Shopping for ACA health insurance? What’s new this year?

It reads again, shorter days, cooler temperatures and open enrollment to buy health insurance in the marketplaces established by the Affordable Care Act (ACA).

Buying now means coverage effective January 1, 2023. While most plans remain the same from year to year, there are some changes that consumers should be aware of, especially if they are struggling to afford expensive policies through their home.

Last year, the Biden administration and Congress took steps, primarily related to premiums and subsidies, that will affect coverage in 2023. Meanwhile, confusion caused by the court’s decision may cast doubt on coverage of preventive care or abortion services.

Open enrollment for those who purchase health insurance through the Marketplace begins November 1st and, in most states, lasts until January 15th. To begin coverage on the first day of 2023, enrollment must generally occur before December 15.

Many people who get coverage through their jobs must select a plan this time of year. And your decisions may be affected by the new ACA rules.

So what’s new and what should you know when you buy? Here are five things to keep in mind.

1. Some families who did not qualify for ACA subsidies are now eligible

One big change is that some families who were previously unable to access these federal subsidies may now be eligible to help them buy ACA coverage.

A rule recently finalized by the Treasury Department called the “family fault.” The change expands the number of families with work-based insurance who can qualify for subsidies to give up that coverage and get an ACA plan instead.

The White House estimates the adjustment could help nearly 1 million people get coverage or more affordable insurance.

Previously, employees could qualify for a Marketplace insurance subsidy if the cost of their employer’s coverage was deemed unaffordable based on a threshold set each year by the IRS.

But that determination only took into account how much a worker would pay for insurance on their own. The cost of adding family members to the plan was not part of the calculation, and family coverage is generally much more expensive than employee-only coverage.

Families of employees who fall into the “failure” are either uninsured or pay more for coverage through their jobs than if they could get ACA subsidies.

Now, the rule says that subsidy eligibility must take into account the cost of family coverage.

“For the first time, many families will have a real choice between an employer-sponsored coverage offer and a subsidized plan from the marketplace,” said Sabrina Corlett, a researcher and co-director of Georgetown University’s Center for Health Insurance Reform.

Workers will now be able to receive subsidies from the marketplace 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 on the employer’s plan because their payment for coverage falls below the affordability threshold, but family members will be able to get ACA-subsidized plans.

Previous legislative efforts to fix the “family fault” have failed, and the Biden administration’s use of regulation to fix it is controversial. The measure could eventually be challenged in court. Still, the rules are in place for 2023, and experts including Corlette say families who could benefit should go ahead and sign up.

“It’s going to take a while to figure it out,” he said, adding that a timely decision affecting 2023 policies is unlikely.

An Urban Institute analysis published last year estimated that the net savings per household could be about $400 per person, and that the new subsidies would cost the federal government $2.6 billion a year.

Not all families will save money by switching, so experts say people should weigh the benefits against the potential costs.

2. Preventive care will continue to be covered with no copays, but abortion coverage will change

Many people with insurance are happy when they get a cancer screening test or other preventive care and find that they don’t have to pay anything out of pocket. It stems from an ACA provision that prohibits cost sharing for various preventive services, including certain tests, vaccines and drugs.

But a September ruling by U.S. District Judge Reed O’Connor in Texas has created confusion over what could be covered next year. Judge declares unconstitutional use of government to prescribe certain preventive treatments that are included without cost-sharing for patients.

Ultimately, this may mean that patients have to pay a portion of the cost of cancer screening tests or drugs that prevent HIV infection.

The judge has not yet ruled on how many people the case will affect. However, for the time being, this ruling applies only to traders and individuals who file cases. Then don’t worry. Your free mammogram or colonoscopy is still free. The ruling may be appealed with a decision expected before the start of the 2023 coverage year.

Another judicial decision that has raised doubts 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 ban or restrict abortion.

State rules for insurance vary.

26 states limit abortion coverage to ACA marketplace plans, while seven require it as a benefit in both marketplace 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 refer to health plan documents for information on covered benefits, including abortion services.

3. Premiums are rising, but this may not affect most people with ACA plans

Health insurers are raising premiums for both ACA plans and employer coverage. But most people who receive market subsidies will not experience it.

This is because the subsidy is tied to the cost of the second cheapest silver plan offered in a marketplace. (Marketplace plans are offered in metal “tiers” based on potential out-of-pocket costs for policyholders.)

As the costs of those basic silver plans rise, so do the subsidies, offsetting all or most of the premium increase. Nevertheless, shopping around, experts advise. Changing plans can be profitable.

As for subsidies, the passage this summer of the Inflation Reduction Act ensured that the increased subsidies that many Americans received under the law related to the Covid-19 pandemic will remain in place.

People earning 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 premiums. Consumers earning 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% should not spend more than 8.5% of their family income on premiums.

For those who have insurance through work, employers typically determine the amount workers will pay for their coverage. Some can “afford” rising costs by increasing the amount taken out of their paychecks for premiums, setting higher deductibles, or changing health care benefits.

But anyone whose employer share of insurance premiums is expected to exceed 9.12% of their income can check to see if they qualify for a subsidized ACA plan.

4. Will not close debt coverage with insurance companies or the IRS

This is thanks to covid. Generally, people who receive subsidies to buy ACA plans must prove to the government on their next tax return that they received the correct subsidy based on actual income. If they don’t coordinate with the IRS, policyholders will lose subsidy eligibility the next time they sign up.

But, due to ongoing Covid-related problems with IRS return processing, those consumers will receive another relief, continuing efforts set forth by the American Rescue Plan Act for fiscal year 2020.

Additionally, insurers can no longer deny coverage to individuals or employers who owe excess premiums for prior coverage, said Karen Politz, a senior researcher at KFF. The decision came after a review of 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 be allowed to re-enroll in 2023,” Politz said. “And when they make the first month’s premium payment to activate coverage, the insurer must apply that payment to their January 2023 premium.”

5. It will probably be easier to compare prices

Although ACA plans have always been required to cover a wide range of services and provide similar benefits, patients have varied in the amount paid for office visits and other out-of-pocket costs.

Starting with open enrollment this year, new rules will go into effect aimed at making comparisons easier Under these rules, all ACA health insurers must offer a set of plans with specific and standardized benefits. Standard plans will have, for example, the same deductibles, copays and other cost-sharing requirements. They will offer more coverage before a patient starts paying a deductible.

Some states, such as California, already required similar standardization, but the new rules apply nationwide to health plans sold on the federal marketplace, healthcare.gov. Any insurer offering a non-standard plan in the market must now offer standard plans

Under a different set of rules, starting Jan. 1, all health insurers must make cost comparison tools available online or by phone that can help patients predict their costs for 500 “services that can be purchased,” such as knee joint repairs, A colonoscopy, a chest X-ray, or childbirth.

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