Health Care Reform

General Information

• Health care reform, the Affordable Care Act (ACA) and Obamacare mean the same thing. They all refer to the new health insurance rules passed in 2010.
• For plan years through 2018, if you can afford health insurance but choose not to buy it, you may pay a fee called the individual Shared Responsibility Payment. (The fee is sometimes called the "penalty," "fine," or "individual mandate.") Starting with the 2019 plan year (for which you’ll file taxes in April 2020), the Shared Responsibility Payment no longer applies.
• You cannot be denied insurance coverage based on your health needs. Health insurance plans must offer coverage to all individuals regardless of their health status, age, gender or other factors that might predict the use of health services. This is true even if you've been declined coverage in the past.
• Open enrollment begins November 1st each year. You can sign up for health insurance between November 1st and December 15th for coverage to begin on January 1st. People can sign up other times, but only if they qualify for a special enrollment period. You may be eligible for a special enrollment period if you experienced a qualifying life event, such as getting married or having a baby.

Additional Resources

1. You might be able to get help with your health insurance costs. If your household income is between 100% and 400% of the Federal Poverty Level (FPL), you may be able to get help paying for your health insurance. To get financial assistance, you must buy your insurance through the Health Insurance Marketplace (Exchange). Learn more.
2. Some preventive services are covered at no out-of pocket cost to you. Certain preventive services must be covered at no out-of-pocket cost to you when delivered by a provider that is in your health insurance network. Dozens of services are covered for all adults, women and children. View the list.
3. All health insurance plans must cover specific health care benefits. The Affordable Care Act helps ensure that health insurance plans offer a full set of items and services. These services are called Essential Health Benefits.
4. Certain plans do not follow all the Health Care Reform rules. Grandfathered plans and transitional plans may not comply with certain rules. Learn more.

Resources to make health care coverage more affordable

Health Care Reform – Helping to Make Health Insurance Affordable with Subsidized Health Insurance

Individuals and families with low to medium income, those making between 100 percent and 400 percent of the Federal Poverty Level (FPL), may be able to get help paying for health insurance costs. To get this help, you will need to purchase a plan through the Health Insurance Marketplace. Depending on your income, you may qualify for help paying monthly bills and / or out-of-pocket costs like deductibles and copays.

Affordable Health Insurance – Lowering Your Monthly Bill

Individuals and families who make less than 400 percent of the FPL may qualify for Advance Premium Tax Credits (APTC). If you qualify, you may choose to use some or all your advance credit towards your bill each month. When you file your taxes, you'll determine if you used too much or too little credit. If you used too little, you'll be refunded the remainder on your federal tax return. If you used too much, you'll pay the difference back with your federal tax return.

Affordable Health Care – Lowering Your Out-of-pocket Costs

Individuals and families who make less than 250 percent of the FPL may qualify for a cost share reduction (CSR). CSRs help lower the costs you pay when using your health insurance, such as deductibles, coinsurance and copays. If you qualify, you be able to purchase a silver level plan through the Health Insurance Marketplace. These silver plans will have similar benefits to more expensive plans, but at a lower price.

Additional help for Wisconsin
and Dane County Residents!

• Dane County residents who make 100-150 percent of the FPL may qualify for additional help from HealthConnect through United Way of Dane County. Learn more about HealthConnect.
• Individuals in WI who make less than 100 percent of the FPL may qualify for BadgerCare Plus. Learn more about BadgerCare Plus.

Advance Premium Tax Credit (APTC)
The Affordable Care Act provides a new tax credit to help you afford health care insurance purchased through the Health Insurance Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. Learn more.

Coinsurance
Your share of the costs of a covered health care service. It is calculated as a percent (for example, 20 percent) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe.

For example, if your plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20 percent would be $20. Your health plan pays the rest of the allowed amount.

Copayments (or Copays)
A fixed amount you pay for a covered health care service. It is usually paid at the time you get the service.

For example, if you have an office visit with your doctor, your copay may be a fixed amount such as $30. If you have a copay, this is usually the only fee you will have to pay when you visit your doctor (other services such as lab tests or x-rays may result in additional fees). Choosing a plan with a copay for services you receive often may help you minimize your out-of-pocket expenses.

Cost Share Reductions
If you qualify, these can help you with the cost of health care. Your out-of-pocket costs like deductibles, coinsurance, and copayments may be reduced, depending on your income. Those that qualify can pay the premium of a Silver plan but get the benefits of a Gold or Platinum plan. Learn more.

Deductible
The amount you pay for covered health care services before your health insurance begins to pay. If your deductible is $1000, your health plan won’t pay anything until you’ve paid $1,000. The deductible may not apply to all services.

Health Insurance Marketplace (Exchange)
The Health Insurance Marketplace (Exchange) is an open market for dental and health care insurance. You'll be able to compare types of health care insurance, check prices, find out if you qualify for subsidies and enroll in a health care insurance plan.

Health Plan Categories (Metal Levels)
All health insurance plans are divided into five categories – Catastrophic, Bronze, Silver, Gold and Platinum. These are called the “metal levels.” The categories are based on the average total amount* your plan will pay for your covered medical costs: 60 percent for Bronze, 70 percent for Silver, 80 percent for Gold and 90 percent for Platinum (catastrophic plans will vary).

*Plans in each category pay different amounts of the total covered costs of an average person’s care. This takes into account the plans’ deductibles, copayments, coinsurance and out-of-pocket maximums. The actual percentage you’ll pay in total or per service will depend on the services you use during the year.

Maximum Out-of-Pocket
The most you will pay in calendar year for covered health care services. This does not include your monthly premium or out-of-pocket costs for benefits that are not essential health benefits.

Out-of-Pocket
Your costs for health care not paid by health insurance. These costs can include deductibles, coinsurance, and copayments. They also include costs for services that aren't covered by your health insurance.

Premium
A premium is the amount that you pay each month for your health insurance.

Subsidies
Help with paying for your health care and insurance plan costs based on your income level. You can get help with your monthly premium (Advance Premium Tax Credit) or help with your out-of-pocket expenses (Cost Share Reductions).  Learn more.