The Patient Protection and Affordable Care Act, referred to as the Affordable Care Act or “ACA” for short, is the comprehensive health care reform law enacted in March 2010. The law has 3 primary goals: Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level (FPL). Expand the Medicaid program to cover all adults with income below 138% of the FPL. Not all states have expanded their Medicaid programs. Support innovative medical care delivery methods designed to lower the costs of health care generally. If you would like to read the certified, full text version of the law go here .

Small business owners with fewer than 50 full-time employees are not required to offer health care coverage to their employees. For those who are required to offer insurance, the penalties are steep if they do not. There are two types of penalties an employer can face. 4980H(a) In 2023, a yearly penalty of $2,880 (or $240 for each month) per full-time employee minus the first 30 will be imposed if the company fails to provide minimum essential coverage to at least 95% of its full-time employees and their dependents, and if any full-time employee obtains coverage through the exchange. 4980H(b) The employer will face a penalty if the employer-sponsored coverage is unaffordable or does not provide minimum value, and if one or more full-time employees receive subsidized coverage through the exchange. The penalty is $4,320 (for calendar year 2023) divided by 12 for each full-time employee who receives subsidized coverage through an exchange in a month. The affordability criteria, which is used to assess whether employer-sponsored health coverage is deemed affordable for employer shared responsibility, is 9.12% for 2023, down from 9.61% in 2022. This percentage is used to calculate affordability based on an employee’s required contribution for coverage. Note: An employee may be eligible for subsidized coverage through an exchange If: The employee’s household income is no more than 400% of the federal poverty line, and The employee is not able to get affordable coverage through an eligible employer-sponsored plan that provides minimum value.

The short answer is probably not. However, as with most things to do with the health care exchange the answer is not cut and dry. Employees who are offered health coverage by their employer that is affordable and meets minimum value standards do not qualify for financial help to lower the cost of a Covered California health plan. You may still buy a Covered California health plan, but you will have to pay the full cost of that plan. Also, if you turn down your offer of affordable employer-sponsored coverage and enroll in a plan through Covered California with financial help, you may have to pay back some or all of the premium tax credits when you file your federal taxes. A health plan meets minimum value standards if it pays at least 60 percent of the total cost of medical services. It must also provide enough coverage for hospital and doctor services. In other words, it must be similar to a Bronze plan with Covered California. The affordability threshold percentage changes every year. For 2023, employer-sponsored coverage is considered affordable if the employee’s share of the premium for the lowest-cost plan to cover the employee only (not including the family) is not more than 9.12 percent of the employee’s household income. If the lowest-cost health plan offered by your employer to cover only you costs more than 9.12 percent of your household income, you can apply for a Covered California plan with financial help. If the lowest cost health plan option is 9.12 percent or less for the employee only, but over 9.12 percent to cover the other family members, those family members may qualify for financial help to lower the cost of a Covered California plan. To determine if your plan is affordable, you can ask your employer to help you fill out this worksheet or you can go here, scroll to the bottom of the page and use Covered California's Affordability Tool.

If you stated that your income would be a certain amount, and then you received premium assistance based on that amount, but your income turned out to be lower than you stated, you may have been entitled to more premium assistance than you received, and you will receive the balance as a tax credit when you file your tax return. If your income turned out to be higher than you projected, then you likely received too much premium assistance. If so, you will have to pay back the difference at tax time, up to a certain limit. The table below shows the repayment limits. << Insert IMG here >>

