Common questions about healthcare reform

Managing the cost

What if I just can’t afford health insurance?

You may be able to find financial help with government subsidies, earmarked for individuals and families with low to moderate incomes. That works out to between $15,521 to $46,680 for singles and $31,721 to $95,400 for a family of four, based on 2014 figures. One form of subsidy is a monthly tax credit to be put toward the cost of premiums. Another is a reduction of some out-of-pocket spending, such as the deductible and co-payments for doctor’s visits. If you buy your insurance on an online Marketplace offering plans from a wide range of insurer’s, like Humana, you’ll be able to find out if you quality for a subsidy.

Another option may be Medicaid coverage. Eligibility can be expanded to cover adults under age 65 without children. States now have the option to offer Medicaid coverage to all adults over the age of 19 with an income of $15,521 or less (this figure will be adjusted each year).

"After The Election: A Consumer's Guide To The Health Law",Kaiser Health News, (accessed 11 Feb. 2013)

What has caused the rise in premiums?

Rates are affected by many things including medical utilization and increased cost of services. Benefits now  guarantee certain health services, no matter which insurance plan you’re on. A few examples: Preventive care, including annual check-ups, vaccinations, and routine screenings has been expanded and insurers cover these at 100% - no out-of-pocket costs when you go to a doctor in your network.

Every insurance plan now includes a core package of what’s called Essential Heath Benefits. These benefits include coverage for a hospital stay, lab services (for example, blood tests), maternity care and prescription drugs.

Young, Jeffrey, "Obamacare Costs To Rise For Some Young People As Benefits Improve," Huff Post Business, (accessed 11 Feb. 2013)

Is there a limit to how much I’ll have to pay for my medical expenses?

Each year limits are set on the maximum amount your insurer expects you to pay before it picks up 100% of covered expenses considered medically necessary. These are called out-of-pocket expenses. They may include the cost of your deductible, copayments, and prescription drugs. In 2014, these limits are $6,350 for individuals and $12,700 for families. People with lower incomes may pay less; their limits are capped on a sliding scale between one-third to two-thirds of the regular maximum.

“For 2014, Higher Limits for HSA Contributions, Out-of-Pocket Expenses,” Society for Human Resource Management, (accessed 20 June, 2013)

In the past I’ve been denied coverage because I have diabetes. Will I be able to get insurance? Will my premiums cost more?

Yes, you’ll be able to get insurance, and no, your premiums won’t cost more because of it. Insurers will no longer deny or limit coverage if you have a health problem or a history of health problems (sometimes called a pre-existing condition). You also can’t be charged a higher premium because of your health status – past or present. Premiums can be based on your age (older adults can’t be charged more than three times what a younger person is charged), geography (insurers can charge more in areas where medical costs are high), family size (an individual versus an individual plus a spouse and/or children) and tobacco use (those using tobacco products can’t be charged more than 1.5 times what a non-tobacco user is charged).

“Health Insurance Market Reforms: Rate Restrictions,” The Henry J. Kaiser Family Foundation , (accessed 25 Feb. 2013).

What if I decide not to buy health insurance?

If you skip it you’ll have a tax penalty. In 2014 the penalty is $95 per adult and $47.50 per child (up to $285 for a family) or 1% of household income, whichever is more. In 2015 the penalty increases to $325 per adult and $162.50 per child (up to $975 for a family) or 2% of household income, whichever is more. This then increases to $695 per adult and $347.50 per child (up to $2,085 per family) or 2.5% of family income in 2016 and beyond.

However, there are a few reasons why the requirement may be waived, such as religious beliefs that bar someone from using health insurance benefits and extreme financial hardship.

"After The Election: A Consumer's Guide To The Health Law," Kaiser Health News, (accessed 25 Feb. 2013)

Is there a way to get free healthcare coverage?

No. The law does not provide free government health insurance. Instead, it was designed to help low and moderate-income people who don’t have health insurance obtain it. Some may receive government subsidies, based on family size and income, that reduce the monthly premium. Some people may even qualify for a subsidy amount large enough that they have a $0 monthly premium. Or you may qualify for Medicaid , which states now have the option of expanding to cover more people by loosening income guidelines.

Changes in benefits

How will the law affect my children's benefits?

Like adults, children are also able to be covered, regardless of any health problem, such as asthma or diabetes. In addition, insurers no longer have lifetime dollar limits on how much they spend on medical expenses, like doctor’s visits. Annual spending limits have also been phased out, so there’s no cap on how much your insurance company will pay towards your child’s care for the year. Parents now have access to many preventive care services for their kids – including regular exams, behavioral check-ups, developmental screenings, and immunizations – that are covered at 100% when you use a doctor in your network, which means no copayments or paying towards a deductible. Pediatric dental and vision check-ups must also be a part of the plan.

