Help With Understanding the New Healthcare Coverage

You probably have heard about the Affordable Care Act (ACA) but like many may wonder how it could impact you. The biggest change will happen this fall when Health Insurance Marketplaces open for enrollment for coverage starting on January 1, 2014. However, there have been some parts implemented over the past two years that have already benefitted many, including some people with lupus. For example, young adults can stay on their parents’ insurance plans until the age of 26, people cannot be denied health insurance due to pre-existing conditions, and life time dollar limits have been eliminated.

New for 2014
For 2014, how individuals and families that do not have access to employer sponsored health insurance purchase coverage will change. Millions of people who are uninsured will now have access to affordable health insurance through Health Insurance Marketplaces. Enrollment begins October 1, 2013 for coverage starting on January 1, 2014. One of the benefits under health plans available through the Health Insurance Marketplace will be no cost sharing (deductibles and copayments) for preventive services like well-child visits, well-woman visits, colon cancer screenings, and flu shots. For a full list of screenings for adults, women, children, and seniors click here.

Here are some answers to some common questions about the Affordable Care Act.

How do I find a plan?
A person who is currently uninsured or has insurance but wants to find out about other available health insurance options can explore the Health Insurance Marketplace. One application will determine what insurance a person is eligible for, including both public insurance like Medicaid, and private insurance. Whether a person is eligible for lower monthly premiums through subsidies will also be determined by the application. There will be online, telephone, and in-person support to help people choose the best health insurance coverage for their needs.

To consider your options, visit

What are Essential Health Benefits?
Essential Health Benefits are categories that must now be covered by health plans offering small group, individual and Medicaid coverage. However, each state defines the scope of the benefits. There are ten categories:

  • ambulatory patient services
  • emergency services
  • hospitalization
  • maternity and newborn care
  • mental health and substance use disorder services,  including behavioral health treatment
  • prescription drugs
  • rehabilitative and habilitative services and devices
  • laboratory services
  • preventive and wellness services and chronic disease management
  • pediatric services, including oral and vision care.

Are there special benefits for women?
Women are eligible for several preventive services through a Marketplace plan for which there is no cost sharing. In addition, women cannot be denied healthcare coverage due to pre-existing conditions (including physical and behavioral health). Healthcare coverage for women must include prenatal and newborn care (e.g. breastfeeding equipment). Furthermore, women can no longer be charged more for healthcare coverage than men.

Is there dental coverage?
Dental coverage for children is considered an Essential Health Benefit, but this is not the case for adults. Either way, an insurer can offer dental coverage within a health plan or as a separate stand-alone plan.

What if I can’t afford insurance?
For some individuals who do not qualify for public insurance [Medicaid, Children’s Health Insurance Program (CHIP)] or employer-based insurance, there is a Health Premium Tax Credit program for insurance plans paid for out of pocket through the Marketplace. There are two options – to receive a larger income tax refund or to be taken in advance in order to decrease the monthly insurance premiums. Eligibility depends on whether or not a family income exceeds the following amounts:

Individual:     $46,960
Family of 2:     $62,040
Family of 3:     $78,120
Family of 4:     $94,200

How will I know if I qualify for Medicaid?
When you submit an application in the Marketplace, it will determine if you are eligible for Medicaid. Medicaid eligibility will expand to include higher annual incomes:

Individual:     $15,856
Family of 2:    $21,404
Family of 3:    $26,951
Family of 4:    $32,499

What if I am on Medicare?
People on Medicare will continue to select their Medicare plan in the same way they do now. Medicare plans are not included in the Marketplace.

Where can I get more information?
Having health insurance is extremely important, particularly with a chronic illness like lupus. If you do not have health insurance through an employer, we urge you to explore your options through the Health Insurance Marketplace.

Here in New York State, visit

To learn how the Affordable Care Act is going to impact healthcare coverage in another state, visit the Department of Health and Human Services state by state guide.