Yes, they offer three different kinds. If you qualify for any of the exemptions below, go here to apply. General Hardship You can apply for this exemption if the hardship you experienced included one of the following reasons: Appeals decision shows eligibility for enrollment through Covered California when not actually enrolled. Bankruptcy. Death of a close family member. Domestic violence. Evicted in the past six months or is facing eviction or foreclosure. Experienced homelessness. Medical expenses that resulted in substantial debt. Medical support order. Natural disaster (i.e. fire, flood, or human-caused disaster). Unexpected increases in necessary expenses or decreases in household income due to divorce/separation; unexpected or sudden disability; or caring for an ill, disabled or aging family member. Utility shut-off. Other (granted on a case-by-case basis). To apply, you will need the following information for all household members: Date of birth. Social Security numbers (SSN) or Individual Taxpayer Identification Numbers (ITIN), if you have one. Proof to support your claim of hardship. Affordability Hardship To be eligible for this exemption, your health coverage must be considered unaffordable. Affordability is calculated on the lowest-cost coverage available to you through an employer or Covered California. This coverage is considered unaffordable if your costs are more than 8.17 percent of your projected annual household income in 2023. What you will need to apply Date of birth Social Security number (SSN) or Individual Taxpayer Identification Number (ITIN), if you have one Information about any offers of job-related health coverage with supporting proof Employer information Expected household income with supporting proof Additional Information This exemption will only be approved for months in the future until the end of the current calendar year. For example, if you apply for an exemption in March and we approve it in April, you will have an exemption for the months of May through December. For the current calendar year, you cannot apply for this exemption after Nov. 30. If you want this exemption for the entire next calendar year, you need to apply at least 30 days before the end of this calendar year. If you would like an exemption because your coverage was not affordable for months in the past, you may claim it on your state income tax return. If you need help doing this, reach out to a tax advisor. Religious Consciences If you or anyone in your tax household is member of a recognized religious sect or division who is opposed to acceptance of public benefits or private insurance benefits, or who relies solely on a religious method of healing, you can apply for a religious conscience exemption. Criteria Member of an approved religious sect or division that is against accepting public benefits, including Medicare and Social Security benefits as described in section 1402(g)(1) of the Internal Revenue Code; For more information about exempt religious groups, go to the United States Social Security Administration. Have an approved and signed IRS Form 4029 (“Application for Exemption from Social Security and Medicare Taxes and Waiver of Benefits”); or Rely solely on a religious method of healing and the acceptance of medical health services is against your religious beliefs. To claim an exemption for this reason you must also attach proof showing that your religious sect or division relies solely on a religious method of healing and attest that you have not received medical health services in the prior tax year. What you will need to apply Date of birth Social Security number (SSN) or Individual Taxpayer Identification Number (ITIN), if you have one The name and address of your religious sect or division If applicable, a copy of an approved IRS Form 4029 (“Application for Exemption from Social Security and Medicare Taxes and Waiver of Benefits”) with required signatures If applicable, proof showing that your religious sect or division relies solely on a religious method of healing such that accepting medical services goes against this belief. If you already have a federal religious conscience exemption certificate number (ECN) from HealthCare.gov that is still in effect, you do not need to reapply for this exemption through Covered California. You can use your existing federal ECN on your state tax return. However, if you were under age 21 when you received a federal ECN and are now 21 or older, you will need to reapply through Covered California. You may contact Covered California to verify whether your existing federal ECN is still valid by calling (800) 300-1506.

Yes, there are exemptions you can claim when you file your state taxes. Income below the state tax filing threshold (you may still choose to file taxes and are required to if you received financial help). A short coverage gap of three consecutive months or less. Health coverage is unaffordable, based on actual income reported on your state income tax return when filing taxes. Individual: Cost of the lowest-cost Bronze plan through Covered California or the lowest cost employer-sponsored employee-only plan is more than 8.17 percent for the tax year 2023. Household: Cost of the lowest-cost employer-sponsored family plan that covers all employee’s dependents is more than 8.17 percent for the tax year 2023. Certain non-citizens who are not lawfully present. Citizens living abroad or residents of another state. Members of a health care sharing ministry. Members of federally recognized tribes including Alaskan Natives, or other individuals eligible for services through an Indian health care provider or the Indian Health Service. Incarceration (in jail, other than incarceration pending the disposition of charges). Enrolled in limited or restricted-scope Medi-Cal or other similar coverage. To learn more, please visit the California Franchise Tax Board.

Yes, it was fixed in 2023! Prior to this year, an estimated 5.1 million people were ineligible for marketplace subsidies because of the family glitch. Generally, people are ineligible for marketplace subsidies if they have an offer of “affordable” job-based coverage – including through a family member’s job. However, until 2023, the affordability of job-based coverage for a worker’s spouse and dependents only measured the premium contribution required for the worker’s self-only coverage. As a result, if an employer coverage offer met the affordability threshold (9.12% of income in 2023) for self-only coverage but not for family coverage, those family members were nonetheless considered to have an offer of “affordable” job-based health coverage and locked out of ACA marketplace subsidies. New rules will take effect for the 2023 coverage year, measuring the affordability of family coverage based on the worker’s premium contribution for family coverage. If that amount is more than 9.12% of household income in 2023, family members will have the option of buying health coverage through the Marketplace and will be eligible for premium tax credits based on their income.

Prior to 2023, carriers within Covered California could refuse to renew coverage for people who had fallen behind on premium payments. For 2023, that will no longer be the case. People who fell behind on premium payments in 2022 (or even lapsed coverage due to nonpayment) will still be able to enroll in a 2023 policy offered by that insurer; and the binder payment (the January 2023 monthly premium payment) required to effectuate coverage cannot be applied to past-due premiums.

