Welcome! This site was created to provide information about the many issues related to the federal Affordable Care Act (ACA).
Many aspects of the health care reform are still to be decided. This site will be continually updated as necessary to provide consumers with the most current information available.
President Obama signed HR 3590, the Patient Protection and Affordable Care Act into law on March 23, 2010. The President also signed HR 4872, the Health Care and Education Reconciliation Act, into law on March 30, 2010. The two Acts combined are collectively referred to as the Affordable Care Act (ACA) or federal health care reform.
The law puts in place a significant number of health insurance reforms that have rolled out over the last three years. Some of the final and most notable changes of the law will take effect on January 1, 2014.
Starting January 1, 2014, you will no longer be declined coverage or charged extra for health insurance because of a health issue you have now or have had in the past. You will also be guaranteed a minimum set of health benefits known as “Essential Health Benefits”.
There are a number of provisions throughout the law intended to help you afford coverage. Primary among the reforms is assistance for individuals and families to purchase health insurance through advanced premium tax credits and cost sharing reduction if medical services are necessary.
Advanced Premium Tax Credit (APTC): The ACA created a refundable tax credit for eligible individuals and families who purchase health insurance through the Marketplace. Based on the information provided to the Marketplace, the individual receives an advanced premium tax credit based on income, and the IRS pays the premium tax credit amount directly to the insurance plan in which the individual is enrolled. The individual then pays to the plan in which he or she is enrolled the dollar difference between the advanced premium tax credit amount and the total premium charged for the plan.
Annual Limit: Many health insurance plans placed dollar limits upon the claims the insurer will pay over the course of a plan year. ACA prohibits annual limits for essential benefits for plan years beginning after September 23, 2010.
Cost Sharing Reduction (CSR): Assistance available, based on income, with out of pocket expenses for deductibles, coinsurance, and copayments for in-network benefits.
Department of Health and Human Services (HHS): The federal agency that has the primary responsibility for implementation of the Affordable Care Act (ACA).
Essential Health Benefits (EHB): A set of health care service categories that must be covered by health plans starting in 2014 in order to meet the individual responsibility requirement.
Grandfathered Plan: A health plan that an individual was enrolled in prior to March 23, 2010. Grandfathered plans are exempt from most changes required by ACA. New employees may be added to group plans that are grandfathered, and new family members may be added to all grandfathered plans.
Guaranteed Issue: A requirement that health insurers sell a health insurance policy to any person who requests coverage, regardless of health history. The ACA requires that all health insurance be sold on a guaranteed-issue basis beginning in 2014.
Lifetime Limit: Many health insurance plans place dollar limits upon the claims the insurer will pay over the course of an individual’s life. The ACA prohibits lifetime limits on benefits beginning on September 23, 2010.
Marketplace: A term used to describe the exchanges that were created to assist individuals and small businesses in comparing and purchasing qualified health plans. The Marketplace will also determine eligibility for Medicaid or Florida Healthy Kids, as well as eligibility for premium and cost sharing assistance.
Medicaid: A joint state and federal program that provides health care coverage to eligible categories of low-income individuals.
Medical Loss Ratio: The percentage of health insurance premiums that are spent by an insurer on health care services. The ACA requires that large group plans spend 85% of premiums on clinical services and other activities for the quality of care for enrollees. Small group and individual market plans must devote 80% of premiums to these purposes. Amounts not within the medical loss ratio requirements must be returned to the policyholder in the form of a rebate.
Medicare: A federal government program that provides health care coverage for all eligible individuals age 65 or older or under age 65 with a disability, regardless of income or assets.
Navigators: Individuals who will help consumers prepare electronic and paper applications to establish eligibility and enroll in coverage through the Marketplace and potentially qualify for an insurance affordability program (including a premium tax credit, Medicaid and the Children’s Health Insurance Program aka Florida Healthy Kids). They will also provide outreach and education to raise awareness about the individual and small group Marketplaces, and will refer consumers to health insurance ombudsman and consumer assistance programs when necessary. Navigators must complete comprehensive training and be certified by HHS/CCIIO. Navigators will also be required to be registered through the DFS, Division of Insurance Agent & Agency Services, Bureau of Licensing.
