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The New ACA Insurance Marketplace: Who needs to shop?

October 10, 2013 5:30am (EDT)

The Affordable Care Act (ACA) marketplace website, (www.HealthCare.gov) is where individuals, families, and small businesses can sign up for insurance coverage. To qualify for ACA marketplace coverage, you must live in the U.S., and be a U.S. citizen or legal U.S. resident. You can’t get coverage if you're in jail.

Coverage is important and mandatory by January 1, 2014. Media reports of glitches in the website enrollment process may have made you leery. While nobody is forced to sign up through the website, here are some who should probably use it:

- the recently unemployed.
- the not or never insured.
-those previously denied insurance coverage for any reason, including pre-existing conditions.
-young people, including recent college graduates, not yet working, or working but not receiving coverage from their employer. These young people should research choices to see which is most economical: staying on parents' policy (an option for kids up to age 26); or choosing from new ACA options available on the website.

If you already have insurance through your employer and you're satisfied, you're set. The general rule of thumb is if you already have affordable coverage, the marketplace is not for you. You can check the site to satisfy your curiosity, but you can’t sign up for coverage through it. The goal is for everyone to have access to "affordable" health care. Those with employer provided coverage can't qualify for coverage at the marketplace website unless the coverage you have is "unaffordable", meaning it exceeds 8 % of household income.

Another group that can check the site, but can’t sign on: those with coverage through Medicare. However, Medicare recipients may be relieved to know Medicare is a pretty good deal, compared to other plans offered in the marketplace. ACA is improving Medicare coverage in some ways. For example, the ACA has already helped more than 3 million seniors who fall in the Medicare Prescription Drug “doughnut hole” save over an average $700 on their drug costs last year alone. This prescription drug doughnut hole is the out of pocket coverage gap in what the drug plan will cover for drugs. ACA will fully close the “doughnut hole” by 2020.

Plans are classified, according to coverage and deductibles, as bronze, silver, gold, and platinum. Just because you have a plan doesn’t mean it will be accepted by all providers and at all points of care. Check the fine print. Each marketplace plan has its own network of hospitals and health care providers. Check to see if your preferred doctor and hospital are included before choosing a plan. You can do this on the website. When reviewing options online, click on a specific plan and search to see if your doctor is part of the provider network. Unfortunately, you can’t search all the plans at one time. You can only check one plan at a time.

The Affordable Care Act calls for just that: affordable health care coverage. There is assistance available for lower income families. All large companies (with 50 or more full time-equivalent employees) must offer health benefits to all employees working at least 30 hours per week by 2015.

For small businesses (with fewer than 50 employees), there’s SHOP: Small Business Health Insurance Options Program. SHOP is now open for online review of available plan options at HealthCare.gov. While you can complete a paper application now, you still will have to go on line in November to complete the enrollment process. Another small business option is wait and do it all online in November. For small businesses, offering health care insurance coverage is optional. Small businesses are not required to provide health insurance, but if they decide to, they may be eligible for tax credits covering up 50% coverage costs. Check out the website (https://www.healthcare.gov/will-i-qualify-for-small-business-health-care-tax-credits/) to see if your small business qualifies.

The ACA purpose is for everyone to have health insurance coverage. The official deadline for having it is January 1, 2014 (but technically the penalty won’t kick in until after March 31, 2014 because the law provides a three month grace period for not having insurance).

For individuals, the ACA Marketplace enrollment period continues through March 31, 2014,
but the sooner you sign up – especially if you’re uninsured – the better. Check it out at HealthCare.gov.

This ACA Facts series helps explain important details of the Affordable Care Act. If you have a particular question you would like answered, send your request to AskDrSandy@gpb.org.

Read Part 1: Ready, Set, Insure
Read Part 2: The New Healthcare Equation For Insurance Coverage

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