Tag: insurance

HHS approves Washington state request to offer health insurance to illegal immigrants, citing ‘health equity’

President Joe Biden’s administration will allow Washington state to provide health insurance to illegal immigrants within its borders by rolling back requirements for the Affordable Care Act (ACA).

The Department of the Treasury and the Department of Health and Human Services (HHS) approved the state’s request via a State Innovation Waiver, which was requested by Washington’s government in May.

WA GOV. INSLEE’S EQUITY SUMMIT TELLS STATE AGENCIES ‘OBJECTIVITY,’ ‘INDIVIDUALISM’ ROOTED IN ‘WHITE SUPREMACY’

HHS approves Washington state request to offer health insurance to illegal immigrants, citing ‘health equity’

Xavier Becerra, secretary of Health and Human Services, speaks during a news conference in Washington, D.C., on Tuesday, June 28, 2022.
(Amanda Andrade-Rhoades/Bloomberg via Getty Images)

“Washington has requested a waiver in order to expand access to qualified health plans, stand-alone qualified dental plans, and a state affordability program to Washington residents regardless of immigration status,” HHS and Treasury said in a joint statement.

The statement continued, “The waiver will help Washington work towards its goals of improving health equity and reducing racial disparities by expanding access to coverage for the uninsured population through the state Exchange, all the while not increasing costs for those currently enrolled.”

BORDER OFFICIALS SEEING MASSIVE MIGRANT NUMBERS, LARGE GROUPS AHEAD OF TITLE 42’S END

The U.S. Treasury Department building viewed from the Washington Monument, Wednesday, Sept. 18, 2019, in Washington.

The U.S. Treasury Department building viewed from the Washington Monument, Wednesday, Sept. 18, 2019, in Washington.
(AP Photo/Patrick Semansky, File)

The ACA’s normal regulations explicitly exclude non-citizens living in the U.S. illegally from collecting the benefits of the program.

Washington’s successful campaign to expand coverage to illegal immigrants is the first of its kind since the ACA was introduced.

TEXAS LAUNCHES TASK FORCE WITH K9S, DRONES TO STOP ILLEGAL IMMIGRANT ‘GOTAWAYS’ AMID SPIKE IN NUMBERS

State Innovation Waivers are granted under the supervision of the HHS and Treasury for states seeking to modify existing ACA regulations to suit their specific needs.

Washington State Capitol

Washington State Capitol
(Dan Mihai/Getty Images)

“Section 1332 of the Affordable Care Act (ACA) permits a state to apply for a State Innovation Waiver (also referred to as section 1332 waiver) to pursue innovative strategies for providing residents with access to high quality, affordable health insurance while retaining the basic protections of the ACA,” according to the Centers for Medicare and Medicaid Services.

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In their statement, the departments said that the approved modification of Washington’s ACA, contingent upon the state accepting “specific terms and conditions,” would be valid from 2024 through 2028.

Timothy Nerozzi is a writer for Fox News Digital. You can follow him on Twitter @timothynerozzi and can email him at timothy.nerozzi@fox.com

Health insurance terms to learn as open enrollment begins

Halfpoint Images | Moment | Getty Images

It’s open enrollment season, the time each year when millions of American workers and retirees must choose a health plan, whether new or existing.

But picking health insurance can be a dizzying venture. Health plans have many moving parts — which may not come into focus at first glance. And each has financial implications for buyers.

“It is confusing, and people have no idea how much they could potentially have to pay,” said Carolyn McClanahan, a certified financial planner and founder of Life Planning Partners, based in Jacksonville, Florida. She is also a medical doctor.

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Here’s what you need to know about 2023 marketplace coverage

Making a mistake can be costly; consumers are generally locked into their health insurance for a year, with limited exception.

Here’s a guide to the major cost components of health insurance and how they may impact your bill.

1. Premiums

The premium is the sum you pay an insurer each month to participate in the health plan.

It’s perhaps the most transparent and easy-to-understand cost component of a health plan — the equivalent of a sticker price.

