The fine schedule was written as follows: [3] [9]. The Internal Revenue Service IRS was given responsibility for collecting the fine, assessed annually as a tax penalty during the income tax filing period. The law established a hardship exemption from the fine for individuals who meet certain qualifications—such as being homeless, being a victim of domestic violence, or filing for bankruptcy. Under the law, medium-sized and large employers could incur fines for not offering affordable health coverage or not offering coverage at all.
The law defined affordable as costing employees less than 9. The law established requirements for employers with at least 50 employees to offer affordable coverage that covers at least 60 percent of costs to at least 95 percent of their workforce. If an employer does not meet these conditions and has at least one employee claim a tax credit to purchase coverage on the exchange, a fine would be incurred. The Affordable Care Act provided for the creation of health insurance exchanges , sometimes referred to as marketplaces, to act as a hub for consumers to browse and purchase health plans.
The exchanges were designed to be accessible via websites, call centers, or in person. The law gave states three options regarding the exchanges: [13] [14].
The law also allowed states to set up more than one exchange to serve residents in different areas within their borders, and multiple states could create a regional exchange. However, as of August , no state had chosen those options. The majority of states, 28 of them, had federally facilitated marketplaces.
Another 17 had state-based exchanges; five of these exchanges were state run while utilizing the federal platform, Healthcare. Six states partnered with the federal government to run their exchanges. States were given grants from the federal government to support the establishment and early administration of their exchanges.
The grants ended on January 1, , after which any state-based exchanges were expected to be self-sustaining. Plans were required to be designed and labeled under one of these four tiers to be sold on the exchanges. Just like other health plans, the portion of costs not covered by the health plan would fall to consumers. The law created advanced premium tax credits—payments from the federal government to help cover the cost of premiums for those buying from the exchanges—for individuals earning incomes between percent and percent of the federal poverty level FPL.
In states that expanded Medicaid to adults with incomes up to percent of the poverty level, eligibility for tax credits was set to begin at percent of the poverty level; individuals were not allowed to be eligible for both Medicaid and health insurance subsidies.
It limited the percentage of income these individuals could be required to pay towards their premiums and calculated credit amounts based on the difference between this percentage and the full premium cost for a benchmark The second-lowest cost silver plan on the applicable exchange.
The percentage of income households must pay was indexed to change each year based on premium growth as compared to income growth. Consumers were given the choice to have their tax credits be paid directly to insurance companies on a monthly basis or claim the total credit on an annual basis when filing taxes. The ACA also established a reduction in cost-sharing responsibilities for individuals earning incomes between percent and percent of the FPL, meaning they could enroll in silver plans that cover up to 94 percent of their costs.
The law restricted eligibility for tax credits and cost-sharing reductions to individuals who purchase a health plan through an exchange. For , the U. Department of Health and Human Services used poverty guidelines to determine tax credit and cost-sharing eligibility: [19] [22] [23]. The law did not make tax credits available for individuals below the poverty level. Childless adults who 1 reside in a state that did not expand Medicaid and 2 earn incomes between their state's Medicaid eligibility threshold and the poverty level could still buy insurance on the exchanges, but would not receive tax credits.
Click 'show' on the tables below to view complete data on incomes and the maximum monthly premium paid for a benchmark plan by poverty level percentage, up to a family of four. The Affordable Care Act designed a program for the creation of nonprofit health insurance companies called Consumer Operated and Oriented Plans , or co-ops for short.
The law provided federal loans for the start-up of co-op insurance companies and outlined a series of regulations for their operation. The controlling board of a co-op was to include members enrolled in health plans through the company in order to act as a voice for enrollees.
The law also stipulated that no representative from an insurance company or association could serve on the co-op boards. Co-ops could sell individual and small group insurance plans on or off the health insurance exchanges described below. The co-ops were not allowed to accept investment income and could only sell one-third of their plans in the large group employer market. Any profits would be reinvested back into the company. Out of 23 co-ops that were created under the law, four remained in operation as of August The Affordable Care Act prohibited individual market insurers from denying coverage to people with pre-existing conditions.
This policy is known as guaranteed issue. Guaranteed issue regulations had already existed for insurers selling employer-sponsored health plans, and the ACA extended this rule to the individual market as well. The law also required insurers to allow young adults to stay on their parents' health insurance plans until age Insurers were also required to allow people in the individual market to renew their health plans each year unless they did not pay their premiums.
