The American healthcare landscape radically changed in 2013 when a key provision of the Affordable Care Act (ACA) was implemented. The (mostly) web-based Health Insurance Marketplace -- a system where the uninsured can buy a private plan, often with financial help -- has improved dramatically over the past few months. But there are still aspects of the website, healthcare.gov, and the system it serves, that can be confusing. Here are five things to know about the ACA and the Marketplace.
1. Thousands of Missourians don’t realize their choice is an economic one.
Financial assistance for the Marketplace is calculated based on household income and the market price of plans available. This means a plan with an average amount of coverage won’t cost more than a set percentage of their income. Many uninsured Missourians, about 40 percent, have access to at least one plan with a monthly premium of $0. For this group, the choice is to pay for this low-cost insurance, or pay a tax penalty and have no insurance.
2. Your Eligibility Determination letter tells you whether you can get financial help or not (but sometimes isn’t entirely clear).
Eligibility for the Marketplace is based on modified adjusted gross income, which for most families is the amount earned from a job before taxes, investment income, and most Social Security income. This amount is compared to the federal poverty level for your family size to determine what (if any) financial aid applies. However, the Eligibility Determination letter, which shows up after entering your income information on healthcare.gov, sometimes does not explicitly tell people they are denied financial assistance. Without subsidies, an average plan on the Marketplace for a 27-year-old person in Boone County, Missouri, is $259 a month. That can cause sticker shock.
If you feel the Eligibility Determination letter is incorrect, you can reapply to the Marketplace or file an appeal. Our Navigators and certified counselors at Primaris can help with this.
3. The mandate only applies to people who can afford health insurance and opt out anyway.
A big misconception about the ACA is that everyone has to buy insurance in 2014 regardless of their income. If people do not have access to a plan that costs less than 8 percent of their household income, they are immune from the mandate. This includes people who fall into the Medicaid gap and most people who are affected by the so-called “family glitch”: typically someone in their household has access to affordable job coverage that is offered to family members (but at a much higher rate).
4. For those who do opt out, the penalty is fairly small.
The fine for not having insurance in 2014 is less than people think. The fine (which only applies to people who have affordable coverage and decline it) is the larger of the following:
1) $95 per adult, $47.50 per child, for a maximum of $285 per household, or
2) 1% of household taxable income above the filing threshold. You have to make more than $48,000 to be in this second category.
5. Most children in Missouri are eligible for the Children’s Health Insurance Program, and their parents don’t know it.
While Medicaid in Missouri tends to be fairly restrictive – working, childless adults who are not disabled do not qualify – the CHIP program, which provides health insurance for children, has broad eligibility rules. Under the S-CHIP program (a subset of the CHIP program, in which families pay a monthly premium for coverage), a family can earn up to three times the poverty level – about $70,000 a year for a family of four – and their children would be eligible. All CHIP programs include a free annual health checkup and dental care.
Ideally, healthcare.gov should automatically send an application to the Missouri Department of Social Services on behalf of your child, but it is not clear how often this is happening. Missouri has made an online application available for these programs here. Navigators and certified counselors can also help with this application.
Our Navigators and certified counselors at Primaris can help you understand the Marketplace application and healthcare.gov. We also can tell you where you stand in terms of financial assistance. Visit primaris.org/counseling for an appointment.