AFFORDABLE
CARE ACT
(ACA) Presented
By
ANDREW H. HOOK, CELA, CFP®, AEP
®
Tel: 757-399-7506 | Fax: 757-397-1267 | www.hooklawcenter.com
295 Bendix Road, Suite 170, Virginia Beach, VA 23452
5806 Harbour View Blvd., Suite 203, Suffolk, VA 23435
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PURPOSE
Increase number of people with HI
Increase Standards Of Coverage
Tax Credits
Subsidies
Penalties
Complex
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Expansion Of Medicaid, i.e., 11 Million
$138 FPL
Marketplaces (previously Exchanges)
Individual Mandate
Employer Mandate
Small Employer
Large Employer
MECHANISM
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MINIMUM ESSENTIAL COVERAGE
(MEC) Medicare Part A
Medicaid
CHIP
TRICARE
VA Plan
Peace Corp
Employer-Sponsored Plan
Offered In State Market
Grandfathered Plan
Other – HHS Approved
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HI Marketplaces
State
State/Federal
Federal
Assistance - Individuals & Small Groups
Comparison Shop
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ESSENTIAL HEALTH BENEFITS
(EHB)
Ambulatory Services
Emergency Services
Hospitalization
Maternity/Newborn Care
Mental Health/Substance Abuse
Prescription Drugs
Rehabilitative & Habilitative
Laboratory
Preventive & Wellness
Chronic Disease Management
Pediatric Including Oral & Vision
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Required Through Exchanges
Not Required Outside Exchanges
No Specific Benefits Within Categories
State-by-State Basis
Cost Sharing 2013
Deductibles, Co-Pays, etc.
$12,500 Family
$ 6,250 Individual
ESSENTIAL HEALTH BENEFITS
(EHB) con’t
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COVERAGE LEVELS
Metal Tiers
Platinum - 90%
Gold - 80%
Silver - 70%
Bronze - 60%
Catastrophic Plans
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ELIGIBILITY FOR VARIOUS
PROGRAMS
Are Individuals Eligible To Apply?
Eligible For Affordable Employer HI,
Medicaid, CHIP Or Other Government
Programs?
Qualify For Premium Assistance Credit Or
Cost-Sharing Reduction?
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PREMIUM ASSISTANCE
Low & Moderate Income
100% – 400% FBL
Exchange Only
Tax Credit
Can Be Applied Toward Premiums
Inapplicable to Employer and Union Plans
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SUBSITY: METAL TIERS
Silver Plan - 30%
Household Income Increase AV
From100-150% FPL 94%
Over150-300% FPL 87%
Over 200-250% FPL 73%
HHS Pays Insurer The Difference
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OPEN ENROLLMENT
October 1, 2013 to March 31, 2014
December 15, 2014 = Coverage 1-1
After December 15th –
First Day of 1st or 2nd Month, then,
October 15, 2013 to December 7, 2014
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INDIVIDUAL MANDATE: WHO MUST BE COVERED & ASSISTANCE
Everyone Except:
Religious Exemption
Non-US Citizens or Nationals & Illegal
Immigrants
Incarcerated Individuals
Assistance
Subsidy
Tax Credits
Exchanges Only
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INDIVIDUAL MANDATE: PENALTY
The Lesser of:
Flat $ - OR -
% of Income
Flat $ Monthly - Individual
$ 95 – 2014
$325 – 2015
$695 – 2016
1% (for 2014)of Household Income over a
threshold gross amount
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SMALL EMPLOYER
49 or Fewer Employees
No Penalty
2-Year Tax Credit
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SMALL EMPLOYER: TAX CREDIT
Two Years Only
Full Credit Up To 50%
10 or Fewer Employees
$25,000 Average Wage
Phase Out
11-25 Employees
Average Wage Of $25,000 - $50,000
Exchange Policies Only
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DEDUCTIBLE
$4,000 Family
$2,000 Individual
Applies To Small Group Plan
Does Not Apply To Large Group Plan
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LARGE EMPLOYER
50+ FTE
Minimum Essential Coverage (Not EHB)
Affordable
9.5% Household Income - Individual
Coverage
Cover FTE (30 hrs) + Dependents
Penalty
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LARGE EMPLOYER: PENALTY
Failure to offer Minimum Essential Coverage
(MEC)
Employee-Enrolled Individual Coverage In
Exchange Premium Assistance Credit Or
Cost-Sharing Subsidy
$2,000 For Each Employee Over 30 Threshold
Example: Employers In Medicaid, CHIP, Or
Other Government Programs
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LARGE EMPLOYER: PENALTY – UNAFFORDABLE COVERAGE
$3,000 Per Year, Per Employee
Per FTE, Enrolled In QHF Through Exchange
Cap Cannot Exceed Penalty For Failure
To Provide Minimum Essential Coverage (MEC)
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PROVISIONS APPLICABLE
TO ALL PLANS
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MEDICAL LOSS RATIO
Adjusted Premiums
Large Group
85% Claims & Quality Improvement
15% Overhead
Small Group & Individuals
80% Claims & Quality Improvement
20% Overhead
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CAPS
Group Plans Only
No Lifetime Caps
No Annual Caps
Restrictions On Number Of Visits & Treatments
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MISCELLANEOUS Waiting Period - 90 Days Maximum
PRE-EXISTING CONDITIONS
No Rescission Except Fraud
Preventive Coverage – No Co-Pay
Choice of Primary Care Provider
Medical Deductible - 10% AGI
Coverage – Child Under 26-Years-Old
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CONCLUSION
ACA Evolving
Pre-Existing Conditions
Future Medicals
Coverage
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Estate Planning
Asset Protection Planning
Life Care Planning
Long-term Care Planning
Veterans Benefits
Financial Planning and Advice
regarding Investments,
Insurance, Annuities, Reverse
Mortgages, and Equity Lines
Tax Planning
Guardianships and
Conservatorships
Estate and Trust Administration
Special Needs Trusts
Care Management Services
Business Planning and
Succession Planning
Tel: 757-399-7506 | Fax: 757-397-1267 | www.hooklawcenter.com
295 Bendix Road, Suite 170, Virginia Beach, VA 23452
5806 Harbour View Blvd., Suite 203, Suffolk, VA 23435
Thank You!
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