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Looking for Affordable Care in Open Enrollment


Affordable Care

Open enrollment for health care through the Affordable Care Act (ACA) insurance marketplace is coming, starting Nov. 15 through Feb. 15. By now, those on individual plans through their state marketplace have received renewal notices with 2015 premium rates and plan changes noted. For many, those notices raised more questions and prodded them into looking further at their options to find affordable care in the upcoming open enrollment.

The reality is that health insurance is expensive and unaffordable for many. That led to the Affordable Care Act, which is not perfect but has enabled many to get insurance who could not before. Last year’s rough rollout involving new computer programs, new marketplaces in each state and new health plans is hopefully behind everyone in most states (Some states allowed legacy plans to remain for one more year, so those states will have a lot of changes processed this year.)

There are some things about which people calling their insurance plan or their state marketplace this year keep asking:

  • Pediatric Dental Coverage – Many members who do not have children are questioning why they see pediatric dental coverage now part of their plan. The ACA plan required certain benefits be included in every health plan available going forward on the individual marketplace. These included benefits for preventive care, maternity, prescription drug and pediatric dental care. Not everyone needs pediatric coverage or maternity, but they might also not need screenings for cancer and other things covered. The idea was a standardization of what is covered in the plans being offered.
  • Networks – The health insurance companies had to created new provider networks and contract with medical groups, hospitals and other providers for the new plans. In many areas, doctors and hospitals remained on the sidelines in 2014 and would not take the new ACA insurance plans. This does make it hard to find a doctor in some areas, but should change eventually. The reality is that as more people are in individual or small group ACA plans the providers will undoubtedly not be able to afford to turn down the business.
  • Tax Credits – Many people were reluctant in 2014 to apply for a “subsidy” from the government to help make health insurance more affordable. They perceive it as a government handout. However, it is not a handout. It is an Advanced Premium Tax Credit that can be used during the year to lower insurance premiums or claimed on tax returns for those who bought coverage through the state or federal marketplace.
  • Tax Penalties – Conversely, there are people who choose to go without health insurance coverage (and are not exempt from the requirement) figuring they will pay the tax penalty. The perception is that the penalty is a mere $95 in 2014. It is really $95 per adult, $47.50 for children to a family maximum of $285 PROVIDED that figure is less than 1 percent of their adjusted gross income. That means that a single person with an income of $50,000 would actually pay a $500 tax penalty for going without coverage. Next year, the penalty jumps to $325 per adult, $162.50 per child and family maximum of $975 or 2 percent of income.

For people who work for an employer that provides health insurance benefits for them and their family, it may not be apparent how much everyone else (and their firm) pays for medical coverage. If the employer covers 75 percent of the premium, someone with a family could pay only $500 a month without realizing the true cost is $2000 a month. That true cost is what self-employed, unemployed or those who do not have insurance through an employer are facing and looking for in the Affordable Care Act insurance marketplace this open enrollment.

By Dyanne Weiss

U.S. Department of Health and Human Services