Our brokers are certified in healthcare reform and can help you understand your obligations under the Affordable Care Act, as well as other federal and state regulations. We assist with ACA Reporting, provide timely updates and provide employer education on compliance.
Following are brief highlights of the ACA that apply to both Employers and Individuals
Individuals and Small Businesses may be eligible for a tax credit under ACA healthcare reform laws. Thus, the credit is applied as a discount on your monthly insurance premium. Accordingly, to see if you are eligible for a tax credit, please use the Subsidy Calculator provided by the Health Insurance Marketplace. Or, if you are a business, use the Small Business Tax Credit Calculator provided by the Health Insurance Marketplace. In any case, both businesses and individuals must purchase benefits through the Health Insurance Marketplace to secure their tax credit. However, note that you must purchase benefits through the Health Insurance Marketplace to secure your premium discount.
You can purchase individual insurance coverage on the Individual Market during the annual open enrollment of November 1st through December 15th of each year. However, if you miss the deadline, you may qualify for special enrollment.
Special Enrollment:
You can still sign up for health insurance after the deadline if you meet any of the following qualifying events:
- change in legal marital status
- a change in the number of dependents
- a change in place of residence and the current carrier is not available
- significant cost or coverage change
- a change in coverage of a spouse or dependent
- a COBRA qualifying event
- legal judgements, decrees and orders
- entitlement to Medicare or Medicaid
EMPLOYERS: Employers who have more than 50 full-time equivalent employees must offer those employees benefits that pay for 60% of the minimum essential benefits. If you are in non-compliance, you will incur a penalty of $2,970 per year multiplied by the number of full-time employees, and excludes the first 30 employees. The penalty is increased each year by the growth in insurance premiums. Note you may also incur a penalty when at least one of your employees receives a premium tax credit in the Health Insurance Marketplace (Exchange).
INDIVIDUALS: Residents of the state of Texas ARE NOT required to have health insurance, therefore there is no penalty. The Federal individual health insurance mandate is no longer applicable as it was eliminated by Congress in 2019. Some individual states have their own health insurance mandate, but residents of the State of Texas are not required to have health insurance. If you qualify for a premium discount/tax credit, or you expect to have a moderate amount of health expenses, it may make sense for you to buy a plan from the Marketplace – Healthcare.gov.
- There is no longer a pre-existing condition clause. In other words, insurance companies can not increase rates or deny coverage because of a pre-existing condition.
- Your dependents can remain on you policy until they turn 26 years old.
- Insurance companies can not consider gender when setting rates.
- Employer renewals must be based on the same rates as new business.
- The waiting period for employer benefits should not exceed 60 days.
You may be subject to a tax penalty if you do not comply with the “Essental Benefits” of ACA. Specifically, to be in full compliance with the law, your insurance policy must cover at least 60% of the costs of the following essential benefits.
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Prescription Drugs
- Mental health and Substance Abuse disorder services
- Rehabilitative and habilitative services and devices
- Pediatric services, including oral and vision care
- Preventive and wellness services, and chronic disease management
