Affordable Care Act (ACA)
The Affordable Care Act (ACA) — commonly called “Obamacare” — is a complex law created by President Barack Obama and his administration. Here are some key things that changed with the ACA:
- All health insurance plans must now cover Essential Health Benefits.
- You can no longer be denied coverage for a pre-existing condition
- Some Americans now qualify for government tax credits to use towards their health insurance costs
- Children can now stay on their parents’ plans until they are 26
- The ACA led to the creation of the public exchange (a government-operated marketplace where individuals can now shop for and buy health insurance, and apply for government tax credits)
Basic Care Dental
Catastrophic Health Plan
A fixed amount (for example, $15) a plan requires you to pay for a covered healthcare service. You usually don’t have to meet your Deductible to qualify for Copays: You only pay the Copay from day 1!
Example: My plan has a $20 co-pay for a doctor visit. When I visit my doctor for a qualified service, I only pay the $20 co-payment when I check in.
Usually represented as a percentage, this reflects the costs of a covered healthcare service that you’re responsible for, after you’ve met your deductible
Example: I met my plan’s $1,500 deductible. My plan has a 20% co-insurance so I must pay 20% of the cost of my next qualified health care service. The health insurance plan will pay the remaining 80%.
Contact Lens Exam
Cost Sharing Assistance
This is the dollar amount you must pay out of pocket for healthcare services before your health insurance plan kicks in.
Example: My health insurance plan has a deductible of $1,500. If I haven’t yet paid $1,500 towards my deductible, I must continue paying out of my pocket until I do. It’s good to know which things apply toward my deductible, and which ones don’t.
Essential Health Benefits
An important component of the Affordable Care Act is a requirement for health insurance plans to provide adequate coverage for “Essential Health Benefits”–broad categories of important health services.
Essential health benefits must include items and services within at least the following ten categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace.
The Federally Facilitated Marketplace (FFM), or HealthCare.gov, is an online resource for individuals to shop for health coverage from different health insurance companies. Some people will receive government tax credits if they buy insurance on the Federally Facilitated Marketplace. The federal government manages HealthCare.gov.
In some states, there are state-operated marketplaces. For example, Minnesota has MNSure. In these states, you cannot go to the FFM to buy health insurance.
Government Tax Credit
Health Insurance Marketplace
Also called the “Public Exchange” or “State Exchange,” the Health Insurance Marketplace is an online resource for individuals to shop for health insurance from different health insurance companies. Tax credits from the government are available to some families to decrease premium costs on the Health Insurance Marketplace.
Some states have their own marketplace, for example, Minnesota has MNSure, but most states use Healthcare.gov.
Health Reimbursement Arrangement
A Health Savings Account (HSA) allows you to put pre-tax money into a savings account to use towards qualified medical expenses. An HSA can only be used with HSA eligible plans.
To determine if a plan is HSA eligible, look for HSA in the name of the plan.
Health insurance companies connect with certain providers and/or healthcare facilities to provide lower rates than out-of-network providers.
Example: I am changing health insurance coverage – it’s important that I check to see if my preferred doctor is considered in-network with my new health insurance company, otherwise it may cost me more to see that doctor.
Major Care Dental
Maximums for Dental
Open Enrollment Period
Providers and/or healthcare facilities that are considered “Out-of-Network” are not connected to the health insurance company and typically cost more than those that are considered “In-Network.” “Out-of-Network” expenses often have a separate much higher deductible and do not have an out of pocket max.
Example: I am changing health insurance coverage. It’s important that I check to see if my preferred doctor is considered in-network with my new health insurance company, otherwise, it may cost me more to see that doctor.
Out of Pocket Costs
Out of Pocket Max
Also known as “OOP Maximum” or “Out of Pocket Maximum,” this is the most you would pay during the coverage time (typically a year) before your eligible costs are paid 100%. Keep in mind that this does not include premiums, which you have to pay each month.
