Your Guide to the New Insurance Marketplaces
What will the coverage sold on the exchanges look like?
Plans will have to offer a set of "essential benefits” that include hospital, emergency, maternity and pediatric care as well as coverage for prescription drugs and lab services. Annual cost-sharing -- or the amount consumers pay for out-of-pocket for care for medical services and deductibles but not premiums-will be capped at $6,350 for individual policies and $12,700 for family plans in 2014.
What if I can't afford the premiums?
The health law provides sliding scale subsidies to help people pay premiums up to 400 percent of the poverty level, which is currently about $46,000 for an individual and about $94,000 for a family of four. There’s also help with cost-sharing for individuals and families with incomes of up to 250 percent of the poverty level ($28,725 for an individual or $58,875 for a family of four). According to government estimates, subsidies will average $5,290 per person in 2014. Recipients must pay a portion of their household income - 2 percent to 9.5 percent - toward the cost of the premium, based on how much they make.
Does everyone on the exchange get a subsidy?
No, subsidies will be limited to people who meet specific income requirements. In addition, individuals with access to insurance through their jobs but who decide to purchase insurance on the exchange instead are eligible for subsidies only if their employer’s plan does not cover at least 60 percent of estimated medical expenses or if it would cost the worker more than 9.5 percent of household income.
The health law also expands Medicaid. How will I know if I qualify?
The law sought to extend Medicaid to all people who earn less than 138 percent of the federal poverty level, just under $16,000 for an individual and $32,500 for a family of four based on current guidelines. However, the Supreme Court ruled in June 2012 that states may opt out of that Medicaid expansion, and 21 states have chosen not to expand People who would have qualified for Medicaid in states that don’t participate in the health law’s expansion can enroll in the exchanges but they won’t qualify for subsidies if their income is below 100 percent of the federal poverty limit.
Mon, Sep 16 2013