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Congresswoman Robin Kelly

Representing the 2nd District of Illinois

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ACA Frequently Asked Questions

Frequently Asked Questions

 
 
 
1. What are the new marketplaces that start in January?
 
The Illinois Health Insurance Marketplace will allow individuals, families and small businesses to shop, compare quality, and purchase comprehensive health insurance coverage at group rates. Each health plan sold on the Marketplace will cover a minimum set of core benefits including doctor visits, hospital visits, and prescription drugs. While the plans will cover the same minimum set of benefits, they will differ in the percentage of costs they (and you) pay. There will be four tiers of insurance plans available: bronze plans will cover 60% of the costs, silver 70%, gold 80% and platinum 90%.
 
Individuals and families with incomes between 100% and 400% of the federal poverty line who purchase coverage in the Illinois Health Insurance Marketplace will be eligible for premium tax credits that will be paid directly to your insurer each month. The Congressional Budget Office (CBO) estimates that the average tax credit will be more than $5,000 a year in 2014. Individuals and families with incomes between 100% and 250% of the federal poverty line will also be eligible for assistance in paying for deductibles, copayments, and coinsurance.
 
For more information, see What Financial Assistance is Available.
 
2. Do I have to buy coverage through the new Illinois Marketplace?
 
No, the Affordable Care Act requires that most individuals have health insurance, but you meet that individual responsibility requirement if you have qualifying health insurance through your job and your employer will let you know that. If you are covered through Medicare, Medicaid, TRICARE or the VA, you automatically meet the requirement and do not have to enroll in the Marketplace.
 
3. If I need insurance, how do I enroll?
 
Between October 1, 2013 and March 31, 2014, you can purchase a private health insurance plan through the Illinois Health Insurance Marketplace that will begin to cover you and your family as early as January 1, 2014. You can enroll online, by phone, by mail, or in person.
 
There will also be tools available to help you enroll, including a toll-free call center, a website with plan comparison tools, and in-person assistors. There will be a number of places where you can get independent counseling and help to make the choice that is right to you. If you have questions about where to go for help, please contact my office.
 
4. What should I look at in choosing a plan?
 
You will need to review each plan to determine which plan meets the needs of you and your family based on your individual health care needs. As you shop for a plan, you should consider the following:
Premium levels.
Out-of-pocket costs, including deductibles, copayments and coinsurance. If you have significant health care needs, you may get better value paying a higher premium if your out-of-pocket costs are lower. In general, the lower the premium, the higher your out-of-pocket costs will be.
The number and types of providers within the plan's network. If you have a regular doctor or want to go to a specific hospital, clinic or pharmacy, you should look to see whether they are in the network.
What coverage options are available to you outside of a plan's network providers – some plans could require you to pay more or pay the entire costs for services received from out-of-network providers.
Whether the plan requires you to meet special criteria for certain services, such as getting prior approval before you can receive certain services and prescription medications or whether you need a referral to obtain certain health care services. You should determine whether a plan does not cover services that you or your family needs.
 
There will be a number of tools to help you compare plans, including interactive website tools and in-person assistors. The Affordable Care Act also requires every plan to provide a Summary of Benefits and Coverage (SBC) – an easy-to-understand summary that allows for you to make "apples to apples" comparisons between multiple plans. The SBC also includes two coverage examples that allow you to see the average you will pay under each plan for two common health conditions: diabetes care and childbirth.
 
5. I've been turned down by insurance companies because I have a chronic illness. Will that happen again?
 
No. Starting January 1, 2014, the Affordable Care Act prohibits insurers from denying you coverage, charging you higher premiums or setting annual or lifetime limits on your benefits because you have a chronic illness or other preexisting condition.
 
6. What happens if I don't enroll in any insurance coverage?
 
Starting in 2014, if you don't have insurance coverage and you do not qualify for an exemption, you will have to pay a shared responsibility payment. You don't have to purchase coverage through the new Marketplace – you can buy a private insurance offered outside the Marketplace or get coverage through your employer, Medicare, Medicaid, Children's Health Insurance Program (CHIP), TRICARE, VA, or Peace Corps Volunteer plans.
 
You may qualify for an exemption if, for example, coverage is unaffordable (premiums cost more than 8.0% of your income), you don't file an income tax return because your income is too low, you experience a short coverage gap of less than three consecutive months, you are a member of certain religious groups, or you are a member of a federal recognized Indian tribe. In 2014, the penalty is the higher of 1% of your yearly income or $95 per adult family member and $47.50 per child. In 2014, the maximum family penalty is $285.
 
Without this requirement, people could wait until they get sick to buy health insurance – and that would drive up the cost of premiums for everyone. It's estimated that the average family health insurance premium includes over $1,000 to pay for the cost of the uninsured.
 