Non-grandfathered Health Plan: An individual or group policy purchased after March 23, 2010, or one purchased before that date that had significant changes which caused it to lose its grandfathered status.
Open Enrollment Period: A specified period during which individuals may enroll in a health insurance plan each year. In certain situations, such as if one has had a birth, death or divorce in their family, individuals may be allowed to enroll in a plan outside of the open enrollment period.
Pre-Existing Condition Exclusion: The period of time that an individual receives no benefits under a health benefit plan for an illness or medical condition for which an individual received medical advice, diagnosis, care or treatment within a specified period of time prior to the date of enrollment in the health benefit plan. The ACA prohibits pre-existing condition exclusions for all new plans beginning January 2014.
Preventive Benefits: Covered services that are intended to prevent disease or to identify disease while it is more easily treatable. The ACA requires insurers to provide coverage for defined preventive benefits without deductibles, co-payments or coinsurance.
Qualified Health Plan (QHP): An insurance plan that is certified by the Marketplace, provides essential health benefits, follows established limits on cost-sharing and meets other requirements.
Rate Review: Review by insurance regulators of proposed premiums and premium increases. During the rate review process, regulators will examine proposed premiums to ensure that they are sufficient to pay all claims, that they are not unreasonably high in relation to the benefits being provided, and that they are not unfairly discriminatory to any individual or group of individuals.
Small Group: The market for health insurance coverage offered to Florida small businesses with between 2 and 50 employees. The ACA will broaden the market to those with between 2 and 100 employees starting in 2016.
The Affordable Care Act (ACA) requires most individuals to have health insurance or health coverage beginning January 1, 2014. Health insurance can be through an employer or individual health plan. Health coverage can be through programs such as Medicare, Medicaid, Florida Healthy Kids, Tri-Care, federal employee health benefit plans, veteran’s health care, or Indian Health Services (IHS).
If you already have coverage you do not need to do anything unless you receive a notice from your insurer indicating your health insurance does not qualify as “Minimum Essential Coverage”. If you receive this notification, you should contact the federal Marketplace at 1-800-318-2596, a licensed agent or broker, or the insurer by using the contact information contained in the notice, if any.
There are several exceptions to the individual health mandate:
Individuals that are at or below 100% of the federal poverty level and eligible for Medicaid Expansion as outlined in the ACA, but coverage is not available due to the State electing not to participate in the expansion.
Individuals for whom coverage would be unaffordable, as determined by the
federal Department of Health and Human Services.
Under a hardship which prevents the consumer from obtaining health coverage. A qualifying hardship is determined by the federal Department of Health and Human Services.
Undocumented immigrants since there is no premium assistance available.
Individuals that are members of health care sharing ministries as well as the
Amish, Mennonite, and Indian tribe communities.
Member of a federally-recognized Indian Tribe.
Not a member of a federally-recognized American Indian tribe, but is eligible for services from an Indian health care services provider or Indian Health Services.
If you have questions about your particular situation or need to obtain a hardship exemption, you should call the federal Marketplace at 1-800-318-2596 for assistance.
Individuals that do not have health coverage and who are not exempt from the federal requirement may be subject to a Shared Responsibility Payment collected by the Internal Revenue Service (IRS). Individuals will not have to make a payment if coverage is unaffordable (as determined by HHS), if they spend less than three consecutive months without coverage, or if they qualify for an exemption.
The total annual tax penalty will be the greater of either a flat dollar amount or a percentage of taxable income:
$95 per person or 1 percent of taxable income in 2014,
$326 per person or 2 percent of taxable income in 2015, and
$695 per person or 2.5 percent of taxable income in 2016.
After 2016, the tax penalty will increase annually based on a cost-of-living adjustment.
