Upgrade to Pro — share decks privately, control downloads, hide ads and more …

Understanding the ACA for 2023

Robin Lee
September 11, 2023

Understanding the ACA for 2023

A breif overview of the ACA for 2023

Robin Lee

September 11, 2023

More Decks by Robin Lee

Other Decks in Business


  1. The Affordable Care Act Understanding it and enrolling in your

    new health care plan RLee Insurance Solutions LLC
  2. How does the ACA improve my health care? • Provides

    health insurance to those that were once considered ‘uninsurable’ with pre- exiting health conditions. • Provides for certain protections and rights to make your coverage fairer and easier to understand. • 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 insurance. • 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)
  3. 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) • Emergency services • 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 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
  4. OK so how do I start ? First thing you

    need to figure out if you qualify for a federal subsidy… • If your income is between 138% - 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 website Healthcare.gov or go enroll through a third-party site that has a broker link to the federal site. In some case if the mid-level silver plans in your area are below certain guidelines, (2.03%-9.66%) of the applicant's wages, it could affect their ability to qualify for a subsidy. • If your income is above 138% - 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 or a broker linked site to enroll. Plans that are “off exchange” may be purchased through various web sites. • Lastly if your income is below 138% 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.
  5. Just what is a subsidy? The ‘subsidy’ or Advance Premium

    Tax Credit (APTC) is actually an advance on next years tax return based on your ‘projected’ income for this year. You can choose to use this tax credit in any one of 3 different ways. 1. You can use the entire monthly credit to reduce your out-of-pocket expense for you monthly health premium. 2. You could use only a portion of your credit and pay more out of pocket for your health premiums each month, you would then get the remainder at the end of the year with a high tax return, this is a good option if you are unsure of the coming year’s income. 3. You could choose to not use your monthly tax credit at all and receive the entire amount at the end of the year on your tax return. *Keep in mind if you misjudge your income for the year, you could be a position where you would owe part of your APTC back to the government. Always report any change in income levels as soon as possible the Federally Facilitated Marketplace at 1-800-318-2596, they can adjust your monthly APTC to the appropriate amount for you.
  6. How to calculate my subsidy? • First determine how many

    in your family/household. • Second calculate your modified adjusted gross income(MAGI). • Third use a subsidy calculator to enter these numbers and find your subsidy. **IMPORTANT** It's important to remember that qualifying incomes levels are linked to the price of silver plans in YOUR area. If more affordable silver plans are available the amount you can make and still get a subsidy will be reduced. Family size 100% 138% 250% 400% 1 $13,590 $18,347 $33,975 $54,360 2 $18,310 $25,268 $45,775 $73,240 3 $23,030 $31,781 $57,575 $92,120 4 $27,750 $38,295 $69,375 $111,000 5 $32,470 $44,809 $81,175 $129,880 6 $37,190 $51,322 $92,975 $148,760 7 $41,910 $57,836 $104,775 $167,640 8 $46,630 $64,349 $116,575 $186,520 2022 Federal Poverty Levels based on number in household
  7. Where do I find my MAGI?... Basically, this is the

    income you make before all of your deductions, and adding back a few that you have taken, like interest from student loans and IRA contributions.
  8. Insurance Terms you need to know… Deductible: The amount you

    pay for covered health care services before your insurance plan starts to pay. With a $5,000 deductible, for example, you pay the first $5,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment. Copay: The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. Let's say your health insurance plan's allowed amount for and office visit is $100. If you’ve paid your deducible, then you would only pay $20 (20%) for the office visit. Max-out-of-pocket: The most you have you pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in network care and services, your health plan pays 100% of the cost of covered benefits.
  9. What are Federal Cost-Sharing Subsidies? Individuals with a household income

    of 138-250 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 2022 federal poverty guidelines, the annual income thresholds to qualify are: $18,754 for individuals; $25,268 for couples; $31,781 for a family of three; and $38,295 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 or co-insurance, and maximum out of pocket expenses. The amount of the reduction depends on the insured’s household income. For those with incomes between 138% 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.
  10. My spouse is offered health insurance at work, but it

    is unaffordable for the whole family. Do we qualify? This scenario is referred to as the “Family Glitch”. Employers often cover at least 50% of the health premium for the employee, but not the spouse or whole family. This can leave insurance premiums outside the reach of many of their employee’s families. • Starting November 1st, 2022, the HHS issued new guidance for applying the affordability rule to families. If the cost of the employer offered plan exceeds 9.12% of the employee's gross income the employee can applying for a subsidy on the healthcare exchange. • If the employer plan is within the 9.12% for the employee, the employee would not qualify for a subsidy, BUT if the cost for a spouse and/or family plan exceeds 9.12% of the HOUSHOLD income the spouse and family WOULD qualify for a federal subsidy and buy a plan from the Marketplace. • If the employer offers more than one plan, the least expensive plan would be the one used in testing for affordability.
  11. But which plan? The new plans will be labeled with

    “metallic” names, bronze, silver, gold, and platinum. There is also one more plan labeled “expanded bronze”. • Each plan will 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.
  12. The Plans… Bronze Plans 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. • Plans often have high deductibles. • Co-pay is at the 60/40 level Expanded Bronze Plans While a traditional bronze insurance plan will only provide coverage after the deductible has been met, expanded bronze plans are required to cover at least one major service before the deductible is met. • These plans most offer at least one major non-preventative service before the deductible is applied. • Still has a high deductible.
  13. The Plans… Silver Plans The Silver Plans have lower out-of-pocket

    costs than the Bronze Plans but higher out- of- pocket 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 significantly. • Subsidies in your state are based on Silver plans in your state. • Co-pay is at the 70/30 level Gold Plans 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. One of the issues that the government intends to monitor is whether Gold and Platinum plans attract more sickly enrollees and drive up premiums. • These plans have the second lowest out-of- pockets of the metallic plans. • Co-pay is at the 80/20 level
  14. The Plans… Platinum Plans 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 standard population. • Co-pay is at the 90/10 level Platinum Gold Silver Expanded Bronze Bronze Most Expensive Least Expensive Most Coverage Least Coverage
  15. 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 34 Executive Dr. Suite C Lafayette, IN 47905 Phone: 765-746-6459 Web: https://rleeinsurancesolutions.com Email: [email protected] Our office Location