ObamaCare 101

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Useful ObamaCare Links

If you would like more information about ObamaCare and all the agencies involved, please visit the websites below:

Where to read the Affordable Care Act

You can read the Affordable Care Act by visiting the links below. The health care law, sometimes known as “ObamaCare,” was signed March 23, 2010.

The Full Law
The law has 2 parts: the Patient Protection and Affordable Care Act (Public Law 111-48), signed March 23, 2010, and the Health Care and Education Reconciliation Act (Public Law 111-152) signed March 30, 2010). We provide links to them in PDF and HTML formats below. We also provide a link to an unofficial, consolidated version that is more readable.

The documents are searchable using the “Control Official certified full-text of the laws in PDF form:

Certified full-text version in HTML (Web page) format:


Everything you wanted to know about ObamaCare (Healthcare Reform) but haven’t asked

Part 1 - The Basics Behind the Affordable Care Act

Rights and Protections

Whether you need health coverage or have it already, the health care law offers new rights and protections that make coverage fairer and easier to understand.

Some rights and protections apply to plans in the Health Insurance Marketplace or other individual insurance, some apply to job-based plans, and some apply to all health coverage.

These rights and protections provide even more choice and control over your health coverage when key parts of the law take effect in 2014.

Use this guide to learn about your rights and protections today and in 2014.

How the health care law protects you

Creates the Health Insurance Marketplace, a new way for individuals, families, and small businesses to get health coverage
Requires insurance companies to cover people with pre-existing health conditions
Helps you understand the coverage you’re getting
Holds insurance companies accountable for rate increases
Makes it illegal for health insurance companies to arbitrarily cancel your health insurance just because you get sick
Protects your choice of doctors
Covers young adults under 26
Provides free preventive care
Ends lifetime and yearly dollar limits on coverage of essential health benefits
Guarantees your right to appeal

Part 2 - The Health Insurance Marketplace

Plans in the new Health Insurance Marketplace will be offered by private companies, and every health insurance plan will cover a core set of benefits called essential health benefits. You’ll be able to compare your options based on price, benefits, quality, and other important features. More people than ever will qualify to save money on private insurance coverage.

You’ll also learn whether you qualify for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP). Fill out one Marketplace application and you’ll see all the programs you qualify for.

You can apply when open enrollment starts October 1, 2013.
Marketplace coverage starts as soon as January 1, 2014.
Get ready and enroll!
To prepare to enroll, you can learn about types of health coverage, research your questions, and figure out what you need to know before open enrollment begins.

Open enrollment starts October 1, 2013. Coverage can start as soon as January 1, 2014.

How to get ready now

Sign up for email or text updates about the Marketplace. We’ll let you know when there’s important new information about the Marketplace, and we’ll send timely reminders about important dates. You can also visit our Facebook page at facebook.com/KSSinsurance or follow @KSSinsurance on Twitter.
Learn about different types of health coverage: Through the Marketplace, you’ll be able to choose a health plan that gives you the right balance of costs and coverage. You can be better prepared if you understand the types of coverage you’ll choose from. Different types of health insurance include: Health Maintenance Organizations, Preferred Provider Organizations, Point-of-Service Plans, High Deductible Health Plans, Catastrophic Health Insurance Plans.
Make a list of questions you have before it’s time to choose your health plan.
Make sure you understand how coverage works, including things like premiums, deductibles, out-of-pocket maximums, copayments, and coinsurance. You will want to consider these details while you’re looking for health insurance.
Gather basic information about your household income: Most people using the Marketplace will qualify for lower costs on monthly premiums or out-of-pocket costs. To find out how much savings you’re eligible for, you’ll need income information, like the kind you get on your W-2, current pay stubs, or your tax return.
Set your budget: There will be different types of health plans to meet a variety of needs and budgets. You’ll need to figure out how much you want to spend on premiums each month.
Ask your employer if it plans to offer health insurance in 2014: If not, you may need to get insurance through the Marketplace or from other sources in 2014. If you don’t have coverage, you may have to pay a fee or “penalty”.
Explore current options. You may be able to get help with getting coverage now through existing programs. Learn more about health insurance for adults up to age 26, and programs for people and children in families with limited incomes including Medicaid and the Children’s Health Insurance Program (CHIP). Medicare covers people who are 65 and older or who have certain disabilities.

Part 3 - Coverage for Pre-Existing Conditions

For plan years beginning in 2014, health plans can’t turn you down or charge you more because you’re sick or have a health condition. They also can’t charge women more than men. The only exception is for grandfathered individual health insurance plans.

Learn more about coverage for pre-existing conditions.

