What the Affordable Care Act Means for You

Sept. 27, 2013— -- One of the most hotly debated public health topics during the past few years has been the Patient Protection and Affordable Care Act (PPACA--or ACA, for short), the landmark legislation aimed at reforming our complex health care system. No matter what you think about the issue, the ACA will--or might already--affect you, even if you and your family are currently covered by an employer-sponsored health plan.

A Bird's-Eye Look at ACA's Provisions

If you're already insured, you'll find new benefits and protections. If you are not insured or if you purchase insurance on your own, a new state-based system will help you get coverage that fits your needs, perhaps at a rate more affordable than you could find before. If you choose not to get insurance, however, and aren't covered under an employer's plan, you may have to pay a penalty. The goal of the new system? Preventing situations like the one in which Cindy Crowley has found herself.

When she was laid off from her job at a start-up company in 2012, Crowley, 54, lost her health insurance. Her monthly $2,000 in unemployment needed to cover her mortgage, food, utilities, and car payment, as well as her daughter's college expenses, so she couldn't afford the $400-a-month premium to continue coverage under her employer's plan. Buying her own plan would cost hundreds, if not thousands, more--if she could even find coverage. Crowley knows she's been playing medical roulette.

She has already postponed her annual physical exam and mammogram because she can't afford the out-of-pocket costs. "It's scary," she says. "There are so many ways you can get hurt, and it would be financially catastrophic if something happened to me." (Everybody has different ways of dealing with a major life event. What's Your Coping Style?)

But Crowley can stop rolling the dice on January 1, 2014. That's when the cornerstone of the ACA kicks in: the insurance-coverage requirements. Also, the insurance you can purchase now through a state insurance marketplace takes effect that month, too.

Insurance Shopping Gets Simpler

If your employer (or your partner's employer) doesn't offer health insurance, you're self-employed, or you're unemployed, your new option is state-based health insurance exchanges. Insurance companies will offer individual plans through these marketplaces via Web sites that allow you to easily compare benefits, premiums, and costs. The law requires that plans use simple language to describe what's covered, so it'll be easier to see exactly what you're getting.

Beginning October 1, you'll be able to log on to your state's marketplace, enter the number of people in your household, their ages, whether or not they smoke, your annual family income, and the level of coverage you want, and up will pop an estimated premium for you and yours, as well as the amount of tax credit or subsidy you may be eligible for to help cover some or even most of the cost.

Those tax credits, depending on your income, could slash your monthly premium by more than half. Even a family of four with a household income up to $94,200 (based on 2013 estimates) qualifies for help.

Four health plan levels will be available through the state marketplaces. The plans should all cover the same services but will vary in the level of costs they cover: Bronze covers 60% of medical costs, silver covers 70 percent, gold covers 80 percent and platinum covers 90 percent of medical costs. The lower your out-of-pocket costs, the higher your premium.

So What's Your Level?

That depends on the number of people in your family, your health, and theirs. If it's just you and you're relatively healthy, then a bronze plan may be fine. If you're married and have a couple of kids but you're all healthy, consider silver. If anyone in your family has a chronic health condition or a past medical problem that may recur, you might be better off with gold or platinum. (Wondering whether that nagging pain is a chronic condition? Here are 6 Health Problems To Never Ignore.)

How the Costs Shake Out

Take a family of four with a 45-year-old husband, a 42-year-old wife, two kids under 21, and an annual income of $70,000. They opt for the silver plan, which covers 70% of their health care bills and costs $1,015 a month before subsidies. Subtract the estimated $466 monthly tax credit the government will provide and their monthly cost drops to $549.

Experts called navigators will be available at no charge via phone and online through live chat to help you identify the best plan for you. The navigators are specially trained to walk you through the process. That's important, because what seems like the cheapest plan may actually cost you more, depending on your health care needs.

