Affordable Care Act

The Affordable Care Act was passed by Congress and then signed into law by the President on March 23, 2010.

Pre-Existing Conditions

Under the Affordable Care Act, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts. They also can’t charge women more than men.

These rules went into effect for plan years beginning on or after January 1, 2014.

What This Means for You

Health insurers can no longer charge more or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer. They cannot limit benefits for that condition either. Once you have insurance, they can’t refuse to cover treatment for your pre-existing condition. Learn more about coverage for pre-existing conditions.

Grandfathered Health Plan

As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act.

Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers.

A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions.

(Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).

The fee for not having coverage in 2017

If you don’t have coverage in 2017, you’ll pay the higher of these two amounts:

  • For tax year 2016, the penalty will rise to 2.5% of your total household adjusted gross income, or $695 per adult and $347.50 per child, to a maximum of $2,085.
  • For tax year 2017 and beyond, the percentage option will remain at 2.5%, but the flat fee will be adjusted for inflation.

How you pay the fee

You’ll pay the fee on the federal income tax return you file for the year you don’t have coverage. Most people will file their 2016 returns in early 2017.

Exemptions from the fee

If you don’t have qualifying health coverage, in some cases you can claim a health coverage exemption. If you qualify for an exemption, you won’t have to pay the fee.

Most people must have qualifying health coverage or pay a fee (also known as the “penalty,” “fine,” “individual shared responsibility payment,” or “individual mandate”). But if you qualify for a health coverage exemption you don’t have to pay the fee.

2017 hardship exemptions and forms

If you qualify for an exemption under the ACA, you won’t be charged the penalty, even if you don’t have coverage. You could be exempt if:

  • The most affordable coverage costs more than 8% of your household income.
  • You were uninsured for less than three months of the year.
  • You are exempt from filing a tax return because your income is too low.
  • You are Native American or eligible for health services through an Indian Health Services provider.
  • Your religion objects to the use of insurance.
  • You’re in prison.
  • You belong to a health-care sharing ministry.
  • You have been abroad for more than one year.
  • You qualify for a hardship exemption due to an issue such as homelessness, bankruptcy, eviction and similarly trying circumstances listed here.

If you believe you qualify for an exemption, you can claim it when you file your tax return, or apply on the Healthcare.gov website.

It pays to know whether you’ll be among the millions expected to face the individual mandate penalty when filing tax returns next year. (If you file taxes online, the preparer you choose will calculate any penalty.) That will help you budget now for penalty costs. And with the next open enrollment period always around the corner, it may be time to reconsider your coverage and potential penalty for the year ahead.

When Will My Coverage Start If I Sign Up During Next Open Enrollment?

Plan changes made prior to December 15, 2016 will take effect January 1, 2017.

  • Plan changes made from December 16, 2016-January 15, 2017 will take effect February 1, 2017.
  • Plan changes made from January 16, 2017 – January 31, 2017 will take effect March 1, 2017.

Types of Coverage

Bronze Plans

Bronze plans tend to have the lowest premiums of all Metal Plans. That is because they only have to provide 60% of cost sharing on average. Bronze plans provide an average cost sharing value (known as Actuarial Value AV) of 60%. This means that a Bronze plan must cover an average of 60% of all that plans enrollees covered out-of-pocket costs. This does not mean that 60% of actual costs will be covered for any one given person. In fact, a small minority of policy holders will account for the majority of costs. So actuarial value should always be looked at as a sign of how good a plan’s cost sharing is, not as a literal amount. Literal cost sharing amounts can be found on a plan’s benefit sheet.

Silver Plans

Silver Plans are the marketplace standard plan. The second lowest cost Silver plan in a state is used as the benchmark plan when determining subsidies.

Silver plans provide an average cost sharing value (known as Actuarial Value AV) of 70%. This means that a Silver plan must cover an average of 70% of all that plans enrollees covered out-of-pocket costs (based on a standard population). This does not mean that 70% of actual costs will be covered for any one given person. In fact, a small minority of policy holders will account for the majority of costs. So actuarial value should always be looked at as a sign of how good a plan’s cost sharing is, not as a literal amount.

Gold Plans

Gold plans provide an average cost sharing value (known as Actuarial Value AV) of 80%. This means that a Silver plan must cover an average of 80% of all that plans enrollees covered out-of-pocket costs. This does not mean that 80% of actual costs will be covered for any one given person. In fact, a small minority of policy holders will account for the majority of costs. So actuarial value should always be looked at as a sign of how good a plan’s cost sharing is, not as a literal amount. In some states Gold plans must meet additional criteria, making cost sharing offered on these plans even more attractive.

Of course with better cost sharing, comes higher premiums.

Platinum Plans

Platinum plans are designed to cover 90% of out-of-pocket costs on average. This is known as having an Actuarial Value of 90%. This means for a standard population the plan will on average cover 90% of all out-of-pocket costs for essential health benefits. This is not the exact amount of cost sharing your plan will provide you.

Given the generous cost sharing, platinum plans have the highest premiums on average. Not all insurers offer Platinum plans on the Marketplace. Different states may have different rules for what these plans must offer beyond minimum standards in the ACA.

Catastrophic Health Plans 

Catastrophic health plans generally have low premiums, high deductibles, and high cost sharing amounts. Catastrophic plans typically won’t pay any out-of-pocket costs like copays and coinsurance. Deductibles on catastrophic plans will tend to be equal to out-of-pocket maximums, this essentially means coinsurance and deductibles will never factor into what you pay.  Often this means you pay a premium simply to get the same deals on care your insurer gets and to know you’ll never pay more than your out-of-pocket maximum in an emergency.