Starting in 2014, being sick won’t keep you from getting health coverage. An insurance company can’t turn you down or charge you more because of your condition.
Once you have insurance, it can’t refuse to cover treatment for pre-existing conditions. Coverage for your pre-existing conditions begins immediately.
This is true even if you have been turned down or refused coverage due to a pre-existing condition in the past.
A. Grandfathered plans

Grandfathered plans are those that were in existence on March 23, 2010 and have stayed basically the same. But they can enroll people after that date and still maintain their grandfathered status. In other words, even if you joined a grandfathered plan after March 23, 2010, the plan may still be grandfathered. The status depends on when the plan was created, not when you joined it.

B. How to find out if your plan is grandfathered

Check your plan’s materials: Health plans must disclose if they are grandfathered in all materials describing plan benefits. They must offer contact information.
Check with your employer or your health plan’s benefits administrator.
C. What grandfathered plans do and don’t have to cover

Here’s a quick look at the consumer protections that do and don’t apply to grandfathered plans:

All health plans must:

End lifetime limits on coverage
End arbitrary cancellations of health coverage
Cover adult children up to age 26
Provide a Summary of Benefits and Coverage (SBC), a short, easy-to-understand summary of what a plan covers and costs
Hold insurance companies accountable to spend your premiums on health care, not administrative costs and bonuses
Grandfathered plans DO NOT have to:

Cover preventive care for free
Guarantee your right to appeal
Protect your choice of doctors and access to emergency care
Be held accountable through Rate Review for excessive premium increases
In addition to the above, grandfathered individual health insurance plans (the kind you buy yourself, not the kind you get from an employer) don’t have to:

End yearly limits on coverage
Cover you if you have a pre-existing health condition

Part 4 - Summary of Benefits and Coverage

You have the right to get an easy-to-understand summary about a health plan’s benefits and coverage.

Insurance companies and group health plans must provide you with:

A short, plain-language Summary of Benefits and Coverage (SBC)
A Uniform Glossary of terms used in health coverage and medical care
This information allows you to make “apples-to-apples” comparisons when you’re looking at different plans.

All individual and group health plans must use the same standard form to help you compare plans. The SBC also includes details, called coverage examples, which allow you to see what the plan would cover in 2 common medical situations: diabetes care and childbirth.

You’ll find a link to each plan’s SBC in the Marketplace when you’re comparing plans.

When can I get a Summary of Benefits and Coverage?
You have the right to get this summary when shopping for or enrolling in coverage.

The SBC is available for every plan in the Marketplace. You’ll find a link to it on each plan page when you enroll through the website.

You can also ask for a copy from your insurance company or group health plan at any time. All health plans must provide the SBC to you at important points in the enrollment process, like when you apply for or renew your policy. You can also ask for a copy of the Uniform Glossary to help you understand words used in health coverage and medical care.

Does this apply to my plan?
Yes. You can get a Summary of Benefits and Coverage for most health plans, including grandfathered plans, whether you get coverage through your employer or buy it yourself.

Part 5 - Cracking Down on Frivolous Cancellations

The health care law stops insurance companies from canceling your coverage just because you made a mistake on your insurance application.

In the past, if your insurance company found that you’d made a mistake on your insurance application, they could:

Take away your coverage
Declare your policy invalid from the day it started
Ask you to pay back any money they’ve already spent for your medical care
It’s now illegal for insurance companies to cancel your coverage simply because you made an honest mistake or left out information that has little bearing on your health.

Does this apply to my plan?
Yes. These protections apply to all health plans, including grandfathered plans, whether you get coverage through your employer or buy it yourself.

Does this mean that my plan can’t be canceled for any reason?
No. Your insurance company can still cancel your coverage if you put false or incomplete information on your insurance application on purpose. They can also cancel your coverage if you don’t pay your premiums on time.

Will I be notified before my plan is cancelled?
Yes. Your insurance company must give you at least 30 days’ notice before they can cancel your coverage for the reasons stated above. This gives you time to appeal the decision or find new coverage.

Part 6 - Doctor Choice & Emergency Room Access

You have the right to choose the doctor you want from your health plan’s provider network. You also can use an out-of-network emergency room without penalty.

You pick your doctor: You can choose any available primary care provider in your insurance plan’s network. You can choose any available network pediatrician as your child’s primary care doctor.
No referrals needed for OB-GYN services: You don’t need to get a referral from a primary care provider before you can get obstetrical or gynecological (OB-GYN) care from a specialist.
Access to out-of-network emergency room services: Insurance plans can’t require higher copayments or coinsurance if you get emergency care from an out-of-network hospital. They also can’t require you to get prior approval before getting emergency room services from a provider or hospital outside your plan’s network.
Does this apply to my plan? It depends. These rights don’t apply to health plans created or bought before March 23, 2010, which are known as grandfathered plans. Check your plan’s materials or ask your employer or benefits administrator to find out if your health plan is grandfathered.

