Do you have questions about the Affordable Care Act (ACA) and how it impacts you? The resources and topics below will help you gain a better understanding of the many aspects of the Affordable Care Act.
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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 since 2010. Some of the final and most notable changes of the law took 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 benefits 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.
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 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 on an annual basis. Navigators are also 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 1 and 50 employees. Self-employed individuals or a business without at least one non-family member employee enrolled in the group health plan must purchase coverage through the individual health insurance market.
The Affordable Care Act (ACA) required most individuals to have health insurance or health coverage beginning January 1, 2014. The tax penalty for not having minimum essential health coverage was reduced to zero beginning with the 2019 calendar year. If you have questions about the shared responsibility payment for years 2014 through 2018, please contact the federal Marketplace at 1-800-318-2596.
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 or other situations 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 online.
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. The individual can choose to have the whole tax credit applied each month, a portion of the tax credit each month, or defer the entire tax credit until the annual tax filing is completed.
Individuals whose income is anticipated to fluctuate during the calendar year may want to consider some deferral of the tax credit in order to minimize a tax burden when the annual tax filing is completed.
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 Office of Insurance Regulation (OIR) reviewed and approved individual and small group rates beginning with the 2016 calendar year. The OIR’s authority for rate review was re-established after its ability was suspended by the Legislature for 2014 and 2015. The Department of Health and Human Services (HHS) was responsible for reviewing new and renewal non-grandfathered individual and small group rates for the 2014 and 2015 policy years.
Information about rate and form filings with the OIR can be obtained from the OIR’s website at www.floir.com. Select the link named “Federal Health Care Reform” to access to the I-File Forms & Rates Search System as well as various other reports for multiple plan years.
The Open Enrollment period for 2022 coverage will be from November 1, 2021, through January 15, 2022. This is the time for individuals or families to purchase new coverage, renew their existing coverage, or decide to switch plans or insurers. All coverage on or off the Marketplace (aka Exchange) is guaranteed issue with no pre-existing condition waiting periods or premium rate ups due to medical history.
All individuals with current coverage should return to the Marketplace, either by phone or online, to update or verify existing information on their Marketplace application.
Coverage purchased or changes made to existing plans between November 1 and December 15 will be effective January 1, 2022. New policies or changes to existing policies made between December 16 and January 15 will be effective February 1, 2022. You will not be able to purchase major medical health insurance coverage for the 2022 calendar year after January 15, 2022, unless you qualify for a Special Enrollment Period (SEP).
Individuals and families with incomes between 100 and 150% of the Federal Poverty Level (FPL) and who qualify for Advanced Premium Tax Credits (APTC), may qualify to enroll or change plans one time per month throughout the calendar year. Coverage should be effective the 1st of the month following the plan selection. Individuals interested in finding out additional information should call the federal Marketplace at 1-800-318-2596 for assistance.
Individuals or families with non-calendar year coverage (transition or grandfathered plans), are eligible for a one-time limited enrollment period beginning 30 calendar days prior to the date the policy year ends during 2021 or 2022 and extends 60-days after the coverage has terminated. You should keep in mind that while you may be able to maintain your coverage until a mid-year date, the ACA plan will be issued on a calendar year basis. This means medical expenses incurred between January 1 and the new policy effective date may not apply toward the deductible, co-insurance, and out of pocket maximum requirements of the new plan.
Special enrollment periods (SEP) exist for policies being purchased on or off the Marketplace (aka Exchange). Unless otherwise stated in federal regulations, the SEP will last a period of 60 calendar days for individual policies and 30 days for small group policies.
Listed below are the common SEPs for coverage purchased on or off the Exchange:
There are additional SEPs depending on whether coverage is purchased on or off the Exchange. If you have additional questions about SEPs, please contact the Marketplace at 1-800-318-2596 or visit their website at www.healthcare.gov.
Insurers must allow an employer to purchase small group coverage at any point during the year as long as they meet the required participation requirement. 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 who is unable to comply with plan requirements for employer participation rules.
Self-employed individuals, including husband-wife or family-only businesses, with no non-family members enrolled in a group health policy are not eligible for small group plans and will need to purchase coverage through the individual health insurance market.
