What does the Affordable Care Act (“ACA”) do?


The ACA, better known as Obamacare, creates a marketplace for uninsured individuals to shop for health insurance, including both medical and dental coverage. You may also have heard the marketplace called a health insurance “exchange.” The marketplace consists of different health insurance plans and is based on the state you live in. Some states have chosen to design their own marketplace, while others have opted for federal control. For example, New Jersey, Pennsylvania, and Delaware have allowed the federal government to control their marketplace exchange, while New York has designed its own.


Generally, the federal government’s website, www.healthcare.gov, is the best place to begin searching to find out more about how the marketplace and ACA will impact you. You may also call the federal enrollment hotline: 1-800-318-2596. If applying on the website, make sure to go to healthcare.gov rather than any other website, as there are websites that have been fraudulently created with similar web addresses.


How can the ACA help you?


The ACA can help a number of current and former Pond Lehocky clients find affordable health care for themselves and their families. Workers’ compensation clients who have made a successful lump-sum settlement of their claim in many instances may not have ongoing medical benefits to cover their work-related injuries and other health conditions. For many, workers’ compensation benefits and/or a settlement may disqualify them from receiving Medicaid, state-funded medical assistance which is frequently based on income and assets. Other clients who have had their workers’ compensation medical benefits suspended or terminated can access the marketplace to determine if they are eligible to purchase medical coverage. The ACA and the marketplace offers an avenue for clients to shop for affordable medical insurance coverage and allows you to choose the cost and level of coverage that best suits your needs.


Pond Lehocky’s Social Security clients will benefit from the ACA as well. Those who are approved for Social Security Disability Insurance (SSDI) are eligible for Medicare through Social Security. However, there is a mandatory twenty-four month waiting period that begins five months after you are first determined disabled by the Social Security Administration. For many clients, this means they will have to go two years without any medical coverage. Additionally for many, once they begin receiving their disability payments, they may no longer qualify for Medicaid insurance benefits they were receiving. The ACA and the marketplace offers an avenue for Social Security clients to shop for affordable medical insurance coverage during the crucial two year waiting period before their Medicare insurance benefits become active.


Likewise, the ACA and the marketplace offer those receiving unemployment compensation and short-term or long-term disability payments the ability to shop for medical coverage.




In order to be eligible to shop for health insurance in the marketplace, you must meet certain eligibility requirements. Anyone looking to shop in the marketplace must be a citizen of the United States or be lawfully present in the United States and must not be incarcerated. Those who are uninsured should definitely shop in the marketplace. Individuals and families with very low incomes (generally those earning at 100% of the poverty level or below), may shop in the marketplace to determine if they are eligible for Medicaid and CHIP. If applicants apply on the marketplace and are eligible for traditional Medicaid, their applications will be sent to the Pennsylvania Department of Public Welfare (DPW), and new cases will be initiated. Twenty-five states and Washington D.C. have chosen to expand Medicaid coverage to cover almost everyone 100% below the poverty level. Those earning above 100% of the poverty line will be eligible to shop for private health insurance plans. Premium and cost-sharing subsidies will be available through the marketplace to reduce the cost of coverage for individuals and families, determined by income.


Anyone can shop in the marketplace, but depending on your “coverage” status, it may not be in your best interest. For example, if an individual is covered by their employer’s plan (if they meet the other eligibility requirements listed above), he/she can still shop for coverage, but he/she may not be eligible for the premium tax credits. Tax credits are available to help individuals between 100% and 400% of the poverty level pay for their insurance premiums and subsidies. Finally, in most circumstances, dependents of the policyholder are covered until they turn age 26.


Pre-Existing Conditions and Plan Details


Beginning in 2014, an insurance company cannot refuse to cover you or charge you more just because you have a pre-existing health condition; this also holds true for Medicaid and CHIP. Once you have insurance coverage, you may begin treating for your pre-existing conditions immediately. Individuals who smoke may be charged more by insurance companies. Further, those with insurance coverage plans that have been “grandfathered” will not necessarily have their pre-existing conditions covered, but they should be eligible to switch plans during the open enrollment period.


There are four levels of healthcare coverage available through the marketplace: bronze, silver, gold, and platinum. The bronze plans have the lowest monthly premiums and the highest out-of-pocket costs, while the platinum plans are just the opposite. However, all plans offered in the marketplace are required to provide coverage in ten key areas: 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, chronic disease management, and pediatric services, including oral and vision care.




Open enrollment in the marketplace began on October 1, 2013 and runs until March 31, 2014. Coverage is beginning on January 1, 2014 for individuals and small businesses. If a person enrolls in a private health insurance plan any time between October 1, 2013 and December 23, 2013 and makes his or her first premium payment by the plan’s specified due date, coverage will begin on January 1, 2014. After March 31, 2014, the open enrollment period will end and individuals will not be able to shop on the marketplace until the next open enrollment period unless they have a change in circumstances. Benefits are renewed each year. Open enrollment will begin again in October 2014 and run until December 7, 2014.


A change in circumstances triggers a special 60-day enrollment period. A change in circumstance includes the birth of a child, death of a household member, change in employment, divorce or marriage, or a move out of the state where they initially purchased coverage. Moreover, people can apply for Medicaid or CHIP at any time during the year.


If you believe you may be eligible under the Affordable Care Act for insurance through the marketplace, please see www.healthcare.gov to assess your eligibility and begin shopping for coverage that works for you. In addition, applications can be made over the phone by calling 1-800-318-2596, or paper application can be completed, found at http://marketplace.cms.gov/getofficialresources/publications-and-articles/marketplace-application-for-family.pdf


The information provided above has been gathered from the following sources:

Ready to Get Help?

Complete the short form below to get your FREE consultation.