
- Your treatment is not covered (because it was pre-existing) –until –
- You have three months treatment-free or are insured for a year
The time limits varied.
- ACA eliminated that exclusion for children under the age of 19
- In 2014, the exclusion is eliminated for all adults and children
Grandfathered plans for individual policies can keep the exclusion.
Essential Health Benefits
This requirement applies only to individual policies (those you purchase yourself) and small group policies.
In 2014, ACA requires these policies cover (at a minimum) certain categories of benefits.
Grandfathered plans are not required to cover these.
You may have heard about (but hopefully not experienced) individuals with serious health conditions who ran out of benefits.
Typically, the reason was due to a lifetime limit on benefits, such as $1 million or $5 million.
- ACA does not allow lifetime limits on the defined essential health benefits.
Some plans placed annual limits on certain services, such as preventive care.
- ACA restricted dollar limits in 2010, and starting January 1, 2014, prohibits ANY annual limit on essential health benefits.
Phew – are you hanging in there? Need a coffee break? Go ahead. We’ll wait.
Health Insurance Exchanges
In Post #1, we reviewed possible health insurance coverage you may be eligible for.
If you do not have access to employer or government-sponsored coverage, chances are you will purchase your health insurance through your state’s health insurance exchange.
What is a health insurance exchange?
ACA requires states to create a marketplace where individuals and small businesses can purchase health insurance.
Note: You may also hear exchanges referred to as the health insurance marketplace.
- Enrollment starts October 1, 2013
- The earliest effective date of coverage is January 1, 2014
- You can apply online, by mail or in person
When you apply, you’ll find out if you are eligible for breaks on cost, like the premium subsidy we talked about in the first post.
The marketplace helps you compare available plans in your area.
- Some states will handle their own website
- Others will use the federal website (healthcare.gov)
States (and the federal government) have been scrambling to get this ready for October 1.
My suggestion is to do the following.
1. Go to Healthcare.gov and click on See Your Options.
2. Answer the questions.
Based on your responses, the site directs you to your state’s site or you go to your state-specific information on healthcare.gov.
Remember: Enrollment doesn’t start until October 1, 2013, so there are no prices or plan information yet.
You can sign up at healthcare.gov to receive email updates.
Dental and Vision Coverage
There have been questions about dental and vision coverage in the insurance exchanges.
ACA requires pediatric services, including oral and vision care, to be included as an essential health benefit. ACA does NOT require dental and vision coverage for adults.
If you are looking for yourself, also check outside the exchange. There is a good chance you will find more comprehensive, less expensive coverage.
Give yourself a gold star. You made it to the end – didn’t you?
What’s that I hear? Crickets?
Let’s see what we learned.
- Grandfathered plans – These plans do not have to follow all the health reform rules.
- Benefit requirements- There were several benefit requirements added that mostly affect individual and small group policies.
- Health insurance exchanges – If you don’t have coverage through your spouse’s employer or a government plan (like Medicare or Medicaid), you want to check out your state’s health insurance exchange — also known as the insurance marketplace.
Please leave your comments/questions. We’ll try to muddle through this together.
Our last post lets you know When To Do What.
Notice of Disclaimer –Cathy Miller is not an attorney or health care provider and cannot provide legal or health care advice. The information provided is for your general background only, and is not intended to constitute legal or health care advice as to your specific circumstances. We recommend you review legislation with legal counsel and visit your physician for health care issues.
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