You can apply for dental insurance at any point during the year. Most carriers have a cut off date during the month in order to have an effective date for the first of the following month. To get more information on dental plans, please call into our office and speak with Desiree, or you may also email her @ desiree@lawilliamsinsurance.com for quotes and benefit outlines.

Yes, most carriers do enforce a waiting period for major services- ranging from 6-12 months. It is very important to make sure you have a comprehensive dental plan in place prior to needing any major work done. Consumers are often surprised and worried to find out they have to wait to have services done when needed, or that they have to pay out of pocket. Don't let that happen to you! There are a few carriers that offer no waiting periods:

The maximum is the amount the dental carrier will spend on your dental care during the calendar year. This maximum resets each year. Most dental carriers do not "roll over" any of the "unspent maximum".

Yes! Not all plans offer this benefit, but we work with some carriers that do.

Starting in 2020, California residents must either: Have qualifying health insurance coverage, or Pay a penalty when filing a state tax return, or Get an exemption from the requirement to have coverage. The penalty for not having coverage the entire year will be at least $850 per adult and $425 per dependent child under 18 in the household when you file your 2022 state income tax return in 2023. A family of four that goes uninsured for the whole year would face a penalty of at least $2,550. The penalty will be applied by the California Franchise Tax Board. For information about the penalty visit the Franchise Tax Board’s website.

We cannot calculate your penalty for you, however you can get an estimate by going to the Franchise Tax Board's website and use their penalty estimator tool.

Individual and family health insurance is a type of health insurance coverage that is available to an individual (one person) or a family (more than one person within the family). This is different than a group health insurance policy which provides health insurance coverage to owners and their employees of a business or organization. If offered, most people would prefer to have their employer provide group health insurance coverage. The truth is, not all employers offer it. If health insurance benefits are not offered, then an individual or family plan is another option. There are many affordable individual and family plans available to fit any budget. Keep in mind, the more you can afford, the richer the benefit.

Individual and family health insurance plans are either “indemnity” or “managed-care” plans. The major differences include choice of healthcare providers, out-of-pocket costs and how bills are paid. Indemnity plans offer a broader selection of healthcare providers than managed care plans. Indemnity plans pay their share of the costs for covered services only after they receive a bill (which means that you may have to pay up front and then obtain reimbursement from your health insurance company). There are several different types of managed care health insurance plans. These include HMO, PPO, and POS plans. Managed care plans typically use provider networks. These providers within a network agree to perform services for patients at pre-negotiated rates and most of the time will submit the claim to the insurance company for you. This means that you will have less paperwork and lower out-of-pocket costs.

With a PPO (Preferred Provider Organization) plan, you’ll be encouraged to use the insurance company’s network of preferred doctors and hospitals. These healthcare providers have been contracted to provide services to you at a discounted rate. You will not be required to choose a primary care physician (like you would with an HMO plan) but you should be proactive in only seeing providers within the network to avoid extra out of pocket expense. You will probably have an annual deductible to pay before the insurance company starts covering your medical bills. You may also have a co-payment for certain services or be required to cover a certain percentage of the total charges for your medical bills. With a PPO plan, services rendered by an out-of-network provider will ultimately cost you extra out of pocket expenses. We cannot stress enough the importance of staying within the network to minimize your medical premium dollars spent.

An HMO (Health Maintenance Organization) plan provides rich benefits. They offer lower out-of-pocket healthcare expenses. They offer less flexibility in the choice of providers than other health insurance plans. You will be required to choose a primary care physician (PCP) when you apply for an HMO plan. You will be required to visit your PCP if and when you need medical attention. If you need to see a specialist, you will need to be referred by your PCP. You may have no coverage provided for services rendered by an out-of-network provider.

Legislation establishing Health Savings Accounts (or “HSAs”) took effect on January 1, 2004. HSAs and HSA-compatible health insurance plans are becoming more and more popular. Here are the basics: An HSA is a savings account that may be used in conjunction with an HSA-compatible high deductible health insurance plan (HDHP) to pay for qualifying medical expenses that are established by the federal government. Not all high deductible health plans are HSA compatible. Choosing an HSA-compatible health insurance plan may help you save money. The monthly premium on an HSA-compatible high deductible plan is less expensive than the monthly premium on a lower-deductible health insurance plan. Contributions to an HSA may be made at any time subject to certain annual limits established by the federal government. Funds in the HSA may be used at your discretion for non medically qualified expenses but you will be subject to a penalty. Record keeping is essential. Unused funds remain in the HSA account and accrue interest year-to-year and are tax-free.

