Essential rules, numbers and websites for health care act [The Charlotte Observer]

Sept. 28--On Tuesday Americans can begin enrolling for next year's health coverage on new state insurance marketplaces. The Affordable Care Act becomes more fully operational three months later in 2014. That's when most people must have health insurance or face a fine for noncompliance. Most of the roughly 260 million Americans with job-based, individual or government coverage probably have nothing to worry about. But if you're unsure -- or among the nearly 49 million uninsured Americans -- here's a guide to bring you up to speed. Tony Pugh, McClatchy Washington Bureau

Where to get help

North Carolina navigators and certified application counselors:

--855-733-3711, toll free number for anyone in the state to make appointments for one-on-one assistance from navigators or certified application counselors.

--North Carolina MedAssist: 704-536-1790, www.medassist.org.

--Legal Services of the Southern Piedmont: 704-376-1600, www.lssp.org.

--C.W. Williams Community Health Center: 704-393-7720, www.cwwilliams.org.

--Novant Health will have financial assistants available at two workshops for walk-in visitors: 1-5 p.m.Nov. 6 at the BB&T building, 108 Providence Road in Charlotte, and 3-7 p.m.Nov. 14 at the Salisbury Civic Center, 315 Martin Luther King Jr. Ave. S., Salisbury.

--Blue Cross and Blue Shield of North Carolina will open two Charlotte stores, near Northlake Mall and in south Charlotte, in mid-October. They will be staffed by agents and customer service representatives.

Other information:

--Kaiser Family Foundation: Offers a "subsidy calculator," an animated video in English and Spanish, and other information about the Affordable Care Act, http://kff.org/health-reform/.

--Families USA: www.familiesusa.org.

--North Carolina Department of Insurance: www.ncdoi.com.

Sources: U.S. Centers for Medicare & Medicaid Services, healthcare.gov, Kaiser Family Foundation.

Penalties for the uninsured

2014 2015 2016

Adult $95.00$325.00$695.00

Child $47.50$162.50$347.50

Family* $285.00$975.00$2,085.00

Penalties will increase yearly by cost-of-living adjustment after 2016.

*Family penalty is whatever is greater: $285 or 1 percent of family income for 2014; $975 or 2 percent in 2015; $2,085 or 2.5 percent in 2016.

Source: Kaiser Family Foundation

10 Essential Health Benefits

All insurance plans, both in and out of the online marketplaces, must cover these 10 "essential" health benefits:

Outpatient services, Emergency services, Hospitalization, Maternity and newborn care, Mental health services, Prescription drugs, Rehabilitation services, Laboratory services, Preventive and wellness care, Pediatric services

Source: Kaiser Family Foundation

Do I have to buy coverage in the exchange?

No, if you have insurance through:

--Your employer

--Medicaid or CHIP (Children's Health Insurance Program)

--Tricare or veteran's health program

--Medicare

--Private insurance you bought, at least equal to the Bronze coverage level

--A grandfathered plan from before the Affordable Care Act was enacted

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No, if you're a member of one of the following exempt groups:

--Part of a religious group opposed to accepting health insurance benefits

--An undocumented immigrant

--In prison

--Part of an Indian tribe

--Too poor to file a tax return ($10,000 single/$20,000 family)

--Paying more than 6 percent of income for health insurance, minus employer contribution or tax credits

Source: Kaiser Family Foundation

Insurance plans:

Health plans will be classed by tiers: Bronze, Silver, Gold, Platinum.

The least expensive, Bronze, will cover 60 percent of medical costs, leaving 40 percent to the individual. The most expensive, Platinum, will cover 90 percent of medical costs, leaving 10 percent to the individual.

Insurers are prohibited from charging women higher rates than men, from charging older people more than three times more than younger people, and from rejecting customers with pre-existing medical conditions.

Sources: U.S. Centers for Medicare & Medicaid

2013 Federal Poverty levels

Family size 100% 138% 200% 250% 400%

1 $11,490$15,856$22,980$28,725$45,960

2 $15,510$21,404$31,020$38,775$62,040

3 $19,530$26,951$39,060$48,825$78,120

4 $23,550$32,499$47,100$58,875$94,200

Each additional person $4,020$5,548$8,040$10,050$16,080

Source: U.S. Department of Health & Human Services

Information needed to enroll

--Social Security number (or document numbers for legal immigrants).

--Employer and income information (for example, from pay stubs or W-2 forms -- Wage and Tax Statements).

--Additional information may be required. For more details, go to: https://www.healthcare.gov/how-do-i-apply-for-marketplace-coverage/

Sources: U.S. Centers for Medicare & Medicaid Services, healthcare.gov, Kaiser Family Foundation.

South Carolina

South Carolina has 731,000 uninsured residents, and about 418,000 will be eligible for subsidies.

To enroll, visit www.healthcare.gov or call 800-318-2596.

Four private insurance companies -- BlueCross BlueShield of S.C., BlueChoice, Consumers' Choice Health Plan and Coventry Health Care of the Carolinas -- are offering plans on the exchange.

Source: S.C. Department of Health and Human Services, The (Columbia) State

How North Carolinians currently get their health insurance

4.6 million: Through employers

1.6 million: Medicare

1.4 million: Medicaid

435,000: Individual policies

1.5 million: Uninsured

Source: N.C. Institute of Medicine, N.C. Department of Health & Human Services

Financial assistance

--Subsidies, or tax credits, will offset the cost of premiums for individuals and families with household incomes at 100percent to 400percent of the federal poverty level.

--Additional subsidies will help offset the cost of deductibles, copays and coinsurance for those with household incomes below 250 percent of the federal poverty level.

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--Sliding scale subsidies are set by household income according to federal poverty level and based on the Silver plan. Policy holders are expected to pay a percentage of household income for an insurance premium before receiving a subsidy.

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--The law limits the amount individuals and families have to pay for out-of-pocket costs, such as deductibles, copays and coinsurance. The annual cap is $6,350 per person and $12,700 per family.

Sources: U.S. Centers for Medicare & Medicaid Services, healthcare.gov, Kaiser Family Foundation.

How to sign up:

--Online: www.healthcare.gov, www.cuidadodesalud.gov

--Telephone: 800-318-2596, TTY: 855-889-4325

For small businesses (50 or fewer employees):

--Telephone: 800-706-7893, TTY: 800-706-7915

--Coventry Health Care of the Carolinas: 888-674-4887

--Blue Cross and Blue Shield of North Carolina: www.bcbsnc.com/readyforreform

Send us your questions

Observer health reporter Karen Garloch will try to get your questions about the Affordable Health Care act answered. Email her at kgarloch@charlotteobserver.com.

Read more about it

We've created an online destination for answering your questions and for all the articles and explanations that we've published about the insurance changes. Visit charlotteobserver.com/healthcareact to read more.

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