The ACA required individual and small group health plans that were offered both on and off the exchanges to cover services that fall into 10 broad benefits categories, called essential health benefits : [27]. The exact services covered were selected by each state according to the needs of its citizens; the only requirement was that covered benefits fall into each of the 10 broad categories listed above. All health plans were required to cover percent of the cost of preventive services, such as screenings, as long as the physician providing the service was in the insurance plan's network.
All health plans were also required to cover contraception and services related to breastfeeding. The ACA placed restrictions on the way individual and small group insurers set a plan's premium The amount a consumer is required to pay for a health insurance plan. Premiums are usually paid monthly, quarterly or annually. The law did not place limits on premium variation due to geographic location or the number of individuals covered by a plan.
The law prohibited annual and lifetime limits on the amount insurers will pay out for covered benefits. Additionally, if individuals miss premium payments, insurers were required to allow that person to retain coverage for three months, although insurers only had to pay doctors for one month. If the premium amount was not paid during that time, then coverage could be terminated.
The law established a program for reviewing insurance premium rate increases. If a state decided to administer its own program, it was required to meet minimum standards outlined by the U. HHS was given the authority to review state programs, and if they did not meet the standards, federal regulators could take over the rate review process for that state.
States could also cede rate review responsibility to HHS. Insurers were required to submit proposed rate increases of 10 percent or more to either state or federal regulators, whichever was applicable, for review, along with data supporting the increase. The secretary of health and human services was not granted the authority to reject premium increases; however, many state laws allow state regulators to reject or amend premium requests. A medical loss ratio MLR is the portion of premium revenue that insurers spend on claims, medical care and healthcare quality for their customers.
The remaining revenue typically goes toward overhead costs, such as administration, marketing and employee salaries, and then to profit. The Affordable Care Act ACA placed new regulations on insurers' medical loss ratios by limiting the portion of revenue that goes toward overhead and profit: individual and small group insurers were required to maintain a minimum medical loss ratio of 80 percent, while large group insurers were required to maintain a minimum MLR of 85 percent.
This means at least 80 or 85 percent of premium revenue were required be used to pay customer claims and support improvements in health and healthcare quality, such as wellness promotion programs.
Each year, insurers were required to publicly report their medical loss ratio and other financial information for each state and market segment. If their MLR falls below 80 percent or 85 percent, they would be required to notify their customers and provide a rebate the following year. The law exempted insurers serving fewer than 1, individuals in a state.
The Affordable Care Act outlined three federal programs that were meant to stabilize the individual market during the first few years of the law and prevent premiums from rising too quickly as insurers adjusted to the new regulations: [37]. The Affordable Care Act expanded eligibility for Medicaid to more individuals.
Medicaid was originally limited to pregnant women and young children with household incomes around the federal poverty level, and to disabled people, older children, and parents with household incomes below the federal poverty level. Each state was allowed to decide whether to also cover able-bodied adults without children or people with slightly higher incomes, though they were previously required to obtain a federal waiver to do this.
The ACA provided for the expansion of Medicaid eligibility to cover childless adults whose income amounted to percent of the federal poverty level FPL or below. Although the law originally required states to expand their Medicaid programs or lose federal Medicaid funding, in , the U.
Supreme Court ruled that the federal government could not condition Medicaid funding on an expansion of the program. The ruling essentially made participation in the expansion voluntary on the part of the states. The provision for expanding Medicaid went into effect nationwide in The federal government provided percent of funding to cover newly eligible enrollees through , dropping this funding level to 95 percent in and to 90 percent in and thereafter.
The law did not provide for tax credits for adults with household incomes lower than the federal poverty level, because the law had intended to cover these people under Medicaid.
In states that didn't expand Medicaid, these adults neither qualified for Medicaid nor for federal tax credits to purchase health insurance. As of August , a total of 38 states and Washington, D. The map below provides information on Medicaid expansions by state; for states that expanded, hover over the state to view the political affiliation of the governor at the time of expansion. The Affordable Care Act enacted a temporary increase for Medicaid's reimbursements to primary care physicians, matching Medicare levels during and Supreme Court.