7. I already have insurance through my job. How does Obamacare affect me?
 
As long as your insurance meets the Affordable Care Act’s minimum coverage requirements, you will not have to do anything and you will not have to pay a shared responsibility payment. You will benefit, though, because the Affordable Care Act requires that at least 80% of your premium dollars are spent on health care, guarantees that your young adult children up to age 26 can stay on your health care, prevents your plan from applying lifetime coverage limits on benefits and requires almost all plans to cover preventive services without cost sharing requirements. The Affordable Care Act ends "joblock" – the situation where you have to stay in your job because you'd lose your health coverage if you left. Starting in 2014, if you want to change jobs or start a business, you will be able to get health coverage with no pre-existing condition exclusions or coverage limits.
 
8. I have purchased insurance for my family. How does Obamacare affect me?
 
If you bought health insurance that meets the Affordable Care Act’s minimum coverage requirements, you do not have to do anything and you will not have to pay a shared responsibility payment. Now, however, you will have additional options through the Illinois Marketplace, where you might find a plan that better meets your health care needs. In either event, you will benefit from new protections: the requirement that health insurers spend at least 80% of your premium dollars on health care, the ability to keep your young adult children up to age 26 on your health plan, the elimination of lifetime coverage limits and preventive services without cost-sharing requirements.
 
Beginning in January, 2014, insurers cannot apply annual coverage limits on benefits or charge you more for preexisting conditions. There will be maximum limits on out-of-pocket costs which include deductibles, copayments, and coinsurance.
 
9. I have Medicare, will I lose benefits because of the Affordable Care Act?
 
No. The Affordable Care Act did not cut any guaranteed benefits from Medicare. The Affordable Care Act actually increased Medicare benefits, including coverage for preventive services like cancer screenings and flu vaccinations without cost sharing and a new free Annual Wellness Exam. In 2012, over 24 million seniors received at least one preventive service. The Affordable Care Act has begun to close the Medicare Part D prescription drug coverage gap, or "donut hole," which will be completely closed by 2020. From The Affordable Care Act, more than 6.6 million people with Medicare have saved more than $7 billion on prescription drug when they fell into the "donut hole."  The Affordable Care Act extended the life of the Medicare Trust Fund by 8 years. The Affordable Care Act also provides Medicare with new tools and resources to combat waste, fraud, and abuse.
 
10. Is there some panel that will decide whether I can get health care based on my age or other reasons?
 
No. There is no panel that decides whether you get health care based on your age, health status, or any other reason.
 
11. My premiums have gone up, and I've heard that The Affordable Care Act is the reason. Is that true?
 
No. The Affordable Care Act’s major coverage provisions, such as the prohibition against insurers denying coverage or charging higher premiums due to pre-existing conditions, do not even go into effect until 2014. It is important to note that in the decade prior to the passage of The Affordable Care Act, health insurance premiums increased 125% and out-of-pocket health care spending increased by 74%. The Affordable Care Act includes several provisions that are helping to contain the rate of growth of health insurance premiums including a requirement that insurers publicly justify premium increases of greater than 10% and a requirement that insurers spend at least 80% of premium dollars on health care – not administrative costs, marketing and profits. Since the passage of The Affordable Care Act, consumers have saved approximately $5 billion in rebates because of those provisions.
 
12. Will my employer drop coverage?
 
The nonpartisan Congressional Budget Office (CBO) estimates that the number of Americans who receive coverage from their employer is estimated to increase, growing from 158 million in 2013 to 162 million in 2023. Only a small number of Americans are expected to transfer out of employer-sponsored coverage, at least some will leave to start their own businesses since they will no longer experience "job lock."
 
Employers have been dropping coverage for decades – in the decade before The Affordable Care Act was enacted the percentage of workers covered on the jobs fell by 10.9% -- the equivalent of 29 million workers and their families. The Affordable Care Act may actually help reverse that trend by making coverage more affordable. During the first 7 years of the Massachusetts health plan – which is very similar to the Affordable Care Act – employer-sponsored coverage grew by 1%, while nationally it declined by 5.7%.
 
Beginning in 2014, the Illinois Health Insurance Marketplace will provide small businesses with fewer than 50 employees with access to affordable, quality health insurance options that use to only be available to large employers. Small business with less than 25 employees with average wages of less than $50,000 can qualify for small business tax credits to help them offer coverage to their employees. While those businesses aren't required to buy coverage and face no penalties if they don't, this will provide small business owners who want to offer insurance with more affordable options to do so.
 
And, unlike in the past, losing your job won't mean that you lose coverage because you will have the option of buying coverage in the new Illinois Marketplace and most likely get premium assistance when you do.
 
