The affordable care act power point (updated) again
RLee Insurance Solutions
Understanding it and enrolling in
your new health care plan
How does the ACA improve my health
Provides health insurance to those that were once considered „uninsurable‟ with preexiting health conditions.
Provides for certain protections and rights to make your coverage fairer and easier to
Provides for a health care Marketplace for an easier shopping experience.
Holds insurance companies accountable for rate increases.
Makes it illegal for health insurance companies to arbitrarily cancel your health
Covers young adults under 26.
Provides free preventive care.
Ends lifetime and years dollar limits.
Guarantees your right to appeal
Questions? Call 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325)
What will my new policy cover?
All private health insurance plans offered in the Marketplace will offer the same set of essential health benefits. These are
services all plans must cover.
The essential health benefits include at least the following items and services:
Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Hospitalization (such as surgery)
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
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)
Preventive and wellness services and chronic disease management
OK so how do I start ?
First thing you need to figure out is are you applying “on exchange” or “off exchange”?
If your income is between 100% - 400% of the federal poverty level then you may qualify
for a federal subsidy, premium assistance tax credit. It was put into place to help reduce
the cost of premiums, this subsidy may only be applied to “on exchange” plans. Since
you can only use your subsidy with plans that are “on exchange” and you must enroll
through the government web site Healthcare.gov.
If your income is above 100% - 400% of the federal poverty level you may apply for
either “on exchange” or “off exchange” plans. If you choose to enroll in a “on exchange”
plan then you must go through the Healthcare.gov web site. Plans that are “off
exchange” may be purchased though various web sites.
Lastly if your income is below 100% of the poverty level you do not qualify for a subsidy
and in many cases you can enroll for Medicaid through Healthcare.gov or your State web
site. You may also choose to buy an “off exchange” plan since no subsidy is involved.
How to calculate my subsidy?
First determine how many in your
Second calculate your modified
adjusted gross income(MAGI).
MAGI can also be located on:
line 4 on a form 1040EZ
line 21 on a form 1040A
line 37 on a form 1040
Third use a subsidy calculator to
enter these numbers and find your
2013 POVERTY GUIDELINES FOR THE 48
CONTIGUOUS STATES AND THE DISTRICT OF
Person in family/household
For families/household with more than 8 persons, add
$4,020 for each additional person
* The figures are the 2013 HHS poverty guidelines which are scheduled to be
published in the Federal Register on January 24, 2013. (Additional
information will be posted after the guidelines are published.)
SOURCE: Federal Register, Vol. 78, No. 16, January 24, 2013, pp. 5182-5183
What are Federal Cost-Sharing Subsidies?
Individuals with a household income of 100-250 percent of the federal poverty line,
who enroll in a plan through the exchange, Healthcare.gov, are eligible for a cost
sharing subsidy. Under the 2013 federal poverty guidelines, the annual income
thresholds to qualify are: $28,725 for individuals; $38,775 for couples; $48,825 for a
family of three; and $58,875 for a family of four.
Cost sharing subsidies are designed to minimize out-of-pocket costs by reducing the
amount individuals have to pay for deductibles, co-payments and co-insurance
payments. The amount of the reduction depends on the insured‟s household income.
For those with incomes between 100% and 200% of poverty, a 2/3 reduction applies.
For others, the reduction in the limit is either ½ or 1/3, depending on income. The
precise amount by which an individual‟s out of pocket maximum is reduced by this
assistance depends on what the maximum is for the plan in which they are enrolled.
To receive a Cost-Sharing subsidy you have to have a Silver Plan, as these are the
only eligible plans for this subsidy.
But which plan?
The new plans will be labeled with “metallic” names, bronze, silver,
gold, and platinum. There is also one more plan labeled “catastrophic”
but only certain folks may apply for them.
Each plan with have a deductible, an amount you must pay before
benefits are triggered.
After you have satisfied the deductible you will have to pay a co-pay,
or coinsurance, a set percentage of your bill.
The good news each plan does have a maximum amount listed that
you would have to pay. Should your health expenses exceed the
maximum out of packet amount your plan will generally pay all
remaining medical expenses.
A catastrophic plan generally requires you to pay
all of your medical costs up to a certain
amount, usually several thousand dollars. Costs
for essential health benefits over that are
generally paid by the insurance company.
Generally speaking, the Bronze Plan is
intended to have the lowest premium of the 4
new categories of plans but charge the
highest out-of-pocket costs for healthcare
services. For people without group insurance
from an employer or other group, the Bronze
plan is the minimum health insurance plan in
which they can enroll that will satisfy the
Affordable Care Act‟s mandate for people to
purchase health insurance.
These policies usually have lower premiums than
a comprehensive plan, but cover you only if you
need a lot of care. They basically protect you
from worst-case scenarios.
Only people under 30 may apply for them.
You may apply for a hardship exemption if
Plans often have high deductibles.
*Not a subsidy eligible plan
Co-pay is at the 60/40 level
The Silver Plans have lower out-of-pocket
costs than the Bronze Plans but higher out- ofpocket costs than both the Gold and Platinum
Plans. All Silver Plans share the same
minimum health benefits but the way they
charge out-of-pocket costs can differ
The Gold Plan is one of the two plan types
that an insurance company must offer in
order to participate in a health insurance
exchange. A health insurance exchange is a
state marketplace for health insurance plans
meeting the ACA requirements.
Subsidies in your state are based on Silver
plans in your state.
Co-pay is at the 70/30 level
One of the issues that the government intends
to monitor is whether Gold and Platinum
plans attract more sickly enrollees and drive
These plans have the second lowest out-ofpockets of the metallic plans.
Co-pay is at the 80/20 level
Since the Platinum Plan has the most
generous cost-sharing for enrollees, it is
expected that these plans will typically have
the highest premiums when compared to the
Bronze, Silver, and Gold plans.
It will be important to compare premiums
among different insurance companies
offering Platinum Plans. Moreover,
deductibles and copayments will also differ
among Platinum Plans. This is perfectly
acceptable as long as the Platinum Plan
covers 90% of healthcare expenses for a
Co-pay is at the 90/10 level
Which Exchange is for you?
First Calculate your
Second choose your
Third click one of the blue
balls on the bottom to
Of course you can visit
Or call our office 765-746-6459 for
help, we are here to help.
Our office Location
RLee Insurance Solutions
Located just off IN 26 in Lafayette
Indiana, we are easy to find with ample
parking and our facility is handicapped
accessible. Click here for easy Directions
100 Executive Dr.
Lafayette, IN 47905