The average premium for an individual is $7,911 a year — or $659 a month — in 2022, according to a report on employer coverage from the Kaiser Family Foundation, a nonprofit. It’s $22,463 a year — $1,872 a month — for family coverage.

However, employers often pay a share of these premiums for their workers, greatly reducing the cost. The average worker pays a total $1,327 per year — or, $111 a month — for individual coverage and $6,106 — $509 a month — for family coverage in 2022, after factoring in employers’ share.

Your monthly payment may be higher or lower depending on the type of plan you choose, the size of your employer, your geography and other factors, according to KFF.

Health insurance terms to learn as open enrollment begins

Low premiums don’t necessarily translate to good value. You may be on the hook for a big bill later if you see a doctor or pay for a procedure, depending on the plan.

“When you’re shopping for health insurance, people naturally shop like they do for most products — by the price,” said Karen Pollitz, co-director of KFF’s program on patient and consumer protections.

“If you’re shopping for tennis shoes or rice, you know what you’re getting” for the price, she said. “But people really should not just price shop, because health insurance is not a commodity.

“The plans can be quite different” from each other, she added.

2. Co-pay

Many workers also owe a copayment — a flat-dollar fee — when they visit a doctor. A “co-pay” is a form of cost-sharing with health insurers.

The average patient pays $27 for each visit to a primary-care doctor and $44 to visit a specialty care physician, according to KFF.

3. Co-insurance

Patients may owe additional cost-sharing like co-insurance, a percentage of health costs that the consumer shares with the insurer. This generally kicks in after you’ve paid your annual deductible (a concept explained more fully below).

The average co-insurance rate is 19{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} for primary-care and 20{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} for specialty-care services, according to KFF data. The insurer would pay the other 81{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} and 80{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}, respectively.

As an example: If a specialty service costs $1,000, the average patient would pay 20{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} — or $200 — and the insurer would pay the remainder.

Co-pays and co-insurance may vary by service, with separate classifications for office visits, hospitalizations or prescription drugs, according to KFF. Rates and coverage may also differ for in-network and out-of-network providers.

4. Deductible

Fatcamera | E+ | Getty Images

Deductibles are another common form of cost-sharing.

This is the annual sum a consumer must pay out of pocket before the health insurer starts to pay for services.

Eighty-eight percent of workers covered by a health plan have a deductible in 2022, according to KFF. The average person with single coverage has a $1,763 deductible.

The deductible meshes with other forms of cost-sharing.

Here’s an example based on a $1,000 hospital charge. A patient with a $500 deductible pays the first $500 out of pocket. This patient also has 20{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} co-insurance, amounting to $100 (or, 20{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the remaining $500 tab). This person would pay a total $600 out of pocket for this hospital visit.

When you’re shopping for health insurance, people naturally shop like they do for most products — by the price.

Karen Pollitz

co-director of the program on patient and consumer protections at the Kaiser Family Foundation

Health plans may have more than one deductible — perhaps one for general medical care and another for pharmacy benefits, for example, Pollitz said.

Family plans may also assess deductibles in two ways: by combining the aggregate annual out-of-pocket costs of all family members, and/or by subjecting each family member to a separate annual deductible before the plan covers costs for that member.

The average deductible can vary widely by plan type: $1,322 in a preferred provider organization (PPO) plan; $1,451 in a health maintenance organization (HMO) plan; $1,907 in a point of service (POS) plan; and $2,539 in a high-deductible health plan, according to KFF data on single coverage. (Details of plan types are in more detail below.)

5. Out-of-pocket maximum

Most people also have an “out-of-pocket maximum.”

This is a limit on the total cost sharing consumers pay during the year — including co-pays, co-insurance and deductibles.

“The insurer can’t ask you for a co-pay at the doctor or pharmacy, or hit you for more deductibles,” Pollitz said. “That’s it; you’ve given your pound of flesh.”

More than 99{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of workers with single coverage are in a plan with an out-of-pocket maximum, according to KFF.

And the range can be large: 8{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of workers with single coverage have an out-of-pocket maximum of less than $2,000, but 26{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} have one of $6,000 or more, according to KFF data.

