Coverage and Eligibility Under Healthcare Reform Legislation

The Affordable Care Act makes health insurance more accessible for many people. This happens through a combination of measures, which include expanding Medicaid eligibility, tax credits for employers, new rules for insurance companies, requiring individuals to buy health insurance and more. For example, people with incomes under 400 percent of federal poverty level may be eligible for cost sharing subsidies and premium tax credits to help make their healthcare more affordable.

Healthcare Reform Legislation and You

Click on the appropriate link below to learn more about coverage and eligibility that applies to you:

Families with Children

Families with children are among several groups that gain coverage and benefits. Here are some of the details:

Coverage

  • Insurers can’t deny or exclude coverage to any child under age 19 based on a pre-existing condition.
  • Beginning in 2014, plans cannot deny or exclude anyone or charge more for a pre-existing condition, including a disability.
  • Essential benefits required in new plans include vision and dental coverage for children and pregnancy and newborn care for women.
  • Children who cannot receive coverage through work can remain on their parents’ plan until age 26. This age limit varies by state; in Ohio, for example, the age limit is 28. In 2014, all plans must allow coverage up to age 26 (even if the dependent has access to coverage through work).
  • Insurance companies can no longer impose lifetime limits on the amount they will pay to cover required or essential health benefits.

Eligibility

  • Expands Medicaid eligibility in some states to 133 percent of the federal poverty level ($15,282 for an individual or $31,322 for a family of four). Children in these families who are now covered by the Children’s Health Insurance Program (CHIP) would be transitioned to Medicaid.
  • CHIP is continued through at least 2019.

Individuals and Healthcare Reform Legislation

If you are an individual adult, healthcare reform legislation can mean different things depending on your circumstances. Healthcare reform legislation requires almost all individuals to have health insurance by 2014. It can be through their employer, private insurance or a government program. The law provides a number of aids to make it easier for you to obtain insurance and sets minimum standards for what the insurance must cover.

Healthy Individuals

  • Starting in 2014, if your income is less than the equivalent of about $94,000 for a family of four today, you may get tax credits to help pay for insurance.
  • Starting in 2014, if your employer doesn’t offer insurance, you will be able to buy coverage directly through state health insurance exchanges.
  • All new plans are required to include state-specific essential health benefits that are mandated by each state's government.

Individuals with Health Conditions

  • In 2014, it will be illegal for insurers to deny coverage because of pre-existing conditions, so these plans will eventually be phased out.
  • Prior to 2014, if you had been without health coverage for the past six months and couldn't get coverage because of a pre-existing condition, you could be eligible for a Pre-existing Condition Insurance Plan or High Risk Pool plan. This is a federal program for people who cannot get coverage otherwise.

Eligibility

  • Beginning in 2014, Medicaid will be expanded to include coverage for people who are unemployed with limited income under 133 percent of the federal poverty level in some states.
  • Beginning in 2014, people buying coverage on their own through health insurance exchanges will be eligible for federal tax credits to subsidize the cost if their income level is less than 400 percent of the federal poverty level and they aren't eligible for Medicaid.

Women and Healthcare Reform Legislation

If you are a woman, healthcare reform legislation means additional coverage for preventive services and maternity care, as well as more federal spending on women’s health. Here are some details:

Coverage

  • Insurers must include maternity and newborn care as essential benefits in plans.
  • All plans must cover specific, important preventive services, free of copays or coinsurance, including annual mammograms starting at age 40,  screenings for cervical cancer, osteoporosis, diabetes, high blood pressure, hypertension, depression, obesity and sexually transmitted diseases (STDs) and, contraceptive coverage. 
  • Human papilloma virus (HPV) vaccine will be provided free of copays.
  • Insurers cannot charge women more because of their gender.
  • Beginning in 2014, plans cannot deny or exclude coverage to anyone or charge a higher premium because of a pre-existing condition, including previous pregnancies.
  • Healthcare reform includes a variety of limits on coverage benefits for abortions. For example, individuals with subsidized coverage can’t use federal subsidies for abortions. Federal law does have some exceptions, such as rape, incest and saving the life of the mother. At least one plan in each state provided by a health insurance exchange must limit abortion coverage to these exceptions. However, states do have the right to prohibit plans that cover abortion in their exchanges. New state health plans to cover people with pre-existing conditions cannot provide abortion coverage beyond federal limit exceptions.
  • Women joining new insurance plans can choose any primary care physician, OB-GYN or pediatrician in their health plan’s network or emergency care outside the network, without a referral.

Additional Reforms for Women

  • Offices in major federal agencies will be created regarding women’s health to establish goals, provide information on women’s health activities and identify women’s health priorities.
  • A National Women’s Health Information Center will spread information about advancements in women’s health.
  • The Health Resources and Services Administration will decide what additional women’s preventive care and screening services should be covered in the future.
  • States can establish Medicaid family planning programs without federal permission.

