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Every Artist Insured: Navigating the ACA. Artists Health Insurance Resource Center A program of The Actors Fund Renata Marinaro, Eastern Region Health Svcs Director 917-281-5975 , [email protected] Words to know. Co-pay Co-insurance Deductible Premium Out-of-pocket maximum

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Every Artist Insured: Navigating the ACA

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Every Artist Insured: Navigating the ACA

Artists Health Insurance Resource Center

A program of The Actors Fund

Renata Marinaro, Eastern Region Health Svcs Director

917-281-5975, [email protected]

Words to know





Out-of-pocket maximum


Federal Poverty Level


Advanced Premium Tax Credit (aka subsidy)

What has health care reform done for me so far?

  • Children under age 19 with pre-existing conditions can’t be denied coverage.

  • Young adults up to age 26 (in NY, through age 29) can stay on or enroll in their parents’ coverage. Note: special rules apply for coverage from age 26-29.

  • Insurers can’t retroactively cancel the policies of people who get sick.

What has health care reform done for me so far?

  • All new plans must cover certain preventive services for free. These include: certain breast, colon and cervical cancer screenings; blood pressure, diabetes and cholesterol tests; vaccines, immunizations, and flu shots; and HIV & STD testing.

  • Insurers can’t impose annual or lifetime dollar limits on medical benefits.

What happens in 2014?

  • Insurers can’t refuse coverage

    to anyone, or exclude pre-

    existing conditions

  • Most people will be mandated to have coverage or pay a penalty. In 2014, the penalty is $95 or 1% of your income, whichever is greater.

  • Medicaid eligibility in roughly half the states will be expanded to people with incomes up to 138% of FPL (approx $15,856/yr or $1,322 per month)

What happens in 2014?

  • New insurance marketplaces, called Exchanges or Marketplaces, will offer insurance to those who don’t get it through their employer or Medicare.

  • Subsidies will be available to people who buy insurance through an exchange with income less than 400% of the Federal Poverty Level. ($45,960)

  • Enrollment in Exchanges will begin Oct 1, 2013 and end March 31, 2014.

Do I have to have insurance in 2014?

  • YES!! Penalty increases from $95 ($47.50 per child) or 1% of income in 2014 , whichever is greater, to $695 or 2.5% of income in 2016.

  • Exceptions include: Native Americans, those w/religious objections, undocumented immigrants, those who don’t meet tax filing threshold ($9,350 single), people who’ve been uninsured for less than 3 mo.

  • You will file proof of coverage with your taxes.

  • The penalty is prorated by the number of months you’re uninsured.

I’m an employer. Do I have to offer insurance?

  • Employers do not have to offer coverage. However, starting January 1, 2015, those with 50 or more FTE employees will have to pay a penalty if they don’t.

  • If an employee chooses to opt out of an employer’s coverage, they will still have to be insured or pay a penalty.

  • Employees who are offered coverage and choose not to take it will not be eligible for subsidies to pay for coverage through the Marketplace, unless the employer’s plan fails to meet certain benefit guidelines.

What is the small business tax credit and how do I know if I’m eligible?

  • Businesses with fewer than 25 FTEs with average yearly wages of less than $50,000 may qualify.

  • To receive the credit, the employer must offer a group health plan and pay at least 50% of the premium.

  • The credit is equal to a percentage of what the employer pays. For 2014, the maximum credit is 35% of the employer’s contribution (for non-profits), and 50% (for for-profits).

  • For more information: http://www.irs.gov/uac/Small-Business-Health-Care-Tax-Credit-for-Small-Employers

I’m self-employed. How will this affect me?

  • You can buy insurance as an individual on the Marketplace, without having to worry about being turned down for pre-existing conditions, or paying more because of your medical history or gender. This increases your options and will reduce premiums for those with lower to middle incomes.

  • You may qualify for Medicaid if your income is under $15,856 (single).

Where will I buy insurance?

  • If you don’t get it through your job or a public program, you can buy it directly through an insurer, a broker, or through what’s called an Exchange or the Marketplace.

  • An Exchange/Marketplace is an online private insurance marketplace. You can compare plans and buy coverage on the website or apply by mail. Only plans that meet certain quality and affordability guidelines will be allowed to sell on the Marketplace.

  • Marketplaces will also administer the new subsidies and help enroll people in Medicaid and the Child Health Insurance Program (CHIP).

How do I find the Marketplace in my state?

  • In New York, the Marketplace is called New York State of Health. Visit http://www.nystateofhealth.ny.gov/ or call 1-855-355-5777.

  • In California, the Marketplace is called Covered California. Visit http://www.coveredca.com/ or call 1-800-300-1506

  • In all other states, visit www.healthcare.gov or call 1-800-318-2596 to be directed to the Marketplace in your state. This website and phone number will also direct you to local Navigators and In Person Assistors who can help you apply.

When can I enroll?

The initial open enrollment period for plans on the Marketplace is October 1, 2013 - March 31, 2014. In an open enrollment period, you’re free to sign up for a plan or switch plans. Only in limited circumstances will you be able to enroll in or switch plans outside of this period.

Circumstances that would trigger a “special enrollment period” include: losing job-based insurance, losing Medicaid coverage because of an increase in income, marriage, divorce, and the birth or adoption of a child.

Considerations when picking a plan

What will the federally-run Exchange plans look like?