As part of the ACA, the Marketplaces (aka Exchanges) were established 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. Self-employed individuals, including husband-wife or family-only businesses who do not have at least one non-family member enrolled in a group health plan, are not eligible for small group plans so they will participate in the individual health insurance market.
The individual Marketplace can be accessed at http://www.healthcare.gov or call 1-800-318-2596 or TTYTDD at 1-855-889-4325. You can view available health plans without identifying yourself but you will need to create an account in order to purchase coverage.
The individual Marketplace call center is operational 7 days per week/24 hours a day, 362 days per year. A live chat feature is also available from the website https://www.healthcare.gov. The open enrollment period for 2021 will be from November 1, 2020, through December 15, 2020. You will need to apply on or before December 15, 2020, to have a January 1, 2021, effective date. You will not be able to purchase a major medical health plan for 2021 after December 15 unless you qualify for a Special Enrollment Period (SEP).
Individuals needing enrollment assistance can locate local help by visiting https://www.healthcare.gov/apply-and-enroll/get-help-applying/, click on “In-person help in your community” and then input your zip code. If you are looking for an insurance agent to assist you, be sure to click on the “Agents & Brokers” option.
Individuals can access the Spanish healthcare website - https://www.cuidadodesalud.gov/es/.
Individuals who do not qualify for an Advanced Premium Tax Credit (APTC) or who do not want to take advantage of an APTC can purchase coverage off the Exchange. A list of all companies participating in the individual market is available on our website at
The Small Business Health Options Program (SHOP) Marketplace for businesses with 50 or fewer employees can be accessed at https://www.healthcare.gov/small-businesses/ or call 1-800-706-7893 (TTY: 711). The SHOP Marketplace is operational Monday through Friday from 9:00 a.m. to 7:00 p.m. Eastern Standard Time.
The SHOP Marketplace opened on October 1, 2013, so small employers could get an overview of available plans and premiums in their area. Coverage can be purchased by contacting the insurer or an agent directly.
Coverage for small employers can be written year-round but there is an annual enrollment period from November 15 to December 15 for employers who are unable to meet companies’ participation requirements.
Small businesses that choose to provide insurance for their employees for the first time, or maintain coverage they already have, may be eligible for tax credits when coverage is purchased through the SHOP Marketplace. You can visit the federal website at https://www.healthcare.gov/small-businesses/ for more details. This site also includes a Full-Time Equivalent (FTE) Calculator to help small employers determine if they are eligible for SHOP coverage well as a SHOP Tax Credit Estimator to help a small business learn the size of the tax credit it may be eligible for if coverage for their employees is purchased through the SHOP.
Small businesses can choose to purchase their group health plan through the SHOP Marketplace or off the Exchange. A list of all companies participating in the small group market is available on our website at
If you already have an ACA policy through the Marketplace you should go back to the Marketplace either online or call the customer service number at 1-800-318-2596 to confirm your eligibility and the amount of your Advanced Premium Tax Credit (APTC), if any. Failure to confirm this information by December 15 may cause you to lose your APTC, receive too much or too little of an APTC, or you may be automatically enrolled in a replacement plan if your current plan is not available in the next calendar year. Since the Open Enrollment Period extends until January 15, you can still update your Marketplace application between December 16 and January 15, but the change(s) will not be effective until February 1.
This is also your opportunity to shop around for a new policy with the same or different carrier or confirm you wish to stay enrolled in the same plan you currently have if it is still available. All coverage on or off the Marketplace (aka Exchange) is guaranteed issue with no pre-existing condition waiting periods or premium rate ups due to medical history so a new insurer cannot turn you down or raise your premium because of a medical condition. Be sure to contact your current insurer to advise them you are switching companies if you choose to do so.
If your ACA policy is off the Exchange, you do not need to do anything unless your insurer advised you that your policy is being discontinued or if you wish to shop around. A list of all companies participating in the individual market is available on our website at www.myfloridacfo.com/Division/Consumers/PurchasingInsurance/IndividualCarrierList.htm.
