November 6, 2014 – By Alisa Allen, RHU, REBC, Insurance Advisor, Wisconsin Medical Society Insurance and Financial Services
The Affordable Care Act (ACA) will continue to have a significant impact on health insurance in 2015. Individuals who are losing group coverage or are currently enrolled in an individual health plan may be eligible for a 2015 Marketplace health insurance plan. The 2015 rates for plans sold on the Marketplace (also known as the Exchange) are expected to be released by mid-November.
The ACA requires most individuals (U.S. citizens and legal residents) younger than age 65 to carry minimum essential coverage for themselves and their dependents or pay penalties. Minimum essential benefits include items and services within at least the following 10 categories:
- Preventive and wellness services and chronic disease management
- Ambulatory outpatient services
- Emergency care
- Maternity and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitation and habilitation services and devices
- Laboratory services
- Pediatric services, including oral and vision care
Insurance policies must cover these essential benefits in order to be certified and offered in the Health Insurance Marketplace. All Marketplace insurance plans fall into five coverage categories:
- Platinum–90 percent of medical expenses paid by insurer/10 percent insured
- Gold–80 percent of medical expenses paid by insurer/20 percent insured
- Silver–70 percent of medical expenses paid by insurer/30 percent insured
- Bronze-60 percent of medical expenses paid by insurer/40 percent insured
- Catastrophic–high out-of-pocket plan for people under age 30, or people over age 30 who qualify for a hardship exemption
When can individuals enroll? The 2015 ACA annual enrollment period is Nov. 15, 2014 to Feb. 15, 2015. Individuals currently enrolled in a Marketplace plan may make changes to their coverage at this time. Please note, there are submission deadlines for the applications in order to receive requested effective dates. Be sure to check with the insurance carrier to determine cut-off dates.
Individuals may also qualify for a Special Enrollment outside of the annual enrollment period if they experience certain events. A special event would include changes in income, divorce, marriage, or losing coverage under a current insurance plan due to loss of employment or eligibility. Please note, cancellation due to nonpayment of premiums does not qualify as a special event.
The 2015 Annual Penalty for not complying with the minimum insurance requirements of ACA is $325 per adult and $162.50 per child. There are exemptions for people on Medicare, individuals that receive hardship waivers from the federal government or people that experience an insurance gap of less than three months. Individuals and families with lower household incomes may qualify for federal cost-sharing and/or federal premium subsidies.
Contact the insurance experts at Wisconsin Medical Society Insurance & Financial Services at firstname.lastname@example.org, or call 866.442.3810 for more information on ACA.
This article is for informational purposes only, does not constitute legal advice and is subject to change.
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