Pregnant Women

If you are pregnant, healthcare reform means insurers must cover maternity care and newborn care, as well as other services. Here are some of the details:

During Pregnancy

  • Health insurance plans must pay for maternity care and preventive services, such as counseling, screening and vaccines to ensure healthy pregnancies.
  • Medicaid must pay for tobacco cessation programs for pregnant women.
  • Women joining new insurance plans can choose any primary care physician, OB-GYN or pediatrician in their health plan’s network or emergency care outside the network, without a referral.

Post-Partum

  • Health insurance plans must pay for newborn care.
  • New grants to states to pay for healthcare workers to visit new mothers at home and to pay for postpartum depression services.
  • Employers must provide workplace accommodations for nursing mothers, including mandatory break time and private space to pump breast milk.
  • Plans cannot deny or exclude coverage to your baby based on health conditions, including babies born with health problems.
  • Beginning in 2014, plans must provide essential health benefits, including pediatric vision and oral care.
  • Plans must include regular well-baby and well-child visits, from birth to age 21.

Young Adults

The group where there is expected to be the largest growth in coverage under the Affordable Care Act is young adults who were previously uninsured. Between expanded eligibility for government plans and the individual mandate, it is estimated that millions of additional young people will be covered by healthcare insurance. Here’s an overview of some key provisions in the law that affect young adults:

  • By 2014, most people will be required to have health insurance, whether through an employer, private insurer or government program.
  • Children who cannot receive health insurance through employers can stay on their parents’ plans until age 26. This age limit varies by state. In Ohio, for example, the age limit is 28. In 2014, all plans must allow coverage up to age 26 (even if the dependent has access to coverage through work).
  • Beginning in 2014, people who are unemployed with limited income will be eligible for Medicaid.
  • New health plans must now cover preventive services, such as screenings, without copays or coinsurance.
  • Beginning in 2014, people will be able to buy insurance directly through a health insurance exchange. The majority of exchanges are expected to be state-run, regulated, online marketplaces where individuals and small businesses can purchase coverage. The exchanges are intended to bring together plans from multiple insurance carriers, making it easier for consumers to compare plans.
  • Starting in 2014, if your income is less than the equivalent of $45,960 for a single individual and your job doesn’t offer affordable coverage, you may get premium tax credits and cost-sharing subsidies to help pay for insurance. On a sliding scale, premium tax credits limit the maximum percentage of income that a family would have to spend on its health insurance premium. Cost-sharing subsidies lower the cost of the deductibles and other forms of cost-sharing that a consumer must pay for care.

Seniors

If you are a senior citizen, healthcare reform means more services and an emphasis on wellness and prevention. But it will also likely mean premium, out-of-pocket cost and benefit changes to Medicare Advantage members. Here are more details:

Medicare

  • Medicare recipients can visit their physicians once a year for comprehensive wellness visits without a copay. Patients and doctors can devise personalized plans or checklists of activities people can do to keep healthy longer.
  • The law gradually reduces the amount Medicare Part D enrollees pay for their prescriptions when they reach the coverage gap. Enrollees already receive a 50 percent discount on the total cost of their brand-name drugs in the coverage gap. Additional discounts will be added until, by 2020, enrollees will only have to pay 25 percent of the cost for generic and brand-name drugs.
  • Individual payments to Medicare Advantage plans are reduced to bring them closer to the average costs of traditional Medicare. As a result, premiums for Medicare Advantage plan holders may rise, fewer services, healthcare choices may be offered and there may be higher out-of-pocket costs. This is because the new law reduces funding of Medicare Advantage by $200 billion.
  • An Independent Payment Advisory Board will be created to recommend ways to reduce Medicare spending if spending exceeds projected rates.
  • For Medicare Parts B and D, premiums will be segmented by income levels so individuals with higher incomes pay a higher premium.

Coverage

  • There are no copays for preventive services, including screenings for diabetes, high blood pressure, hypertension and more.
  • There will be greater support for home- and community-based services rather than hospital or nursing home care.
  • Insurers can no longer impose lifetime dollar limits on care and annual limits will be phased out by 2014.

People with Disabilities

If you have a disability, healthcare reform means additional services and expanded eligibility for health insurance. Here are some of the details:

Coverage

  • A Community First Choice Option will be established in Medicaid. This provides community-based supports and services to disabled people who require care at the level that would be provided in a hospital or nursing home. This allows people to more easily receive care and services in their communities, rather than being admitted to a facility. These are services required by the elderly or disabled, with the end goal of keeping more people in their homes and out of institutions.
  • Insurers can no longer impose lifetime dollar limits on care. Annual limits will be phased out by 2014.
  • Insurers cannot cancel coverage because of an unintentional mistake on the applicant’s paperwork.
  • Beginning in 2014, plans cannot deny or exclude coverage to anyone or charge a higher premium because of a pre-existing condition, including disabilities.
  • Insurers cannot deny or exclude coverage to any child under 19 based on a pre-existing condition, including disabilities.
  • People who cannot get health insurance elsewhere and who have been without insurance for six months can obtain it through the federal Pre-Existing Condition Insurance Plan.

Eligibility

Starting in 2014, most adults under age 65 with incomes up to about $15,000 a year for an individual will qualify for Medicaid in every state. State Medicaid programs can offer additional services to help for those who need long-term care at home and in the community.