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Health Care Reform: What Changes are Coming?

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By: A. Paul Holdren
August 30, 2013

As you know, there are some significant changes happening to health care and health insurance as a result of the Affordable Care Act, or ACA, which is also referred to as Health Care Reform. The ACA has numerous and complex provisions, and is primarily intended to help more people access and afford health care coverage regardless of their health status.  But like many laws, it is complicated. 

Some provisions of the law are already in place, but other important changes are yet to come.  Let’s take a look at some of the key provisions of the law that will take effect on January 1, 2014.

What’s Changing?

  • Virtually every American will be required to have qualifying health coverage beginning January 1, 2014.
  • Most individuals who do not have qualifying coverage and who choose not to purchase coverage will be subject to penalties, with few exceptions.
    • In 2014 the penalty will be $95 per adult and $47.50 per child (up to $285 for a family) or 1% of family income, whichever is greater. Penalties will increase each year. For example, in 2016, the penalty will have risen to $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater.
  • Currently, children under age 19 with an illness or disability, often called a “pre-existing condition,” cannot be denied coverage.  As of January 1, 2014, the same will also apply to adults.
  • Individuals who do not have coverage through their employer, or through a government program like Medicare or Medicaid, will be able to buy insurance directly in the private insurance market or through a state- or federally-operated (also called “public”) Marketplace, commonly referred to as an Exchange.
  • The public Marketplace will be an online site where consumers can view and compare plans from multiple insurance companies, make their purchasing decision and enroll right online.  Each state had the option to create and operate its own Marketplace or to default to the Federally Facilitated Marketplace.  Pennsylvania chose to default to the Federally Facilitated Marketplace.   
  • Financial assistance in the form of federal tax credits and cost-share subsidies will be available from the government to help those who qualify pay their insurance and health care costs.  To access financial assistance, you must access coverage through the public Marketplace.
  • Open enrollment is slated to start on October 1, 2013, for coverage that will become effective on January 1, 2014.

Are there standards that plans will have to meet to be offered on the Marketplace?

  • All qualified health plans will be required to cover 10 Essential Health Benefit categories (see side bar).
  • Plans will be assigned a metal level (Bronze, Silver, Gold or Platinum) to help shoppers understand how much they will pay and how much the plan will pay toward medical care costs.
  • Plans being offered must pay at least 60% of the average health care costs.
  • Rates for medical plans can no longer be different based upon gender or medical condition.

Is there anything I need to do right now?

You may need to take action after the Marketplace opens on October 1st if your employer doesn’t offer qualified health insurance or if you are not covered by an existing government plan like Medicaid or Medicare. 

Start to prepare by gathering Social Security numbers (or documents for legal immigrants), birth dates, pay stubs, W-2 forms or wage and tax statements for you and any family members that will be seeking coverage.  Policy numbers for any current health insurance, or information about any health insurance you or your family could be eligible for through your jobs, will also be helpful.

To learn more about Health Care Reform, visit Blue Cross of Northeastern Pennsylvania’s enhanced website any time.

Essential Health Benefit Categories

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance abuse
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including dental and vision care