A person will only pay 1/12 of the total annual penalty for each month without coverage after three months. The penalty for a child is half that of an adult and total liability for a family is capped at 300% of the individual penalty. Only the first two children will be counted in calculating the penalty.
Consumers with additional questions about the penalties should contact the Marketplace at 1-800-318-2596. Additional information is also available at www.healthcare.gov.
Health plans must be certified by HHS to be offered on the Marketplace and must meet certain minimum standards. Plan benefits, premiums, and enrollee out of pocket expenses will vary depending on the plan chosen.
Health plans will be standardized in four coverage tiers based on the percentage of the total allowed cost of benefit paid by a health plan on average:
Bronze Plans cover 60% of the costs
Silver Plans cover 70% of the costs
Gold Plans cover 80% of the costs
Platinum Plans cover 90% of the costs
Catastrophic health plans will also be available to individuals up to age 30 and to individuals who are exempt from the individual mandate because no affordable coverage is available or he or she has a hardship exemption, as determined by HHS.
Coverage is available on or off the Marketplace but in order to receive Advanced Premium Tax Credits or Cost Sharing Reduction, the plan must be purchased through the Marketplace. Coverage purchased off the Marketplace will take place by you contacting an agent or insurance company directly or by purchasing on-line.
One of the goals of the ACA is to make health coverage more affordable. The ACA has two features to assist eligible individuals and families that purchase coverage through the Marketplace:
Advanced Premium Tax Credit
Amount depends on income as percentage of the federal poverty level:
Based on a sliding scale
Based on the cost of the second lowest Silver Qualified Health Plan, adjusted for age and rating area of the covered person
Limits premium payments as a percentage of income
The tax credit is advanced directly to the insurer so it can lower the premium payments paid by the policyholder each month rather than waiting for a tax refund.
Cost Sharing Reduction
Some individuals and families may also qualify for reduced cost-sharing (copayments, coinsurance, and deductibles ) for in-network services.
Eligibility for the reduced cost sharing allowance is based on:
Incomes at or below 250% of the federal poverty level
Receiving the advance premium tax credit
Meeting enrollment requirements
Enrolling in a Marketplace Silver level plan
Members of Federally Recognized Indian Tribes are not eligible to receive cost sharing assistance if income is below 300% of the federal poverty level.
The only factors that can be used to vary the premium rate for a plan in the individual or small group market are:
Family or Individual
The age factor limits the company’s highest rate for a 64 year old to no more than three times the cost of a 21 year old.
The total premium for family coverage generally must be determined by summing the premiums for each individual family member. For family members under age 21, the total premium includes only the premiums for no more than the three oldest covered children.
Individuals that use tobacco can be charged up to 50% more than someone that does not use tobacco.
Gender or health history can no longer be used to determine the premium.
Medicare beneficiaries will not be charged a different rate than non-Medicare beneficiaries even if the health plan is secondary coverage since coordination with Medicare benefits is not among the allowable rating factors.
Premium Rate Review
The Department of Health and Human Services (HHS) will be responsible for reviewing new and renewal non-grandfathered individual and small group rates for the 2014 and 2015 policy years.
If you have specific questions about the premium for a non-grandfathered individual or small group policy, please contact the Marketplace at 1-800-318-2596.
The initial open enrollment for ACA coverage will be October 1, 2013, through March 31, 2014. If coverage is purchased through the Market place between October 1 and December 23, the effective date will be January 1, 2014. For coverage off the exchange, it will need to be purchased on or before December 15 in order to have a January 1 effective date. After this time period, coverage purchased between the 1st and 15th of the month will have an effective date on the first day of the following month.
Marketplace coverage purchased between December 24 and 31, 2013, will have a February 1, 2014, effective date. Beginning in January 2014, coverage purchased between the 16th and last day of the month through March 2014 will be effective on the first day of the second following month. Off exchange coverage purchased between the 16th and last day of the month during December 2013 through March 2014 will be effective on the first day of the second following month.