Part 7 - Young Adult Coverage

If you’re under 26 years old, you may be able to get insured under a parent’s plan.

You can join, remain, or return to a parent’s plan even if you’re:

not living with your parents
attending school
financially independent
eligible to enroll in your employer’s plan (with one exception, below)
Learn more about covering young adults under 26.

Does this apply to my plan? Yes. These rights apply to all health plans that offer dependent coverage, including grandfathered plans, whether you get coverage through your employer or buy it yourself.

But there’s one temporary exception: Until 2014, grandfathered group plans that offer dependent coverage don’t have to offer it up to age 26 if a young adult is eligible for job-based coverage through their own employer.

If you’re under 30, you may buy an insurance policy that covers only very high medical costs. Learn more about these “catastrophic” plans.

Part 8 - Free Preventive Care

Many health plans are required to cover certain preventive care services at no cost to you.

You may be eligible for free preventive screenings, like blood pressure and cholesterol tests, mammograms, colonoscopies, and more. This includes coverage for vaccines and new preventive services for women.

Part 9 - Ending Lifetime & Yearly Limits

The health care law stops insurance companies from limiting lifetime coverage for essential health benefits. In 2014 this applies to yearly limits too.

Lifetime Limits
Insurance companies can’t set a dollar limit on what they spend on essential health benefits for your care during the entire time you’re enrolled in that plan.

Yearly Limits
Insurance companies can still set a yearly dollar limit of $2 million on what they spend for your coverage for plan years or policy years starting before January 1, 2014. No yearly dollar limits on essential health benefits are allowed for plan years starting January 1, 2014.

Exceptions to the rule?

Insurance companies can still put a yearly dollar limit and a lifetime dollar limit on spending for health care services that are not considered essential health benefits.
Some health insurance plans may have received a temporary waiver from the rules on yearly dollar limits. Yearly limit waivers end with plan or policy years beginning in 2014.

Part 10 - Rate Review & the 80/20 Rule

The health care law provides 2 new ways to hold insurance companies accountable and help keep your costs down: Rate Review and the 80/20 rule.

Rate Review
Rate Review helps protect you from unreasonable rate increases. Insurance companies must now publicly justify any rate increase of 10% or more before raising your premium. This does not apply to grandfathered plans.

80/20 Rule
The 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in on premiums on your health care and quality improvement activities instead of administrative, overhead, and marketing costs.

The 80/20 rule is sometimes known as Medical Loss Ratio, or MLR. If an insurance company uses 80 cents out of every premium dollar to pay for your medical claims and activities that improve the quality of care, the company has a Medical Loss Ratio of 80%.

Insurance companies selling to large groups (usually more than 50 employees) must spend at least 85% of premiums on care and quality improvement.

If your insurance company doesn’t meet these requirements, you’ll get a rebate from your premiums.

Will I get a rebate check from my insurance company?
If your insurance company doesn’t meet its 80/20 targets for the year, you’ll get back some of the premium that you paid. You may see the rebate in a number of ways:

A rebate check in the mail
A lump-sum deposit into the same account that was used to pay the premium, if you paid by credit card or debit card
A direct reduction in your future premium
Your employer may also use one of the above rebate methods, or apply the rebate in a way that benefits employees
If you or your employer are going to get a rebate, your insurance company must notify you by August 1.

If you have an individual insurance policy, you’ll get the rebate directly from your insurance company.

For small group and large group plans, the rebate is usually paid to the employer. It may use one of the above rebate methods, or apply the rebate in a way that benefits employees.

Note: The 80/20 rebate rules don’t apply when an insurance company has fewer than 1000 enrollees in a particular state or market.

Part 11 - Your Right to Appeal Coverage Decisions

You have the right to appeal private health plan decisions.

Private Insurance plans have to tell you why a claim has been denied and they have to let you know how you can dispute their decision.

Internal Appeals: You can ask your insurance company to reconsider its decision to deny payment for a service or treatment. It must review its decision.

External Review: If your insurance company still denies payment, the law allows you to have an external review. The review will be done by an independent organization that will decide if the insurance company should pay or not.

Where you live matters
Depending on the state you live in and the type of plan you have, your rights may vary. In certain states, some group plans may require more than one level of internal appeal before you can get an external review.

When can I request an appeal?
You can request an appeal when a health plan denies payment for a treatment or service. When your plan gets your request it is required to review its own decision. When your plan denies a claim, it’s required to notify you of:

The reason your claim was denied
Your right to file an internal appeal
Your right to request an external review if your internal appeal was unsuccessful
The availability of a Consumer Assistance Program (if your state has one)

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