ACA Questions & Answers

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Check back here every Tuesday and Friday for new answers! We will post as many responses as we can each week. If you submitted a question and don't see a response, check our archive, it may have already been answered, or check back on the next posting date.

Tuesday, September 18th New Q&A's

Q: What premiums will be charged in the health insurance Exchanges?

A: Prices for policies sold in Affordable Insurance Exchanges have not been established yet. Exchanges—state-run marketplaces where individuals and small businesses can purchase private insurance policies—will begin operation in 2014. Insurers will offer plans with a certain guaranteed set of benefits at a range of prices. Members of Congress will purchase their health insurance through the new Exchanges, and you will be able to as well. 

The law makes clear that insurers won’t be able to charge more based on your gender or your health status, and there will be limits to how much premiums can vary based on your age.

In addition, consumers with income below 400% of the Federal Poverty Level (about $88,000 per year for a family of four) who are buying insurance for themselves or their family will get tax credits that cover a significant part of their costs. A recent report estimated that a family earning twice the federal poverty level would pay less than $3,000 for their coverage for a year – compared to more than $11,000 without the Affordable Care Act.

Q: What if I make too much for Medicaid but still can't afford coverage?

A: You might be eligible for government subsidies to help you pay for private insurance that would be sold in the new state-based insurance marketplaces, called exchanges, slated to begin operation in 2014.

Premium subsidies will be available for individuals and families with incomes between 133 percent and 400 percent of the poverty level, or $14,404 to $43,320 for individuals and $29,326 to $88,200 for a family of four.

The subsidies will be on a sliding scale. For example, a family of four earning 150 percent of the poverty level, or $33,075 a year, will have to pay 4 percent of its income, or $1,323, on premiums. A family with income of 400 percent of the poverty level will have to pay 9.5 percent, or $8,379.

In addition, if your income is below 400 percent of the poverty level, your out-of-pocket health expenses will be limited.

Q: What are grandfathered plans, and why does grandfathered status matter?

A: A grandfathered health plan is one in which at least one employee continues to be enrolled since March 23, 2010. They are exempt from most of the new qualified health plan mandates. Grandfathered plans may stay in effect indefinitely, as long as they meet certain conditions set forth by the PPACA. Beginning September 23, 2010, all grandfathered plans were required to comply with the following plan provisions:

  • No lifetime dollar limits on coverage.
  • Maximum waiting period for new employee coverage is no more than 90 days.
  • Reasonable annual limits.
  • For insured plans, required medical loss ratio of at least 85 percent for large employers and at least 80 percent for small employer and individual plans.
  • No rescissions (retroactive terminations).
  • Coverage for children up to age 26 on family policies, unless they have access to employer-provided coverage.
  • No pre-existing condition exclusions for covered individuals younger than 19.

Q: How do I know if my insurance plan is grandfathered?

A: If you have an individual policy and have had it since March 23, 2010 or earlier, your policy may be grandfathered. If you are in an employment-related group health plan that existed on March 23, 2010, your plan may be “grandfathered,” even if you enrolled in it after that date.

To find out if your health plan is grandfathered:

  • Check your plan’s materials. Health plans must disclose their grandfathered status in plan materials distributed to subscribers. These materials must include contact information for questions and complaints.   
  • Check with your employer or your health plan’s benefits administrator. If you are in a group health plan, the date you joined may not reflect the date the plan was created.  New employees and new family members may be added to a grandfathered group plan after March 23, 2010. Your employer or benefits administrator will be able to tell you whether your plan is grandfathered.

Q: How could my health plan lose its grandfathered status?

A: Your health plan will no longer be grandfathered if:

  • It stops offering all or most benefits to diagnose or treat a particular condition, such as diabetes, cystic fibrosis, or HIV/AIDS.
  • It increases the share of health services costs it requires you to pay--for example, from 20% of every hospital bill to 25%.
  • It increases the deductible, out-of-pocket maximum, or any cost-sharing other than a copayment, that was in effect on March 23, 2010, by more than a specified amount.
  • It increases your copayment -- the flat fee that you must pay for a covered health care service—by more than a specified amount.
  • It imposes a new annual limit on the dollar value of all benefits or lowers an existing annual limit.
  • Your employer decreases the share of a health insurance premium it pays for you by more than five percentage points (for example, from 20% to 15%.)

Note:Your health plan may increase your premiums and still be considered grandfathered, as long as it doesn't make any of the changes listed above.

Archive of Q&A's

Q&A - 9/18/2012 - pdf