Out-of-pocket maximums for health plans purchased through an Affordable Care Act marketplace can’t exceed $9,100 for individuals or $18,200 for a family in 2023.

6. Network

Portra | E+ | Getty Images

Health insurers treat services and costs differently based on their “network.”

“In-network” refers to doctors and other health providers that are part of an insurer’s preferred network. Insurers sign contracts and negotiate prices with these in-network providers. This isn’t the case for “out-of-network” providers.

Here’s why that matters: Deductibles and out-of-pocket maximums are much higher when consumers seek care outside their insurer’s network — generally amounting to about double the in-network amount, McClanahan said.

There’s sometimes no cap at all on annual costs for out-of-network care.

“Health insurance really is all about the network,” Pollitz said.

“Your financial liability for going out of network can be really quite dramatic,” she added. “It can expose you to some serious medical bills.”

Some categories of plans disallow coverage for out-of-network services, with limited exception.

For example, HMO plans are among the cheapest types of insurance, according to Aetna. Among the tradeoffs: The plans require consumers to pick in-network doctors and require referrals from a primary care physician before seeing a specialist.

Similarly, EPO plans also require in-network services for insurance coverage, but generally come with more choice than HMOs.

POS plans require referrals for a specialist visit but allow for some out-of-network coverage. PPO plans generally carry higher premiums but have more flexibility, allowing for out-of-network and specialist visits without a referral.  

“Cheaper plans have skinnier networks,” McClanahan said. “If you don’t like the doctors, you may not get a good choice and have to go out of network.”

There’s crossover between high-deductible health plans and other plan types; the former generally carry deductibles of more than $1,000 and $2,000, respectively, for single and family coverage and are paired with a health savings account, a tax-advantaged way for consumers to save for future medical costs.

How to bundle it all together

Mstudioimages | E+ | Getty Images

Budget is among the most important considerations, said Winnie Sun, co-founder and managing director of Sun Group Wealth Partners in Irvine, California, and a member of CNBC’s Advisor Council.

For example, would you struggle to pay a $1,000 medical bill if you require health care? If so, a health plan with a larger monthly premium and a smaller deductible may be your best bet, Sun said.

Similarly, older Americans or those who require a lot of health care each year — or who expect to have a costly procedure in the coming year — may do well to pick a plan with a bigger monthly premium but lower cost-sharing requirements.

Healthy people who generally don’t max out their health spending every year may find it cheaper overall to have a high-deductible plan with a health savings account, McClanahan said.

Consumers who enroll in a high-deductible plan should use their monthly savings on premiums to fund an HSA, advisors said.

Cheaper plans have skinnier networks. If you don’t like the doctors, you may not get a good choice and have to go out of network.

Carolyn McClanahan

certified financial planner and founder of Life Planning Partners

“Understand the first dollars and the potential last dollars when picking your insurance,” McClanahan said, referring to upfront premiums and back-end cost-sharing.

Every health plan has a “summary of benefits and coverage,” which presents key cost-sharing information and plan details uniformly across all health insurance, Pollitz said.

“I’d urge people to spend a little time with the SBC,” she said. “Don’t wait until an hour before the deadline to take a look. The stakes are high.”

Further, if you’re currently using a doctor or network of providers you like, ensure those providers are covered under your new insurance plan if you intend to switch, McClanahan said. You can consult an insurer’s in-network online directory or call your doctor or provider to ask if they accept your new insurance.

The same rationale goes for prescription drugs, Sun said: Would the cost of your current prescriptions change under a new health plan?

How to spot misleading marketing for insurance

It took approximately a yr for Kelly Macauley to know the wellbeing program she purchased even though purchasing for insurance coverage protection final October was not, in fact, insurance policy. Guaranteed, purple flags popped up along the way, but when she named to complain, she claimed, she was satisfied with explanations that sounded realistic plenty of and saved her shelling out her $700 monthly rates.

