The Affordable Care Act makes a number of changes in existing law including:
• Forcing insurers to justify premium increases and spending 80 percent of premium dollars on health care, not administrative costs like salaries and marketing;
• Implementing no lifetime limits on coverage;
• Forcing insurance companies to cover preventive care and screenings, including mammograms, colonoscopies and contraception; as well as ambulatory care, emergency service, hospitalization, maternity and newborn care, mental health and substance abuse treatment, prescription drugs, rehabilitation services and devices, lab services and pediatric services, including dental and vision.
• Allowing those who are 26 and younger to remain on their parents' health care plan;
• Forcing insurance providers to cover a person who pays even if there is a pre-existing condition;
• Requiring companies with 50 or more employees working 30 hours or more to provide health insurance or at least half the cost starting in 2015. In return, companies may get tax credits up to 50 percent of insurance contributions;
• Penalizing small businesses which do not provide health care for their employees by 2015.
ACA provides exceptions for some Americans to not participate, including members of an Indian tribe, prisoners, those with such a low income they do not file taxes and those with religious beliefs that oppose health insurance. Another exception is individuals whose lowest possible premiums are more than eight percent of income.
For the first time in U.S. history, the federal government is requiring all citizens to buy a product — health care insurance. But as the controversial Affordable Care Act — often called Obamacare — takes effect, many Americans are confused about the mandates and what the new law means.
That's why state Senator Anthony Cannella staged a Town Hall meeting in Ceres on Oct. 8 to bring in local experts to talk about what is being required of citizens. About 45 attended the event at the Ceres Community Center.
Many working people already have health insurance through their employer but are finding that premiums are rising along with deductibles and coverage because of the new law. Several new government programs will be available to offer financial aid to lower the cost of health insurance, such as tax credits, cost-sharing subsidies and Medi-Cal assistance. Eligibility is based on family income and size.
Those who fail to get insurance by January will not only be without coverage but will be paying fines via the income tax return. The fines for noncompliance in 2014 will be one percent of annual income or a minimum $95 per adult or up to $285 for a family; to $325 per adult in 2015 ($975 per family); and $695 per adult and $2,085 per family in 2016. The fines do not grant insurance coverage, however.
"My fear is that people will get the fine and not even know they got the fine," said Marc Smith, a Special Projects Manager of Golden Valley Health Centers.
Each state is required by ACA to set up a health "marketplace" to help residents buy health insurance. The California marketplace is called Covered California. By logging onto the Covered California website at www.coveredca.com, a legal resident of California may find out what health care programs, costs and coverage are available. Premiums are based on age, zip code, household size and income and the desired benefit level selected.
Changes in the health care law are also expanding Medi-Cal to qualify more lower income families. As of today, Medi-Cal is limited to those with children living at home, pregnant women, disabled people or those 65 and older. Beginning Jan. 1, Medi-Cal will cover more people under age 65, including people with disabilities and those who make 138 percent or less of the federal poverty limit. Medi-Cal coverage will also expand to children living in families with annual incomes up to 250 percent of the federal poverty limit (FPL).
"Medi-Cal was limited to children and linked to a low-income family linked to a child so that has changed," said Smith.
As of May 1, some dental care will be restored to Medi-Cal since periodontal disease has more of an effect on heart issues than high blood pressure and bad cholesterol, said Smith.
Covered California provides options for coverage for the uninsured and could be a better option than a plan offered by an employer. Smith explained that those whose insurance premiums are over 9.5 percent of annual income "might get a better deal under Covered California."
Subsidized insurance is offered to those whose income are between 138 and 400 percent of the FPL, or between $15,857 to $45,960 per year for a single person; or $32,300 to $94,200 annually for a family of four. A person or household making more than those limits may still buy insurance through the Covered California exchange that comes without a subsidy.
As the state's exchange, Covered California offers plans that include Kaiser Permanente (in Stanislaus County), Anthem PPO, Blue Shield PPO, and Health Net PPO.
"These are the major insurance companies that cover our area," said Smith.
It's up to each individual to pick the level of care they wish to buy but the better plans cost more, said Smith. The Bronze Plan pays 60 percent of medical costs, the Silver Plan pays 70 percent, Gold Plan 80 percent and Platinum Plan pays 90 percent.
Smith wouldn't debate the politics of Obamacare but did say that it's not fair that the uninsured are depending on taxpayers to pay for their care when they need it. He noted that the Ceres Golden Valley office at the corner of Third and North streets sees 1,300 uninsured persons, or 29 percent of the patient load.
"That's part of the problem," said Smith. "You have a number of people who don't have coverage. They get sick, they go to the hospital emergency room or they're hospitalized. We all - society -- pays for that. They don't pay for that on an ongoing basis ... there are a lot of people who are not putting dollars in the system and when they have an event happen the system is paying for their care."
Covered California has a current annual open enrollment period until March 31.
"If you're uninsured, look into it," suggested Smith. "Decided what you'd like to do."
Those who do not apply in the next month or so won't be eligible for coverage in January, he said.
The next open enrollment won't begin until Oct. 1, 2014 and closes Dec. 31, 2014.
Medi-Cal applications are accepted throughout the year.