It’s fall again, which means shorter days, cooler temperatures, and open enrollment for Affordable Care Act Marketplace insurance — sign-ups begin this week for coverage that begins January 1, 2023. While much of the coverage remains the same year over year, there are some upcoming changes that consumers should note this fall, especially if they have trouble buying expensive policies through their employer.
Over the past year, the Biden administration and Congress have taken steps — mainly related to premiums and subsidies — that will affect 2023 coverage. Meanwhile, the confusion caused by the court’s decision could raise questions about coverage for preventive care or abortion services.
Open enrollment for people who buy health insurance through the marketplace begins Nov. 1 and, in most states, runs through Jan. 15. To get coverage starting on January 1, enrollment must normally be by December 15
Many people who get coverage through their jobs also need to select a plan this time of year. And their decisions may be affected by new ACA rules.
So, what’s new, and what should you know if you’re shopping? Here are five things to keep in mind.
1. Some families who did not qualify for ACA subsidies now do
One big change is that some families who were barred from getting federal subsidies to help them buy ACA coverage can now qualify.
A rule recently finalized by the Treasury Department was designed to address what has long been called the “family problem.” The change expands the number of families with job-based insurance who can qualify for subsidies to give up their coverage at work and get an ACA plan instead. The White House estimates the adjustment could help nearly 1 million people gain coverage or get more affordable insurance.
Previously, employees could qualify for subsidies for Marketplace insurance if the cost of their employer-based coverage was deemed unaffordable based on thresholds set each year by the IRS. But that determination only took into account how much a worker would pay for insurance for himself or herself. The cost of adding family members to the plan was not part of the calculation, and family coverage is often much more expensive than employee-only coverage. Employees whose families fall into the “story” are either uninsured or pay more for coverage through their jobs if they are able to get ACA subsidies.
Now, rules say subsidy eligibility must take into account the cost of family coverage.
“For the first time, many families will have a real choice between employer-sponsored coverage and a marketplace plan with subsidies,” said Sabrina Corlett, researcher and co-director of the Center on Health Insurance Reforms at Georgetown University.
Workers will now be able to receive Marketplace subsidies if their share of premiums for job-based coverage exceeds 9.12% of their expected 2023 earnings.
Now, two calculations will occur: the cost of employee-only coverage as a percentage of the worker’s income, and the cost of adding family members. In some cases, the worker may decide to stay in the employer’s plan because his or her payment for coverage falls below the affordability threshold, but family members will be able to get a subsidized ACA plan.
Previous legislative efforts to fix the family problem have failed, and the Biden administration’s use of the regulation to fix it is controversial. The move could eventually be challenged in court. Still, the rules remain in effect through 2023, and experts, including Corlette, say families who could benefit should go ahead and enroll.
“It’s going to take a while to resolve it all,” he said. It adds that no decision is likely to be made in time to affect the 2023 policies.
An Urban Institute analysis published last year estimated that the net savings per household could be about $400 per person and that the federal government’s new subsidies would cost $2.6 billion a year. Not every family will save money by switching, so experts say people should consider the benefits and potential costs.
2. Preventive care will still be covered without a copay, but abortion coverage will change
Many people with insurance are happy when they go for cancer screenings, or seek other preventive care, and find that they don’t have to pay anything out of pocket. This stems from a provision in the ACA that bars cost-sharing for a range of preventive services, including certain tests, vaccines and drugs. But a September ruling by U.S. District Judge Reed O’Connor in Texas has sparked confusion over what could be covered next year. The judge declared unconstitutional a system the government uses to prescribe certain preventative treatments that are covered without patient cost-sharing.
Ultimately, this may mean that patients have to pay a portion of the cost of cancer screenings or drugs that prevent HIV infection. The judge has not yet ruled on how many people the case will affect. But, for now, this ruling applies only to employers and individuals who have brought cases. So, don’t worry. Your no-cost screening mammogram or colonoscopy is still no cost. The ruling may be appealed and a decision is not expected before the start of the 2023 coverage year.
