percent and 400 percent of the federal poverty level (FPL) may be subsidy eligible. Benefit subsidies will also be available to provide assistance with co-pays and out of pocket amounts for individuals who earn less than 250% of the FPL. • Premiums – Premiums can only vary by age, geography, and family composition in California. They may not vary by gender or health conditions. • Annual or Lifetime Limits – Individual and group plans may not impose limits on essential benefits. • Out of Pocket Expenses – Limits out-of-pocket expenses for co-pays, co-insurance, deductibles, etc., to $6,350 per individual to a maximum of $12,700/family annually.
Options for Coverage
The impact on individuals depends on a variety of factors. • No coverage in place: Individuals must purchase and maintain qualifying health coverage or instead pay a penalty. If their income is between 138% – 400% of the federal poverty level and they have no other coverage available to them that is affordable and qualifying, they could be eligible for a tax credit in the exchange. In 2013, the range is between $15,860 – $45,960 for
individuals, and for a family of four between $32,500 and $94,200. Individual plans in and out of the exchange will provide guaranteed issue coverage and include essential benefits and plan designs that meet the four metal levels: platinum, gold, silver and bronze. A silver plan is meant to cover 70% of an average person’s expenses with the insured expected to pay 30% for deductibles, co-pays, co-insurance, etc. • Existing coverage: If you currently have an individual policy in force, one of two things can occur: ȧȧ If the plan was in place prior to the ACA signing on March 23, 2010, and has not undergone any significant change since, it may be continued.
Metal Tiered Plans
• Platinum Plan: ȧȧ Plan pays 90% of expenses ȧȧ Insured pays 10% • Gold ȧȧ Plan pays 80% of expenses ȧȧ Insured pays 20% • Silver ȧȧ Plan pays 70% of expenses ȧȧ Insured pays 30% • Bronze ȧȧ Plan pays 60% of expenses ȧȧ Insured pays 40%
ȧȧ If an individual’s plan is not grandfathered, and the plan of benefits does not meet one of the tiered metal levels, the benefits will be modified. This will likely have an impact on plan premiums as well. Individuals trapped in old, high-priced plans due to health conditions, are now eligible to move to a new plan at possibly lower costs without having to be concerned about underwriting considerations. The individual should look very carefully at the provider networks available under each plan to ensure they are still able to seek care from their personal physician and hospital.
Learn More
Let Marsh be your partner on this new adventure. For more health care reform communications, including information on the Marsh/ Seabury & Smith Insurance Program Management private health care exchange for members, please call Marsh at 800-842-3761 or go to www. CountyCMAMemberInsurance.com.
Marsh and the association/society do not provide tax or legal advice. Please consult with your own advisors to determine how the law’s changes and your decisions impact your personal situation.
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