Written by Julie Appleby,
word in black
It’s dropping again, which means shorter days, cooler temperatures, and open enrollment to secure the Affordable Care Act market—subscriptions begin this week for coverage beginning January 1, 2023. Although much of the coverage remains the same from year to year Else, there are a few changes coming consumers should note this fall, especially if they’re having trouble purchasing expensive policies through their employer.
In the past year, the Biden administration and Congress have taken steps — primarily related to premiums and subsidies — that will affect coverage for 2023. Meanwhile, confusion caused by court decisions may raise questions about coverage for preventive care or abortion services.
Open enrollment for people who buy health insurance through the markets begins on November 1, and in most states, it lasts until January 15. For coverage beginning January 1, registration must normally be completed by December 15.
Many people who have secured coverage through their jobs should also choose a plan at this time of year. And their decisions could be affected by the 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 that were not eligible for ACA benefits do so now
One big change is that some families who were denied federal benefits to help them buy ACA coverage may now qualify.
A final rule was recently put in place by the Treasury to address what has long been called “family dysfunction.” The change expands the number of families with job-based insurance that can choose to forgo their coverage at work and qualify for benefits for an ACA plan instead. The White House estimates that this amendment could help about 1 million people obtain coverage or obtain more affordable insurance.
Previously, employees were eligible for market insurance support only if the cost of employer-based coverage was unaffordable based on a threshold set by the IRS each year. But this decision took into account only the amount that the worker would pay for insurance for himself. The cost of adding family members to the plan was not part of the calculation, and family coverage is often much more expensive than just employee coverage. Families of employees who fall into the “glitch,” either go without insurance or pay through their jobs for coverage more than they would have paid if they were able to get ACA support.
Now, the rules state that eligibility for support must take into account the cost of family coverage.
“For the first time, many families will have a real choice between offering employer-sponsored coverage and a market plan with benefits,” said Sabrina Corlett, a researcher and associate director at Georgetown University’s Center for Health Insurance Reforms.
Workers will now be able to receive market benefits if their share of work-based coverage premiums exceeds 9.12% of their projected 2023 income.
Now, two calculations will be made: the cost of covering the employee only as a percentage of the worker’s income and the cost of adding family members. In some cases, a worker may decide to stay on their employer’s plan because their payments for coverage fall below the affordability limit, but family members will be able to get a subsidized ACA plan.
Previous legislative efforts to resolve the family’s dysfunction have failed, and the Biden administration’s use of regulation to fix it is controversial. This move may eventually be challenged in court. However, the rules are in place for 2023, and experts, including Corlett, said families who could benefit should go ahead and enroll.
“It will take some time for all of that to be resolved,” she said, adding that it is unlikely that there will be any decision in time to influence 2023 policies.
An urban institute analysis published last year estimated that net savings per household could be about $400 per capita and that the cost to the federal government for the new benefits would be $2.6 billion annually. Not every family will save money by making the change, so experts say people should weigh the potential benefits and costs.
2. Preventive care will still be covered without co-pay, but abortion coverage will vary
Many people with insurance are happy when they go for a cancer screening, or seek other preventative care, and find that they don’t have to pay anything out of their own pockets. That comes from a provision in the ACA that forbids cost-sharing for a range of preventative services, including some tests, vaccines and medications. But the September ruling by Texas District Judge Reed O’Connor led to confusion about what could be covered next year. The judge declared unconstitutional one of the methods the government uses to determine which preventative treatments are covered without patient sharing of costs.
Ultimately, it may mean that patients will have to start paying a share of the cost of cancer screenings or drugs that prevent HIV transmission. The judge has yet to rule on how many people the case will affect. But for now, the ruling only applies to employers and individuals who have filed the lawsuit. So don’t worry. A mammogram or colonoscopy is still free of charge. The ruling is likely to be appealed, and a decision is not expected before the start of the coverage year in 2023.
Another court decision that raised questions was the Supreme Court ruling that overturned the constitutional right to abortion. Even before that decision was announced in June, coverage of abortion services in insurance plans varied by plan and by state.
Now it’s more complicated as more countries move to ban or restrict abortion.
State insurance rules vary.
Twenty-six states restrict abortion coverage in ACA Marketplace plans, while seven states require it as a feature in both ACA and insurer-purchased employer plans, according to the 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 going up, but this may not affect most people on ACA plans
Health insurers raise premium rates for both ACA plans and employer coverage. But most people who receive benefits for the ACA will not feel this hardship.
That’s because the support is tied to the cost of the second cheapest “silver” plan on the market. (Market plans are offered in colored “layers,” based on how much they could potentially cost policyholders out of pocket.) As the cost of basic silver plans increases, so does the subsidy, offsetting all or most of the premium increases. Still, shopping, experts advise. Switching plans can be cost-effective.
As for subsidies, the passage of the Inflation Reduction Act this summer ensured that the boosted benefits many Americans received under the COVID-19-related legislation would remain in place.
People who earn up to 150 percent of the federal poverty level — $20385 for an individual and $27,465 for a couple — can get an ACA plan without a monthly premium. Consumers who earn up to 400 percent of the federal poverty level — $54,360 for an individual and $73,240 for a couple — receive tiered benefits to help offset the costs of premiums. People with income over 400 percent are required to pay no more than 8.5 percent of their family income toward insurance premiums.
For those who have work-based insurance, employers generally specify how much workers must pay for their coverage. Some employers may pass on increased costs by increasing the amounts from their salaries to direct them toward premiums, setting higher deductibles, or changing health care benefits. But anyone who expects their share of job-based coverage to exceed 9.12 percent of their income can check to see if they qualify for a subsidized ACA plan.
4. Debt to insurance companies or the IRS will not stop coverage
Thanks covid for this. Typically, people who receive subsidies to purchase ACA plans must prove to the government in their next tax file that they received the correct subsidy, based on the income they already received. If they fail to reconcile this with the IRS, policyholders will lose their eligibility for support the next time they register. But, given the ongoing covid-related problems with processing returns in the IRS, these consumers will receive another deferment, while continuing efforts laid out for tax year 2020 under the US bailout act.
Karen Politz, a senior fellow at KFF, said insurers can no longer refuse coverage to people or employers who owe premiums for previous coverage. It comes after a wide range of Medicare and ACA rules were reexamined based on an April executive order from President Joe Biden.
“If people default on their 2022 installments, they should be allowed to re-enroll in 2023,” Politz said. “And when they pay the first month’s premium to activate the coverage, the insurance company must apply that payment to the January 2023 premium.”
5. Comparison shopping will likely be easier
Although ACA plans have always been required to cover a wide range of services and provide similar benefits, there is variance in the amounts patients pay for office visits and other out-of-pocket costs. Starting with this year’s open enrollment, new rules intended to make comparison easier are in effect. Under the rules, all ACA health insurers must offer a set of plans with defined, standardized benefits. Standard plans, for example, will have the same deductions, joint costs, and other cost-sharing requirements. They will also offer more coverage before a patient starts paying for a discount.
Some states, such as California, have already requested similar standardization, but the new rules apply nationally to health plans sold on the federal market, health.gov. Any insurance company that offers a non-standard plan in the market now must also offer the standard plans as well.
Under a different set of rules, starting January 1, all health insurers are required to provide online or telephone cost comparison tools that can help patients predict their costs for 500 “shoppable services”, such as a knee joint repair. colonoscopy, chest x-ray, or childbirth.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and survey, KHN is one of the three major drivers of KFF (Kaiser Family Foundation). KFF is a non-profit organization that provides information on health issues to the nation.
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