Q: How did the Affordable Care Act change coverage?
A: The changes made by the Affordable Care Act to health insurance differ depending on the type of insurance coverage you have. If you have had individual or small employer group coverage, you will likely have seen more significant changes than if you had health insurance coverage through a large employer (one with more than 50 workers).
Q: What changes have been made to coverage provided by large employers?
A: In 2014, large group coverage became subject to the following new rules: (1) plans may not exclude coverage for pre-existing health conditions; (2) out-of-pocket spending by enrollees cannot exceed $6,850 for individual coverage and $13,700 for family coverage (for 2016); and (3) plans may not impose annual or lifetime limits on the total amount a health plan is required to pay. Most large employers already provided comprehensive coverage, so you may not have seen many changes.
Q: Do employers have to offer coverage to full-time workers?
A: Beginning in 2016, employers with more than 50 full-time workers must offer coverage to at least 95 percent of full-time workers. Some large employers that did not offer employee health insurance are now required to provide coverage or face penalties. Some employers have considered dropping coverage and paying the resulting penalties or keeping employees at part-time status to avoid providing them with coverage. However, most employees are not likely to see significant changes in their health care coverage, although premium rates for health insurance are expected to continue to rise.
Q: What changes did the Affordable Care Act make to small employer coverage?
A: Small employers (with 50 or fewer workers) experienced significant changes to health benefits in 2014. Some requirements include: (1) no pre-existing condition exclusions; (2) coverage of essential health benefits that include coverage in 10 categories such as physician, hospital, prescription drug, mental health, maternity, preventive, wellness and pediatric services; (3) coverage with copays and deductibles that fall into “metal tiers” (bronze, silver, gold and platinum plans); and (4) no annual or lifetime limits. Also, the way insurers determine premium rates has changed. Under the new law, insurers cannot consider the health condition of employees, and the age of employees will be only a limited factor. Therefore, small employers with healthy, younger workers are required to pay more for insurance while small employers with older and less healthy workers are required to pay less. On average, the cost of small group coverage has risen.
Q: What if I bought my own individual health insurance policy?
A: Ohio citizens with individual policies have seen many of the same changes as those covered by a small group employer, including: (1) no preexisting condition exclusions; (2) coverage of essential health benefits; (3) copay and deductibles that fall into metal tiers; and (4) no lifetime or annual limits. Insurers no longer consider health status in setting premium rates and age is a limited factor.
Also, if you earn less than 400 percent of the federal poverty level ($47,520 for an individual; $97,200 for a family of four), you may get low-income subsidies to buy coverage through the federal government’s Health Insurance Marketplace (HealthCare.gov
). Generally, premium rates for people who are young, healthy and not eligible for subsidies may go up, while premium rates for older individuals, people with serious health conditions and lower-income families may go down. Whether premiums will go up on down for you will depend on the circumstances.
Q: What other coverage is available to me?
A: In 2014, Ohio decided to expand Medicaid eligibility for Ohio citizens with incomes at or below 138 percent of the federal poverty level ($16,394 for an individual and $33,534 for a family of four). If your income level qualifies you, you can get Medicaid coverage without having to pay a premium. If your income is low, but not low enough to qualify you for Medicaid coverage, insurance companies can no longer deny you coverage, and the federal government will provide you with subsidies to buy affordable coverage if your income is at least 100 percent, and no higher than 400 percent, of the federal poverty level.
If, however, you can afford health insurance, but decide not to buy it, you likely will have to pay a penalty on your tax return. For 2016, the penalty is $695 per adult and $347.50 per child (up to $2,085 per family) or 2.5 percent of family income, whichever is greater. In 2017 and beyond, the specific dollar amount "prong" of the penalty calculation will be adjusted annually for inflation, and the percentage of income prong of the penalty calculation will remain at 2.5 percent of income.
This “Law You Can Use” column was provided by the Ohio State Bar Association. It was prepared by Douglas L. Anderson, an attorney in the Columbus office of Bailey Cavalieri LLC.