Note that the catastrophic plan is only available to those who are under age 30

What are the federally mandated essential benefits for every state?

  • Outpatient services (such as office visits)

  • emergency services

  • hospitalization

  • maternity and newborn care

  • mental health and substance abuse services

  • prescription drugs

  • rehabilitative services and devices

  • laboratory services

  • preventive and wellness services

  • chronic disease management

  • pediatric services, including oral and vision care

What will the plans look like in NY?

* For all plans except the Bronze and Catastrophic plans, the deductible does not apply to drugs

What are the benefits on the New York Marketplace?

  • Hospitalization

  • Office visits (PCP & Specialist)

  • Emergency Room

  • Ambulance

  • Mental Health treatment

  • Substance Abuse treatment

  • Medications

  • Diagnostic and lab work

  • Preventive Screenings (free)

  • Maternity care

  • Chiropraxis

  • Gym reimbursement!

What will the Covered California plans look like?

* for medical services and drugs ** for medical services only; a separate drug deductible applies

Note that the catastrophic plan is only available to those under age 30

What will HSA plans look like on Covered California?

You can also buy the Silver and Bronze plans with a Health Savings Account (HSA) if you wish. An HSA is like a savings account, but the money is used solely to pay for health care expenses. The deductibles are different than for the Bronze and Silver plans without an HSA.

* for medical services and drugs

What benefits do plans on Covered California offer?

  • Outpatient services (such as office visits)

  • emergency services

  • ambulance

  • hospitalization

  • maternity and newborn care

  • mental health and substance abuse services

  • prescription drugs

  • rehabilitative services and devices

  • laboratory services

  • preventive and wellness services

  • chronic disease management

  • pediatric services, including oral and vision care

  • home health care

What about family coverage?

  • If a company offers coverage to an employee, the company must also offer coverage to children (but not spouses).

  • The employer must make insurance “affordable” to the employee (definition: less than 9.5% of household income) but does not have to offer affordable family coverage.

  • If the employer-offered coverage for the employee is “affordable”, then no matter what the employer charges to cover the employee’s dependents, those dependents will not be eligible for government-subsidized coverage on the Marketplace.

What about family coverage?

  • Dependents (incl. spouses) who decline employer-provided coverage that they cannot afford will not be penalized under the Individual Mandate if the cost of the family coverage exceeds 8% of modified adjusted gross income.

  • All states have the Children’s Health Insurance Program, which covers kids up to age 18. However, eligibility guidelines vary by state. All children in New York – regardless of parents income - are eligible for Child Health Plus (CHIP). The Marketplace website will determine whether your child qualifies for your state program.

What about same-sex married couples?

If you were married in New York or a state that recognizes same-sex marriage, you will be eligible for Medicaid and subsidies based on household income, not single income.

As far as we know, there will be no changes to ADAP/AHIP/APIC in New York

Are there special programs for people under 30?

  • Under age 30: high-deductible plan option. Deductible is $6,350. Prevention benefits and 3 primary care visits are exempt from deductible.

  • Under age 26: can stay on/enroll in parents’ plan, regardless of living situation, marital status, student status, or financial dependence. In NY, adults age 26-29 can stay on their parents coverage, but special rules apply: you must be unmarried, live or work in NY, and have a policy that was issued in NY.

I’m broke. How Will I Afford Insurance?

  • Some states, including New York and California, will expand their Medicaid income eligibility guidelines in 2014. If your income is below 138% of the Federal Poverty Level - which is $15,856 annually for 1 person, and $21,404 for a household of 2 - you will be eligible for Medicaid in those states.

  • Medicaid is a joint federal-state program that provides comprehensive health insurance at no cost to patients. There are no premiums or deductibles, and very small co-pays.

  • To find out what the Medicaid guidelines are in your state, visit www.healthcare.gov

What will it cost to buy coverage on the Marketplace?

  • To view full-cost rates, visit: http://www.dfs.ny.gov/about/press2013/pr1307171_health_rates_2014.pdf

  • People who have low to moderate incomes will receive subsidies (APTC) which will lower the cost of premiums. Some people will also qualify for cost-sharing subsidies. The amount of the subsidy will depend on your household size and income.


  • If your household income is below 400% of the Federal Poverty Level you’ll receive a subsidy. This is equal to an income of $45,960 (single) or $62,040 (couple).

  • You can take the credit in advance, or when you file your taxes. Advance payments are made directly to the insurer.

  • If you choose to wait until you file taxes, the credit will be applied to what you owe, or refunded to you.

  • If the advance subsidy payments exceed the amount of credit for which you’re eligible, a portion of the overpayment must be repaid.


  • The tax credit will be the difference between the premium for the second lowest-cost silver exchange plan in the area and the amount the individual is expected to pay in premiums based on income.

  • You can apply that amount to whatever level plan you choose.

Subsidy Chart


  • Example: Susan is single and makes $22,000/yr. She will have her premiums capped at 6.3% of her income (approx $130/mo) and her annual out-of-pocket medical costs will be limited to under $4000/yr (excluding premiums).

  • New York: calculate your potential subsidy here:

  • http://www.nystateofhealth.ny.gov/resource/tax-credit-and-premium-estimator

  • All other states: calculate your potential subsidy here:

  • http://kff.org/interactive/subsidy-calculator/

For more information visit www.ahirc.org

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