Issues - Health Reform

On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act, into law. Health reform is designed to provide almost every American, regardless of their pre-existing conditions, income level, age, or gender, a quality and affordable health insurance option.

I voted for health reform to help New Jerseyans who play by the rules and who, until now, have found health coverage out of reach. Beginning on October 1, 2013, the new insurance Marketplace (Exchange) will provide individuals and small business owners with the opportunity to compare and purchase comprehensive insurance options, and potentially even qualify for subsides to help cover the costs of their selected insurance plans. Additionally, because health reform expands Medicaid, nearly 300,000 eligible New Jerseyans can gain access to reliable health care coverage.

I also support heath care reform because it will make health insurance work better for those who already have coverage. For example, because of health reform, insurance companies must spend at least 80 percent of health insurance premium dollars on actual health care—not administrative or advertising costs. Children can now stay on their parent's policy until they are 26 years old, and seniors have access to free preventive services, such as mammograms and annual wellness visits. Health insurance companies can no longer deny or charge more for coverage if a child in a family has a pre-existing condition, and beginning in 2014, that will be true for all, including adults. These changes will increase the value of your health care dollars and help mitigate rising health care costs.

While there is more to be done to address our nation's health care needs, comprehensive health reform moves us closer to a quality health care system that is accessible to all.

Frequently Asked Questions About the New Health Insurance Marketplace

I have heard from many of my constituents who have questions about health care reform and the new insurance Marketplace (formerly known as the Exchange). I have included more information on a few of the topics that I hear most about from Central New Jerseyans.

Should you have further questions about how health care reform may affect you, I encourage you to call my District Office in West Windsor, New Jersey (609-750-9365) or my Washington, D.C. office (202-225-5801).  Additionally, you can call the Marketplace hotline number, 1-800-318-2596.

What is the Marketplace?

I already have insurance through my employer or the private market.  Do I need to do anything with the health insurance Marketplace?

I am on Medicare.  Do I need to do anything differently?

If I don't have health insurance, how can I gain coverage?

What different plans will be offered on the Marketplace?  What is the difference between Bronze, Silver, Gold, and Platinum plans?

When does the health insurance Marketplace open?

I would like to talk to someone about my options on the Marketplace.  How can I do this?

Am I eligible for financial assistance to help me afford the cost of health insurance?

I am a business owner.  Do I need to offer health insurance to my employees?

I have a preexisting condition.  Can an insurance company deny me coverage or charge me more?

What has been the impact of health reform in New Jersey?

What is the Marketplace?

The Marketplace (formerly called the Health Exchange) is a new, online service – available at HealthCare.gov – that offers a new way for you to compare and purchase insurance options, as well as learn if you qualify for cost-sharing assistance to help you pay for health care. The purpose of the health insurance Marketplace is to help individuals and employers make apples-to-apples comparisons of affordable insurance options that provide comprehensive coverage.

You may be interested in exploring coverage options on the Marketplace if:

• you do not currently have health insurance
• your employer does not offer health insurance
• you are unsatisfied with your employer sponsored health insurance
• you have a pre-existing condition
• you are a small business owner

I already have insurance through my employer or the private market. Do I need to do anything with the health insurance Marketplace?

No. In these cases, your insurance coverage will continue.

If you have insurance through your employer or the private market, you do not need to take any action. However, you will have the opportunity to explore the online Marketplace to compare plans and determine if you can find a better health insurance option.

If you are currently purchasing insurance through the private market, you may find that you qualify for cost-sharing assistance on health plans offered through the new Marketplace.

I am on Medicare. Do I need to do anything differently?

No. If you have Medicare, you will continue with your Medicare coverage. Medicare is not part of the health insurance marketplace.

Although you will not enroll for your health insurance through the Marketplace, you may be interested to learn that the health care reform already improves your Medicare coverage. For example, health care reform:

• Created new annual wellness visits
• Closes the prescription drug “donut hole,' by 2020
• Requires Medicare plans to include free preventive services, such as mammograms, colonoscopies, and flu shots, with not out-of-pocket costs. Before health care reform, these services could have a co-pay as high as $160 a year

To learn more, please visit Medicare's health reform page or view Medicare's fact sheet.

If I don't have health insurance, how can I gain coverage?

You and your family may qualify for free or low-cost health insurance coverage through Medicaid, known in our state as New Jersey FamilyCare. Medicaid eligibility is based on income, family size, and age. Because of the health care reform, if you are an individual ages 19-64 years old with an income up to $15,282 per year, you may now qualify for Medicaid. Similarly, if your family of four earns $31,322 or less per year, your family may now qualify for Medicaid.

In order to learn more about the Medicaid eligibility and how to apply, please visit New Jersey's Medicaid page or contact your county welfare office.

If you are not eligible for Medicaid, you can instead purchase health insurance through the new online health insurance Marketplace – and, as described further below, you may be eligible for subsidies to help you pay the cost.

What different plans will be offered on the Marketplace? What is the difference between Bronze, Silver, Gold and Platinum plans?

Insurance companies will offer products that the Marketplace will group into four different categories of coverage: Bronze, Silver, Gold, and Platinum. These plans offered in each of these categories will vary based on the how much the consumer will be expected to pay each month in premium charges, as well as out-of-pocket for receiving specific medical services.

For example, the Platinum plan will likely have the highest monthly premiums, but the lowest out-of-pocket spending for services such as doctor's visits and prescription drugs. On the other hand, the Bronze plan will likely have the lowest monthly premium but the highest out -of-pocket costs for medical services.

