Serving Florida and Texas

HEALTH REFORM

Let's face it. The Affordable Care Act (ACA) is long and complicated, over 2000 pages long and still counting! We have broken down for you the most important areas for individuals and families by topic, these are the topics you should be familiar with. Need more information or have a question?

No problem just contact us and we're happy to help!

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ACA Marketplaces

  • States are required to operate health insurance marketplaces (exchanges) for individuals and small businesses (less than 50 full time employees) that will allow the purchase of health insurance under the ACA.

  • A state may operate its own marketplace, partner with the federal government on the marketplace, or defer to the federal marketplace.

  • HealthinsurancemarketplaceUSA.com is a certified web broker for the federal marketplace for the states of Florida and Texas.

Marketplace Operations

 

  • The Open Enrollment Period is November 1, 2020 through DEcember 15, 2020. All effective dates are for January 1, 2021. 

  • An application submitted by the 15th of a month will have an effective date of the 1st of the following month. Applicatons received after the 15th until the end of the month will have an effective date of the 1st of the month after the following month.

Plan Requirements and Offerings

  • All health plans on the marketplace must be Qualified Health Plans offering Essential Health Benefits with no dollar limits.

  • Plans have metallic names including Platinum, Gold, Silver, Bronze and Catastrophic (child only up to age 30).

  • Metallic plan level is defined by percentage of costs covered by the plan starting at 60% for Bronze and 90% for Platinum.

Financial Aid For Individuals

and Families Under ACA

  • To use the financial aid, an individual or family must purchase coverage through their state marketplace or the federal marketplace if their state is using the federal marketplace.

  • Assistance is called Federal Premium Assistance Tax Credit. Once qualified for the tax credit,  and upon enrollment in a Qualified health plan from a marketplace, the government will send the credit amount directly to the insurance carrier so the individual only pays the net premium.

Who qualifies for the tax credit

and how much do I qualify for?

  • The subsidy is available to individuals and families with incomes between 100 and 400% of the Federal Poverty Level (FPL)

  • Tax Credit is determined by Health & Human Services based on the amount which premiums exceed a threshold amount, or the maximum percentage of income that individuals will be required to pay toward the second-lowest cost Silver Plan in their area. For those not eligible for Medicaid, the threshold rises from 2% of income for those at 133% of the FPL to 9.5% of the income for those at 400% of the FPL.

  • The size of the tax credit is determined on a sliding scale based on income, with the lowest incomes receiving the largest subsidies.

ACA Essential Health Benefits

  • Commence with coverage as of January 1, 2017

  • Applies to non-grandfathered health plans for individuals and small business (less than 50 employees).

  • Must be included in Qualified Health Plans (QHPs) on the federal and state marketplaces and Health plans available off the marketplaces.

Essential health benefits include:

 

  • Ambulatory patient services

  • Emergency services

  • Hospitalization

  • Maternity and newborn care

  • Mental health and substance abuse services

  • Prescription drugs

  • Rehabilitative services and devices

  • Laboratory services

  • Preventive and wellness services

  • Chronic disease management

  • Pediactric services (includes oral and vision care)

ACA Annual & Lifetime Limits

  • Annual dollar limits on benefits are prohibited.

  • There is no restriction on annual dollar limits for covered benefits that are not essential health benefits.

  • Limits on lifetime benefits on the dollar value of essential benefits is prohibited.

  • The provision also states there is no restriction on the use of lifetime follar limits for covered benefits that are not essential health benefits.

ACA Preventive Care & Services

  • Coverage of specified preventive care and services is required without cost sharing (deductibles, copays, coinsurance) when provided in network.

Covered preventive services are defined by age, category and gender to include adults, women including pregnant women, children, and certain immunization vaccines for children from birth to age 18.

Examples of preventative care for adults:

  • Alcohol misuse

  • Blood pressure screening

  • Depression screening

  • Type 2 diabetes screening for adults with high blood pressure

  • Cholesterol screening for adults of certain ages or at higher risk

  • Colorectal cancer screening for adults over age 50

 

Covered preventative services for

women, including pregnant women:

  • Breast cancer mammography screenings every 1 to 2 years for women over age 40

  • Hepititus B screening for pregnant women at their first prenatal visit

  • Osteoporosis screening for women over age 60 depending on risk factors

  • Cervical cancer screening for sexually active women

Covered preventative services

for children:

  • Alcohol and drug use assessments for adolescents

  • Behavioral assessments for children of all ages

  • Hearing screening for all newborns

  • Height, weight, and body mass index measurements for children

  • HIV screening for adolescents at higher risk

Covered immunization vaccines for children from birth to age 18:

  • Hepititus A, B

  • Influenza, Measles

  • Mumps, Rubella

  • Medical history for all children througout development

  • Obesity screening and counseling

  • Oral health risk assessment for young children