Whether you need health coverage or have it already, the ACA offers rights and protections not in effect prior to its passage. 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:
You can file a request for an expedited (faster) appeal if the time needed for the standard appeal process would jeopardize your life or your ability to attain, maintain, or regain maximum function. The expedited appeal request should specifically explain how a standard appeal would jeopardize your life or their ability to attain, maintain, or regain maximum function.
The Marketplace has indicated the request to expedite their appeal will be processed as quickly as possible but may be as long as 90 days. The final decision will be made as quickly as your situation requires. There are a couple of ways to file an appeal:
Write a letter to:
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061
Or mail in an appeal request form which is located on the www.healthcare.gov website.
Faxing your request to a secure fax line at 1-877-369-0130.
If you need assistance with filing an appeal or have questions about the appeal process you can contact a navigator for additional help. You can visit www.healthcare.gov and select the Find Local Help button in order to find a navigator in your area. You can also appoint an authorized representative to help you. The representative can be a family member, friend, advocate, attorney, or someone else who will act for you. Even if you have already appointed an authorized representative for your Marketplace application, you will need to send a new form or letter to authorize someone to represent you for the appeal.
You can appoint a representative either of two ways:
Complete the appropriate form on the www.healthcare.gov website under the appeals section, or
Submit a written request with the appeal and mail it to:
Authorized Representative Request
Marketplace Appeals Center
P.O. Box 311
Pittson, PA 18640
Or fax the form to their secure fax line to 1-877-369-0129
The Healthcare.gov website lists the information that must be included in a written request to appoint a representative.
If you have additional questions about the appeal process, you should visit their website at www.healthcare.gov or call the Marketplace at 1-800-318-2596.
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 100 or more full-time equivalent employees (FTE) that do not offer coverage to at least 70% of its workforce 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 will be required to cover 95% of its workforce starting January 1, 2016, in order to avoid a penalty.
Employers with 100 or more FTEs that offer coverage but have 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 50 to 99 FTEs are exempt from the above requirements and penalties until January 1, 2016. They will be required to cover 95% of their workforce at that time in order to avoid a penalty. These employers will be responsible for reporting certain information about their group health plan to the federal government starting in 2015.
Employers with 49 or fewer FTEs are exempt from the above requirements and penalties.
Employers with additional questions about the requirements and/or penalties should contact the IRS at 1-800-829-4933 or visit their website on the Affordable Care Act Tax Provisions at https://www.irs.gov/affordable-care-act.
Protect Yourself from Fraud in the Health Insurance Marketplace
Your best protection against fraud is you! Individuals can apply for health insurance through the Health Insurance Marketplace on HealthCare.gov. A few simple things can protect you from fraud, while getting 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 - November 1 to December 15. No one can enroll you in a health plan in the Marketplace or off exchange until Open Enrollment begins or after it ends unless you have special circumstances to qualify for a Special Enrollment Period.
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 they work for, telephone number, street address, mailing address, email address, and website. Insurance agents should give you their state license number.
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 Florida Department of Financial Services Consumer Helpline at 1-877-693-5236 or the Health Insurance Marketplace consumer call center at 1-800-318-2596. TTY users should call 1-855-889-4325. 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.
Purchasing a Short-Term Health Insurance Policy? Flyer
Available for download in English
View Consumer Protections - Short-Term Limited Duration Policies for more information on this topic.
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.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.
https://www.healthcare.gov/small-businesses/provide-shop-coverage/qualify-for-shop-marketplace/ - SHOP Marketplace calculator to help an employer determine its number of full-time equivalent (FTE) employees.
https://www.healthcare.gov/small-businesses/provide-shop-coverage/small-business-tax-credits/ - SHOP Marketplace calculator to help an eligible small business estimate the amount of small business tax credits it qualifies for.
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.
https://www.healthcare.gov/small-businesses/: This is an official website of the U.S. government and contains a wizard application to help small businesses understand options available to them.
https://www.irs.gov/affordable-care-act: The Internal Revenue Service created this website to help individuals and businesses understand the tax provisions related to the Affordable Care Act.