If you are a working professional and searching for affordable health care options, then you may have a hard time deciding which plan is best for you. In this article, you will learn about three important features of the Affordable Care Act (ACA): cost-sharing reductions, Medicaid expansion, and the CSR subsidies. These features will help you find a plan that is right for you. While many people choose a self-only plan, it is still necessary to find the right balance between coverage and cost.
ACA’s requirement that plans include categories of essential health benefits
Under the Affordable Care Act, all individual market plans must cover at least 10 of the ten categories of essential health benefits (EHBs). However, this law has been challenged by members of Congress, as well as the Trump administration, which has sought to undermine these protections. One such proposal is the administration’s expansion of “short-term” health insurance plans, which do not meet the ACA’s essential health benefits requirements.
Before the Affordable Care Act’s implementation, many individual market health plans did not cover essential health benefits. Preventive care, mental health services, and substance abuse treatment were frequently excluded from coverage. Now, these services must be covered, regardless of preexisting conditions. Additionally, all health insurance plans must cover 10 of the essential health benefits, or EHBs. Other important benefits include dental coverage for children and emergency services.
In addition to these provisions, the ACA also requires that health plans include certain categories of essential health benefits. The legislation also prohibits annual and lifetime dollar limits on the coverage of certain essential health benefits. As of Jan. 1, 2014, major nationwide essential health benefit requirements will go into effect. In the meantime, two other ACA provisions reference essential health benefits: Medical Loss Ratios and Mental Health Parity.
ACA’s cost-sharing reductions
ACA’s cost-sharing reductions offer coverage subsidies for people who qualify for them. They are offered to people who are between 100% and 250% of the federal poverty level or 138 percent for those in states that have expanded Medicaid. Generally, cost-sharing reductions are more beneficial for people with incomes below 139% of the poverty level. However, for people who make over 250% of the poverty level, the subsidy benefits become weaker.
ACA’s cost-sharing reductions program helps people purchase health insurance plans. It helps low-income individuals purchase plans with lower deductibles and coinsurance. These subsidies can be as much as 45% of the premium cost. Fortunately, Massachusetts’s subsidies are a big help to those who are struggling with these costs. The state also provides generous subsidies to those in the marketplace below 300 percent of the poverty level, which reduces their premium costs greatly.
The amount of cost-sharing reductions offered by HHS is lower than what the administration initially proposed. This is due to a change in methodology used to estimate employer-sponsored insurance premiums. Now, the administration uses National Health Expenditure Accounts (NHEAs) to estimate premiums. The cost-sharing reductions, however, are still available to everyone who qualifies for them.
ACA’s Medicaid expansion
Although a large number of states have embraced the ACA’s Medicaid expansion for affordable health coverage, a number of states have failed to do so. Congress is evaluating ways to close the Medicaid coverage gap. This federal policy would generate wide-ranging benefits for newly insured individuals, including significant health and economic gains. Until now, Medicaid eligibility was based on financial requirements and other factors, including age, disability, and parenting status.
However, the Medicaid expansions have been accompanied by numerous problems. Most notably, they have increased current and past-due child support payments by an estimated $20 million. As a result of the ACA’s Medicaid expansions, Vogler and others have estimated a corresponding decrease in aggravated assaults and violent crimes. In addition, the study has produced estimated social costs savings of $4 billion in 31 states.
Despite these challenges, the ACA’s Medicaid expansion has helped thousands of low-income Americans. According to research from the University of Michigan, Medicaid expansion has lowered the all-cause mortality rates of non-elderly adults in low-income regions. As a result, timely treatment of health conditions may prevent further deterioration in health. And as evidenced by Borgschulte and Vogler, timely access to health care can prevent the development of chronic conditions.
ACA’s CSR subsidies
While the ACA’s cost-sharing reduction (CSR) subsidies for affordable health care are based on your income level, many consumers still cannot afford the insurance. To qualify for these subsidy payments, you must be at least sixty percent low-income and have an annual income of less than $110,000. In addition to income, you may qualify for premium tax credits that reduce the cost of your health plan.
Insurers argued that the Federal Circuit misapplied the Supreme Court precedent in Maine Community Health Options by analogizing CSR payments to contract law. The ACA is clear about the CSR statute and its purpose. But the Federal Circuit incorrectly concluded that unpaid CSRs must be offset by higher premium tax credits. In the end, the government agreed with the House and found that the CSR payments were inequitable without congressional appropriations. The case was settled in May 2018.
When people receive cost-sharing reductions, their health insurance company will reduce their premiums by 30 percent or more. The cost-sharing reductions are most significant for people who earn less than 200% of the FPL. If you’re at least 250% below that level, however, the subsidy is more limited. But you can still get a reduction if you qualify. A standard silver plan has a $7,150 annual deductible, a 30% coinsurance after the deductible, and a $70 copayment for a physician visit. A CSR subsidy is worth up to $7,350 in total costs for a health insurance plan.
ACA’s requirement that plans cover breastfeeding support
The Patient Protection and Affordable Care Act (ACA) amends the Public Health Services Act to require health insurers to cover certain preventive services for women, including comprehensive lactation support and equipment. While this requirement will not affect grandfathered plans, all non-grandfathered group health plans must include comprehensive lactation support, including the costs of breast-feeding equipment and supplies. This rule also applies to non-grandfathered plans that offer dental and vision coverage.
While breastfeeding is an important national priority, the current patchwork of state and federal law presents an unacceptable patchwork and does not represent a unified commitment to eliminating disparities in breastfeeding care. While ACA’s new coverage is a major step forward from earlier legislation, insurers and providers must continue to prioritize implementing the law effectively. Similarly, more research is needed to determine how insurers comply with the law and ensure that breastfeeding resources are included.
While the ACA has made breastfeeding more affordable and easier, many families will remain largely out of reach. The ACA’s requirement that plans cover breastfeeding support, or SS4207, leaves room for less-than-optimal equipment, counseling, and other supports. However, the ACA’s provisions have contributed to the rise in breastfeeding rates in the US. Currently, a study by the Centers for Disease Control and Prevention (CDC) indicates that breastfeeding rates increased between 2011 and 2014. The ACA’s new guidelines, along with other provisions, can help ensure that women continue to access breastfeeding support.
ACA’s requirement that plans ensure value for premium payments
As of January 2014, the Patient Protection and Affordable Care Act (ACA) has implemented two major requirements for health insurance plans. The first is that they must spend at least 80 percent of the premium payment on health care, while the other five-tenths must go to improving quality of care. Second, they must provide rebates to consumers to offset high administrative costs. Both of these requirements go into effect on January 1, 2014.
Premium tax credits make coverage more affordable for middle-class consumers. These subsidies are calculated based on the difference between benchmark premiums and a specified share of income. For example, those earning between 300 and 400 percent of the poverty level would receive a premium tax credit equal to 9.86 percent of their income. The premium tax credit then covers the rest of the cost of a health plan. This is a valuable tool for helping middle-class consumers afford coverage.
In addition to out-of-pocket costs, the Affordable Care Act prohibits lifetime dollar limits on covered health expenses. These limits were common practice before the law’s enactment. After a certain dollar amount, a plan would stop paying for a health care enrollee’s coverage, leaving those with the highest costs to bear. Thus, the ACA’s prohibition on lifetime dollar limits is a valuable protection for patients with chronic illnesses.