o The “Individual Mandate” requires all individuals (with some limited exceptions) to have qualifying health coverage or pay a tax penalty.
o For 2017, the penalty was either 2.5% of your household income or $695 per adult and $347.50 per child, whichever is higher. If you’re uncovered just some months of the year, you pay 1/12 of the penalty for each month you are uninsured.
- You may be exempt if:
- You are uninsured for less than three months per year.
- You have a very low income.
- You would qualify for expanded Medicaid in a state that has chosen not to expand eligibility.
- You are a member of a recognized American Indian tribe
- You belong to a health care sharing ministry.
- You have religious objections to health insurance.
o As of right now, the individual mandate will no longer be in effect in 2019 and failing to be insured will not result in a tax penalty.
o Minimum Essential Coverage Standards (MEC) means that a plan must have Actuarial Value of 60% or more and cover 10 Essential Health Benefits
o Actuarial Value – Equal to the percentage of total average costs for covered benefits that a plan will pay.
- The insurer/carrier will pay an average of 60% of all of the covered medical costs on the plan and you would be responsible for 40% of covered medical costs until you reach your plan’s cost-sharing or out-of-pocket limit.
o 10 Essential Benefits (EHBs)
- Laboratory Services
- Emergency services
- Prescription Drugs
- Mental Health & Substance Abuse Services
- Maternity & Newborn Care
- Pediatric Services – Including Oral and Vision care
- Rehabilitative & Habilitative Services and Devices
- Ambulatory Patient services
- Preventative & Wellness Services and Chronic Disease Management
o Certain types of preventative care must be covered at no additional costs to the patient. Click here to see a full list of free preventative services that must be covered.
o Insurers may not cancel policies in response to an illness
o Individuals may not be denied coverage for pre-existing conditions. Insurers must offer the same premiums within the same age and geographical group regardless of gender(except for tobacco use)
o Annual and lifetime dollar limits on care are prohibited
o Insurers are required to provide individuals with a standardized, plain-language summary of benefits (SOBs) that are easy to understand
o Rate increases of more than 10 percent must be publicly justified; 80 percent of premiums must be spent on actual health care services
o Patients are free to choose any physician within the plan’s network and may use an out-of-network emergency room without penalty
o Patients are granted the right to appeal whenever an insurer denies payment for health care services.
o Dependents may be covered by their parents’ insurance plans until they turn 26
o Medicaid eligibility expands to include those earning 133% of the official poverty level, including dependents (in participating states)