Health Care Reform Updates
Information shared is a result of the Patient Protection and Affordable Care Act (PPACA) which was signed by President Obama on March 23, 2010. PPACA, and the interim and final rules issued since PPACA’s enactment date, will affect the health plans of our members in their plan years beginning on or after Sept. 23, 2010.
To learn more about the Healthcare Reform Bill, visit http://www.healthcare.gov.
To help you understand your options with health insurance:
Implemented to assist Americans to have access to affordable health care coverage.
Individuals can apply for a tax credit through Avera Health Plans this year by clicking “Get A Quote or Apply” to help them reduce the cost of their monthly premium. The website for individuals can be referred to the Health Insurance Marketplace or sometimes called the exchange.
Yes, if you meet specific criteria such as being lawfully present in the United States you can purchase insurance. Only those eligible will be able to apply for the tax credit. Get A Quote or Apply
Individuals are required to have a health plan during open enrollment each year to avoid penalties. Next open enrollment will begin November 15 for 2015 coverage. If you do not have health insurance, you may apply if you have a qualifying life event. Learn More About Qualifying Life Events >>
The penalty for not having insurance in 2015 is $325 per adult, $162.50 for a child, and up to $975 per family, or 2% of your family income, whichever is greater.
When you file your income tax return with the IRS.
Yes, if the employee has access to employer-sponsored insurance and decides not to take it, he/she may still enroll in coverage through the individual exchange or Avera Health Plans, but you will not be eligible for a tax credit unless the employer-sponsored coverage is unaffordable.
2. Most people can get a break on costs. You may qualify for a tax credit and therefore, get lower costs on your monthly premiums and out-of-pocket costs.
3. Gives you control. We will provide you comparisons of prices and benefits before you enroll. You can take your time to look, learn and research before you decide which plan to provide coverage for you and your family.
Each metal tier is defined by the portion of the claims paid by your plan. For instance, for the Bronze tier, the plan typically pays 60 percent of the cost and you are responsible for the remaining 40 percent through out-of-pocket costs such as co-pays, coinsurance and deductibles.
The graph below shows the value of the metallic tiers:
If you choose a bronze plan, you will pay more when you receive health care but your monthly premiums will be less. If you purchase a gold or platinum, you will pay less when you go to receive services however your monthly premium will be more.
NOTE: Only the Silver plans will allow you to have cost-sharing reductions to your health care cost.
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Maternity and newborn care (care before and after your baby is born)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services
While essential health benefits are minimum requirements for all plans in the Marketplace, our plans may offer additional coverage.
NOTE: Only non-grandfathered plans that are purchased on your own or obtained through a small employer groups with 1 to 50 employees will be required to cover essential health benefits.
Health Insurance Can Be Confusing
Below is a video to help explain some of the most common terms.
Grandfathered Plan: Employers (and individuals) could choose to keep their current health plan “grandfathered” by not changing their health insurance plan. Therefore, it is excused from having to comply with certain rules of the Affordable Care Act. This allows the plan to generally stay as it was before March 23, 2010.
Non-grandfathered Plan: An individual or employer group loses it grandfathered status if the health insurance plan benefits or cost structure is changed.
NOTE: If you are insured under an employer-sponsored self-funded plan, some of these reform updates may not apply. Please contact your company’s Human Resources.