The “Patient Protection and Affordable Care Act” or ACA for short and also known as Obamacare, affects all health insurance policies. This would include large and small group health insurance as well as individual policies. All ACA policies have no dollar limits on benefits, no pre-existing condition clauses that would reduce the quality or quantity of care and have mandated, “Ten Essential Heath Benefits” included in each policy. The Ten Essential Health Benefits are:
- Hospitalization
- Prescription Drugs
- Emergency Services
- Laboratory Services
- Ambulatory Patient Services
- Maternity and Newborn Care
- Pediatric Dental and Vision Care
- Rehab and Facilitative Services & Devices
- Preventative, Wellness & Chronic Disease Management
- Mental Health, Substance Abuse and Behavioral Health Treatment
Policy rates are determined on three characteristics; age, zip code and tobacco use. Therefore, no one can be declined coverage based on health. In addition, adult children can remain on their parent’s policy until their 26th birthday. When looking for a plan, you must first understand when to apply, the categories of insurance, the definitions of networks, subsidies, cost sharing, Out-of-Pocket expenses and how they function. Even though the ACA affects all policies, this article will focus on individual policies, especially in high populated areas in Texas such as Dallas health insurance, Arlington health insurance and Fort Worth health insurance. These areas were singled out in Texas because there will be many changes in the type of networks and metal plans. Open Enrollment vs. Special Enrollment Period The Health Insurance Marketplace Exchange has open enrollment between November 1st and January 31st of each year. The effective day of coverage starts on January 1st if the application is completed before December 15th. If the application is completed between December 16th and January 15th, the effective day of coverage would start February 1st; and if the application is completed between January 16th and January 31st, the effective day of coverage will be March 1st. This will be the only time to acquire an individual health insurance policy unless you have a Qualifying Life Event. There are several Qualifying Life Events such as job loss, marriage, childbirth, divorce, or a move from another state to name a few. The sign up period for a Qualifying Life Event is 60 days from the time of the event. This is known as a Special Enrollment Period or SEP for short. SEPs are year round for individual coverage. Persons’ starting a new job that offers health insurance has 60 days to be insured through that job. Once leaving a job, a person has 60 days from the day of termination to acquire health insurance. Outside of this window, you will have to wait until Open Enrollment to acquire an individual insurance policy. Subsidies, Cost Sharing and Out of Pocket Expenses A subsidy is when the Federal Government contributes to the payment of premiums based on household income. Cost Sharing is when your deductible is lowered or eliminated based on household income. A co-pay is the set amount an insured individual must pay for a benefit such as Doctor’s office visits or prescription drugs. Co-insurance is the percentage of covered expenses an insured individual shares with the insurance company after the deductible is paid. Total Out-of-Pocket expense will include all of your expenses associated with the policy with the exception of monthly payments. This includes the deductible, co-payments and co-insurance. Applications submitted to the Health Insurance Market Place will be eligible for a subsidy, cost sharing and a reduction in the total Out-of Pocket expense based on house hold income. The Metal Tiers of Insurance The Marketplace has divided insurance plans into categories. The health plan category you choose determines how you and your selected plan will share the costs of care. These categories have nothing to do with the quality or amount of care you get. There are 5 categories or “metal levels” of coverage in the Marketplace. Plans in each category pay different amounts of the total costs of an average person’s care. This takes into account the plan’s monthly premiums, deductibles, copayments, coinsurance, and out-of-pocket maximums. The actual percentage you’ll pay in total or per service will depend on the services you use during the year.
- Bronze: Your health plan pays 60% on average. You pay about 40%.
- Silver: Your health plan pays 70% on average. You pay about 30%.
- Gold: Your health plan pays 80% on average. You pay about 20%.
- Platinum: Your health plan pays 90% on average. You pay about 10%.
- Catastrophic: Catastrophic coverage plans pay less than 60% of the total average cost of care. They’re available only to people who are under 30 years old or have a hardship exemption.
All of this information are things to keep in mind when purchasing Health Insurance on the exchange. This is very important as networks change in Texas. Insurance4Dallas, (I4D) helps insure all of Texas and provides consumers with detailed information and the ability to apply for insurance online. I4D provides a full spectrum of health, dental, vision, life and other ancillary insurance products providing a diverse selection of price and benefit options complemented by personable customer service. Available via phone, email or fax, Insurance4Dallas answers consumer questions throughout the purchasing process and utilization of the health insurance policy.