What MUST policies cover in 2014 and beyond? 10 ESSENTIAL BENEFITS

  • Hospitalization
  • Emergency Services
  • Laboratory Services
  • Maternity and newborn care
  • Mental health, substance abuse disorder services, behavioral health treatment
  • Prescription Drugs
  • Habilitative and rehabilitative services and devices
  • Preventive and wellness services and chronic disease management
  • Ambulatory patient services
  • Pediatric services, including oral and vision care

When can you enroll? If you enroll:

  • Enroll between November 15- December 15, 2014 coverage effective Jan. 1, 2015
  • Enroll between December 16 – January 15, 2015 coverage effective Feb. 1, 2015
  • Enroll between January 16 – February 15, 2015 coverage effective Mar. 1, 2015
  • You can enroll at any time if you have a qualifying event, for  example, marriage, birth of a child,  loss of group coverage

If you have coverage from a job (or a family member’s job), you’re considered covered and won’t have to pay the fee that uninsured people must pay.

You may be able to change to individual coverage, but you might not qualify for lower costs on your premiums based on your income.  This will depend on the type and cost of insurance the employer provides.

Can I sign up for a subsidy instead of choosing my employer paid policy?

If you decide to check out the individuals policies offered, be aware that you may not qualify for lower costs on your monthly premiums, even if your income would qualify you otherwise. Whether you qualify for lower costs based on your income will depend on the coverage the employer offers. You won’t be able to get lower costs if our job based coverage is considered affordable and meets minimum value.

What is considered “affordable”?’

A job based plan health plan is considered “affordable” if the employee’s share of the premiums for the lowest cost self only plan coverage that meets the minimum value standard is less than 9.5% of their family’s income.  In other words, if your share of your premiums for a plan that covers you (the employee)-not your family-is less than 9.5% of your family’s income, the plan is considered affordable. 

You may pay more than 9.5% of your income on premiums for spouse or family coverage from your employer. But affordability is determined only by the amount you’d pay for self only coverage from your employer.

What is considered Minimum Value?

A health plan meets minimum value if it’s designed to pay at least 60% of the total cost of medical services for a standard population.  In most cases the plan will cover 60% of the covered medical costs, and the person will cover 40%