Another option may be available, depending on your income: Medic-aid. Some states are expanding Medicaid programs to more uninsured people with very low incomes--childless adults and others whose household incomes are up to 138 percent of the federal poverty level (which comes out to $15,856 for a single person; $21,404 for a couple).

If you're not eligible for Medicaid, you can use the marketplaces to get insurance. But there's a glitch in the system: Tax credits to help pay for insurance are available only to those whose household incomes are between 100 and 400 percent of the federal poverty level--so there's currently no financial help for people with incomes of less than $11,490 for a single person or $15,510 for a couple. This may one day be resolved through future legislation.

What's New: Free Preventive Care

Some ACA components have already taken effect--all of which are key for women, says Usha R. Ranji, associate director for Women's Health Policy at the Kaiser Family Foundation in Menlo Park, CA. Nearly one out of five women under age 65 is unable to find or afford health insurance. A major boon, particularly for women, will be free preventive care.

Co-pays for recommended services, including mammograms and Pap tests, as well as breast-feeding support and breast pumps, are free for women who have private insurance. Now many women can get an annual "well-woman" visit, which includes prenatal care and contraceptive counseling, as well as all recommended preventive services, at no cost. Also covered are contraception, HIV and other sexually transmitted disease screenings and counseling, and services such as screening and counseling for domestic violence.

"The well-woman visit is a fantastic opportunity for women to take care of themselves," says Therese Fitzgerald, PhD, who directs the policy and advocacy program at the Connors Center at Brigham and Women's Hospital in Boston. "It's something we may not do because we're so busy taking care of everyone else." (A good topic to breach during those visits is menopause. Click here to read our Complete Guide To Everything You Need To Know About Menopause—but didn't know that you should ask!)

Be AwareYour doctor's office may not know about the free checkups. You may need to offer a reminder.

What We're Getting

Greater access to health insurance If you get health insurance through your employer, send your CEO a thank-you note, because today, companies like yours have no obligation to provide it and face no penalties if they don't. That changes in 2015, however, when employers with 50 or more "equivalent" employees (who work 30 hours or more a week) must provide "affordable" health insurance. That means the portion that you pay can't be more than 9.5% of your household income. (If your household income is $60,000, that makes your monthly premium about $475.) If employers don't offer insurance, they face substantial fines; unlike health insurance premiums, however, the fines are not tax deductible, so employers will take major financial hits for not complying. In addition, small businesses with fewer than 25 full-time employees who make $50,000 or less a year may be eligible for tax credits to help owners purchase health insurance for their employees. Small businesses will also have access to specialized marketplaces called the Small Business Health Options Program (SHOP) that will help them compare the costs and benefits of insurance options for their employees.

Better Coverage

The law requires that all individual and commercial plans cover at least 10 categories of benefits, known as essential health benefits. These include:

All outpatient medical care

Mental health and substance abuse services

Emergency services

Hospitalization

Prescription drugs (For natural remedies that work, check out these 10 Alternatives To The Leading Prescription Drugs)

Pediatric services, including dental and vision care

Rehabilitative (including devices) and "habilitative" care, including autism treatment

Laboratory services

Preventive, wellness, and chronic disease services

Prenatal, maternity, and newborn care

Even if you're not in the baby-making demographic, it's good to know that your daughter or niece is protected. Today, few states require coverage for maternity care in the individual market, leaving millions of women uninsured when they have a baby. Nearly 7.5 million women are expected to gain maternity coverage on the individual market.

Between state Medicaid expansions, health insurance exchanges, and employer mandates, it's estimated that about 19 million women will gain health insurance, with slightly more than half of them eligible for subsidized coverage through the marketplaces. Many are between ages 50 and 64--too young to qualify for Medicare but possibly burdened with significant medical bills.

Visit our ACA Resource Center, packed with links and information and be sure to check out the November issue of Prevention, where we'll run part two of our story about ACA changes coming in January. Our ACA expert, Prevention's editor-at-large Debra Gordon, will host online chats to answer your questions.