California will become the first state in the country to allow adult children to add parents and step-parents to their health insurance plan thanks to the Parent Healthcare Act. There’s no age requirement for parents, but they must meet the federal definition of a “qualifying relative,” meaning their annual gross income is very limited and the adult child covers more than half of their total annual expenses. This new rule may be especially helpful for older adults who aren’t eligible for Medicare, including green card holders who haven’t lived in the U.S. for the required five years.

Generally, when you turn 65. This is called your Initial Enrollment Period. It lasts for 7 months, starting 3 months before you turn 65, and ending 3 months after the month you turn 65. When your coverage starts The date your coverage starts depends on which month you sign up during your Initial Enrollment Period. Coverage always starts on the first of the month. If you qualify for Premium-free Part A: Your Part A coverage starts the month you turn 65. (If your birthday is on the first of the month, coverage starts the month before you turn 65.)

If you miss your 7-month Initial Enrollment Period, you may have to wait to sign up and pay a monthly late enrollment penalty for as long as you have Part B coverage. The penalty goes up the longer you wait. You may also have to pay a penalty if you have to pay a Part A premium, also called “Premium-Part A.” Learn more about how to avoid late enrollment penalties.

After your first chance to sign up (Initial Enrollment Period), there are certain situations when you can sign up for Part B (and Premium-Part A) without paying a late enrollment penalty. A Special Enrollment Period (SEP) is only available for a limited time. If you don’t sign up during your Special Enrollment Period, you’ll have to wait for the next General Enrollment Period and you might have to pay a monthly late enrollment penalty. Situations that don’t qualify for a Special Enrollment Period: Your COBRA coverage or retiree coverage ends. You missed your 8-month window to sign up when you stopped working or lost job-based coverage. You have or lose your Marketplace coverage. You have End-Stage Renal Disease (ESRD). Learn more about Medicare coverage for ESRD. Special Enrollment Periods for Part A & Part B Lost Medicaid coverage on or after 1/1/2023 SEP Starts: The day you’re notified that your Medicaid coverage is ending. SEP Ends: 6 months after your Medicaid coverage ends. Coverage begins: The month after you sign up, or the date your Medicaid coverage ends, whichever you choose. Fill out form CMS-10797 and send the completed form to your local Social Security office by fax or mail. Missed a chance to sign up because you were impacted by a natural disaster or an emergency that’s declared or starts on or after 1/1/2023 (or if your authorized representative, legal guardian, or caregiver was impacted by a disaster or emergency) SEP Starts: The day the Federal, state or local government declares the emergency or disaster, or the date in that declaration (whichever is earlier). SEP Ends: 6 months after whichever of these happens later: The end date in the original declaration. The last day of any extensions to the declaration. The date the government revokes or announces the end of the declaration. Coverage begins: The month after you sign up. Fill out form CMS-10797 and send the completed form to your local Social Security office by fax or mail. Missed a chance to sign up because you got inaccurate or misleading information from your health plan or employer on or after 1/1/2023 SEP Starts: The day you notify the Social Security Administration that your health plan or employer misrepresented or gave you incorrect information. SEP Ends: 6 months later. Coverage begins: The month after you sign up. Fill out form CMS-10797 and send the completed form to your local Social Security office by fax or mail. Missed a chance to sign up because you experienced other exceptional conditions Note: You must contact Social Security to ask for this Special Enrollment Period SEP Starts: Once you contact Social Security. SEP Ends: At least 6 months later. Coverage begins: The month after your sign up. Fill out form CMS-10797 and send the completed form to your local Social Security office by fax or mail. Have or had health insurance through your job, your spouse’s job (or a family member’s job if you’re disabled) SEP Starts: The first month after your Initial Enrollment Period ends. SEP Ends: 8 months after the group health plan coverage or the employment ends, whichever happens first. Coverage begins: Generally the month after you sign up. In some situations you can choose to have your coverage start on the first day of any of the 3 following months. COBRA isn't considered group health plan coverage. Getting COBRA doesn’t change when this Special Enrollment Period ends. If you already have Part A, go to SSA.gov to sign up for Part B. You can also send completed forms to your local Social Security office by fax or mail. I want to sign up for Part A and Part B. I have part A and I want to sign up for Part B. Volunteer and serve in a foreign country SEP Starts: The first day of the month any of these happen: You’re no longer a volunteer outside the United States. The organization you’re volunteering with no longer has tax-exempt status. You no longer have health insurance that provides coverage outside of the United States. SEP Ends: 6 months later. Coverage begins: The month after you sign up. To enroll, sign up for Medicare Part A and Part B online. If you already have Part A, you can enroll in Part B only. Have TRICARE SEP Starts: When Social Security notifies you. SEP Ends: 12 months later. Coverage begins: The month after you sign up, or, you may decide for coverage to begin after the end of your Initial Enrollment Period. Get more information here. Were released from incarceration on or after 1/1/2023 (and missed a chance to sign up while you were incarcerated) SEP Starts: The day you're released from custody. SEP Ends: The last day of the 12th month after the month you're released. Coverage begins: The month after you sign up, or you can select retroactive coverage back to your release date (but not a date before your release date). You can only request retroactive coverage up to 6 months in the past. Fill out form CMS-10797 and send the completed form to your local Social Security office by fax or mail. What happens if I choose a coverage start date in the past? You have an option to request entitlement for a retroactive period of up to 6 months so long as it is after your release from custody. If you sign up for Medicare within the first 6 months of your release from custody and choose to start your coverage in the past: Your coverage will start on your incarceration release date. You’ll be responsible for paying Medicare premiums back to your coverage start date. If you sign up for Medicare more than 6 months after your release from custody and choose to start your coverage in the past: Your coverage will start 6 months after your release date. You’ll be responsible for paying Medicare premiums back to your coverage start date. Example: Carla is in prison. She had Medicare Parts A and B, but was terminated from Part B because she didn’t pay her premiums while she was incarcerated. She is released from custody on April 15, 2023, and signs up for Medicare (using the Special Enrollment Period) on November 4, 2023. Carla needs to choose an effective date: Option 1 – Future effective date. If Carla chooses this option, her coverage would be effective December 1, 2023, and she would start paying premiums in December. Option 2 – Past effective date. If Carla chooses this option, her coverage would be effective May 1, 2023 (since it can only apply back for 6 months). Carla will be responsible for paying Medicare premiums from May 2023 and beyond.

