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A High Level View of Health Care Reform

Commonly referred to as ObamaCare and certainly misunderstood, the Affordable Care Act (ACA) is officially in effect with the new year. With ACA comes numerous changes to health care as you know it.  First, ObamaCare isn’t a typeof insurance as many of my peers have thought it to be.  It’s a law, and it applies to both the (new implementation of the) marketplace or exchange as well as private insurance (off exchange) market.

In California, the marketplace is called Covered California.  There are two components to CoveredCA: SHOP (for businesses) and the Individual side.  Within CoveredCA, premium subsidies and cost-sharing subsidies are available based on your annual income.  To determine if you are eligible for a cost-sharing subsidy, you must visit their website and enter your personal information into their Shop and Compare calculator.  Premium assistance does exactly what you think it does; it reduces your monthly premium payments.  It comes as a form of a tax credit which you may choose to receive monthly and reduce your premium, or all at once when you file taxes.  Cost-sharing subsidies are in addition to the premium assistance and reduce the amount of money you pay when you actually seek services at the doctor/ER (copayments/coinsurance).  Should your income change during the course of the year, your premium assistance will be adjusted accordingly.  If you don’t report the change – you’ll end up paying the difference at tax time.  If you make less than $15,856/yr you are eligible for Medi-Cal.

One of the most notable changes to healthcare is the removal of pre-existing conditions.  Another chief change is the addition of Essential Health Benefits (EHB).  The Act mandates that non-grandfathered health plans cover a core set of services or Essential Health Benefits.  Essential Health Benefits must include items and services within at least the following 10 categories:

  • ambulatory patient services
  • emergency services
  • hospitalization
  • maternity and newborn care
  • mental health and substance use disorder services, including behavioral health treatment
  • prescription drugs
  • rehabilitative and habilitative services and devices
  • laboratory services
  • preventive and wellness services and chronic disease management
  • pediatric services, including dental and vision care.

Regardless if you apply for coverage through the marketplace or directly with one of the insurance carriers, you cannot be denied coverage based on a preexisting condition and all plans include essential health benefits.  Some carriers, like Blue Shield require an additional pediatric dental plan to be purchased to satisfy the EHB requirement.


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