ACA 2014 Update for Individuals

The 2015 open season for the Affordable Care Act  starts November 15, 2014

Whether you call it by its official name the Patient Protection and Affordable Care Act or by one of its nick names (ACA or Obamacare), this legislation continues to bring big changes to health insurance.

Our staff atmedical-exam Richard A Hall, PC is fielding many questions from clients about the impact of the ACA on employers and individuals.

In an effort to address the most common questions, we reached out to a local health insurance expert, Dennis Shefski, president of Smart Business Options in Sterling, VA.

Dennis provided answers to some common questions regarding the Patient Protection and Affordable Care Act. If you have any questions about your health insurance, you can reach Dennis at Shefski at (703) 421-6827.

Question: Describe the individuals covered by ACA next year?
Answer: The ACA requires most individuals (U.S. Citizens and legal residents) younger than 65 to have health insurance or potentially pay a penalty. ACA requires individuals to maintain minimum essential coverage for themselves and their dependents. Exemptions include: individuals who are on Medicare, receive hardship waivers from the government, or experience an insurance gap of less than 3-months.

Question: What are the penalties if you don’t get required coverage?
Answer: Starting next year, the annual one-time penalty for not having proper health insurance increases to $325 per adult and $162.50 per child.

Question: If an individual enrolled last year, what happens to them this year?
Answer: If you don’t select a new plan or don’t opt out of your existing health plan, your existing provider will automatically re-enroll you for another year. You should make sure you have the coverage you want and make a change before the new deadline.

Question: What is the ACA enrollment deadline in 2015?
Answer: For 2015 ACA coverage, the open enrollment period is November 15, 2014–February 15, 2015. You may qualify for Special Enrollment Periods outside of open enrollment if you experience certain events. A special event would include changes in your income, or changes in your family size (for example, if you marry, divorce, or have a baby).

Question: What are the projected insurance rates for ACA-compliant plans?
Answer: Your health insurance premiums depend on the level of plan you select. ACA provides for three basic levels:

  • Bronze (60% medical expenses paid by the insurer/40% covered by you),
  • Silver (70% medical expenses paid by the insurer/30% covered by you)
  • Gold (80% medical expenses paid by the insurer/20% covered by you) and
  • Platinum plans (90 % medical expenses paid by the insurer/10% covered by you).

Each plan allows you to get a free physical yearly and covers at least a base-line of services. If you qualify for an ACA tax credit, the government will give your insurer a monthly payment to lower your net premium costs.

The government bases the tax credit on your family income and number of family members. I have seen applicants pay as little as $35 per month for an $860 per month plans due to this. The lowest I have seen is 97 cents.

Question: How do I know the right coverage for me?
Answer: Your best option is to consult a health insurance expert. This is complicated stuff. An agent can help you pick a carrier, deductible, co-pay and co-insurance that is best for your needs. For example, if you can only afford a high-deductible plan, an agent may be able to find other carriers to pay down the deductible. Agents can also help you find supplemental plans such as dental, vision, etc.

Question: What happens if my income goes up or down substantially during the year and I receive a credit for my health insurance?
Answer: You should talk to your insurance agent or insurance company about adjusting your tax credit if your income changes during the year, either up or down.

Question: What impact does ACA have on individual health savings account (HSAs)?
Answer: The law does have an impact on HSAs. First, you can no longer pay for over-the-counter drugs from your HSA. The second and more onerous change is you will incur a 20% (up from 10%) penalty if you withdraw funds from your HAS before you are 65.

Question: What is the best way to get individual coverage if I do not have it?
Answer: The best way is to contact a certified Marketplace Agent, such as me. We have taken hours of training on the process and can quickly answer questions from individuals. Marketplace Agents are often more up-to-speed than the navigators working the help desk at

Question: If I use an Agent, do I need to pay for the service?
Answer: No, agents receive fees from the health insurance plans in the MarketPlace.

Editor’s Note:
Thanks to Dennis Shefski for taking time to answer our ACA questions. If you need assistance in enrolling in ACA-compliant health insurance plan, you can reach him at (703) 421-6827

Dennis Shefski has been an insurance agent for more than 18 years. He serves clients in Virginia, Maryland and Washington, DC.  He also serves as an expert witness in court cases involving health insurance and Medicare.

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