You will receive what Medicare refers to as a "Medicare Summary Notice" (MSN) every 3 months if you get any services or medical supplies during that 3-month period. If you don’t get any services or medical supplies during that 3-month period you won’t get an MSN for that particular 3-month period. Medicare Summary Notice Example: Part A Part B DME What should I do if I get this notice? If you have other insurance, check to see if it covers anything that Medicare didn’t. Keep your receipts and bills, and compare them to your MSN to be sure you got all the services, supplies, or equipment listed. If you paid a bill before you got your notice, compare your MSN with the bill to make sure you paid the right amount for your services. If an item or service is denied, call your doctor’s or other health care provider's office to make sure they submitted the correct information. If not, the office may resubmit. If you disagree with any decision made, you can file an appeal. The last page of the MSN gives you step-by-step directions on when and how to file an appeal. Note: Did you know you can get your MSNs electronically (eMSNs)? If you choose eMSNs, you’ll get an email with a link to your MSN for that month. You won't have to wait 3 months for a paper copy in the mail. Find out how to get eMSNs. If you need it, you can also get your MSN in an accessible format like large print or Braille.

Small business owners with fewer than 50 full-time employees are not required to offer health care coverage to their employees. For those who are required to offer insurance, the penalties are steep if they do not. There are two types of penalties an employer can face. 4980H(a) In 2023, a yearly penalty of $2,880 (or $240 for each month) per full-time employee minus the first 30 will be imposed if the company fails to provide minimum essential coverage to at least 95% of its full-time employees and their dependents, and if any full-time employee obtains coverage through the exchange. 4980H(b) The employer will face a penalty if the employer-sponsored coverage is unaffordable or does not provide minimum value, and if one or more full-time employees receive subsidized coverage through the exchange. The penalty is $4,320 (for calendar year 2023) divided by 12 for each full-time employee who receives subsidized coverage through an exchange in a month. The affordability criteria, which is used to assess whether employer-sponsored health coverage is deemed affordable for employer shared responsibility, is 9.12% for 2023, down from 9.61% in 2022. This percentage is used to calculate affordability based on an employee’s required contribution for coverage. Note: An employee may be eligible for subsidized coverage through an exchange If: The employee’s household income is no more than 400% of the federal poverty line, and The employee is not able to get affordable coverage through an eligible employer-sponsored plan that provides minimum value.

You can apply for vision insurance at any point during the year. Most carriers have a cut off date during the month in order to have an effective date for the first of the following month. To get more information on vision plans, please call into our office and speak with Desiree, or you may also email her @ desiree@lawilliamsinsurance.com for quotes and benefit outlines.