The Affordable Care Act "Obamacare"

 

The Patient Protection and Affordable Care Act (PPCA), or Affordable Care Act (ACA) for short, is the new health care reform law in America and is often called by its nick-name "Obamacare".

The Patient Protection and Affordable Care Act is made up of the Affordable Health Care for America Actthe Patient Protection Act, and the health care related sections of the the Health Care and Education Reconciliation Act and the Student Aid and Fiscal Responsibility Act.

The ACA, the Affordable Care Act, aims to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce the costs of healthcare for individuals and the government. It provides a number of mechanisms—including mandates,subsidies, and insurance exchanges—to increase coverage and affordability. The law also requires insurance companies to cover all applicants within new minimum standards and offer the same rates regardless of pre-existing conditions or gender. Additional reforms aim to reduce costs and improve healthcare outcomes by shifting the system towards quality over quantity through increased competition, regulation, and incentives to streamline the delivery of healthcare.

The Affordable Care Act is a long, complex piece of legislation that attempts to reform the healthcare system by providing more Americans with affordable quality health insurance and by curbing the growth in healthcare spending in the United States.

What is the Affordable Care Act?

The Affordable Care Act was passed by Congress and signed into law on March 23, 2010. On June 28, 2012 the United States Supreme Court rendered a final decision to uphold the health care law.

The Affordable Care Act (ACA) has.10 Sections or Titles:

Title I. Quality, Affordable Health Care for All Americans
Title 2. The Role of Public Programs
Title 3. Improving the Quality & Efficiency of Health Care
Title 4. Prevention of Chronic Disease & Improving Public Health
Title 5. Health Care Workforce
Title 6. Transparency & Program Integrity
Title 7. Improving Access to Innovative Medical Therapies
Title 8. Community Living Assistance Services & Support Act (CLASS Act)
Title 9.Revenue Provisions
Title 10. Reauthorization of the Indian Health Care Improvement Act

The complete text of the ACA or Sections can be read at the United States Department of Health and Human Services.

The Act will be phased in over the next four years. On October 1, 2013 open enrollment in the Health Insurance Marketplace begins.

The Health Insurance Marketplace, (www.healthcare.gov) also called the Exchange, will let Americans compare competitive, private health insurance options based on price, benefits, quality, and other features.

The Health Insurance Marketplace

  • All health plans offered in the Marketplace must cover a set of benefits including physician visits, preventive care, hospital stays, and prescriptions.
  • Insurance plans must also treat everyone fairly; discrimination against preexisting conditions is banned.
  • The Marketplace gives consumers a clear picture of costs and benefits before making a choice for them..
  • Enrollment begins on October 1, 2013 with insurance coverage beginning as early as January 1, 2014.
  • Consumers will need to fill out a single application on the Marketplace to choose from the health plans available in their area. It is also to learn if they qualify for programs like Medicaid or the Children's Health Insurance Program or to find out if the qualify for lower costs on monthly premiums or out of pocket expenses.

How to Apply Online for Coverage

 

Getting covered under the Affordable Care Act may feel like doing your taxes and making a big purchase that you would do some research on.

Information & Documents You will Need to Get Started

You will need the following to complete an application in the Marketplace.

For Spanish speaking consumers CuidadodeSalud.gov is also available.

Birth dates and Social Security Numbers for yourself and family members

Immigration documents

Most recent income tax documents

Any current health insurance policy information

Pay stubs

Pension documents

Alimony / child support information

Getting Started Online!

Go to Healthcare.gov and click on "Get Insurance." You will need to set up an account and password. (Treat your password like a bank account or credit card password to be sure it is secure)

You will need birth dates and Social Security numbers for yourself and other family members listed on your federal tax return.

You will be asked if you are a citizen. Legal immigrants will need their immigration documents. For more information on Immigration Status and the Marketplace.

You will be asked about your income. You will need your most recent pay stubs, details on other type of income, such as alimony, pensions and rents. You can still apply even if you have not filed a tax return. You will be asked about access to health insurance through your job. You may be required to take that insurance if available.

Your personal and income details will be routed through a new government entity called the "Data Services Hub", which will tap agencies like Social Security, Homeland Security and the Internal Revenue Service for verification of your application information.

A list of health care plans will be returned to you with cost and coverage information.