13. Will my employer cut my hours?
 
In an attempt to avoid their responsibility to their employees, some businesses have decreased employee hours – but they have been doing so long before the Affordable Care Act was passed. There is little evidence that the Affordable Care Act’s employer responsibility requirement will have a large effect. According to a recent survey by HR consulting firm Towers Watson, 98% of firms indicated that they were not planning to reduce employee hours to avoid the employer responsibility requirement. JP Morgan has found that 99% of large employers won't drop coverage and it's a 'non-issue.' A recent study by the Center for Economic and Policy Research concluded that the number of employees working just below the 30 hour cutoff,
or between 26 and 29 hours per week, is actually lower in 2013 than in 2012.
 
14. I'm a small business person, how does the Affordable Care Act affect me?
 
Employers with fewer than 50 employees – 94% of all companies -- will have no responsibility to provide health insurance coverage to their employees and you will not face a penalty if you don't. But, if you want to provide coverage for your family and your employees, the Affordable Care Act provides new options that can lower your costs.
 
Beginning in 2014, employers with less than 50 full-time employees will be able to shop and purchase affordable, comprehensive health insurance coverage for their employees through the Illinois Health Insurance Marketplace. The Marketplace will allow small businesses to pool their risk and purchase affordable plans that were previously reserved for only large employers. Those plans will be unable to deny you coverage or charge you more because you have employees who become sick or have preexisting conditions. The insurer must spend at least 80% of premium dollars on health care or quality improvement -- not marketing or CEO bonuses. Insurers that do not meet this requirement must offer rebates or decrease your premiums the following year. In 2012, this requirement saved small businesses approximately $1.6 billion in premiums.
 
Under the Affordable Care Act, employers with fewer than 25 employees and average wages of less than $50,000 qualify for a tax credit to help them offer coverage to their employees. Currently the tax credit is worth up to 35% of the cost of your business's premiums. In January, the value will increase to up to 50%.
 
15. I'm a small business person. Is it true that I won't be able to gain coverage through the new Marketplace until 2015?
 
The Illinois Health Insurance Marketplace Small Business Health Options Program (SHOP) will allow you to purchase coverage for you and your employees in 2014 – and you will be able to buy insurance then (or at the end of your plan year if you are currently providing insurance). Beginning on October 1, you will be able to compare plans and select one plan that can cover you and your employees beginning as early as January 1, 2014.  Beginning January 1, 2015, employers will be able to allow their employees to select the Marketplace health plan of their choosing.
 
16. I've heard the Affordable Care Act doesn't do anything to lower costs, is that true?
 
No. The Affordable Care Act contains many provisions that will lower costs. the Affordable Care Act’s medical loss ratio (MLR) requires insurers to spend at least 80 percent of your hard-earned premium dollars on health care – and not profits, CEO pay, or marketing. The Affordable Care Act also requires insurers to publicly justify rate increases of 10% or greater. Since the passage of the Affordable Care Act, consumers have saved $5 billion on their premiums either in upfront reductions or through rebates.
 
The Affordable Care Act includes other reforms to lower costs, such as requiring uniform insurance forms, using health information technology to avoid duplicative tests, promoting prevention and wellness services to reduce preventable diseases and injuries, and paying for value.
 
The Affordable Care Act has begun to close the Medicare Part D coverage gap, also known as the 'donut hole.' More than 6.6 million people with Medicare have saved more than $7 billion on prescription drug when they fell into the "donut hole."
 
The Affordable Care Act also created new delivery system reforms that are helping to ensure that we promote quality care over quantity of care. The creation of new models of care including Accountable Care Organizations (ACOs) is helping to transform the way we deliver care. ACOs allow physicians and other health providers to work together to coordinate care for Medicare beneficiaries and provide them with the tools they need to manage their health – while helping to eliminate unnecessary and duplicative services that increase costs to patients and Medicare.
 
In the most recent three years of data available, 2009 through 2011, U.S. health care spending grew at a rate of 3.9%, the lowest rate of growth in the last 50 years. Experts have attributed structural changes that have resulted from the Affordable Care Act as a contributing factor to this decrease in the rate of growth.
 
17. Does the Affordable Care Act add to the federal deficit?
 
No. The most recent estimate by the nonpartisan Congressional Budget Office found that the Affordable Care Act reduces the deficit by $109 billion over the next 10 years and over $1 trillion over the following decade.
 