She reported she was told that her clinical costs weren’t remaining paid out mainly because the healthcare facility was distributing them improperly. That Jericho Share, the nonprofit that despatched her a membership card studying “THIS IS NOT Insurance policies,” was just her policy’s underwriter, not the genuine insurance provider. That she hadn’t acquired a plan welcome packet because the company was saving paper and passing people cost savings on to buyers.

Then, this summer season, the 62-yr-aged retired trainer who recently moved from the Philadelphia region to South Carolina, realized her program had paid only $120 of the invoice for her hip substitute previous calendar year, leaving her with a balance of in excess of $40,000. She said she’d been assured the technique would be included when she was browsing for insurance coverage. But it turns out that the plan she obtained was not insurance policy at all but rather component of a little something referred to as a health care sharing ministry.

How to spot misleading marketing for insurance

Wellbeing treatment sharing ministries are an alternate to health insurance plan in which associates concur to share healthcare charges. They are generally religion-primarily based and can be less costly than classic insurance, whilst they never automatically address their members’ professional medical bills, according to a Commonwealth Fund report.

“That was never, at any time mentioned to me,” Macauley reported. “I actually thought I was buying respectable clinical insurance.”

Starting Nov. 1, millions of Americans will order overall health insurance plan for 2023 in a period known as “open enrollment.” Via the federal and state insurance plan marketplaces, customers can shop for Very affordable Care Act-compliant health insurance options and discover out no matter whether they qualify for money aid.

But industry experts caution that the rush to obtain coverage also offers an option for people offering substitute products and solutions, these as quick-phrase wellness designs and health and fitness care sharing ministries, that are normally more affordable than thorough coverage but give significantly fewer protections. While individuals choices are themselves legal, authorities warning that deceptive internet marketing can immediate customers searching for thorough protection into getting wellness strategies that exclude protections for preexisting ailments and depart individuals susceptible to substantial health care charges.

“It’s a primary time to go seeking for consumers who are out purchasing for coverage and take them down the completely wrong route,” reported JoAnn Volk, co-director of Georgetown University’s Heart on Wellbeing Insurance Reforms.

Volk identified telltale symptoms of that incorrect route: if the person offering you a system commences inquiring about your well being historical past, or if they refuse to mail you details about the program completely, or they agree to provide that details only just after you give them your payment information. According to a 2021 magic formula-shopper report on deceptive advertising and marketing techniques, which Volk co-authored, one broker incorrectly cited HIPAA, the legislation to secure affected person privateness, as a explanation to not share data about the health and fitness strategy.

“Just produced-up stuff,” Volk reported. “If you are committing fraud, there are no boundaries.”

In a assertion to KHN, Jericho Share spokesperson Mark Hubbard mentioned the organization couldn’t talk about Macauley’s circumstance with no her prior composed approval but doesn’t tolerate any misrepresentation or unethical perform on the aspect of its courses.

Nationwide, lawmakers and regulators are taking recognize of how wellbeing care ideas are marketed. Senate Finance Committee Chairman Ron Wyden, a Democrat from Oregon, is investigating problems about the advertising and marketing of Medicare Benefit ideas. And in Might, the Facilities for Medicare & Medicaid Products and services mentioned that complaints about marketing and advertising procedures for Medicare Gain and Medicare prescription drug benefit plans rose from 15,497 in 2020 to at least 39,617 in 2021.

“Scams involving wellbeing treatment have amplified exponentially,” stated Delaware Insurance policies Commissioner Trinidad Navarro, who also chairs the antifraud endeavor force of the Nationwide Association of Insurance Commissioners.

Various factors are creating the boost, Navarro stated. Rising wellness care price ranges can travel up the price tag of regulated health and fitness strategies, this sort of as all those that are compliant with the Very affordable Care Act. Larger charges force far more Americans to glimpse for cheaper solutions that normally really do not provide as considerably protection and can confuse consumers. Those varieties of plans proliferated under President Donald Trump’s administration, Navarro explained.

“I don’t want to audio political,” reported Navarro, an elected Democrat, “but the former presidential administration was really pushing the skinny plans and the options to the ACA, and I don’t essentially think that they understood the fraud that was associated with these programs.”