Example: My health insurance coverage out of pocket max is $5,000. My out of pocket expenses include my annual deductible of $1,500, my copayments for doctors and prescriptions, and the coinsurance on eligible healthcare services. If I spend over $5,000 on qualified health services in these areas, my health insurance company will begin paying 100%.
Pediatric dental is for people 18 years and younger and usually includes routine dental services like cleanings and X-rays. Because of changes in healthcare law, people 18 and under must have dental coverage.
Pediatric dental coverage can be included in your medical plan or offered as a separate dental plan. If it’s not included in your medical coverage, your insurance company may require that you provide proof of your dental coverage.
Part of the Affordable Care Act is a rating system that has been implemented for health plans available on the Public Exchange. Plans are ranked as Platinum, Gold, Silver, Bronze, and Catastrophic.
Think of the tiers as a type of ranking-from the most amount of coverage for health services (Platinum) to the least amount of coverage for health services (Catastrophic). Keep in mind that “most coverage” does not necessarily mean “better” as Platinum plans also come with the highest monthly cost per month.
Example: I only want health insurance coverage for major health events. A Platinum plan is going to cost the most per month and provide more coverage than I am looking for. A Catastrophic Plan will cost the least per month and provide only minimal coverage.
Preferred Provider Organization
Prescription drugs are one of many Essential Health Benefits. They’re often in categories called “Tiers” with an associated friendly term that describes them.
Generic (or Tier 1) Drugs: Generic prescription drugs are not a familiar brand name, but are made of the same active ingredients and must meet the same quality and safety standards. They are the lowest-cost tier of drugs.
Preferred Brand Name (or Tier 2) Drugs: Medications sold under a trademarked name, like Nexium or Advair. Only the company that has the patent can produce and sell these specific medications. Some “Brand Name” drugs have better coverage than others so they can cost less.
Non-Preferred Brand Name (Tier 3) Drugs: Another type of Brand Name Drug that the insurance company doesn’t prefer so they often cost more.
Specialty or Medical (Tier 4) Drugs: These prescriptions are typically extremely costly and are used to treat severe and chronic conditions. They are sometimes prescribed and administered with a medical procedure, for example, chemotherapy.
A qualifying life event is when something happens in your life that allows you to make changes or enroll in new insurance coverage outside of Open Enrollment.
Common examples of Qualifying Events include, but aren’t limited to:
Loss of Coverage
I lost my existing coverage because:
- I left my previous job and lost my employer sponsored insurance
- I’m turning 26 and can’t be on my parent’s insurance anymore
- I lost eligibility for Medical Assistance, a State Program or other government-sponsored coverage
Note: This does not include loss of coverage that is voluntarily for example a plan became unaffordable and you want to change the plan mid-year or you didn’t pay your premiums.
I got married.
Change in Family Size
My family got bigger or smaller:
- Birth or adoption – I had or adopted a child
- Dissolution of Marriage – I’ve legally divorced my spouse and lost coverage
- Death – I lost insurance when my spouse/parent died
- I permanently moved to a place that my insurance company doesn’t offer my plan.
- I moved from one state to another.
There are some other special circumstances that can grant a special enrollment period including eligibility for a tax credit or change in citizenship status. These are rarer and can be discussed further with the Gravie Care Team.
Special Enrollment Period
Tax Credit Eligible
The amount you qualify for in Government Tax Credit or “subsidy” can be used towards the cost of Tax Credit Eligible plans. To receive the tax credit, you must:
- Fill out an additional application via your state’s exchange. This will take between 20-60 minutes.
- Make sure dependents on the insurance plan are tax dependents of the main applicant. If you’re married and have your spouse on the plan, you must file your income taxes jointly with them.
- You’ll also need to fill out some extra forms when you file your income taxes at the end of the year.
Please note: The tax credit amount displayed is an estimate based on the information you’ve provided about your household. The final amount you may qualify for will be determined during the application process.