18. I'm a healthy 23-year old, will I have to pay more under the Affordable Care Act?
 
While 60% of young adults receive health insurance when they are offered it on the job, many cannot find affordable health care. The Affordable Care Act includes several options to make your health insurance more affordable. The Affordable Care Act allows you to stay on your parents' plan until your 26th birthday – and many Illinois residents have already taken advantage of that right. You will have new options through the Illinois Marketplace to buy coverage, and you will also be able to purchase catastrophic (high-deductible) coverage that covers preventive services and three primary care visits at no charge until your 30th birthday. The new law allows individuals with incomes below 138% to be covered through Medicaid. If you meet certain income requirements, the Affordable Care Act allows you to receive subsides to help you purchase coverage and pay out of pocket expenses.  For more informational see What Financial Assistance is Available?
 
Many young adults will experience lower premiums for their health insurance coverage because of the Affordable Care Act. Healthy young adult women are expected to see their premiums decrease under the Affordable Care Act, since insurance companies will no longer be able to charge women more than men. According to the National Women's Law Center, that practice of gender-rating costs women $1 billion a year. Young adults with preexisting conditions are also expected to experience lower premiums since, beginning in 2014, insurers will no longer be able to charge higher premiums based on preexisting conditions.
 
According to Census Bureau Data, it's estimated that about 3% of young adults may face higher premiums, but note they will be buying much better coverage, getting much more value for their premium dollars and receiving premium assistance through the Illinois Marketplace when eligible.
 
19. I'm a veteran. Can I stay with my VA coverage?
 
Yes. The Affordable Care Act does not affect your ability to remain in VA coverage. Your insurance meets the Affordable Care Act’s coverage requirement so you will not have to pay a shared responsibility penalty.
 
20. Our family is in TRICARE? Can we stay with it?
 
Yes. The Affordable Care Act does not affect your ability to remain in TRICARE. Your insurance meets the Affordable Care Act coverage requirement so you will not have to pay a shared responsibility penalty.
 
21. Will we have enough doctors and nurses?
 
The Affordable Care Act contains many provisions to increase the supply of health care providers available to meet the health needs for all Americans. The new health law includes funding to train doctors, nurses and other health care professionals with a focus on primary care providers. The Affordable Care Act expands physician and nursing workforce development programs, increases training opportunities, and provides more scholarships and loans to make medical education more affordable.
 
22. Why are we expanding Medicaid at a time when the state budget deficits are so high?
 
Illinois will actually save money through Medicaid expansion. Under the Affordable Care Act, the federal government will cover 100% of the care provided to the Medicaid expansion population for the first three years, 2014 through 2016. The federal government's contribution will gradually phase down to 90% in 2020 and beyond. A report by Families USA found that Illinois will receive an additional $1.7 billion in federal Medicaid funds in 2016 as the result of the Affordable Care Act. The report concluded this additional federal revenue would support approximately 19,800 new jobs across all sectors in Illinois and increase economic activity in Illinois by $2.6 billion in 2016. A study by the Kaiser Family Foundation estimates that Illinois could save $953 million in savings in uncompensated care between 2013 and 2022.
 
23. What happens if I have a gap in coverage during the year?
 
You will not have to pay the individual responsibility penalty for not maintaining coverage if your coverage gap is less than 3 consecutive months or you qualify for one of the Affordable Care Act’s other exemptions. (See question #5)
 
24. What if I can't afford any coverage options available through the Exchange?
 
The Affordable Care Act is designed to make health care more affordable by providing premium assistance to help you purchase insurance through the Illinois Marketplace and, for those with incomes below 138% of the federal poverty level, allow coverage through Medicaid. However, if you remain uninsured and the cost of purchasing insurance is more than 8% of your income, you will not have to pay the individual responsibility penalty for not having health insurance. Additionally, you will have the option of purchasing a catastrophic insurance (high deductible) plan that covers preventive services and three primary care visits at no charge.
 
25. I am a small employer and my plan year falls outside of the annual open enrollment period. How can I enroll in the new Marketplace?
 
The Illinois Health Insurance Marketplace will offer rolling enrollment for small businesses. An employer with less than 50 employees may purchase coverage at any point during the year. The plan year would be the 12-month period beginning on the effective date of coverage.
 
26. I am a health care provider, how does the Affordable Care Act improve my ability to serve patients?
 
The Affordable Care Act helps your patients receive the health care services that you recommend and guarantees that 80 percent of premium dollars goes to medical care – not administrative costs or marketing. The Affordable Care Act will help millions of Americans obtain coverage so that they can afford to access medically necessary services. It promotes prevention by providing access to certain preventive health services without cost sharing. The law will also help patients receive care in medically appropriate settings rather than rely on emergency departments for their health care needs. In addition, the Affordable Care Act requires that insurance companies use the same forms – making it easier for providers to file claims and appeals. Finally, the Affordable Care Act provides new, more affordable options to buy health insurance policies for you and your employees.
 
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Robin Kelly

 

 

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