Affordable Care Act Information

The Patient Protection and Affordable Care Act (ACA) is a federal statute effective March 2010. It is often referred to as the Affordable Care Act, ACA, “Obamacare” or health care reform. The following information is about programs resulting from the ACA. 

Health Insurance Marketplace
If you are uninsured, purchased individual coverage last year that is or is not being renewed in 2018, or believe your coverage is inadequate or unaffordable, you may wish to apply for coverage directly in the federal Health Insurance Marketplace - a marketplace where you can shop for and compare health benefit plans.

Open enrollment for 2018 coverage in the Marketplace is November 1, 2017 through December 15, 2017. This is the only time to purchase a health plan for 2018 unless you qualify for a special enrollment period.

Healthy Michigan Plan:
Some Michigan residents may be eligible for the Healthy Michigan Plan. To be eligible for the Healthy Michigan plan, you must be:

  • Ages 19-64
  • Not currently eligible for Medicaid
  • Not eligible for or enrolled in Medicare
  • Not pregnant when applying for the Healthy Michigan Plan
  • Earning up to 133% of the federal poverty level
    • The federal poverty level is adjusted annually. In 2017, 133% of the poverty level for an individual was $16,040 or $32,718 for a family of four
  • A resident of Michigan

Financial Help to Purchase Health Care Coverage
Advanced premium tax credits (APTC) are available to assist with the cost of health coverage in the Marketplace for those with income between 100 percent and 400 percent of the federal poverty level who are not eligible for other affordable coverage.

The federal poverty level is adjusted annually. In 2017, 400 percent of the poverty level for Michigan residents is $48,240 for an individual or $98,400 for a family of four.  The 2017 federal poverty level applies to plans purchased for the 2018 plan year. 

Cost-sharing reductions (CSR) are available to individuals that purchase a silver plan on the Marketplace and are up to 250% of the federal poverty level. Those eligible for a CSR silver plan will experience lower out-of-pocket costs, such as lower deductibles, copayments, and coinsurance.

To apply for insurance during open enrollment and see if you are eligible for the APTC or CSR benefit, contact the Marketplace.

Health Coverage Requirement
The “individual mandate” provision of the ACA requires that people obtain health insurance or pay a federal tax penalty. If you currently have coverage from the Healthy Michigan Plan, Medicare, Medicaid, an employer or you have a major medical plan that you purchased yourself, you are considered covered and will not pay a tax penalty.

Those who were uninsured for more than two months in 2017 may pay a federal tax penalty of $695 or 2.5% of their household income.

You may be exempt from paying the penalty for not having coverage if you were uninsured for only one or two months, experienced a financial hardship, religious or moral objection, belong to a Health Care Sharing Ministry, or if it would cost more than 8.16% of your income in 2017 and 8.05% of your income in 2018 to purchase coverage.  The Marketplace provides more information about the exemptions from the requirement to have health insurance.

Essential Health Benefits
The ACA ensures that health plans offered in the individual and small group markets, both inside and outside of the Marketplace, offer a comprehensive package of items and services, known as Essential Health Benefits. Essential health benefits must include items and services within at least the following ten categories:

  • ambulatory patient services
  • emergency services
  • hospitalization
  • maternity and newborn care
  • mental health and substance use disorder services, including behavioral health treatment
  • prescription drugs
  • rehabilitative and habilitative services and devices
  • laboratory services
  • preventive and wellness services and chronic disease management
  • pediatric services, including oral and vision care

Insurance policies must cover these benefits to become certified and offered on the Marketplace. All Medicaid state plans must cover these services as well.

No Denial for People with an Illness or Chronic Condition
An insurance company can no longer turn you down, charge you more or impose a waiting period for coverage because you have a pre-existing medical condition.

No-Cost Preventive Care
Under the ACA, health plans cannot impose any cost-sharing for certain preventive services. Health carriers cannot charge a deductible, copayment, or coinsurance for preventive care services such as flu shots and other immunizations, mammograms and other cancer screenings, diabetes screenings and more.

No Lifetime Limits on Your Health Care Costs
Health carriers are prohibited from setting lifetime limits on significant benefits, such as hospitalization and emergency services.

Extended Coverage for Young Adults
Most health carriers and employers providing dependent coverage to children are required to make coverage available to adult children up to age 26. This applies to adult children who do not have access to coverage from their own job and regardless if they are students, financially dependent on their parents, live with their parents, or are married.

If you are in a health plan for retirees, also known as a retiree-only plan, these plans are exempt from this requirement and do not have to offer coverage for children up to age 26. If you are in a retiree-only plan, check with your plan to determine its policy for covering young adults.

Medicare Prescription Drug Discounts
Seniors who are in the Medicare prescription drug coverage gap known as the “donut hole” will receive discounts on covered prescription drugs and the donut hole will be phased out by 2020.

Help for Small Business
Some small businesses may qualify for a small business tax credit to help offset the costs of providing health insurance for employees. Small businesses may wish to contact a licensed health insurance agent or the Marketplace to assist with purchasing coverage from the SHOP Marketplace.

Disclaimer - The information provided is only intended to be general summary information for the public. It is not intended to take the place of either the written law or regulations. If you have questions about whether a provision applies to your plan, contact your health carrier, plan administrator, employer, or the Department of Insurance and Financial Services - HICAP (DIFS-HICAP@michigan.gov).

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