Example: Coverage purchased on January 17 will be effective March 1 but coverage that is purchased on January 14, it would be effective February 1.
In addition, for persons with non-calendar year coverage, individual insurers must offer a one-time limited open enrollment period beginning 30 calendar days prior to the date the policy year ends in 2014 in 2015.
The open enrollment period in 2014 (for 2015 coverage) will be from November 15, 2014, through January 15, 2015. Beginning in 2015, the annual open enrollment period will be October 15 through December 7 with a January 1 effective date.
Special enrollment periods exist for policies being purchased on or off the Marketplace (aka exchange). Unless otherwise stated in federal regulations, the special enrollment period will last a period of 60 calendar days for individual policies and 30 days for small group policies.
Listed below are the common special enrollment periods for coverage purchased on or off the exchange:
An individual loses minimum essential coverage. Please note that loss of coverage does not include termination or loss due to failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage, or situations allowing for a rescission.
An individual gains a dependent or becomes a dependent through marriage, birth, adoption, or placement for adoption.
An individual gains citizenship or qualifying immigration status.
An individual becomes newly eligible or ineligible for assisted premium tax credit, or change in eligibility for cost sharing reductions.
An individual gains access to new Qualified Health Plans (QHP) as a result of a permanent move.
An individual is enrolled in an eligible employer-sponsored plan that is not qualifying coverage and is allowed to terminate existing coverage.
An individual’s enrollment or non-enrollment in a QHP is an unintentional, inadvertent, or erroneous and as the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Marketplace or HHS.
An individual adequately demonstrates to the Marketplace that the QHP in which they are enrolled substantially violated a material provision of its contract.
Members of a federally-recognized Indian tribe may enroll or change QHPs one time per month.
Exceptional circumstances, as determined by HHS.
There are additional special enrollment periods depending on whether or not coverage is purchased on or off the Exchange. If you have additional questions about special enrollment periods, please contact the Marketplace at 1-800-318-2596.
Insurers must allow an employer to purchase small group coverage at any point during the year as long as they meet the required participation and contribution requirements. However, a health insurer may limit the availability of coverage to an annual enrollment period that begins November 15 and extends through December 15 of each year in the case of an employer that is unable to comply with plan requirements for employer contributions or group participation rules.
Self employed individuals will participate in the individual health insurance market.
As part of the ACA, the Marketplaces have been established in order to provide an easier means of shopping and purchasing individual and small group health coverage. The State of Florida elected not to create a state-based exchange so Florida residents and employers will participate through a federally facilitated marketplace (FFM).
There are two types of federal exchanges: the Marketplace through which individuals can purchase qualified coverage and the Small Business Health Options Program (SHOP), through which small businesses between 2 and 50 employees can purchase a Qualified Health Plan (QHP), as defined under federal law. This number will increase to up to 100 employees beginning January 1, 2016. Self - employed individuals will participate in the individual marketplace.
The individual Marketplace can be accessed at www.healthcare.gov or call 1-800-318-2596 or TTYTDD at 1-855-889-4325.
The individual Marketplace call center is operational 7 days per week/24 hours a day, 360 days per year. A live chat feature is also available from the website www.healthcare.gov. The individual Marketplace will be fully operational on October 1, 2013, so individuals can purchase health insurance coverage to be effective January 1, 2014, as long as it is purchased by December 23, 2013.
Individuals currently will not be able to enroll for coverage through the Spanish healthcare website - https://www.cuidadodesalud.gov/es/. An application in English can be completed with the assistance of a Spanish Marketplace employee until this site becomes fully functional.
The Small Business Health Options Program (SHOP) Marketplace for businesses with 50 or fewer employees can be accessed at www.healthcare.gov or call 1-800-706-7893 or TTY users – 1-800-706-7915. The SHOP Marketplace is operational Monday through Friday from 9:00 a.m. to 7:00 p.m. Eastern Standard Time.
The SHOP Marketplace will be available on October 1, 2013, for small employers to start the application process and get an overview of available plans and premiums in their area. The SHOP employer application will be available to employers as a PDF on Healthcare.gov. Employers may fill out and print the application and mail it in for processing if they would like to apply before they are able to do so online. If employers enroll through SHOP by December 15, 2013, coverage will begin on January 1, 2014.
The availability of the marketplaces coincides with the individual mandate that begins on January 1, 2014. Individuals needing enrollment assistance can locate local help by visiting localhelp.healthcare.gov and inputting their zip code. This information will be updated regularly so consumers should check for updates any time enrollment assistance is needed.
Whether you need health coverage or have it already, the ACA offers new rights and protections. Some rights and protections apply to plans in the Marketplace or other individual insurance, some apply to employer-based plans, and some apply to all health coverage.
Listed below are a few features of the ACA that can help you and your family:
Creates the Marketplace, a new way for individuals, families, and small business to get health coverage. One-stop shopping that allows for an apples to apples comparison of benefits.
Requires insurance companies to cover people with pre-existing health conditions.
Advanced Premium Tax Credits and Cost Sharing Reductions are available for eligible individuals and families.
Helps you understand the coverage you are getting by requiring a standardized Summary of Benefits and Coverage (SBC).
Covers young adults under the parents’ policy until age 26.
Provides free preventive care for defined services.
Guarantees your right to an internal and external appeal when a health plan denies payment for a treatment or service.
Small Business Health Care Tax Credits
Although the Affordable Care Act does not require that businesses provide health insurance, it does offer tax credits for eligible small businesses that choose to provide insurance to their employees for the first time, or maintain the coverage they already have. To qualify for a small business health care tax credit of up to 35%, an employer must have fewer than 25 full-time equivalent employees, pay average annual wages below $50,000, and contribute 50% or more toward the employees’ self-only health insurance premiums. In 2014, this tax credit goes up to 50% and is available to qualified small businesses that purchase coverage in the Small Business Health Options Program (SHOP) Marketplace.
The SHOP Marketplace opened on August 1, 2013, and will be ready for enrollment to start on October 1..
Employers Offering or Not Offering Group Health Coverage
The ACA does not require employers to offer health insurance coverage to its employees. However, beginning January 1, 2015, certain employers must pay penalties if they do not offer affordable health coverage to their employees.
Employers with 50 or more full-time equivalent employees (FTE) that do not offer coverage and have at least one full-time employee (works 30 hours or more per week) who receives a premium assistance tax credit for obtaining coverage will be assessed a per month fee of one-twelfth of $2,000 per full-time employee receiving the assistance.
Employers with 50 or more FTEs that offer coverage but has at least one full-time employee receiving a premium tax credit for obtaining affordable coverage, will pay a per month fee of the lesser of one-twelfth of $3,000 for each employee receiving a premium credit or one- twelfth of $2,000 each for the total number of full-time employees (the penalty that would be charged if the employer did not offer health coverage.) Employers with more than 200 employees and offers group health coverage will be required to automatically enroll their employees into the health insurance plans. However, employees may opt out. Employers with 49 or fewer FTEs are exempt from the requirement and penalties.
Employers with additional questions about the requirements and/or penalties should be referred to the IRS at 1-800-829-4933 or visit their website on the Affordable Care Act Tax Provisions at http://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Home.
Protect Yourself from Fraud in the Health Insurance Marketplace
Your best protection against fraud is you! Starting October 1, 2013, you can apply for health insurance through the Health Insurance Marketplace, on HealthCare.gov. A few simple things can protect you from fraud, while getting you the coverage you need.
Visit HealthCare.gov, the official Marketplace website, to learn the basics.
Compare insurance plans carefully before making your decision.
Look for official government seals, logos or web addresses.
Know the Marketplace Open Enrollment dates -- October 1, 2013 through March 31, 2014. No one can enroll you in a health plan in the Marketplace until Open Enrollment begins or after it ends unless you have special circumstances.
