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Learn About the Affordable Care Act

I Have Insurance From My Employer

If you get your insurance from your employer then you have private insurance. Some of the biggest changes to private insurance begin in 2014. However, many changes affect you now.

Is Your Insurance Grandfathered?

All of the changes in the Affordable Care Act (ACA) apply to new health plans. Some do not apply to 'grandfathered' private plans.

Did you have your current health insurance when the ACA became law on March 23, 2010 and it hasn't been changed in a major way?

  • If yes, then you have a 'grandfathered' plan.
  • If no, then you have a 'new' plan.

A plan stays grandfathered so long as no major changes are made to its terms or conditions. Major changes include cutting benefits or increasing out-of-pocket costs. Plans must tell you if they are grandfathered and give contact information for questions. But, check your plan papers or call your insurer if you are not sure.

So far these changes affect ALL plans:

You…

  • CANNOT pay for over-the-counter medicines with your Health Reimbursement/Savings Account (HRA, HSA) or Flexible Spending Accounts (FSA). You can only buy prescribed medications with these funds.
    • 20% tax on unpermitted purchases.

Insurers…

  • May NOT deny coverage to children 19 and younger with prior health problems (often called pre-existing conditions)
  • May NOT deny family coverage to parents because they have children with prior health problems.
  • May NOT put lifetime limits on the dollar value of essential health benefits
  • May NOT put annual limits on essential health benefits of less than:
    • $750,000 for plans that started between Sept. 23, 2010 and Sept. 22, 2011
    • $1,250,000 for plans that started between Sept. 23, 2011 and Sept. 22, 2012
  • May NOT cancel your coverage if you get sick unless you have lied or committed fraud
  • MUST allow your children to remain on your plan until age 26.
    • Grandfathered plans only have to do this if your child cannot get insurance through their own employer.
    • In 2014, all plans must cover children until 26 even if they can get insurance through their own employer.
  • MUST use a standardized summary of benefits and explanation of coverage.
  • MUST spend 80% of premiums on medical services for individual plans, and 85% for large group plans. If an insurer spends less than this they must you some money back.

Employers…

  • Must report the cost of your employer-sponsored health insurance on your W-2. This is so people know how much their health care costs. It is not taxable income.
  • Who have more than 200 employees must automatically enroll new full-time employees in coverage unless the new employee says they do not want to be enrolled.

These changes only affect NEW plans right now:

You…

  • Can appeal an insurer's decision to an internal insurer review board
  • Can appeal an insurers' decision to an independent outside review board once you have gone through the insurer's internal process

Insurers…

  • MUST cover 100% of the cost of preventive services (click here for the current list of these services). They cannot charge a co-pay for these services or require a deductible to be met.
  • MUST tell you what your share of the cost is for items and services
  • MUST share with the government its rules on payment policies and enrollee rights.
  • May NOT decide whether you are eligible for a certain plan based on your income.

Employers…

  • May NOT have rules that only allow high-income employees to enroll in certain plans. All employees must have the option of enrolling in all health insurance plans offered.

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