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HEALTH CARE REFORM OVERVIEW

Q 1: When will the ACA take effect?
Different parts of the law have different effective dates. Some pieces are already in place.  Most reforms will start January 1, 2014. All reforms are expected to be implemented by 2020.

Q 2: What changes are already in place?

  • Lifetime dollar limits on essential health benefits aren’t allowed. Annual dollar limits on essential health benefits are being phased out by January 1, 2014.
  • The process for consumers to appeal decisions made by their health insurers is different.
  • Insurers can’t deny benefits to children younger than 19 years old related to a preexisting condition.
  • Nearly all children up to age 26 are eligible to remain on a parent’s health insurance policy, regardless of the child’s marital status, financial dependency, enrollment in school, or place of residence.
  • There can be no cost-sharing for preventive services (see Question 24) if these services are provided by in-network providers.
  • Consumers have more access to information about proposed rate changes.
  • All health insurers must use a standardized Summary of Benefits and Coverage (SBC) to make it easier to compare plans.
  • Small businesses that provide health care for employees can apply for a tax credit
  • Persons with Medicare prescription drug coverage receive a rebate to help cover the cost of the “donut hole.” This “donut hole” should be totally phased out by 2020.
  • ACA made subsidized coverage available in every state for people with preexisting conditions who can’t find coverage in the private market. However, because there’s not enough money, no new enrollments in this program are being accepted and coverage will end on December 31, 2013.

Q 3: What changes will take effect on January 1, 2014?

  • Plans must include new consumer protections. Health insurers can no longer exclude or limit benefits related to a preexisting medical condition. Health insurers also can’t put annual dollar limits on essential health benefits.
  • Insurers must cover routine medical costs if a person participates in a clinical trial for cancer or other life-threatening diseases.
  • Individuals who can afford it must have basic health insurance coverage, referred to in the ACA as “minimum essential coverage.”
  • Health insurance marketplaces (also known as “exchanges”) will begin enrolling individuals and small businesses on October 1, 2013, for coverage that will take effect on January 1, 2014.
  • Individuals and families who need help affording coverage will have access to financial assistance when they shop in the new health insurance marketplaces.

Q 4: What is a “grandfathered” health plan?

A grandfathered health plan is a plan that has existed continuously — without significant changes — since before March 23, 2010. Grandfathered plans aren’t subject to many of the ACA requirements.

Grandfathered plans that make certain changes, such as major increases in their cost-sharing (such as coinsurance, deductibles, copayments) or eliminating benefits to diagnose or treat a particular condition may lose grandfathered status and then would have to follow the ACA. Employer-sponsored plans that raise the employee share of the premium also could lose grandfathered status.

A plan must provide notice to enrollees if they have a grandfathered plan. Also, consumers can check with their insurance company or employer.

Q 5: Where can a person find more information about the ACA?

Feel free to call the Bureau of Insurance at 1-800-300-5000 (in-state) between 8 am and 5 pm.

For more general or detailed information about the ACA and its key provisions, visit the federal government’s website at www.healthcare.gov  or call 1-800-318-2596 (TTY: 1-855-889-4325).

 

MARKETPLACE BASICS

Q 6: What is the Maine Health Insurance Marketplace?

Maine’s Health Insurance Marketplace is the ACA-created place where individuals, families, and small employers can compare health insurance plans and shop for coverage. Marketplaces also provide access to tax credits to help lower- and middle-income individuals pay for coverage. Through marketplaces, lower-income individuals can get help to lower their out-of-pocket costs (deductibles, coinsurance, or copayments). Insurers may sell plans through the marketplace and in the market outside the marketplace. This assistance to reduce premiums and cost-sharing will not be not available for plans outside the marketplace.

To learn more, or to apply for coverage through Maine’s Health Insurance Marketplace, individuals and families should visit www.healthcare.gov

Q 7: Are there different types of health insurance marketplaces?

While the basic features of marketplaces are the same in all of the states, the ACA allows for differences in who operates them. Some states run their own marketplace (known as state-based marketplaces), some have the federal government run it (known as federally facilitated marketplaces), and some have the federal government run it but handle some regulatory or consumer assistance functions themselves (known as partnership marketplaces). Maine’s Health Insurance Marketplace is a federally facilitated marketplace.

Q 8: Who can buy a plan through Maine’s Health Insurance Marketplace?

