The Affordable Care Act – What Next?

By Tracey Wilkes, Certified Application Counselor for the Health Insurance Marketplace

The first annual Affordable Care Act (ACA) Health Insurance Marketplace open enrollment period is now one for the history books. Everyone is examining, celebrating and discussing the numbers. Let’s look at the results. (Facts provided by US Dept. of Health and Human Services)

Nationwide, over 8 million people have enrolled and selected a plan through the Health Insurance Marketplace during open enrollment, which was October 1, 2013 to March 31, 2014. In Tennessee, 151,352 selected a plan through the Health Insurance Marketplace, known as “Obamacare.” Of those, 55% are female and 45% are male; 32% are under age 35; 28% are between age 18 and 34. 80% of the people who enrolled received financial assistance to lower monthly premiums and out of pocket expenses. Another 53,665 Tennesseans enrolled in Medicaid (Tenncare) and CHIP.

Polls show that 42% of the uninsured had not heard of “Obamacare” and/or were not aware of the March 31 deadline to enroll. Although open enrollment is officially over, Special Enrollment Periods (SEP) are available to people who experience what is called “life changes,” such as losing coverage at your job, becoming a US citizen, income changes, divorce or marriage, birth of a child, gaining/becoming a dependent, and other special circumstances that are outlined on the website.

Due to the problematic website startup, many of the requirements and benefits of the ACA were never reported. Here are some little-known important facts.

  • If you get insurance through your job, Medicare, etc… you do not need to enroll through the Marketplace. You cannot opt out of job coverage unless your plan is more than 9.5% of your income, and/or does not provide minimum coverage.
  • People living between 100-400% of the Federal Poverty Level (FPL) may qualify for a “subsidy,” or Premium Tax Credit, to lower their monthly premiums, and those below 250% receive additional help to lower out of pocket costs like deductibles, co-insurances and co-pays. The amount of the subsidy varies based on household income and size.
  • This is not universal coverage, and the safety net that was available to those living below the FPL is the expansion of Medicaid, which was fully funded by the Federal Government for the first 3 yrs with the states taking on 10% of the cost in 2017. However, Governor Bill Haslam turned down the billions in federal dollars and chose not to expand Medicaid (Tenncare), leaving an estimated 150,000 Tennesseans without coverage.
  • You do not have to purchase insurance in The Health Insurance Marketplace, but The Marketplace is the only place you can qualify for Premium Tax Credits to lower costs. You must enroll during the Open Enrollment Period to get these savings, (unless you qualify for a SEP) but you can purchase insurance on the private market at any time during the year to avoid the penalty as part of the Shared Responsibility provision of the ACA.
  • All Qualified Health Plans (QHP) in The Marketplace must provide the same Essential Health Benefits, including:
  • Ambulatory patient services
  • Hospitalization and Emergency services
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Pediatric services, including oral and vision care
  • Preventive and wellness services are free, including chronic disease management. (No deductibles, co-pays or co-insurance for preventive doctor visits, tests, screenings, etc.)
  • Health insurance companies must cover pre-existing conditions and cannot drop you, charge more or place limits on coverage.
  • Children can stay on their parent’s health plans until age 26.

If you do not have insurance and do not qualify for an exemption, you will be fined 1% of your income or $95 per person, whichever is higher the first year. Penalties will increase every year you go without coverage.

Many people do not know there are exemptions for those who cannot afford insurance or who fall into specific categories, such as a member of an Indian Tribe. The most common exemption is based on affordability. In other words, if you are not eligible for Premium Tax Credits, making the insurance too expensive and you live in a state (like Tennessee) that did not expand Medicaid, you qualify for a Hardship Exemption. It is important to know that if you fall into this group, you need to apply for Tenncare and receive a denial of coverage letter to avoid the penalty, or complete an IRS exemption form prior to the 2015 tax filing deadline. (Forms are available at or at any community health center).

If you are uninsured, The Affordable Care Act (ACA) increased funding to Community Health Centers to hire Certified Application Counselors to assist people who need help with enrollment and to provide care for folks without health insurance. Perry County Medical Center in Linden and Three Rivers Community Health of Hickman offer sliding fee discounts for primary care doctors visits based on household income and household size and that includes on site lab services and X-Ray. For more information call (931) 589-2104 in Linden and (931) 670-5520 in Lyles.

The next Marketplace Open Enrollment Period will begin November 15, 2014. To learn more contact Tracey Wilkes at Three Rivers Community Health, (931) 670-5520.

Sara and Stevie Hickerson of Linden, TN qualified for a family plan with premium tax credits that lowered their monthly premium from $800 a month, to $103.45 a month, plus they got additional help that lowered their deductibles and out of pocket expenses – the Hickersons’ will never pay more than $2900.00 out of their pocket per year as a household, or $1,450.00 per individual.)

NOTE: Permission was obtained by Tracey Wilkes, to use the Hickerson’s name/story for marketing purposes. The signed permission form is on file at Three Rivers Community Health.


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About Cody Newbold

Cody Newbold holds a Bachelor of Science in software engineering from Middle Tennessee State University and serves as Director of Digital Innovation for Validity Publishing.


The Affordable Care Act – What Next? — 1 Comment

  1. What’s next is we need to look at how the ACA is treating the self-employed…many fall through the cracks or actually see their premiums rise under the ACA.