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Health Care Changes

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Learn more about the current health care law

The current health care law says that almost everyone must have health insurance coverage or be subject to a tax penalty. Individual or family coverage will fulfill this requirement. Here's what you need to know:

  • You can purchase a plan each year during the open enrollment period. If you don't purchase during that period, you will have to stick with your existing coverage unless you experience a change in your circumstances that qualifies you for a special enrollment.
  • You can purchase a new plan each year through the Health Insurance Marketplace ( or directly from a health insurance company like Medica. A licensed agent or broker can help you with either option.
  • Depending on your income, you may be eligible for financial assistance such as premium subsidies and cost-sharing reductions. You must buy your coverage through the Health Insurance Marketplace in order to receive a premium subsidy or cost-sharing reduction.
  • All plans available through the Health Insurance Marketplace and directly from insurance companies will be categorized based on how medical costs are divided between the insurer and the member, so it will be easier for you to compare plans. The categories are called metal levels.
  • Any plan you choose will include coverage for a set of 10 benefit categories called essential health benefits.
  • Your health status is not considered in setting your premiums.
  • If you have a pre-existing condition, it can't be excluded from your coverage.
  • If you are under age 26, you can be on your parent's plan.
  • If you are under age 30 or qualify under certain rules, you may purchase a catastrophic plan that has a lower premium. A health insurance marketplace or insurance company can help you determine if you would qualify.

Under the current law some individuals are exempt from the requirement to have insurance coverage:

  • Members of certain religious groups
  • Members of Native American tribes
  • People who are incarcerated
  • Undocumented immigrants, who are also not eligible for premium subsidies
  • People whose income is below the level required to file a tax return
  • People who cannot afford coverage based on formulas contained in the health care reform law
  • People who were uninsured for short periods of less than three months
  • People who have received a hardship waiver based on an unexpected financial or domestic circumstance
  • U.S. citizens who reside outside the United States on a long-term basis

If any of the situations above apply to you, talk to your insurance agent or broker, or call the Health Insurance Marketplace to confirm your eligibility and request a formal exemption so you can avoid being charged a penalty on a future tax return.

The current health care law says that insurers offering coverage for individuals, families and small businesses must:

  • Extend an offer of coverage to everyone who applies. This is called guaranteed issue.
  • Not drop a member's coverage at the end of a plan year. This is called guaranteed renewability.
  • Not exclude pre-existing conditions from coverage.
  • Not consider an individual's health status in establishing premiums. Only age, tobacco use, family composition and geographic area may be considered.

One of the ways the current health care law ensures that everyone can get insurance is to disallow the use of information about health status in making offers for coverage or setting premiums:

  • You cannot be declined an offer of coverage based on pre-existing conditions or your past use of medical services. This rule is called guaranteed issue and it applies to all eligible individuals or groups of any size that apply for health insurance coverage.
  • Your health status or past use of medical services may not be considered in setting premiums for your individual, family or small business coverage. The only factors that insurers may use to vary premiums for these types of coverage are the age, tobacco use, family composition and geographic location of the applicants. This is called adjusted community rating.
  • Insurers are required to renew coverage without regard to the use of medical services by individuals covered under the policy. This is called guaranteed renewal.

The current health care law generally requires health plans offered to individuals, families and small businesses to fall into one of four categories based on how the expected health care costs will be divided between the insurer and member. Each category is named for a precious metal.

The categories make it easier to compare benefit plans and determine which provides the best value for your needs.

If you have individual, family or small business coverage, your plan name will include its metal level.

Metal Level Average Share of Costs Paid by Insurer Average Share of Costs Paid by Member*
Platinum 90% 10%
Gold 80% 20%
Silver 70% 30%
Bronze 60% 40%

*Members pay their share of costs in the form of deductibles, copayments and coinsurance. When the percentage of costs paid by the member is higher, the plan premium will be lower.

  1. The health reform law created online health insurance marketplaces in all 50 states to help individuals and small businesses purchase coverage.
  2. You can apply for and purchase coverage from a variety of health plans at You'll find Medica plans there, too.
  3. Each marketplace has a network of assisters — individuals and organizations that are trained to assist you in getting health care coverage on the marketplace.
  4. The only way to receive any financial assistance you might qualify for is to purchase your coverage through the Health Insurance Marketplace.
  5. If you don't qualify for financial assistance, you may purchase coverage through the Health Insurance Marketplace or buy it directly from a health insurance company like Medica, either on your own or with help from a licensed insurance agent or broker.

The current health care law states that you cannot be denied coverage or receive limitations on your benefits because you have health problems that developed before you applied for coverage.

Health changes timeline

Here are some key dates* to keep in mind if you'll be shopping for individual or family coverage this year:

2018 open enrollment – November 1, 2017 through December 15, 2017

2018 renewal letters sent to existing members – November 1, 2017

2018 coverage start – January 1, 2018


New to buying Insurance?

Learn how to be a smart shopper.

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Interested in learning about other plans? 

Medica offers a wide variety of plan options for individual and family coverage.

Learn more »

Want more tips for getting the most value from your plan?

Get the scoop using our member tip sheets and videos.

View tip sheets »

 *Dates are subject to change

Date: 8/18/2018 9:41:54 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CMSWEB02