Ultimately, Navarro explained, due to the fact states are the most important regulators of insurance policies, tamping down on health and fitness treatment scams can be like enjoying a video game of whack-a-mole — when one point out usually takes action, scammers shift to one more one particular to open up shop.

To fight that tactic, Navarro said, insurance policy regulators nationwide have made what he described as a “confluence page” to share among the by themselves facts about terrible actors. For buyers, Navarro mentioned, regulators are conversing about creating a community lookup resource to search for problems against well being insurance policy brokers, related to the BrokerCheck tool established by the Economical Field Regulatory Authority to observe stockbrokers.

For now, he implies performing with health and fitness treatment navigators, who help buyers enroll in ideas by means of the formal overall health insurance policies market, healthcare.gov. Also, regulators have been having legal action on deceptive sales ways. In August, the Federal Trade Commission received $100 million in refunds for customers it mentioned ended up “tricked” into sham well being options. Past year, the Massachusetts attorney standard gained $515,000 in shopper relief from an insurance policy corporation accused of deceptive gross sales tactics.

Court docket filings from October indicate the California attorney common is investigating Jericho Share — the health care sharing ministry that Kelly Macauley stated she unwittingly purchased a prepare from — to see no matter if it is in compliance with the state’s requirements for wellness treatment sharing ministries.

Jericho Share’s spokesperson, Hubbard, claimed the business is “responding appropriately” to the lawyer general’s inquiry.

Macauley arrived at out to KHN following looking at a June investigation about consumers who said they imagined they were purchasing insurance policy only to afterwards discover they had been marketed memberships to that overall health care sharing ministry.

Hubbard famous that since that tale was printed, Jericho Share mechanically delivers refunds in 72 hours for new consumers requesting a single inside of 30 times of signing up, no for a longer time lets “outsourced advertising for enrollments,” and extra a member manual and pop-up on its web page stating that Jericho Share is a health and fitness treatment sharing ministry.

The organization did reply on line to Macauley’s lousy evaluate on the Better Enterprise Bureau site, asking for far more data about her circumstance. She said she equipped that info but under no circumstances listened to back.

Just after Macauley unsuccessfully attempted to cancel her Jericho Share approach with the company directly, she reported, she identified as her credit history card corporation to quit it from approving any additional expenses by the firm. When she described her situation, Macauley mentioned, the sympathetic credit score card agent advised her, “This is fraud,” and provided to consider to get Macauley all of her rates back.

Even if that effort is thriving, Macauley will be left with the tens of 1000’s of bucks of health care rates she incurred though unknowingly uninsured.

She is on the current market for health insurance plan once more and plans to opt for a company she’s listened to of before.

“Whatever it costs,” Macauley stated, “I just want to know I truly have coverage.”

KHN (Kaiser Wellbeing News) is a national newsroom that produces in-depth journalism about overall health concerns. Collectively with Policy Analysis and Polling, KHN is just one of the a few major functioning courses at KFF (Kaiser Spouse and children Foundation). KFF is an endowed nonprofit group delivering details on overall health problems to the country.

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What’s new for ACA health insurance open enrollment : Shots

What’s new for ACA health insurance open enrollment : Shots
Illustration of a group of people putting together a large scale puzzle on the floor. The image on the puzzle is the health care cross. Medications surround the people putting the puzzle together.

It’s fall again, meaning shorter days, cooler temperatures, and open enrollment for Affordable Care Act marketplace insurance — sign-ups begin this week for coverage that starts Jan. 1, 2023. Even though much of the ACA coverage stays the same from year to year, there have been a few changes you’ll want to take note of this fall, including those that might help you even if you don’t usually buy ACA insurance, but have been having trouble finding an affordable health plan through your employer.

In the past year, the Biden administration and Congress have taken steps — mainly related to premiums and subsidies — that will affect 2023 coverage, and could reduce your cost. Meanwhile, recent court decisions have triggered questions about what sorts of preventive care or abortion services each plan covers.

So, what’s new, and what should you know if you’re shopping for a health plan? Here are six things to keep in mind.