After you compare and choose a plan you will make your premium payments directly to the health insurance company. The Marketplace will direct you to your insurance company’s web site to make the initial premium payment. Insurance companies must accept different forms of payment and they cannot discriminate against consumers who do not have credit cards or bank accounts. The insurance company must receive and process your payment at least one day before coverage begins. Make sure you understand your insurance company’s payment requirements and deadlines and follow them so your coverage begins on time. Your enrollment in the health plan is not complete until the insurance company receives your first premium payment. 

Note that if you have qualified to receive an advanced premium tax credit, the government will pay the credit directly to your insurer and you will pay the remainder of the premium directly to the insurer.

Important Tips

Provide the most accurate estimate of your expected income for 2014.This is because you will most likely be given a subsidy (tax credit) to help pay your premiums. These credits are based on your income.

Make sure your doctors and hospitals are in the plan you pick.

You may have to live with the policy you chose until the next enrollment period so do your research!

Citizenship Status: If you are not a US citizen, a US National, or an alien lawfully present in the US, you are not eligible to buy a plan on the health insurance Marketplace. However, you can shop for health insurance outside of the Marketplace in the non-group market. Insurers outside of the Marketplace are prohibited from turning you down based on your health status or your immigration status and must follow generally the same rules as plans in the Marketplace. To obtain coverage, contact a state licensed health insurance company or a licensed broker or agent. The New Jersey Department of Insurance can help you find one.

 

Need Help with This Process?

 

The United State Department of Health and Human Services (HHS) awarded over $67 million in grant awards to 105 Navigators grant applicants in Federally-facilitated and State partnership Marketplaces, New Jersey has a Federally Facilitated Marketplace. These Navigators grantees and their staff will serve as an in-person resource for Americans who want additional assistance in shopping for and enrolling in Health Insurance plans in the Health Insurance Marketplace..

In Person Help

  • In all states, there are people trained and certified to help you understand your health coverage options and enroll in a Marketplace plan. They’re known by different names, depending on who provides the service and where they’re located. All can provide the help you need with your application and choices:

    • Navigators
    • Application assisters
    • Certified application counselors
    • Government agencies, such as State Medicaid and Children’s Health Insurance Program (CHIP) Offices

    Insurance agents and brokers can also help you with your application and choices.

    Visit LocalHelp.HealthCare.gov to find help in your area. You can search by city and state or zip code to see a list of local organizations with contact information, office hours, and types of help offered, such as non-English language support, Medicaid or CHIP, and Small Business Health Options Program (SHOP).

4 Ways to Begin the Health Care Coverage Process

There are four ways you can apply for health coverage in the Marketplace.

1. Online: Healthcare.gov

New Jersey did not create a state specific insurance marketplace, so NJ residents will use this federal site to select and enroll in a health insurance plan.  Please note that  since 36 states  are sending their residents to this federal marketplace,  there may be delays depending on the amount of traffic to the site.  

2. Phone: To apply by phone: 1-800-318-2596, 24 hrs a day, 7 days a week (TTY: 1-855-889-4325). A customer service representative will work with you to complete the application and enrollment process.

3. Paper Application: To get a paper application download the application form and instructions: call the number above for help with the application.

4. In person with an assister. To get personal help with your application process please use the "Find Local Help" on the Marketplace Home Page. You will be provided a list of trained people to help with your questions.

 

If you are unhappy with the proceedure you can file a complaint with the New Jesery Department of Insurance and Banking at or call the department at: 609-292-7272.   

Understanding the Language of "Obamacare"

Accountable Care Organization (ACO) A health care organization that includes doctors, hospitals, and other health care providers under one umbrella to provide coordinated coverage for Medicare patients. The goal is to avoid duplication of services and unnecessary procedures. The Affordable Care Act (ACA) provides financial incentives to doctors and others to join or create ACO's.

Adjusted Community Rating (ACR) The Affordable Care Act (ACA) makes it illegal for insurance companies to charge higher premiums based on certain factors, such as gender or a pre-existing condition. Beginning in 2014 insurers selling small group plans will be allowed to adjust premiums based only on family size, place of residency, tobacco use and age.

Affordable: employers based coverage is considered affordable if the lowest cost single coverage option does not exceed 9.5 percent of an employee's taxable income.

