What does health care reform mean for individuals?
The Affordable Care Act makes large, sweeping changes to the way health insurance is packaged, priced, and delivered. Insurers may no longer rate people based on their health status and must meet certain pricing restrictions. Exchanges will alter the way people without employer-sponsored coverage shop and compare health insurance plans. Some of the changes will benefit some individuals and families, while others may experience an increase in insurance premiums.
In the spotlight: ACA INSURANCE REFORM
The individual mandate is a widely recognized provision of the Affordable Care Act. Most individuals are required to purchase insurance or pay a penalty. In 2014, the penalty is of the greater of $95 or 1% of income and becomes greater every year following, maxing out in 2016 at the greater of $695 or 2.5% of income.
In the spotlight: Health Care Reform and Individual Mandate
Affordable Care Act
The Affordable Care Act (ACA) was signed into law in March 2010 and contains many provisions that have staggered implementation dates from 2010 through 2018. The flagship achievements of health care reform are a dramatic expansion of health insurance coverage and the inclusion of many new and richer benefits in most health insurance plans.
In the spotlight:
The Implementation of Health Care Reform on September 23
The Implementation of Health Care Reform in 2011
Halfway to Health Care Reform
The ACA and the Supreme Court – After the Decision
Full Steam Ahead – ACA in 2013
The Affordable Care Act got its name from the provisions intended to make health insurance coverage more affordable to the majority of the uninsured individuals in the country. The law accomplishes this primarily through two kinds of subsidies: one covers a portion of the premium and one reduces eligible consumersâ€™ out of pocket expenses.
These subsidies, offered exclusively through the Exchange, are only available to qualifying individuals and families who are at 400% of the federal poverty level In 2012, that results in those with an income of less than $45,960 for individuals and less than $94,200 for families of four.
In the spotlight: Health Care Reform and Health Insurance Subsidies
Exchanges (also known as Health Insurance Marketplaces) are online marketplaces where individuals, families and small businesses can shop for coverage. Exchanges also serve many functions for implementing the Affordable Care Act, including allowing individuals and small businesses to shop and compare coverage, providing standardized information about the coverage and pricing and, perhaps most importantly, determining eligibility for and connecting individuals with federal subsidies to purchase insurance. While Exchanges will be implemented in all 50 states, some states have chosen to implement their own, state-based Exchanges, while the federal government will implement Exchanges in others, and still other states will have a hybrid version, called a Partnership Exchange. North Carolina plans to operate under a Federally Facilitated Exchange (FFE) in 2014.
In the spotlight: Health Care Reform and American Health Benefit Exchanges
Actuarial value is a way of determining the average amount of a consumerâ€™s health care expenses that will be paid by their health plan compared to how much the consumer pays out of pocket. In the Affordable Care Act, this term is frequently used to describe the requirements and restrictions of qualifying plans.For example, plans offered through the Exchanges will be categorized into metallic levels (bronze, silver, gold, platinum) based on their actuarial value.
In the spotlight: ACA and Actuarial Value
Agents and Brokers
Health insurance brokers will no doubt be affected by the Affordable Care Act â€“ their services will be especially needed to explain the complicated changes and opportunities for businesses and individuals. The Affordable Care Act makes many sweeping changes to how health insurance is sold, including new requirements on rating, medical spending and Exchanges (please see Exchanges section or Spotlight). Brokers will be at the forefront of these changes, as the primary actors between health insurers and consumers.
In the spotlight: Health Care Reform and Insurance Brokers
“If you like your plan, you can keep it” seemed to be the Affordable Care Act motto when it was signed into law in 2010. To “keep the plan you like,” you must remain on what is referred to as a “grandfathered plan” or a plan that existed before March 23, 2010 (when the law was passed) and has not undergone particular changes.Grandfathered plans are exempt from some provisions of the Affordable Care Act, like providing certain preventive services at no cost-share, but must implement others, like no waiting periods longer than 90 days.Additionally, changes made to grandfathered plans including changing deductibles, copayments and coinsurance could result in the loss of grandfathered status.
Student Health Plans
In North Carolina, there are around 570,000 students pursuing higher education at any given time. Of those, about 65,000 are enrolled in a BCBSNC student health insurance plan.These programs have usually been unique in that they provide limited benefits and most services are performed at the student health center. This has allowed these plans to carry a very low premium.The Affordable Care Act requires that these plans comply with certain provisions, like the medical loss ratio (see: Spotlight on Medical Loss Ratio) and the removal of annual limits.
In the spotlight: The Affordable Care Act and Student Health Plans
When the Affordable Care Act passed, one of the major ways it expanded health insurance coverage was through the expansion of Medicaid. The Supreme Court decision in 2012 made the expansion of Medicaid optional for states. Some states may choose to expand in 2014 or later. For those states that do not expand Medicaid, many additional thousands of residents may remain uninsured.
In the spotlight: Health Care Reform and Medicaid
Consideration for young adults
It’s a mantra that’s been repeated time and time again across the state of North Carolina: reform impacts everyone differently. That’s especially true for individuals and families who purchase their own insurance – there are subsidies, grandfathered plans, and transitional plans, oh my! In particular, young adults have many considerations when choosing how to carry insurance for the year 2014. A lot of the choices depend on an individual’s circumstances and age. This paper will explain the different options for folks in this age group.
In the spotlight: Health Care Reform and Young Adults
Essential Health Benefits
The Affordable Care Act includes a requirement that all non-grandfathered individual and small business insurance plans must cover a certain set of services within 10 categories established by the Institute of Medicine. Though the 10 categories are dictated federally, the specific services that must be provided are determined at the state level by the selection of a benchmark plan. They include:
- Ambulatory patient services
- Emergency services
- 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
- Pediatric services, including oral and vision care
In North Carolina, the benchmark plan is a BCBSNC plan and covers a comprehensive set of services that all North Carolina health plans must now offer in the individual and small group markets.
In the spotlight: Health Care Reforms and Essential Health Benefits
The Affordable Care Act does a lot to boost access to preventive services and encourage consumers to use them. Health care reform also requires that many preventive services be provided at no cost to the consumer, such as colonoscopies and contraceptive services.
In the spotlight: Health Care Reform and Prevention
Employers have long been the primary source of health insurance coverage in this country. As the nationâ€™s health continues to deteriorate, employersâ€™ costs have risen exponentially. A few >unhealthy employees can account for 25-30% of an employerâ€™s overall health care costs. The Affordable Care Act has several provisions intended to enable employers to help their employees maintain or improve their health. The allowable incentive for employees participating >in a company-sponsored wellness program increases from 20% to 30% and there are grants available for certain small businesses to implement a new program.
In the spotlight: The Affordable Care Act and Wellness Programs
Summaries of Benefits and Coverage
Summaries of Benefits and Coverage and Uniform Glossary documents are a requirement of the Affordable Care Act that went into effect in September of 2012. The documents are intended to help consumers as they compare and shop for health insurance companies by explaining benefits in a consistent manner. The federal government compares these documents to the nutrition labels found on prepared food packaging, but evaluating a health insurance planâ€™s benefits can be a bit more complex than evaluating the nutritional value in a can of peas.
In the spotlight: Health Care Reform and Uniform Coverage Documents
Health care reform means more benefits and improvements, but at a cost.
Some consumers will pay less than they do now for health insurance. Some will pay more. Learn More
Tax credits and more health insurance purchasing options for businesses in NC. Learn More
The impact of health care reform changes looks different for every consumer. Learn More