1. Sign up soon

Open enrollment for people who buy ACA health insurance via HealthCare.gov or one of the state exchanges begins Tuesday, Nov. 1 and, in most states, lasts through Jan. 15. To get coverage that begins Jan. 1, enrollment usually must occur by Dec. 15.

2. Your family might now qualify for a subsidy

One big change is that some families who were barred in past years from getting federal subsidies to help them purchase ACA coverage may now qualify.

Applying for health insurance doesn't have to be confusing. Here's a handy glossary

A rule recently finalized by the Treasury Department aims to address what has long been termed the “family glitch.” The change expands the number of families with job-based insurance who can choose to forgo their coverage at work and qualify for subsidies to get an ACA plan instead. The White House estimates that this adjustment could help about 1 million people gain coverage or get more affordable insurance.

Before, employees could qualify for a subsidy for marketplace insurance only if the cost of their employer-based coverage was considered unaffordable based on a threshold set each year by the IRS. But that determination took into account only how much workers would pay for insurance for themselves. The cost of adding family members to the plan was not part of the calculation, and family coverage is often far more expensive than employee-only coverage. The families of employees who fall into the “glitch,” either go uninsured or pay more through their jobs for coverage than they might if they were able to get an ACA subsidy.

Now, the rules say eligibility for the subsidy must also consider the cost of family coverage.

“For the first time, a lot of families will have a real choice between an offer of employer-sponsored coverage and a marketplace plan with subsidies,” says Sabrina Corlette, a researcher and co-director at Georgetown University’s Center on Health Insurance Reforms.

Workers will now be able to get marketplace subsidies if their share of the premium for their job-based coverage exceeds 9.12{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of their expected 2023 income.

Health Costs Bear Down On Families Who Don't Qualify For ACA Subsidies

For Some Uninsured, Simply Signing Up Is A Challenge

Thanks to the change in the rules, two calculations now will occur: the cost of the employee-only coverage as a percentage of the worker’s income and the cost of adding family members. In some cases, the worker may decide to remain on the employer plan because his or her payment toward coverage falls below the affordability threshold, but the family members will be able to get a subsidized ACA plan.

Previous legislative efforts to resolve the family glitch failed, and the Biden administration’s use of regulation to fix it is controversial. The move might ultimately be challenged in court. Still, the rules are in place for 2023, and experts, including Corlette, say families who could benefit should go ahead and enroll.

“It will take a while for all that to get resolved,” she says, adding that it unlikely that there would be any decision in time to affect policies for 2023.

An Urban Institute analysis published last year estimated that the net savings per family from this change in regulations might be about $400 per person, and the cost to the federal government for new subsidies could be $2.6 billion a year. Not every family would save money by making the change, so experts say people should weigh the benefits and potential costs.

3. Preventive care will still be covered everywhere without a copay, but abortion coverage will vary

Many people with insurance are happy when they go in for a cancer screening, or seek other preventive care, and find they don’t have to pay anything out-of-pocket. That comes from a provision in the ACA that bars cost sharing for a range of preventive services, including certain tests, vaccines, and drugs. But a September ruling by U.S. District Judge Reed O’Connor in Texas led to confusion about what might be included in that category next year. The judge declared unconstitutional one method the government uses to determine some of the preventive treatments that are covered without patient cost sharing.

Ultimately, that might mean patients will have to start paying a share of the cost of cancer screenings or pay part of the cost of drugs that prevent the transmission of HIV. The judge has yet to rule on how many people the case will affect. But, for now, the ruling applies only to the employers and individuals who brought the lawsuit. So, your no-cost screening mammogram or colonoscopy is still no-cost. Whatever the judge decides, his ruling is likely to be appealed, and no decision is expected before the start of the 2023 coverage year.

The other court decision that has raised questions is the Supreme Court ruling that overturned the constitutional right to an abortion. Even before that decision was announced in June, coverage of abortion services in insurance plans varied by plan and by state.

Now it’s even more complicated as more states move to ban or restrict abortion.

State insurance rules vary.

