As full implementation of the Patient Protection and Affordable Care Act (known more generally as health care reform) draws near, we know that our members and Kansas consumers will seek more information about what this law means for them and their families. We hope that the information in this section helps you with your research.
The centerpiece of the Affordable Care Act is the creation of online health insurance exchanges, which are now also called marketplaces, where individuals and families who are shopping for their own insurance can compare benefit plans, side-by-side, from a number of different insurance companies or issuers. Consumers will be able to compare price, benefits, quality and other features that are important to them. For consumers that would like assistance with the shopping process, there will be “navigators” to help them through the process.
To make shopping easier, all issuers must offer the same set of comprehensive benefits – including coverage for doctor’s visits, hospital stays and medication – and consumers will be able to choose from plans that offer different levels of out-of-pocket costs (deductibles, copays and coinsurance) so they can find one to best suit their personal needs.
In addition, individuals and families who meet certain income requirements might qualify for a subsidy to help them purchase coverage through the marketplace. Or, depending on their income level, individuals and families might be directed toward KanCare, the state’s Medicaid program, for their coverage.
These exchanges or marketplaces will open in October 2013 so individuals and families may purchase coverage that would begin Jan. 1, 2014.
In Kansas, consumers will see a marketplace run by the federal government. However, the marketplace will offer benefit plans from many of the issuers that Kansans are used to comparing, including Blue Cross and Blue Shield of Kansas.
Individuals and families who meet certain income requirements will be eligible to receive tax credits – sometimes referred to as subsidies – to help them purchase health insurance. Rather than having to wait to file your taxes – as is the case with most tax credits – these tax credits for health insurance will be available immediately to help individuals and families lower their monthly health plan premium.
These tax credits will be available for U.S. citizens and legal immigrants with incomes up to 400 percent of the federal poverty level who are not eligible for other public programs such as Medicaid, Children’s Health Insurance Program (CHIP), Medicare or military coverage. In addition, one must not have access to health insurance through his or her employer in order to receive a tax credit. However, there are exceptions to this if the coverage offered by the employer does not cover 60 percent of the required covered benefits or the employee share of the premiums exceeds 9.5 percent of the employee’s income.
The premium tax credits will vary with income and are structured in such a way that an individual or family will not pay more for their health insurance premiums than a certain percentage of their income. The scale ranges from no more than 2 percent for those with incomes of 133 percent of the federal poverty level to 9.5 percent for those with incomes between 300-400 percent of the federal poverty level.
Beginning in 2014, most Kansans will be required by law to have health insurance or pay a tax penalty; this requirement is often referred to as the individual mandate. To meet the requirements, Kansans may have coverage provided through their employer, they may purchase it themselves or they might be covered through KanCare, the state’s Medicaid program. Health insurance issuers will provide documents to people they insure to prove that they have the minimum coverage required by law.
Some Kansans, however, will be exempt from this mandate, such as those who would have to pay more than 8 percent of their income for health insurance; people with incomes below the threshold of filing federal income tax; those who qualify for a religious exemptions; undocumented immigrants; people who are incarcerated; and members of Indian tribes.
The penalty that someone would pay for not having insurance will be the greatest of two amounts: either a specified percentage of income or a specified dollar amount. These specified penalties increase over time. In 2014, a person who chooses not to have insurance would pay the greater of either 1 percent of their income or $95. In 2015, either 2 percent of their income or $325, and, in 2016, either 2.5 percent of their income or $695.
Each benefit plan sold through the marketplace, regardless of which health insurance issuer is offering it, must offer the same minimum set of benefits based on a benchmark plan chosen by the state or federal government.
For most of Kansas, the benchmark plan is the Comprehensive Major Medical plan offered by Blue Cross and Blue Shield of Kansas, with the addition of habilitative services, and pediatric oral and vision care. This means that all plans offered through the marketplace must, at a minimum, offer the same coverage benefits as the Comprehensive Major Medical benchmark plan. A health insurance issuer may choose to offer additional benefits but all plans will provide coverage in these general categories:
All individual plans sold through the marketplace beginning Jan. 1, 2014 will be non-grandfathered health plans, meaning that they are required to include the many preventive services with no cost-sharing that Kansans have heard about since 2010.
No cost-sharing means that these services will be provided without the patient having to pay a copay, deductible or coinsurance as long as the primary purpose of the visit was for the recommended preventive service.
The list of recommended preventive services includes:
For a more complete list of preventive services, please visit https://www.healthcare.gov/what-are-my-preventive-care-benefits.
One of the most popular elements of the Affordable Care Act has been the opportunity for young adults to remain on their parents’ health plan until the age of 26. This benefit offers peace of mind to parents who worry that their children might choose to go without health insurance while continuing their education or beginning their work careers without health benefits.
Since September 2010, adult children have been able to remain on their parents’ plan regardless of whether they are in school, living with the parent, married or otherwise financially dependent on their parents. In most cases, a dependent can remain or re-enroll in a parent’s plan even if he or she is eligible for coverage through his or her employer group, with just one exception: grandfathered health plans do not need to extend coverage to young adults if they are eligible for coverage outside of the parent’s plan.
That will change in 2014 when all health plans are required to allow young adults to stay on a parent’s plan until the age of 26. Blue Cross and Blue Shield of Kansas has been working with employer groups who have grandfathered plans since 2010 to implement this portion of the law earlier than required.
Keeping young, healthy adults insured helps create a better mix of people in the health insurance risk pool, which benefits everyone.
People with pre-existing conditions who have been unable to purchase their own insurance will be able to purchase coverage without concerns for their medical history or health status beginning in 2014.
As of Jan. 1, 2014, all health insurance issuers must sell coverage to anyone who applies, regardless of that person’s medical history or health status. Issuers will not be able to charge higher premiums for these individuals, nor will they be allowed to exclude coverage of those conditions from their benefit plans.
In addition, adult women will no longer pay more than men for health coverage. Health insurance issuers will be able to charge higher premiums for people who use tobacco and also may increase premiums based on a person’s age.