Individual insurance plans must also include a core package of what’s called Essential Health Benefits. These include maternity and newborn care, vision check-ups for kids, prescription drugs, and hospitalization.

Which benefits must insurers offer?

There’s a combination of benefits plus consumer protections that have been put into place. Here are some highlights:

Focus on preventive health services

Your insurer picks up the entire cost for well-baby and well-child visits, vaccinations, cancer screenings such as mammograms and colonoscopies. Women also receive woman's health visits, which include a physical exam and other services, such as contraceptive counseling and breastfeeding support.

Coverage can’t be denied

Your application will not be impacted by any current or past health problem, referred to as a “pre-existing condition.”

No limits on reimbursable expenses

There are no annual or lifetime limits on the amount of your healthcare expenses that it covers.

Insurance shopping made simple

Health insurance “Marketplaces” (also called Exchanges) have been created for each state. These virtual mini-malls make it easy for you to shop and compare plans. Similar in concept to the Nutrition Facts label you see on packaged foods, insurers describe their benefits in a simple, standardized way.

Choose your own doctors

You are able to choose any primary care physician (PCP) you want from your insurer’s network, a pediatrician for your kids, and women won’t need a referral to choose an in-network OB/GYN.


You can get Emergency Room medical care in hospitals outside of your plan’s network without incurring higher out-of-pocket costs in the case of true medical emergencies. This is especially beneficial if you get sick or injured while away from home.

Coverage for more healthcare expenses

A rule (called the Medical Loss Ratio) requires your insurer to put at least 80% (85% for large groups) of premium dollars collected towards covering your medical costs or improving quality of care. Administrative and other costs are limited to 20%.

I'm pretty healthy. Are there plans for people like me?

Yes, there’s something called a catastrophic plan option. This type of policy typically includes a high deductible but still covers preventive services and three primary care visits. Catastrophic plans are permitted for young adults under age 30 and those suffering financial hardships. Because of the high deductible, premiums for catastrophic coverage will be less than for most other plans. This means people who are young and healthy can still have insurance, without paying higher premiums for benefits they may not use.

Choosing doctors

Will I be able to keep my doctor? If I don’t have one, will I be able to choose my own?

The Affordable Care Act isn’t meant to influence your choice of healthcare providers. You can keep your own doctor, but you’ll want to be sure he or she is in your insurer’s network. Otherwise you’ll end up paying higher out-of-pocket expenses. If you don’t have a doctor it’s up to you to select one -- just be sure to choose from your insurer’s network.

Are there different plans to choose from?

Yes, the government doesn't select an insurer for you; it’s up to you to make the best choice for you and your family. You can buy coverage directly from a health insurance company, like Humana, where you will find several quality plans to choose from. In addition, virtual “marketplaces” have been set up for each state. There you will find more options, as you can shop and compare policies and prices online from a wide range of insurers, including Humana. Or you can work with an insurance agent to find a plan that’s right for you.

Medicare and Medicaid

Is Medicaid and CHIP still offered?

Yes. In fact, some states chose to extend Medicaid coverage to include low-income adults without children who are under age 65 and meet the income requirements.

Coverage concerns

Do I really need to get health insurance? Is it mandatory?

Yes, for most people it is. Exceptions to the rule include those whose religious beliefs bar them from using health insurance benefits, those with a family income so low that they aren’t required to file a tax return, those who would have to pay more than 8% of their income on insurance (after factoring in any tax credits and employer contributions) and undocumented immigrants. Those who don’t comply will be faced with tax penalties.

“The Requirement to Buy Coverage Under the Affordable Care Act,” The Henry J. Kaiser Family Foundation (accessed 11 Feb. 2013)

When does all of this go into effect?

The Affordable Care Act was signed into law March 23, 2010. Most of its provisions took effect by January 1, 2014.

How does the government know whether or not I have insurance?

Your health insurance company provides documents to you and the IRS proving that you have adequate coverage, as required by law.

Will there by an open enrollment period for getting coverage?

Yes. Open enrollment begins Nov. 15, 2014, and will end on Feb. 15, 2015. You can buy insurance directly from an insurer, like Humana, buy through an independent insurance agency, or shop online in the virtual Marketplaces being set up in each state.


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This information is only a high-level summary of certain provisions of the health care law. This information does NOT attempt to summarize all provisions of the health care reform law. This information is not and should NOT be used as legal or tax advice; it should not be used as a basis for decisions regarding how the health care reform law will affect you and/or your business. Should you have any questions on how the health care reform law (including the high level summary of certain provisions of health care reform) will affect you and/or your business, you should seek professional advice from attorneys or other advisors.

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