Sebelius, Secretary of Health and Human Services, et al. Federal Register. Texas Attorney General. Texas et al ," Page 1. The White House. Health Insurance. Actively scan device characteristics for identification. Use precise geolocation data. Select personalised content. Create a personalised content profile. Measure ad performance. Select basic ads. Create a personalised ads profile. Select personalised ads. Apply market research to generate audience insights.
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It was designed to extend health coverage to millions of uninsured Americans. The act expanded Medicaid eligibility, created a Health Insurance Marketplace, prevented insurance companies from denying coverage due to pre-existing conditions, and required plans to cover a list of essential health benefits.
Lower-income families qualify for subsidies for coverage purchased through the Marketplace. The law included more than 1, pages of provisions intended to make coverage affordable for and accessible to millions of Americans who struggled to pay for individual coverage — many of whom could not buy individual coverage at any price due to pre-existing medical conditions.
The law sharply reduced the number of uninsured Americans. The Affordable Care Act included major provisions designed to make comprehensive health coverage affordable to Americans who struggled to pay for coverage prior to the ACA. Chief among those provisions:. Use our updated subsidy calculator to estimate how much you can save on your health insurance premiums. As of early , more than 9. And the subsidies have been made larger and more widely available since then, thanks to the American Rescue Plan.
The premium subsidies — which are actually tax credits — offset the cost of premiums for any metal-level ACA-compliant health plan available through an ACA marketplace. Subsidy eligibility is largely based on income, but there are a handful of other factors, including immigration status, age, and access to government-sponsored or employer-sponsored coverage.
In addition to the premium subsidies, the ACA also provides cost-sharing reductions CSR — also known as cost-sharing subsidies — which reduce out-of-pocket spending for eligible enrollees. The Supreme Court made the expansion optional for states, but as of mid, 37 states and the District of Columbia had accepted federal funding to expand Medicaid — providing coverage for nearly 20 million Americans.
COBRA gives employees the option of continuing their group coverage after leaving a job or otherwise losing access to their employer-sponsored coverage. State continuation provides this option in many states for people who work for smaller employers. Since the mids, COBRA provided a realistic way for people to maintain coverage while between jobs if they had pre-existing conditions and were unable to qualify for medically underwritten individual health coverage.
COBRA allowed these individuals to keep the same coverage they had at their job, but the coverage was expensive, since the employee assumed the full price of the plan — including the portion the employer had been paying.
For most enrollees, coverage under the ACA is also affordable, thanks to premium subsidies. And — depending on income levels after leaving a job — some of these individuals now qualify for expanded Medicaid with free or very low-cost premiums. Before the Affordable Care Act was implemented, some states tried to ensure that premiums on state-regulated health plans were actuarially justified, but others did very little — and residents in some states were getting fleeced by some insurers.
Plans can have out-of-pocket caps that are lower than the federally determined amount, but not higher. Under Obamacare, small businesses that provide employees with health insurance may be eligible for an ACA-created tax credit to make offering coverage more affordable.
Who can help if I have a problem with my ACA-compliant coverage or exchange enrollment? Health insurance marketplaces — also referred to as health insurance exchanges — were established to help American consumers easily compare coverage details and costs across a wide range of qualified health plans. These policies — deemed ACA-compliant — must meet standards established and enforced by the federal government and state governments.
The ACA called for the creation of an exchange — or marketplace — in each state, but marketplace implementation including the type of marketplace varies by state. As of , there are 15 state-based exchanges, six federally supported exchanges, six state-partnership exchanges and 24 federally facilitated exchanges.
A key goal of the marketplaces was to provide coverage explanations in easy-to-understand, standardized formats, along with uniform definitions of health insurance terminology. Plans are categorized under metal level classifications based on their actuarial value, and catastrophic plans are also available to eligible enrollees.
Included in the exchange options is an enrollment platform called SHOP Small Business Health Options Program — a tool that allows small businesses to compare plans and enroll in coverage for their employees. In some states, however, there are still thriving SHOP markets. The ACA also created nonprofit health insurance co-ops — private, nonprofit, state-licensed health insurance carriers — that offer ACA-compliant plans in individual and small-business markets.
But only three CO-OPs are still operational in five states. Before the implementation of the ACA, Americans with pre-existing conditions could find it expensive — or impossible — to buy health coverage in the individual market.
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