While the four categories of plans will differ in premium and out-of-pocket cost sharing, all plans offered on the insurance marketplace must offer coverage of at least 10 essential health benefits, including hospitalizations, rehabilitation services, prescription drugs, and pediatric oral and vision care.

• View a short video explaining the health insurance marketplace
• Visit the Marketplace

When does the health insurance Marketplace open?

You can begin comparing and shopping for different plans online beginning October 1, 2013. While you can apply for coverage anytime between October 1, 2013 and March 31, 2014, you will need to enroll in a health plan by December 15, 2013 in order for your coverage to begin on January 1, 2014. To sign up for coverage, visit HealthCare.gov.

I would like to talk someone about my options on the Marketplace. How can I do this?

There is a toll-free 24/7 hotline number you can call to talk with a person and receive assistance. The phone number is 1-800- 318-2596 / TTY: 1-855-889-4325.

Additionally, trained experts known as Navigators or Certified Application Counselors in our area are available to provide in person assistance free of charge. To locate a market-placed trained Navigator or Certified Application Counselor near you, please visit LocalHelp.HealthCare.gov.

Am I eligible for financial assistance to help me afford the cost of health insurance?

Health care reform includes provisions to provide financial assistance for working families who qualify. You may be eligible for help paying premium costs, out-of-pocket expenses, or both.

When you apply for coverage on the Marketplace, you will be asked about your income in order to determine whether you are eligible for cost-sharing assistance. If you are eligible, the subsidy will be automatically reflected in the price you are quoted on the Marketplace, and the subsidy will be paid directly to your insurer each month – lowering the cost you pay for each month's premium.

In order to be eligible for subsidized coverage, you must purchase health insurance on the Marketplace, and your income must be between 100 percent and 400 percent of the Federal Poverty Level (FPL). For example, in 2013 this would mean an income of between $23,550 and $94,200 for a family of four. If you are interested in learning more about your eligibility for cost-sharing assistance, you can use an online calculator to determine your potential savings.

• Learn more about how cost-sharing assistance will work

I am a business owner. Do I need to offer health insurance to my employees?

If you are a business owner with fewer than 50 employees, you are not required to offer health insurance coverage to your employees. However, you will be able to compare Qualified Health Plans on the SHOP (Small Business Health Options Program) and learn if you qualify for tax credits to help you pay for your employees’ health care costs. With one application, on your own or with the help of an agent, broker, or other assister, you can compare price, coverage, and quality of plans on the SHOP in a way that's easy to understand.

To learn more, I encourage you to visit the Small Business Administration or HealthCare.gov or to call the SHOP call center at 1800-706-7893.

If you are an employer with 50 or more full-time equivalent employees, beginning in 2015 you could face a financial penalty if you do not provide your full-time employees with access to affordable and comprehensive health insurance. Most employers of this size already provide insurance for their employees. To learn more about this requirement and to determine whether it applies to you, please visit the Small Business Administration website.

For additional information, you may view presentations from the Department of Health and Human Services or the Small Business Administration offered at my forum on the Affordable Care Act's effects for small businesses.

I have a preexisting condition. Can an insurance company deny me coverage or charge me more?

Beginning on January 1, 2014, health insurance plans will no longer be able to deny you coverage or charge you more for pre-existing conditions. The only exception to this rule is if you remain covered by a health plan that was offered on the private market prior to 2010. Additionally, health reform requires more consumer protections of insurance plans to make sure your coverage is there when you need it. For example, the health reform law limits insurers' ability to deny, limit or cancel coverage. Health reform also prohibits insurers from imposing annual or lifetime caps on your coverage, and it requires that certain preventive services, such as mammograms and other cancer screenings, be available with no out-of-pocket costs.

• Learn more about health reform's consumer protections
• Learn more about your health care rights

What has been the impact of health reform in New Jersey?

Many Central New Jersey residents have already begun to experience a few of the benefits of health care reform. The House of Representatives Energy and Commerce Committee Minority Staff reports that:

6,100 young adults in the district now have health insurance through their parents plan.

More than 14,900 seniors in the district received prescription drug discounts worth $23.8 million, an average discount of $760 per person in 2011, $1,060 in 2012, and $440 thus far in 2013.

105,000 seniors in the district are now eligible for Medicare preventive services without paying any co-pays, coinsurance, or deductible.

218,000 individuals in the district – including 51,000 children and 88,000 women – now have health insurance that covers preventive services without any co-pays, coinsurance, or deductible.

198,000 individuals in the district are saving money due to health reform provisions that prevent insurance companies from spending more than 20% of their premiums on profits and administrative overhead. Because of these protections, over 18,900 consumers in the district received approximately $1.6 million in insurance company rebates in 2011 and 2012 – an average rebate of $104 per family in 2012 and $300 per family in 2011.

Up to 41,000 children in the district with preexisting health conditions can no longer be denied coverage by health insurers.

274,000 individuals in the district now have insurance that cannot place lifetime limits on their coverage and will not face annual limits on coverage starting in 2014.

93,000 individuals in the district who lack health insurance will have access to quality, affordable coverage without fear of discrimination or higher rates because of a preexisting health condition. In addition, the 29,000 individuals who currently purchase private health insurance on the individual or small group market will have access to more secure, higher quality coverage and many will be eligible for financial assistance.

Should you have further questions about how health care reform may affect you, I encourage you to call my District Office in West Windsor, New Jersey (609-750-9365) or my Washington, D.C. office (202-225-5801).