Health Care Reform for Individuals

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Health Care Reform for Individuals

The Patient Protection and Affordable Care Act (PPACA) was passed into law in March 2010 – it was over 2,500 pages long. It has already had an impact on the lives of most Americans.

This material does not cover all items contained in the law and is subject to change based on the interpretations of various federal agencies. In addition, numerous legal challenges have been filed against PPACA and the outcomes of these challenges may alter this information.

PPACA requires U.S. citizens and legal residents to have qualifying health coverage in 2014 or pay a tax penalty.

Year Penalty
2014 Greater of $95 or 1.0% of modified adjusted gross income
2015 Greater of $325 or 2.0% of modified adjusted gross income
2016 Greater of $695 or 2.5% of modified adjusted gross income
2017 and beyond Indexed for inflation

U.S. citizens will avoid this penalty by being enrolled in qualifying health coverage. Some hardship waivers may apply. The main avenues for being enrolled in qualifying health coverage will be as follows:

  • Being enrolled in qualifying health coverage offered by an employer for you and/or your dependents
  • Being enrolled in qualifying health coverage offered through the new Individual Exchange Marketplace
  • Being enrolled in Medicare
  • Being enrolled in Medicaid
  • Being enrolled in the Indian Health Services system
  • Being covered as a veteran or on active duty (TRICARE)

CommunityCare will be undertaking ongoing communication efforts to ensure that all of our members understand the changes associated with health care reform. We will be regularly updating information at

Individuals without qualifying health coverage from an employer, Medicare or Medicaid are able to purchase health insurance plans on the new Individual Exchange Marketplace. The next open enrollment period will begin November 15, 2014.

Insurance carriers will not be allowed to reject applicants meeting the conditions given by health care reform, nor will they be allowed to apply pre-existing conditions provisions to their members.

CommunityCare HMO members have never had a pre-existing conditions provision applied to their policies.

Individual policies may be purchased outside the Individual Exchange Marketplace, but by purchasing a policy on the Individual Exchange Marketplace, members will be assured of two key factors:

  1. The policy you are purchasing from CommunityCare is certified as qualifying coverage.
  2. You may be eligible to receive subsidies to your premiums and receive enhanced benefits in the form of lower deductibles, copays and other out-of-pocket cost-sharing responsibilities. These premium and cost-sharing reductions are available to persons enrolling on the Individual Exchange Marketplace with incomes between 100%-400% of the Federal Poverty Level (FPL).

    The subsidies are not available to persons buying coverage off the Individual Exchange Marketplace or to persons offered qualifying, affordable coverage through an employer. The health care reform regulations define coverage from an employer as affordable if no more than 9.5% of an employee's household income is required as a contribution toward single coverage.
Individual Exchange Marketplace plans will be tiered:
Platinum 90% coverage
Gold 80% coverage
Silver 70% coverage
Bronze 60% coverage

Individual Exchange Marketplace plans will be offered in a tiered format. The tiers are named after metals: bronze, silver, gold and platinum. Bronze plans will have the lowest monthly premium, but cost shares will be more when health care services are provided.

Coverage must be purchased on the Individual Exchange Marketplace to be eligible for the premium reductions and out-of-pocket cost-sharing reductions.

Premium subsidies available to persons with incomes between 100% - 400% of the Federal Poverty Level (FPL) are projected to range between 30% - 90%, depending on their income level.

Some additional information on Federal Poverty Levels (FPL) is presented below:

HHS Poverty Guidelines

Size of family unit 100% FPL 150% FPL 200% FPL 250% FPL 300% FPL 400% FPL
1 $11,490 $17,235 $22,980 $28,725 $34,470 $45,960
2 $15,510 $23,265 $31,020 $38,775 $46,530 $62,040
3 $19,530 $29,295 $39,060 $48,825 $58,590 $78,120
4 $23,550 $35,325 $47,100 $58,875 $70,650 $94,200

For all states (except Alaska and Hawaii) and for the District of Columbia

These levels are adjusted annually by the federal government.

On their website at, the Department of Health and Human Services suggests the following checklist for individuals and families:

7 things you can do to get ready now

  1. Learn about different types of health insurance. Through the Marketplace, you'll be able to choose a health plan that gives you the right balance of costs and coverage.
  2. Make a list of questions you have before it's time to choose your health plan. For example, "Can I stay with my current doctor?" or "Will this plan cover my health costs when I'm traveling?"
  3. Make sure you understand how insurance works, including deductibles, out-of-pocket maximums, copayments, etc.
  4. Start gathering basic information about your household income. Most people will qualify to get a break on costs, and you'll need income information to find out how much you're eligible for.
  5. Set your budget. There will be different types of health plans to meet a variety of needs and budgets, and breaking them down by cost can help narrow your choices.
  6. Find out from your employer whether they plan to offer health insurance, especially if you work for a small business.
  7. Explore current options. You may be able to get help with insurance now, through existing programs or changes that are in effect already from the new health care law. Use resources to get information about health insurance for adults up to age 26, children in families with limited incomes (CHIP) and Medicare for people who are over 65 or have disabilities.

Thank You

Thank you for being a CommunityCare customer, or for considering becoming a CommunityCare customer. Please click here to contact us with any questions.

We will regularly be updating this information on health care reform and look forward to working through these changes with you.