Affordable Care Act: What You Need to Know

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Affordable Care Act: What You Need to Know . Disability Rights NC is a nonprofit law firm that provides free legal and advocacy services for people with disabilities throughout all 100 counties of North Carolina
Affordable Care Act:What You Need to Know
  • Disability Rights NC is a nonprofit law firm that provides free legal and advocacy services for people with disabilities throughout all 100 counties of North Carolina
  • In 2013, Disability Rights NC , along with a consortium of organizations, became a Navigator entity, helping people understand their rights under the ACA
  • Background of the ACA
  • In North Carolina alone, there are approximately 1.5 million people who are uninsured.
  • Reforms began in 2010 and will continue to roll out through 2014.
  • The ACA required Medicaid expansion, but the US Supreme Court said that provision was not enforceable as written. NC did not expand Medicaid eligibility.
  • ACA Features All Americans and documented immigrants must have health coverage which provides certain essential health benefits:
  • Well-baby and well-child care for children under age 21
  • Oral health and vision services for children
  • Preventative Services and immunizations and no cost sharing
  • Mental health and substance abuse coverage
  • Hospital/emergency services
  • Rehabilitation and habilitative services
  • Prescription drug coverage
  • Maternity Care
  • ACA Features
  • Beginning in 2014, insurers may not deny coverage or charge people more because of pre-existing health conditions
  • Insurers cannot impose annual or lifetime limits on health plans
  • Insurers must offer parents the choice of covering their children up to their 26th birthday through the parent’s health insurance coverage
  • Individual Mandate
  • As of January 2014, citizens and others legally present will be required to pay a penalty if they do not have a qualified health plan (QHP)
  • You can meet this requirement if you have
  • Public health insurance coverage (Ex: Medicaid, Medicare, Tricare, CHIP, etc.)
  • Employer-sponsored insurance
  • Purchasing coverage in the Marketplace or elsewhere
  • How does the new law affect me?
  • If you already have health insurance coverage, there is nothing you need to do (until you file your taxes for year 2014). However, anyone can create an account in the Marketplace and weigh their options
  • If you do not already have a qualified health plan and choose not to enroll in one, you may have to pay a penalty
  • Penalties ** Children are only assessed half of the penalty Penalties Continued
  • The maximum penalty is equal to the amount the individual or family would have paid for the lowest cost bronze plan
  • Penalties are paid when you file your taxes the following year
  • Exemptions from Penalties
  • Those who have to pay greater than 8% of their income for the lowest cost premium
  • People who do not have to pay taxes because their income is too low
  • Certain people with religious exemptions
  • Prisoners, while incarcerated
  • Those experiencing a hardship (ex: domestic violence victims, those being evicted, etc.)
  • Native Americans and/or Alaskan Natives
  • Those who would have been covered by Medicaid had NC expanded eligibility
  • What is the Marketplace?
  • North Carolina does not have a State-operated Marketplace
  • North Carolinians must use the Federally Facilitated Marketplace (FFM) available at
  • In the Marketplace, you can:
  • Find information which helps you choose a qualified health plan
  • Find links to provider directories
  • Determine eligibility for government subsidies
  • Enroll in a qualified health plan
  • Plans in the Marketplace
  • The Marketplace organizes plans into “metal bands.”
  • Bands are like Olympic medals plus Platinum, so Bronze < Silver < Gold < Platinum.
  • The bands correspond to the amount of health care expenses for an average person that actuaries estimate the plan will cover.
  • Bronze = 60%...Platinum = 90%
  • Other Options You can:
  • Call the federal telephone number at 1-800-318-2596
  • Use the “live chat” feature on the Marketplace website
  • Call the NC Navigator line to schedule a 1 on 1 appointment with a certified Navigator or Certified Application Counselor (CAC) 1-855-733-3711
  • What is a subsidy? Subsidies help you pay for health care. There are two kinds.
  • Advance Premium Tax Credits help to pay for health insurance premiums each month
  • These are for people with incomes 100%-400% of the Federal Poverty Level (FPL)
  • Subsidies Continued
  • Cost Sharing helps pay for other health care costs like copayments, deductibles, and coinsurance. This is for families with incomes 100-250% FPL who enroll in a silver-level plan in the Marketplace
  • Both kinds of subsidies are determined based on a sliding scale.
  • Your subsidy is determined during your initial application based on your projected income for 2014.
  • Enrollment Period
  • The initial enrollment period began on October 1st, 2013 and ends March 31st 2014
  • If you fail to enroll during this time period, you may be subject to a penalty and may not enroll until the next open enrollment period for year 2015
  • If you have a “qualifying event” (ex: birth of a child, divorce, marriage, loss of job, etc.) you can apply for a special enrollment period
  • **Being a member of a Federally-Recognized Indian Tribe qualifies an individual for a special enrollment period Special Enrollment Periods
  • Loss of minimum essential coverage
  • Gain a dependent—Pregnancy does not trigger an SEP
  • Loss of dependent status
  • Change in status to become a citizen or lawfully present
  • Exceptional circumstances, including loss of eligibility for a hardshipexemption **Includes those who were in the Medicaid gap but now make over 138% FPL
  • Release from jail or prison
  • Employer-sponsored Insurance
  • In North Carolina, more than half of the population (approximately 54%) receive health insurance coverage through their employer
  • Small employers (25 or fewer FTEs) with average annual wages of less than $50,000 can receive a tax credit if they offer coverage and pay at least half of the premium
  • Enforcement of the Law
  • If you have insurance outside of the Marketplace, you will need to report your insurance coverage to the IRS every year when you file your taxes. Your insurer and your employer (if applicable) will provide you with the necessary proof of coverage to include in your tax return
  • Resources
  • The FFM:
  • Epass:‎
  • NC Department of Insurance:
  • Remember that navigators are available to assist you with your Marketplace application. You can schedule an appointment by calling 1-855-733-3711 statewide
  • For additional questions regarding your disability (ex: discrimination issues, accessibility, employment, special education, etc.) please call Disability Rights NC’s toll free line at 1-877-235-4210 to speak with an intake specialist
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