With all of the new and coming changes to health insurance, it's easy to get bogged down and overwhelmed in the details. Let's take a look at the basics and identify the top 10 questions you may want to make sure you and your loved ones know.

10 health reform questions everyone should know

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1. What is Health Reform?

The Affordable Care Act (ACA), officially known as the Patient Protection and Affordable Care Act (PPACA) but commonly referred to as “Obamacare,” is a collection of new laws. You may have heard people talk about it as “Health Reform.” The laws affect most people, including employers, healthcare providers, individuals, and health plans such as Optima Health. The goal is to improve access to affordable health coverage for everyone, including 31 million Americans currently uninsured.

2. Do I have to purchase health insurance?

Starting in 2014, most people will be required to have health insurance or pay a penalty. Coverage may include employer-provided insurance, individual insurance, or insurance through a government program such as Medicare or Medicaid.

3. What is the penalty if I do not purchase health insurance?

People without insurance will face tax penalties that will be phased in and increased over several years, starting with the 2014 tax filing. The penalty for the 2014 tax year will be $95 or 1 percent of taxable income (whichever is greater). In 2015 the penalty increases to $325 or 2 percent of taxable income, whichever is greater.

4. What is the Exchange?

Beginning 2014, individuals and small group employers (2-50) will be eligible to purchase health insurance through an online marketplace, referred to as the Exchange. The Exchange serves as an aggregator of health plans sold by private insurers (such as Optima Health), where people can compare options, shop, and learn if they are eligible for financial assistance. Think of it as an Expedia or Orbitz for the health insurance market.

5. What is the timing – enrollment periods, effective dates, etc. for the Exchanges (also called the Health Insurance Marketplace or Small Business Health Options -SHOP)?

Virginia is participating in the federally facilitated exchange (FFE). Initial enrollment for the FFE is October 1, 2013 – March 31, 2014. If you enroll by December 15, your effective date will be Jan. 1, 2014. Then, enrollment between the first and fifteenth will be first of following month, sixteenth – end of month enrollment is first day of second following month.

For example:

If you Enroll Effective Date
10/1/13  -  12/15/13 1/1/2014
12/16/13  -  1/15/14 2/1/2014
1/16/14  -   2/15/14 3/1/2014
2/16/14  -  3/15/14 4/1/2014
3/16/14  -  3/31/14 5/1/2014

Off the Exchange, carriers were given the opportunity to create their own open enrollment period, as long as it overlaps with the Exchange’s. Optima Health open enrollment for plans off the Exchange will be the same dates as on-exchange enrollment. Other carriers may choose to extend or shorten their open enrollment period.

6. Is Optima Health participating in the Exchange?

Yes – Optima Health will participate on both the Health Insurance Marketplace for individual plans and the Small Business Health Options Program (SHOP) for small business groups with 2-50 eligible full-time employees. Groups with 51 or more full-time eligible employees will be able to participate on the SHOP in the future.

7. What do I need to do to get ready for 2014? The following is a list of things you can do to make sure you are ready:

  • Educate yourself on the different types of health coverage being offered
  • Find out if your employer will offer coverage or if you need to purchase an individual plan.
  • Are you under age 26? You may be able to stay on a parent’s health plan until you reach age 26.
  • Understand how deductibles, copayments, and coinsurance work
  • Gather information on your household income – can you qualify for a subsidy or cost-sharing reduction or other government program (Medicare/Medicaid)?
  • Set your budget. Larger premiums usually mean lower out-of-pocket costs for prescription drugs, office visits, and procedures, and vice versa. How much of a premium can you afford, and how much can you spend out of pocket for Deductibles, Coinsurance, and Copayments?
  • Individuals and small groups should consider renewing early (December 1). Please check with your sales representative for details.

8. How do I get discounted (commonly referred to as “free”) health insurance?

Depending on your income level and other factors, you could qualify for Medicaid, Medicare, or a subsidy through the Health Insurance Marketplace (also known as the Exchange). To estimate your eligibility, go to the Kaiser subsidy calculator located at http://kff.org/interactive/subsidy-calculator/.  

Persons in family/household

100% FPL

250% FPL

300% FPL

400% FPL

For families/households with more than 8 persons, add $4,020 for each additional person.

1 $11,490 28,725 34,470 45,960
2 15,510 38,775 46,530 62,040
3 19,530 48,825 58,590 78,120
4 23,550 58,875 70,650 94,200
5 27,570 68,925 82,710 110,280
6 31,590 78,975 94,770 126,360
7 35,610 89,025 106,830 142,440
8 39,630 99,075 118,890 158,520

9. Are rates going up?

The primary two reasons contributing to growing premiums among all health insurers are the rising costs of healthcare costs due to normal medical inflation, and the Affordable Care Act (ACA). More specifically, the ACA requires Optima Health and all insurers to offer benefits that were not previously covered, to charge taxes and fees to fund the ACA, and to restrict insurers from turning away customers with pre-existing conditions.

10. Where can I go for information?

You can speak with an Optima Health representative, your employer’s benefits administrator, or your broker. For more information: