• Health reform has placed regulations on the health insurance industry. The law’s intention is to increase quality, affordability and availability of health insurance.
• The first open enrollment for the Health Insurance Marketplace ended March 31, 2014. The next time individuals can enroll begins Nov. 15, 2014 until Feb. 15, 2015. Groups can apply on the SHOP (Small Business Health Options Program)—a subsection of the Marketplace—at any time. Enrollment is on-going. They should enroll by the 15th of the month for coverage starting as soon as the 1st of the month.
• Individuals making about $45,960 or families of four making approximately $94,200 may be eligible for premium tax credits through the Marketplace. These tax credits help offset the cost of insurance premiums. (Income numbers for 2015 and forward are likely to change a little bit.)
• Health insurance carriers can’t place lifetime limits on coverage. Annual limits (caps on the amount an insurance company will pay in a year while they’re enrolled in a health insurance plan) are eliminated as well.
• Health insurance plans must offer a comprehensive package of items and services, called essential health benefits (EHBs). EHBs include services in at least these 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
• Medicare isn’t part of the Marketplace, so if individuals have it, they should keep it!
• In some states, Medicaid and Children’s Health Insurance Program (CHIP) have been expanded to provide insurance to up to 16 million people.

What Employers Need to Know

• All full-time workers employed by companies with over 50 employees must be offered job-based health insurance.
• Large groups will pay a penalty if they:
  1. Don’t offer minimum essential coverage to a certain percentage of their full-time employees and their employees’ children, or
  2. Offer coverage to a certain percentage of those employees and their children, but the coverage doesn’t provide “minimum value” (generally, covers at least 60 percent of the cost of benefits), or is not “affordable” (generally, the cost of coverage doesn’t exceed 9.5 percent of the employee’s income
  Note: The penalty won’t kick in unless a full-time employee receives a premium tax credit or cost-sharing reduction because of the circumstances outlined above.
• Small businesses with under 50 full-time employees can use the SHOP to purchase group health plans for their employees. However, businesses of this size are not required to offer health coverage.
• Small businesses with under 25 full-time employees may qualify for a small business health care tax credit, making the cost of providing health insurance lower. The tax credit is only available if the business gets coverage through the SHOP.

What Individuals Need to Know

• Kids can stay on their parents’ health insurance plan until age 26.
• They can’t be denied health coverage based on health status.
• They can’t be dropped from coverage when they are sick.
• Pre-existing conditions and gender discrimination are eliminated and will no longer affect the cost of their insurance on or off the Marketplace.
• If they don’t currently have coverage, they can go to the federal government’s Health Insurance Marketplace, or to their state’s exchange, if applicable, during open enrollment to buy a private insurance plan.
• They’re not required to buy insurance on the Marketplace, but it’s worth it to fill out an application to see if they qualify for assistance before shopping for outside insurance.
• When they apply, they’ll find out if they qualify for free or low-cost coverage from Medicaid or the CHIP.
• To buy Marketplace insurance outside of open enrollment, they have to qualify for a special enrollment period. Qualifying events include things such as marriage, birth/adoption of a child, or loss of health coverage.
• If they don’t have coverage, they’ll have to pay a fee. The fee for 2014 is $95 per adult ($47.50 per child) or 1 percent of income, whichever is higher. The family max is $285. The penalty increases every year. In 2015 it’s 2 percent of income or $325 per person. In 2016 and later years it’s 2.5 percent of income or $695 per person. After that it's adjusted for inflation.

There you have it: the ACA boiled down! Of course, there’s much, much more to the legislation, but we wanted to give the high-level highlights. If you have further questions on the ACA, the Marketplace website itself has a lot of really good, user-friendly info. You can use the “Search” field and type in pretty much any topic you’re wondering about. Take a look at www.healthcare.gov. You can also check out this ACA guide for more info.

Should your groups "Pay" (give the government their employer shared responsibility payment of $2,000 per employee, in lieu of providing employer-sponsored health coverage), or "Play" (purchase employer-sponsored health coverage for employees that meets new affordability and quality standards)?

Use this downloadable "Pay or Play" calculator to determine which course of action may be best for their business needs.

Any questions about your current Solstice products? Login to your portal on https://www.solsticemarketplace.com/ 

Want to start selling Solstice? Give us a call at 877-760-2247 or email us at sales@solsticebenefits.com