What changes can I expect?
1. Insurance coverage is guaranteed, even if you have a pre-existing condition
Insurance companies selling plans through the state or federal marketplaces (see item 4 below) cannot deny you coverage if you have a pre-existing condition (e.g., cancer, asthma or depression). Additionally, insurance companies can no longer charge you higher rates based upon your gender or health status.
2. Basic health insurance is a requirement
Everyone is now required to carry minimum essential health insurance or have a coverage exemption or make a shared responsibility payment. Minimum essential coverage covers the core services (also known as "Essential Health Benefits") required by the federal government. People who are not exempt and who choose not to carry insurance will be required to pay an individual shared responsibility payment from the IRS.
Minimum essential health insurance is available through any of the following:
- Health plans offered by the federal government
- Health plans offered by your employer including COBRA and retiree coverage
- Certain health plans purchased privately by an individual
- Grandfathered health plans (a group health plan that was created or an individual health insurance policy that was purchased - on or before March 23, 2010)
- Other health plans approved by the Department of Health and Human Services and Department of the Treasury (e.g., state health benefits risk pools)
3. Certain medical services must be covered by your insurance company
All health insurance plans offered to individuals and groups must cover the same basic services. These are called "Essential Health Benefits" and include:
- Ambulatory (walk-in) patient visits
- Emergency services
- Maternity and newborn care (care before and after your baby is born)
- Mental health and substance abuse treatment, including behavioral health treatment (e.g., counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities or long-term illnesses/conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services (e.g., blood pressure screenings or hearing screenings for children)
- Chronic disease management (long-term illnesses such as arthritis, heart disease or diabetes that don't go away and require lifelong checkups, tests and treatment)
- Pediatric services, including dental and vision care
4. Creation of health insurance marketplaces
On Oct. 1, 2013, state and federal health insurance marketplaces opened for business. Through these online marketplaces, you can easily compare health insurance products and sign up for the one that best meets the needs of your family or small business. You also have the option to sign up for insurance by phone, mail or in person, if preferred.
Pennsylvania has decided not to launch its own marketplace. This means that state residents who don't have health insurance and cannot buy it through their employer will be able to purchase it through the Federal Health Insurance Marketplace.
There will be two types of marketplaces where individuals and small businesses can shop. The public marketplace will offer health plans and products from many different companies. Both state and federally operated marketplaces are public.
Private marketplaces will be specific to just one insurance provider's products and services.
5. Financial help for qualifying individuals or families who cannot afford health insurance
If you and your family cannot afford to buy health insurance you may qualify for tax credits. These tax credits (also called advance premium tax credits or subsidies) can be used to lower the cost of your insurance when it is bought through health insurance marketplaces. They are also refundable.
Households with a total annual income that is between 100 and 400 percent below the federal poverty level (FPL), and are not eligible for Medicaid, may qualify for the tax credit. These households may also qualify for lower co-payments, co-insurance and deductibles.
This chart will help you determine if your income is within federal poverty limits for 2017:
For families/households with more than 8 persons, add $4,180 for each additional person.
Once you create your marketplace account and submit your application, you will see immediately how much of a tax credit you can receive. This same application will also tell you whether you or your family members might qualify for free or low-cost coverage available through Medicaid or the Children's Health Insurance Program.