Commercial Insurance Specialty & Programs Personal Insurance Life & Health Insurance
Get A Quote

Health Care Reform 2014 Information

The initial open enrollment period begins October 1, 2013 (before the Marketplaces first make coverage available on January 1, 2014), and continues through March 31, 2014.
The annual open enrollment period is between October 15 and December 7 each year, beginning in 2014.

-Subsidy Calculator
-Applying for a Health Plan With a Subsidy

NOTE: Miami Insurance Broker Codes

FFM: miabrokers
NPN: 7534251

-Applying for a Cigna Plan Without a Subsidy

Guaranteed Issue and Guaranteed Renewability


The Affordable Care Act requires health insurance issuers to offer all of their individual market and group market plans to any applicant in the state. It also requires health insurance issuers to accept any individual who applies for those policies, as long as the applicant agrees to the terms and conditions of the policy, including the payment of premiums. This provision is called “guaranteed issue.

Additionally, the Affordable Care Act requires health insurance issuers to offer to renew or continue in force coverage at the option of the policyholder. This is called “guaranteed renewability.


Coverage of Pre-existing Health Conditions Regardless of Age

10 of 36

Effective for all health plans with plan years beginning on or after January 1, 2014, the Affordable Care Act prohibits health insurance issuers from limiting or excluding coverage related to pre-existing health conditions, regardless of the age of the covered individual. For persons under age 19, this provision became effective for policy years beginning on or after September 23, 2010.

Generally, a pre-existing condition is any health condition or illness that was present before the coverage effective date, regardless of whether medical advice or treatment was actually received or recommended.


Medical Loss Ratio

12 of 36

The Affordable Care Act helps keep costs down by limiting the proportion of premiums that a health insurance issuer can spend on things other than providing and improving the quality of the health care of their enrollees.

Medical Loss Ratio (MLR) is a basic financial measurement that shows how much of the premium dollars a health insurance issuer spends on health care expenses, as opposed to profits or administrative costs. As of 2012, a health insurance issuer that does not spend enough of its premium dollars on health care services must provide rebates to insured individuals or policyholders.

In general, if a health insurance issuer uses an average of 80 cents out of every premium dollar to pay customers’ medical claims and to conduct activities that improve the quality of care, the company has an MLR of 80%. MLR is not calculated at the individual policy level but at the state level for each issuer separately for the small group and individual markets.

An MLR of 80% indicates that the health insurance issuer is using the remaining 20 cents of each premium dollar for administrative costs and profits, including salaries and other expenses. As of 2012, a health insurance issuer is required to spend at least 80% of premium dollars on medical care.

The Affordable Care Act sets minimum MLRs for different markets, as do some state laws

Eligibility for Premium Tax Credits

7 of 19

Eligibility for the premium tax credit is based on the household income and access to minimum essential coverage. The following summarizes the key eligibility standards for premium tax credits (tax credits that reduce the cost of insurance premiums).

Individuals must meet the following eligibility criteria to be eligible for a premium tax credit:

·         Not be eligible for minimum essential coverage — including employer-sponsored coverage, Medicaid, CHIP, Medicare, and other forms of coverage — other than through the individual insurance market, unless their employer-sponsored coverage is not affordable or does not provide minimum value

·         Have an annual household income that is between 100% and 400% of the Federal Poverty Level (FPL) (or below 100% of FPL for lawfully present non-citizens who are ineligible for Medicaid by reason of immigration status)

·         Be a part of a tax household that will file a tax return for the coverage year and, if the tax household includes a married couple, that files a joint return


Be eligible for coverage through a QHP

Savings depends on income and family size

The amount you save depends on your family size and how much money your family earns. In general, if your income falls within the following ranges you'll qualify to save money on your premiums in 2014. The lower your income within these ranges, the more you'll save. (The amounts below are based on 2013 numbers and are likely to be slightly higher in 2014.)

  • $11,490 to $45,960 for individuals
  • $15,510 to $62,040 for a family of 2
  • $19,530 to $78,120 for a family of 3
  • $23,550 to $94,200 for a family of 4
  • $27,570 to $110,280 for a family of 5
  • $31,590 to $126,360 for a family of 6
  • $35,610 to $142,440 for a family of 7
  • $39,630 to $158,520 for a family of 8
If your income falls below the amounts shown, you may qualify for coverage under your state’s Medicaid program. But if your state is not expanding Medicaid in 2014--and you don't qualify for Medicaid under your state's rules--you can’t get lower costs on Marketplace coverage based on your income. You'd have to pay the entire cost of a Marketplace insurance plan.

Can I make Changes to my Plan in 2014

In order to apply for coverage outside of the Open Enrollment periods you must have a Qualifying Life Event:

A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby).

What Happens if you Do Not Have a Qualified Health Plan in 2014 and Beyond?

The fee in 2014 is 1% of your yearly income or $95 per person for the year, whichever is higher. The fee increases every year. In 2016 it is 2.5% of income or $695 per person, whichever is higher.

In 2014 the fee for uninsured children is $47.50 per child. The most a family would have to pay in 2014 is $285.

It's important to remember that someone who pays the fee won't get any health insurance coverage. They still will be responsible for 100% of the cost of their medical care.

After open enrollment ends on March 31, 2014, they won't be able to get health coverage through the Marketplace until the next annual enrollment period, unless they have a qualifying life event.