Any individual or family who wants to may buy coverage through Maine’s Health Insurance Marketplace. The only people who can’t are those who aren’t legally in the United States or who are currently serving jail or prison sentences.

Small employers (employers with 50 or fewer employees) may also buy health insurance for their employees through Maine’s Health Insurance Marketplace. 

Q 9: What is a CO-OP plan?

CO-OP stands for Consumer Operated and Oriented Plan. The ACA gave low-interest loans to private organizations to create this new type of non-profit insurer. Any profits earned by CO-OPs must be applied to either lower premiums or expand benefits for customers. The federal Center for Insurance Information and Insurance Oversight (CCIIO) in the U.S. Department of Health and Human Services (HHS) oversees the CO-OPs. CO-OPs also must be governed by their members (customers) and must offer plans through their respective states’ marketplaces.

Maine Community Health Options is the CO-OP available through Maine’s Health Insurance Marketplace. For more information:  www.cms.gov/CCIIO/Programs-and-Initiatives/Insurance- Programs/Consumer-Operated-and-Oriented-Plan-Program.html.

Q 10: What is the Multi-State Plan Program?

The new Multi-State Plan Program (MSPP) is administered by the U.S. Office of Personnel Management (OPM). The MSPP is designed to increase the plan choices available.  Anthem may have MSPs available through Maine’s Health Insurance Marketplace. OPM, which also administers the program that provides health insurance to federal government employees, retirees, and their dependents, will check on the MSPs’ market performance and make sure they follow the law and other requirements. FOR MORE INFORMATION:  www.opm.gov/healthcare-insurance/multi-state-plan-program.

Q 11: When will consumers be able to enroll in plans through Maine’s Health Insurance Marketplace?

Individuals and families could start enroll October1, 2013, and will be able to enroll through March 31, 2014.

Coverage becomes effective on January 1, 2014, for people who sign up between October1 and December 15, 2013. For people who sign up between December 16, 2013 and January 15, 2014, coverage will be effective on February 1, 2014. After that, coverage will be effective on either the first day of the following month—if a consumer enrolls by the 15th of the month—or the first day of the second following month, if a consumer enrolls after the 15th of the month.

In future years, open enrollment will be between October15 and December 7 each year. During this time, consumers will be able to change plans, change insurance companies or stay with the plan they have, if it’s still available.

Consumers also may be eligible to enroll at times other than during the open enrollment period if they experience a “triggering event,” such as: (1) loss of minimum essential coverage for an individual or their dependent; (2) gaining or becoming a dependent; (3) newly gaining citizenship; and (4) being enrolled in a plan through the marketplace without tax credits and then becoming newly eligible for tax credits. Maine’s Health Insurance Marketplace will process the application and tell the consumer whether or not they can enroll. Contact Maine’s Health Insurance Marketplace at [insert website] or [insert phone number] for information about whether a consumer might be eligible to enroll in coverage during a special enrollment period.

People who are eligible for Medicaid can apply and enroll in MaineCare at any time.

Q 12: If a person lives in one state but works in another, which state’s marketplace should they apply to?

If a consumer doesn’t have access to coverage through their employer (or their spouse’s employer), they should apply for coverage in the state where they live.

Q 13: How can a consumer prepare to enroll?

The federal website www.healthcare.gov/how-can-i-get-ready-to-enroll-in-the-marketplace has suggestions for things consumers should be thinking about to prepare to enroll in a plan.

Consumers who don’t currently have health insurance should find out now if help might be available now through existing programs or because of changes already in effect from the ACA. For example, a parent’s plan may cover young adults under age 26. The federal website  www.healthcare.gov/what-if-i-need-coverage-that-starts-before-january-2014 has tips to find coverage. Consumers also can contact an insurance agent or broker for help.

Consumers also can check with their employers to find out whether they intend to offer health insurance in the future or whether the coverage they currently offer meets the minimum level to meet the law’s requirement and avoid paying a penalty. Insurance companies must tell policyholders if their plan doesn’t meet the ACA requirements.

Finally, consumers can start gathering basic information about household income, such as their 2012 tax return if they filed one, or other income information. Many people will qualify for financial help to make insurance affordable, and consumers will need income information to find out how much help they are eligible for. Consumers can find more information about how to save money on coverage at  www.healthcare.gov/how-can-i-save-money-on-marketplace-coverage.

For updated information, visit the federal government’s website at  www.healthcare.gov or call 1-800-318-2596 (TTY: 1-855-889-4325).

 

Last Updated: October 8, 2013