Protect your private health care and financial information.
No one should be asking for your personal health information. Don’t give it to anyone.
Keep personal and account numbers private. Don’t give your Social Security number or credit card or banking information to companies you didn’t contact or in response to unsolicited advertisements.
Never give your personal health or financial information to someone who calls or comes to your home uninvited, even if they say they are from the Marketplace.
Ask questions and verify the answers you get.
The Marketplace has trained assisters in every state to help you at no cost. You should never be asked to pay for services or help.
Ask questions if any information is unclear.
Write down and keep a record of a salesperson’s name or anyone who may assist you, who he or she works for, telephone number, street address, mailing address, email address, and website.
Double check any information that is confusing or sounds fishy. Visit HealthCare.gov or call us at 1-800-318-2596. TTY users should call 1-855-889-4325.
Don’t sign anything you don’t fully understand.
Report Anything Suspicious
If you suspect fraud, report it! Call the Health Insurance Marketplace consumer call center at 1-800-318-2596. TTY users should call 1-855-889-4325. Or contact local, state, or federal law enforcement agencies or your state department of insurance. If you suspect identity theft, or feel like you gave your personal information to someone you shouldn’t have, call your local police department and the Federal Trade Commission’s ID Theft Hotline at 1-877-438-4338. TTY users should call 1-866-653-4261. Visit www.ftc.gov/idtheft to learn more about identity theft.
Listed below are websites that may assist you in learning more about the ACA:
https://www.healthcare.gov/ : Official federal website to learn more about the Affordable Care Act (ACA) and enroll in coverage through the Marketplace. You can sign up for e-mail updates related to the many provisions of the Act on this website.
https://www.cuidadodesalud.gov/es/: This is the Spanish version of the official federal website.
https://localhelp.healthcare.gov: This website allows individuals to input their zip code in order to locate local enrollment assistance for their area.
http://www.cms.gov/cciio/: This website is maintained by the Center for Consumer Information and Insurance Oversight (CCIIO) which is a division of HHS. There is a wealth of information about multiple topics dealing with health care reform including the federal marketplace, navigators, qualified health plans, agents’ roles in the marketplace, and much more. You can sign up to receive an email notification when updates are made to this website.
http://marketplace.cms.gov: The purpose of this website is to provide a place for professionals that will be learning about the Marketplace and helping people understand their options to go for training and marketing materials. Training, marketing materials, and official government resources are available on this site.
www.kff.org: The site is a very comprehensive website maintained by the Henry J. Kaiser Family Foundation.
http://www.healthreformgps.org/: This site is designed to present unbiased information about the health reform legislation while also setting forth implementation issues that may arise from a full range of stakeholder views on any particular topic. This project is specifically designed to help people understand the legislation and its implementation.
http://www.myflfamilies.com/: Visit the Department of Children and Families (DCF) website to check Medicaid eligibility in Florida.
https://www.healthykids.org/: Do you have a child that is uninsured? Healthy Kids is designed to provide quality, affordable health insurance for children not eligible for Medicaid. Visit the Florida Healthy Kids website for more information.
www.SBA.gov/healthcare: This webpage is maintained by the Small Business Administration and has information on what the Affordable Care Act means to small businesses including a timeline of important dates, key provision details and a glossary of terms.
www.dol.gov/ebsa/healthreform: This website is maintained by the U.S. Department of Labor and includes information regarding Affordable Care Act regulations, guidance and frequently asked questions.
www.business.usa.gov/healthcare: This is an official website of the U.S. government and contains a wizard application to help small businesses understand options available to them.
www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Home: The Internal Revenue Service created this website to help individuals and businesses understand the tax provisions related to the Affordable Care Act.
Should you need additional information, you may speak with an insurance specialist between the hours of 8:00 am – 5:00 pm at one of the telephone numbers listed below:
Out of State Callers: (850) 413-3089
View notices that show the impact of the Affordable Care Act on health insurance costs of the insurers most popular plan prior to federal health care reform.