Catastrophic Coverage: People younger than 30 and some people with limited incomes may buy what is called "catastrophic" health plans from the Marketplace. A catastrophic plan generally requires you to meet a high deductible, usually several thousand dollars. The plan usually have lower premiums, and provide less coverage.

Common Control: The Affordable Care Act (ACA) requires businesses with more than 50 employees to provide insurance for all its workers or pay a fine. Businesses under one owner, or common control, are not permitted to divide the company into smaller segments that employees less than 50 people.

Deductible: The amount an individual pays before the insurance company begins reimbursement. As a rule, lower premiums come with higher deductibles.

Dependent: The ACA requires businesses with more than 50 employees to offer coverage to dependents. The IRS define dependents as children up to 26 years old, There is no requirement for businesses to cover spouses.

Employer Mandate: The law requires employers with 50 or more workers to provide insurance for all full time employees or pay a penalty. This will take effect in 2015.

Essential Health Benefits: The Affordable Care Act (ACA) has established 10 broad categories that must be covered by individual and small group health insurance plans. They are: hospitalization, lab services, rehabilitative services and devices, outpatient services, emergency care, prescription drugs, maternity care, preventive services, mental health and substance abuse treatment, and pediatric services, including oral and vision care. There is no lifetime cap on these services.

Exchange : A marketplace where uninsured individuals who do not qualify for Medicaid may purchase private health insurance. In New Jersey the Federal Government is running the exchange. Currently three companies are offering plans on the exchange. They are Horizon Blue Cross Blue Shield, AmeriHealth New Jersey and Health Republic Insurance of New Jersey.

Full Time Equivalent: The job of any employee working more than 30 hours per week is defined as a full-time equivalent positions. Business with more than 50 or more full time equivalent positions must provide health coverage to their employee. Employers are not required to provide part timers with health insurance, but their positions must be counted when determining if a company is a small or large business.

Individual Mandate: The Affordable Care Act (ACA) mandates that everyone in the United States have health insurance. If your employer does not provide coverage, you are responsible for purchasing it on the insurance exchange or applying for Medicaid if you qualify. Those who do not have coverage are subject to a penalty imposed by the IRS.

Lifetime Benefit Maximum: Insurance companies will no longer be able to place dollar limits on any of the 10 essential health benefits required by the ACA.

Medicaid: A federal and state funded program that provides insurance for low-income individuals. The law provides federal money for an expanded Medicaid program. In New Jersey, this allows individuals and families of four with incomes up to 133 percent of the federal poverty level to qualify. This would amount to $15,282 for an individual and $31,321 for a family of four.

Metal Levels: There are four levels of coverage available through the exchange plans: bronze, silver, gold and platinum. The Bronze plan features the lowest monthly premiums, but cover only 60 percent of average costs. Platinum plans have higher premiums and cover 90 percent of expected costs.

Minimum Value: The Affordable Care Act (ACA) requires large employers, with at least 50 full-time equivalent positions, to cover at least 60 percent of their employees' total health care costs, or pay a $3,000 per employee penalty.

Out of Pocket Maximum: The ACA has limits for what an individual or family can spend in out-of-pocket costs. Those limits are $6,350 for an individual and $12,700 for a family policy. This will be implemented in 2015.

Premium: The amount paid to the insurance company. Generally, higher premiums mean lower deductibles, The federal government also is providing subsidies to help the uninsured pay premiums for coverage through the new insurance Marketplace.

Preventive Care Services: The ACA requires preventive care such as mammogram's, colonscopies and annual check ups, to be provided for free. No co payment, no deductible.

Qualified Health Plan: Any insurance plan sold on the Marketplace must be certified by the state and federal government to show it meets minimum standards. Once certified, it becomes a "qualified" health plan.

Self Insured Plan: In a self insured group plan, the employer takes responsibility for collecting premiums and paying claims.

Small Business Health Care Tax Credit: Businesses with fewer than 25 full time employees whose average wage is less than $50,000 may qualify for a tax credit of up to 50 percent for the portion of premiums they pay for their employees.

Tax Penalty: The fine levied on individuals who disregard the insurance mandate. For adults, in 2014 the tax penalty is $95 or 1 percent of taxable income. In 2015, the tax penalty is $325 or 2 percent of taxable income. By 2016, the tax penalty is $695 or 2.5 percent of taxable income, which ever is greater. .

 

Subsidy Calculator

Affordable Care Act graphic

New Jersey Resources