Healthcare Reform and the Affordable Care Act

stethoscope and keyboard researching healthcare reform and the Affordable Care Act

The Affordable Care Act (the ACA) is intended to better our healthcare system. However, with the many complex regulations of the ACA, and with uncertainty currently surrounding the ACA, clients need our help, now more than ever, to understand their obligations under the ACA.  Accordingly, at, our experts are very familiar with the ACA and other healthcare reform, as we are continually working to stay on top of new industry laws and pending legislation.

We have listed below, some of the highlights of the ACA on this page.

You may be eligible for a tax credit under ACA healthcare reform laws.  Thus, the credit is applied as a discount on your monthly insurance premium. Accordingly, to see if you are eligible for a tax credit, please use the Subsidy Calculator provided by the Health Insurance Marketplace.  However, note that you must purchase benefits through the Health Insurance Marketplace to secure your premium discount.

Healthcare reform (the Affordable Care Act – ACA) requires that individuals purchase individual insurance coverage on the Individual Market during the annual open enrollment of November 1st through December 15th of each year.  However, if you miss the deadline, you may qualify for special enrollment.

Special Enrollment:

You can still sign up for health insurance after the deadline if you meet any of the following qualifying events:

  • change in legal marital status
  • a change in the number of dependants
  • a change in place of residence and the current carrier is not available
  • significant cost or coverage change
  • a change in coverage of a spouse or dependant
  • a COBRA qualifying event
  • legal judgements, decrees and orders
  • entitlement to Medicare or Medicaid

Update in 2019.  THE INDIVIDUAL MANDATE (TAX PENALTY) HAS BEEN REPEALED BY THE TRUMP ADMINISTRATION.  The ACA tax penalty may affect individuals who fail to obtain qualifying health insurance.  Thus, qualifying coverage can be satisfied through their employer, or through an individual policy purchased from the Individual Market.  Accordingly, if  you do not have qualifying health insurance, the tax penalty will be $695 for adults. Additionally, the penalty is $347.50 for each child.  However, the maximum family penalty is the greater of 2.5% of income, or three times the adult penalty, which is $2,085.  Accordingly, your penalty will be applied on your annual tax return.

  • There is no longer a pre-existing condition clause.  In other words, insurance companies can not increase rates or deny coverage because of a pre-existing condition.
  • Your dependents can remain on you policy until they turn 26 years old.
  • Insurance companies can not consider gender when setting rates.
  • Employer renewals must be based on the same rates as new business.
  • The waiting period for employer benefits should not exceed 90 days.

Insurers must provide policies with the following “Essental Benefits” of ACA.  Specifically, to be in full compliance with the law, your insurance policy must cover at least 60% of the costs of the following essential benefits.  However, there is no penalty for non compliance starting in 2019 since the Trump administration repealed the individual mandate.

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Prescription Drugs
  • Mental health and Substance Abuse disorder services
  • Rehabilitative and habilitative services and devices
  • Pediatric services, including oral and vision care
  • Preventive and wellness services, and chronic disease management
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