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Affordable Care Act Coming Into Effect: Now What?
11/28/13



As the enrollment period for the Affordable Care Act gets underway, Achiezer has been fielding many general insurance questions, as well as assisting other enrollers and organizations as they learn this new system. Dozens of families have already been successfully enrolled in the system, as Achiezer's insurance staff were from the first in state to successfully train and learn these new programs; approximately 90% have already come away with significant savings. As resident health insurance expert, Achiezer Health Insurance Coordinator Sruly Miller gives us the lowdown on what we can expect.



GENERAL INFORMATION

Is the exchange site even useable these days?
There's been lots of negative media going around about the exchange site; however, that information is all related to the federal exchange site. New York is one of 14 states that have taken the initiative of setting up their own exchange sites. So far, the New York site has been the most successful of them all. There have been some glitches, but mostly, the issues have been minimal, and we've enrolled a few dozen families with good results.

When I search online, I'm coming up with a federal exchange, as well as a New York State exchange. Which one has the information that I need?

It is pointless for you to search on the federal exchange site; all of the information relevant to you is on the New York State exchange site.

Will I be eligible for insurance under the Affordable Care Act?

If you are either: low income; do not receive insurance benefits through your employer; or receive insurance benefits through your employer, but pay more than 9.5% of your total household income in premiums, you will likely benefit from the ACA. If you are on the high end of the income spectrum and receive insurance through your employer, the ACA will not apply to you.

I have never been eligible for subsidized insurance in the past. Is it possible that I might be eligible now?

Yes. The eligible income levels for insurance coverage are much higher now than they've been in the past.



PRE-EXISTING PROGRAMS (Medicaid, Child Health Plus, Family Health Plus, Healthy NY)

If I am already on Medicaid or Child Health Plus, what will happen to my coverage?

The Medicaid and Child Health Plus programs will continue as before. When it comes time to reapply, your application will be submitted through the online exchange site, but the program and coverage remain unchanged. The enrollment times and rules for these programs also remain as they were before.

If I am on Family Health Plus or Healthy NY, what will happen to my coverage?

The Family Health Plus and Healthy NY programs will be terminated as of January 1, 2014. If you are on either of these programs, you need to apply for new coverage through the exchange before December 15, 2013. You will almost definitely be eligible for a subsidy for the new program.



EXCHANGE INFORMATION

What kinds of health insurance plans are available through the exchange?

Health insurance plans available through the exchange are called Qualified Health Plans (QHP). The QHPs are provided by different carriers; some are traditional insurance companies that have adapted their policies to comply with the ACA, and some are brand new companies that have been created for the exchange. Different counties offer different lists of eligible QHPs.

What is the difference between the QHPs?

Each QHP offers 10 main benefits Essential Health Benefits (Required for all QHPs), 1) Ambulatory Patient Services 2) Hospitalization 3) Mental Health 4) Prescription Drugs 5) Preventive Wellness and Chronic Disease Management 6) Emergency Services 7) Maternity and Newborn Care 8) Rehabilitative and Habilitative Services and Devices 9) Laboratory Services 10) Pediatric Services, as required by law. While the broad categories of benefits are the same across the board, some QHPs offer additional benefits and options. Prescription drug coverage varies between QHPs, and the networks of participating doctors vary, as well.

Is there any price difference between the QHPs?

There is a price difference between the QHPs. Subsidies are available for all QHPs to income-eligible families (see below).

Are there price differences within the same QHP?

Within each plan there are four levels, referred to as 'metal levels': platinum, gold, silver, and bronze. The platinum level includes the highest premium, but has no deductible and minimal co-pays. The bronze level has the lowest premium, but requires a $3000 deductible and 50% co-pay on all services. The gold and silver metal levels fall somewhere between those two extremes. Premium subsidies may be applied to any level.

What are the coverage limits?

In accordance with the ACA, there will be no limits to the number of doctor/hospital visits, so long as each visit is medically necessary. There will also be no caps to financial coverage; carriers will be required to foot the bill for even the most expensive and long-term medical issues.

What is the enrollment period, and when will coverage begin?

This year, the enrollment period will extend from October 1, 2013 through March 15, 2014. Applications submitted between now and December 15, 2013, will begin to receive coverage on January 1st, 2014; applications received after December 15, 2013 must be submitted by the 15th of the month in order to begin receiving coverage on the first day of the following month. The annual open enrollment period every year thereafter will be from October 15 - December 7. Applications may be submitted at any time midyear if the applicant experienced a qualifying event, such as loss of a job, or a birth or death in the family.



SUBSIDIES (FOR QHPs ONLY)

What kinds of subsidies are available?

In most cases, subsidies are available for families whose income is below 400% of the federal poverty guidelines. The basic subsidy is applied towards your premium. There is also an additional program called the CSR (Cost Sharing Reduction) Program, which helps cover the cost of deductibles and co-pays. With both programs, the lower the income, the higher the subsidy.

If I am eligible for a CSR subsidy, can I use it at any metal level?

CSR subsidies can be applied to the bronze and silver levels, only.

How will I know which subsidies I am eligible for?

When your application information is processed on the exchange, it is automatically assessed for eligibility for all programs.

How are subsidies paid?

You may choose to apply your subsidy directly against your monthly premium, or to take it as a tax credit. So if, for example, you are eligible for a $250 subsidy, you may choose to pay $250 less per month on your premium, or you may choose to apply a $3000 tax credit to your tax return at the end of the year.



***IMPORTANT***

What happens if my income changes in the middle of the year?

If your income rises in the middle of the year, you become ineligible for your subsidy. If you neglect to adjust your income online and continue to receive the subsidy throughout the year, you will have to pay the difference at the year's end, come tax time. This becomes a particular problem for you if you are self-employed; if your income rises midyear, you may be left with a substantial debt at year's end. The flip-side is also true: If your income fell during the year, you will be able to claim the tax credits for a subsidy that you were eligible for, but never used.



APPLICATION PROCESS

Can I apply for insurance on the exchange on my own?

You may apply for insurance on the exchange on your own, at www.nystateofhealth.ny.gov.

What documents will I need for my application?

You do not need any documentation for the initial application. Once the application is submitted, they may request documentation to be scanned and uploaded. All of your information, with or without documentation, will be cross-referenced amongst several different agencies (i.e. the IRS, Experian, etc.) for accuracy.

How can Achiezer help me with the application process?

Achiezer can help you assess the options and decide on the best one for your particular situation. We may also have more savvy in terms of assessing your eligibility for various programs than you may have on your own.



Achiezer will be presenting 2 public informative sessions explaining the details, specifics and vital updates about the new exchange and regulations. One session will be held in the Far Rockaway/Bayswater area for Queens residents and a second session will be held in the Cedarhurst/Woodmere area for Nassau residents. Specific details will be announced in the coming days. For more information regarding the forum, contact healthinsurance@achiezer.org. For general health insurance questions and appointments, call 516-791-4444 extension 3.

 

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