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Affordable Care Act and Your!

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Beginning January 1, 2014, additional changes to the heath insurance industry in the United States will take effect as a result of the Patient Protection and Affordable Care Act of 2010 (“ACA”).  Additionally, some important facets of the law will NOT be implemented until at least January 1, 2015.   One of the most important changes is that no one can be turned down (“declined”) or rated “substandard” for health insurance, regardless of his or her past or present health conditions.  Men and women cannot be charged different rates for insurance, but everyone will pay a premium based on age and whether or not they use tobacco products (The PPACA allows tobacco users to be charged an additional 50% of the premium for their plan, but California law prohibits insurers from doing this — all persons pay the same rate based only on the plan they choose and their age).  The premiums for persons age 64 or older cannot be more than three times the premiums for persons age 21. Family premiums will be based on the individual premium for each covered person age 21 or older (a “child” may choose to remain covered under a parent’s health plan to age 26, even if married), plus the premiums for the three oldest children under age 21.

However, this still does not mean that health insurance will be “affordable” for everyone.  There is a new requirement that most persons must be covered by a qualified health insurance plan (QHP) that provides the minimum value and all “essential health benefits”, or face the loss of tax credits, and even be exposed to a “shared responsibility payment” payable to the IRS.  Many low income persons and/or their children will be eligible for enrollment in Medi-Cal, California’s version of the federal Medicaid program, and will not have to purchase health insurance or pay any penalties. At the time you submit an eligibility application through the Covered California exchange, your eligibility for Medi-Cal will be determined, and if eligible, you or your dependents will be referred to the Medi-Cal agency for enrollment.

Most employer-sponsored plans are not required to offer coverage for spouses, but must offer coverage for children.  An employer-sponsored health plan is considered “affordable” if the employee’s “self-only” cost is not more than 9.5% of their household income, and a person is eligible for a waiver from the mandate to be insured if the cost of the lowest priced individual “bronze” QHP available is more than 8% of household income.


The Affordable Care Act specifies ten essental health benefits that individual and employer-sponsored health plans must cover.  Although subject to “cost sharing” (deductibles, copays, and coinsurance — which will vary according to the design of each plan and the plan “tier”), preventive health services, which include annual wellness appointments, certain women’s health services including mammograms, prostate cancer screening for men, colorectal exams for persons over age 50, and certain pediatric and teen health services, must be provided without cost sharing.  The ten EHBs are:

  1. ambulatory patient services
  2. emergency services
  3. hospitalization
  4. maternity and newborn care
  5. mental health and substance use disorder services (including behavioral health treatment)
  6. prescription drugs
  7. rehabilitative and habilitative services and devices
  8. laboratory services
  9. preventive and wellness services and chronic disease management
  10. pediatric services, including oral and vision care

When standalone dental plans for children are offered through the Exchange, those services do not have to be included in a QHP.  Adult dental services may only be offered by standalone dental plans.  There are very few things not covered in the list of EHBs, but among those which are not are “cosmetic” services which are not medically necessary, such as elective cosmetic surgery and laser-assisted vision correction procedures.


Because of the confusion surrounding implementation of the ACA, consumers are going to be exposed to a variety of misrepresentations and possible fraud in their search for “affordable” health insurance.  Persons may misrepresent themselves as “Navigators”, “Assisters”, or “Certified Enrollment Counselors”, or even licensed insurance agents, in order to gain access to personal information.  I want to try to protect you from these scam artists by providing the following important tips.


You don’t have to meet with anyone face-to-face to enroll in a health insurance plan.  You could meet with a licensed insurance agent, a Navigator, Assister, or Application Counselor, or attempt to do it yourself.  Many public venues such as libraries, city or county government offices, and some police or fire stations may make computers available to the public for the purpose of enrolling in a QHP.   Enrollment Assisters may be present at some of these locations to help consumers complete the online eligibility application.

Computer-savvy persons may submit their applications electronically via the Covered California website, and enrollment may be completed over the telephone if you have difficulty enrolling on your own online.


No uninvited solicitations for health insurance should ever be accepted over the telephone!   At least not unless you, the consumer, made or requested the phone call.  I am already aware of one telephone scam in which the caller claims to be from a person’s bank or credit card company, wants to verify the card number or account information, and then offers to sell the person health insurance, if they just agree to have the premium paid by the credit card or direct debit from a checking or savings account.


Hang up immediately without giving any information.  Your bank or credit card company knows your account information, will never ask for your PIN number, and, trust me, does not sell health insurance. Navigators, Assisters, Enrollment Counselors, and insurance agents will not ask you for premium payments (but may ask for credit card or bank account information for electronic payment processing) — but your enrollment in any health insurance plan will not be complete until your first payment is made.

No one can charge you money to help you choose or enroll in a qualified health insurance plan.

Navigators and Assisters are compensated for their services by their employers through grants funded by the federal government.  Insurance agents usually receive commissions from insurance companies for enrollments, and must disclose this fact to you.  Agent commissions are factored into the cost of all QHPs and are not added to the cost of your insurance — the cost of health plans offered by an insurance agent through the Exchange are exactly the same even when purchased off the Exchange, when enrollment is completed on one’s own, or through a Navigator, Assister, or Certified Enrollment Counselor.  The advantage of using a licensed insurance agent is his or her expert knowledge of health insurance and the ability to recommend plan(s) which meet your specific needs.



(never to insurance agents or Navigators or the Exchange)


When you choose to enroll in a QHP, you will either decide to make your premium payments electronically or by mail.  Electronic payments may be made via credit card, automatic withdrawal from a checking or savings account, or for employees in group plans, via payroll deduction.   Direct payments by mail can be made with a check, money order, or cash (but mailing cash is never a good choice).  If you are eligible for premium tax credits, you may choose to have those credits paid directly to your QHP and will only need to pay the balance of your premium (or you may choose to receive the credits when you file your 2014 federal income tax return).  However, in order to receive premium tax credits in advance or when filing your tax return, you MUST enroll in a health plan through the Covered California exchange.

As a general rule to protect yourself, never provide bank account credit card or other financial information to anyone you do not know or trust, and when it comes to buying any type of insurance, to anyone who cannot show you proof of their California insurance license.  Navigators, Assisters, and Enrollment Counselors are not licensed insurance agents, but they must be certified by the Covered California Exchange, and should be able to show your their certification on request.  Certified Enrollment Counselors are most likely to be encountered in health clinics, hospitals, and doctors’ offices, and will not be contacting people by telephone (unless requested).  Navigators and Assisters, as well as licensed agents, might make enrollment information available at a local pharmacy, department store, or even in public, non-patient care areas of a hospital or urgent care center.

Mario Pinzon

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