66 clinics stopped providing abortions in the 100 days since Roe fell

Twenty-six states restrict abortion coverage in ACA marketplace plans, while seven states require it as a benefit in both ACA plans and employer plans purchased from insurers, according to KFF. Those states that require abortion services to be covered are California, Illinois, Maine, Maryland, New York, Oregon and Washington.

If in doubt, employees and policyholders can check their insurance plan documents for information about covered benefits, including abortion services.

4. Premiums are going up, but that might not affect most people on ACA plans

Health insurers are raising premium rates for ACA plans and for employer coverage. But most people who get subsidies for their ACA health insurance won’t feel that pinch.

That’s because the subsidies are tied to the cost of the second-cheapest “silver” plan offered in an ACA marketplace. (Marketplace plans are offered in colored “tiers,” based on how much they potentially cost policyholders out-of-pocket.) As those baseline silver plans increase in cost, the subsidies also rise, offsetting all or most of the premium increases. Still, shop around, experts advise. Switching plans might prove cost-effective.

As for subsidies, passage this summer of the Inflation Reduction Act guaranteed that the enhanced subsidies that many Americans have received under legislation tied to the COVID-19 pandemic will remain in place.

People who earn up to 150{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the federal poverty level — so make up to $20,385 for an individual and $27,465 for a couple — can get an ACA plan with no monthly premium. Consumers who earn up to 400{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the federal poverty level — or $54,360 for an individual and $73,240 for a couple — get sliding-scale subsidies to help offset premium costs. And the premiums for ACA plans purchased by people who have higher incomes than that are also capped; according to the rules, they will need to pay no more than 8.5{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of their household income toward premiums.

For workers with job-based insurance, employers generally set the amount they must pay toward health coverage. Some employers may pass along their rising insurance costs by increasing the amounts taken out of paychecks to go toward premiums, setting higher deductibles or changing the health care benefits they offer. But anyone whose share of their job-based coverage is expected to exceed 9.12{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of their income in 2023 can check now to see whether they qualify for a subsidized ACA plan instead.

5. Debts owed to insurers or to the IRS won’t stop coverage

Thank COVID-19 for this one. Typically, people who get subsidies to buy ACA plans must prove to the government in their next tax filing that they received the correct subsidy, based on the income they actually received. If they failed to do that reconciliation with the IRS, policyholders would lose eligibility for the subsidy the next time they enrolled. But, because of ongoing COVID-related problems in processing at the IRS, those consumers will get another reprieve, continuing an effort set in place for tax year 2020 by the American Rescue Plan Act.

Also, insurers can no longer deny coverage to people or employers who owe past-due premiums for previous coverage, says Karen Pollitz, a senior fellow at KFF. This follows a reexamination of a wide variety of Medicare and ACA rules prompted by an April executive order from President Joe Biden.

“If people fell behind on their 2022 premiums, they nevertheless must be allowed to reenroll in 2023,” Pollitz says. “And when they make the first-month premium payment to activate coverage, the insurer must apply that payment to their January 2023 premium.”

6. Comparison shopping will likely be easier

Although ACA plans have always been required to cover a wide range of services and offer similar benefits, variation still existed in the amounts that patients paid for office visits and other out-of-pocket costs. Starting during this year’s open enrollment, new rules are taking effect that aim to make the comparison of plans easier. Under the rules, all ACA health insurers must offer a set of plans with specific, standardized benefits. The standard plans will, for example, have the same deductibles, copays, and other cost-sharing requirements. They will also offer more coverage before a patient has to start paying toward a deductible.

Health insurance prices for care are now out there, but finding them is an ordeal

Some states, such as California, already required similar standardization, but the new rules apply nationally to health plans sold on the federal marketplace, HealthCare.gov. Any insurer who offers a non-standard plan on the marketplace must now offer the standardized plans as well.

Under a different set of rules, starting Jan. 1, all health insurers must make available cost-comparison tools online or over the phone that can help patients predict their costs for 500 “shoppable services,” such as repairs to a knee joint, a colonoscopy, a chest X-ray or childbirth services.

KHN (Kaiser Health News) is an editorially independent, national program of the Kaiser Family Foundation {KFF).