Another court decision that has been questioned is the Supreme Court ruling that struck down the constitutional right to abortion. Even before that decision was announced in June, coverage of abortion services in insurance plans varied by plan and state.
Now it’s even more complicated as more states move to ban or restrict abortion.
State insurance rules vary.
26 states limit abortion coverage to ACA marketplace plans, while seven states require it as a benefit in both ACA plans and employer plans purchased from insurers, according to KFF. These states are California, Illinois, Maine, Maryland, New York, Oregon, and Washington.
Employees and policyholders can check insurance plan documents for information about covered benefits, including abortion services.
3. Premiums are rising, but this may not affect most people on ACA plans
Health insurers are raising premium rates for both ACA plans and employer coverage. But most people who get subsidies for ACA coverage won’t feel that pinch.
That’s because the subsidy is tied to the cost of the second-cheapest “silver” plan offered in a marketplace. (Marketplace plans are offered in colored “tiers,” based on how much out-of-pocket costs policyholders incur.) As the cost of those baseline silver plans rises, so do subsidies, offsetting all or most of the premium increase. Nevertheless, shopping around, experts advise. Changing plans can be cost-effective.
As for subsidies, the passage this summer of the Inflation Reduction Act ensured that the increased subsidies that many Americans received under the law tied to the Covid-19 pandemic would remain in place.
Individuals who earn up to 150% of the federal poverty level — $20,385 for an individual and $27,465 for a couple — can get an ACA plan with no monthly premium. Consumers who earn up to 400% of the federal poverty level — $54,360 for an individual and $73,240 for a couple — receive sliding scale subsidies to help offset premium costs. Those whose income is more than 400% will not have to pay more than 8.5% of their family income for premium.
For those with job-based insurance, employers typically determine the amount employees must pay for their coverage. Some employers can offset rising costs by increasing the amount taken out of paychecks to go toward premiums, setting higher deductibles, or changing health care coverage. Benefits But anyone whose share of job-based coverage is expected to exceed 9.12% of their income can see if they qualify for a subsidized ACA plan.
4. Will not terminate coverage of insurers or the IRS
Thanks to covid for that. Generally, those who receive subsidies to purchase ACA plans must prove to the government in their next tax filing that they received the correct subsidy based on actual income. If they fail to coordinate with the IRS, policyholders will lose eligibility for the subsidy the next time they enroll. But, due to ongoing Covid-related issues with return processing at the IRS, those consumers will get another recoup, continuing efforts set for tax year 2020 by the American Rescue Plan Act.
Also, insurers can no longer deny coverage to individuals or employers who owe past due premiums for previous coverage, said Karen Politz, a senior fellow at KFF. It reexamines a variety of Medicare and ACA rules prompted by President Joe Biden’s April executive order.
“If people fall behind on their 2022 premiums, they should still be allowed to re-enroll in 2023,” Pollitz said. “And when they make a first-month premium payment to activate coverage, the insurer must apply that payment to their January 2023 premium.”
5. Comparison shopping will probably be easier
Although ACA plans have always been required to cover a wide range of services and provide similar benefits, disparities still exist between what patients pay for office visits and other out-of-pocket costs. Starting with this year’s open enrollment period, new rules have been implemented to facilitate comparisons Under the rules, all ACA health insurers A set of plans should be offered with specific, standardized benefits. Standard plans, for example, will have the same deductibles, copays, and other cost-sharing requirements. They will offer more coverage before a patient has to start paying toward a deductible.
Some states, such as California, already require similar standardization, but the new rules apply nationally to health plans sold on the federal marketplace, healthcare.gov. Any insurer offering a non-standard plan in the marketplace must now also offer a standard plan.
Under a different set of rules, starting Jan. 1, all health insurers must make cost-comparison tools available online or over the phone that can help patients predict their costs for 500 “shoppable services,” such as a knee joint repair, a colonoscopy, a chest X-ray. -ray or delivery.
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