Affordable Care Act- The Basics

(Updated Dec 2016)

Sources: National Council on Aging), HealthCare.gov, and Get Covered Illinois

Call Center Hours

The Health Insurance Marketplace Call Center is available for customer service support to start or finish an application, compare plans, enroll or ask a question.

SHOP Call Center for customer service support, including assisting employers and employees apply for and enroll in SHOP. Available M-F 8 am to 6 pm CT and on weekends from 8 am to 4 pm CT. Closed on Memorial Day, July 4th, Labor Day, Thanksgiving Day, and Christmas Day.

Health Tax Credit Tool

General Information

ACA logo; float: rightThe Affordable Care Act (or ACA) was signed into Law in March 2010. The key components of the ACA are to strengthen consumers' health care choices and protections, offer a wide-range of insurance coverage options, and make health care insurance affordable and accessible for all Americans.

The ACA requires that almost everyone have a qualifying health insurance policy or have Medicare, Medicaid, TRICARE, or the Children's Health Insurance Program (for children age 18 and younger).

The U.S. Supreme Court ruled in 2012 that it is legal for the ACA to mandate that individuals have health insurance or pay a health insurance tax. In 2015, the U.S. Supreme Court ruled that individuals can receive tax credits for health insurance from either a federal or state-run website used for such purposes.

Changes to the ACA will undoubtedly occur throughout the next few years. This webpage will be updated as changes are passed by Congress and approved by the President.

People with Medicare and TRICARE

People with Medicare and military personnel with most TRICARE health plans do not have to buy any other health insurance. Medicare, even without a supplement, and most TRICARE health plans meet the ACA requirement for individuals to have health insurance, thus the health insurance tax does not apply.

Under the ACA, the existing Medicare-covered benefits will not be reduced or taken away. Beneficiaries also will continue to be able to choose their own doctor.

Additionally, the ACA increased the number of free or low-cost preventive screenings that Medicare beneficiaries may, but are not required to receive, such as mammograms, prostrate tests, and colonoscopies. In addition, a voluntary yearly "Wellness" visit is available.

The ACA reduces the Medicare prescription drug plan donut hole until by 2020 the amount paid by beneficiaries in the donut hole, a hole in the benefit when the beneficiary pays more, will be gradually reduced to 25 percent, the same as the amount paid after the deductable is met.

Under the ACA, doctors who accept Medicare may get additional resources to make sure that medical treatments are consistent.

The ACA will help to extend the life of the Medicare Trust fund that helps pay for hospital-based care to at least 2029, a twelve-year extension than before the ACA was passed.

The ACA helps to reduce waste, fraud and abuse, and Medicare costs by improving and adding additional detection measures. Under the ACA law, these savings will provide Medicare beneficiaries with future savings on premiums and other costs.

People Who Cannot Afford Health Insurance

A subsidy for the monthly premium for health insurance is available for U.S. citizens and legal immigrants (but not undocumented immigrants) with low and moderate incomes in most states. However, not every state expanded their Medicaid eligibility to include this subsidy.

The subsidy for the monthly premium for health insurance, if available in your state, reduces the amount that an individual or family pays for health insurance coverage by providing a tax credit. This subsidy can only be obtained through the health insurance Marketplace. This Marketplace lists competitively priced health insurance policies that meet qualifying standards for the subsidy and avoid the tax penalty for not having health insurance (more details on the Marketplace is below).

The subsidy is determined on a sliding scale, based on income, so that individuals at the lower end of the income scale get the most help. The subsidy is also based on the premium for the second lowest level or silver plans available in a Marketplace- see Health Coverage Tiers at bottom of this page. An individual or family who wants a more expensive or higher tier plan (that is, gold or platinum plans) must pay the difference.

To qualify for a health insurance subsidy through the Marketplace, an individual must:

Marketplace

logo for health care marketplacesThe ACA requires states to create a health insurance Marketplace or use the federal Marketplace where individuals and small businesses can compare and purchase competitively priced health insurance. In Illinois, use Get Covered Illinois. However, individuals can still buy insurance from an insurance private broker or company.

The concept of the health insurance Marketplace is to provide consumers with more control and greater transparency in making their choices about health insurance. People can also enroll in public programs through the Marketplace. The Marketplace uses the power of a large insurance pool, made up of individuals and small businesses, to generate competition among insurance companies to seek better quality plans at a lower cost.

The ACA creates two kinds of Marketplaces: one for individuals and one for small business owners (called SHOP). The ACA delegates primary responsibility for governing and operating the Marketplace to the states, with the federal government setting minimum standards. States have the option to merge the individual and SHOP Marketplaces, partner with other states to form multi-state regional Marketplaces, or form multiple Marketplaces within their state, if each one serves a geographically distinct area.

If a state decides not to run its own Marketplace or does not meet minimum federal standards, then the government can create a federal Marketplace in that state, or find a non-profit entity to run it.

Each marketplace can be reached online, phone, mail, or in person through local and regional health insurance counselors called Navigators, In-Person Assistors, Certified Counselors, and insurance agents & brokers. The national online website is located at Health Care.gov. The national phone number for information about the Marketplace is mentioned above. There is a language line for information in 150 different languages.

Coverage Tiers

Under the ACA, insurance companies will be required to offer insurance plans that fit within tiers: catastrophic, bronze, silver, gold, and platinum. Companies do not have to offer plans in all tiers, but within the health insurance Marketplace, all companies must offer at least one silver and one gold plan.

Each plan in each tier must cover the same set of minimum essential health benefits- greater detail on these benefits will be determined by the government. While the scope of benefits will be the same among the plans, the costs will vary between the differing tier of plans. This means that the monthly premium, annual deductible, and per visit copay will differ in each tier. For example, bronze plans may have a lower monthly premium, but higher annual deductible and/or per visit copay costs.

However, no health plan will be allowed to charge an amount greater than the limits for catastrophic plans. In addition, health plans for small businesses are barred from charging an annual deductible greater than $2,000 per year for individual or $4,000 per year for family coverage. However, the annual $2,000 & $4,000 limits will be annually adjusted for inflation. No health plan can apply cost-sharing for certain preventive health services.

Enrollment Help

Health insurance counselors (sometimes called Navigators, In-Person Assistors, or Certified Application Counselors) help individuals and small businesses compare and enroll in health insurance plans, and provide information about health insurance. Counselors are not allowed to make decisions about insurance, but to point out the available options for individuals and small businesses. Use this link to find Navigators in Southern Illinois or Get Covered Illinois for other regions in Illinois.

Key Enrollment Dates

Mandates & Exceptions

The ACA requires that almost everyone obtain a qualifying health insurance policy. People who are not required to buy health insurance include the following.

ACA Benefits & Prohibitions

Benefits Under the ACA for Everyone:

Prohibited Under the ACA

Large Business Requirements

Use this link for the latest updates.

Small Business Requirements

Use this link to get the latest updates.

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