Health reform makes health care more accessible and affordable for everyone. Here are some of the options for affordable coverage under health reform, along with information about where you can find out if you’re eligible. (Note that many of these options do not take effect until 2014, but new information sources for existing options are available now).

1. Medicaid: You may be eligible for Medicaid depending on your income and family size. Medicaid provides health coverage for low-income children and adults and people with disabilities, and it also provides assistance with health and long-term care expenses for low-income seniors. Currently, Medicaid eligibility varies from state to state. However, beginning in 2014, health reform will expand Medicaid eligibility levels to 133 percent of the federal poverty level, or $29,327 for a family of four (according to the current poverty guidelines). This means that many more people will be eligible for Medicaid.

2. Premium Subsidies: If you don’t qualify for Medicaid, but you still can’t afford coverage, you may be eligible for help with your premium. Starting in 2014, individuals and families earning up to 400 percent of the federal poverty level, or $88,200 for a family of four in 2010, will get help paying their health insurance premiums in the form of tax credit subsidies.

3. Cost-Sharing and Out-of-Pocket Help: In addition to providing help with premiums, health reform also includes ways to make out-of-pocket costs, like deductibles and copayments, more affordable. Beginning in 2014, plans for individuals and small employers will have new caps that limit how much enrollees have to spend each year out of their own pockets to get care. And, individuals and families with lower incomes will be protected with even lower out-of-pocket spending caps. Depending on your income, you or your family may also qualify for additional help paying copayments, co-insurance, and deductibles.

Next Step – Visit HealthCare.gov
To find out about health coverage options available to you both now and in 2014, visit HealthCare.gov. This new web portal will provide you with information about health coverage options in your state, including private insurance, Medicaid, the Children’s Health Insurance Program (CHIP), Medicare, plans for individuals with pre-existing conditions, and coverage for small businesses.

First off, rest assured, all individuals who are currently covered under Medicaid will continue to receive coverage. Health reform prevents states from enacting Medicaid eligibility cuts between now and 2014. It also prevents your state from making any changes to the program that would make it more difficult for you to keep your Medicaid coverage, such as requiring more frequent recertifications or imposing any additional documentation requirements. In 2014, Medicaid will be expanded to cover all non-elderly Americans with incomes below 133 percent of the federal poverty level (approximately $24,350 for a family of three in 2010). Millions more Americans will be eligible for Medicaid as a result of this expansion.
Health reform should not cause any other immediate changes to your Medicaid coverage, but over time, the network of providers available to you may grow. This is because Medicaid’s physician reimbursement levels for primary care services will be increased (to be equal to provider reimbursement rates in Medicare), which may incentivize more doctors to accept Medicaid patients.

There are two main insurance company practices to discuss when it comes to this question: health status rating and wellness incentive programs.

Health Status Rating
Currently, health insurers in most states set premiums for people looking to purchase coverage on their own (in the individual market) based on their health status. This means that insurers can look at medical histories and any health risks that people have in order to decide how much to charge them. An active person who eats right may fare well when the insurer looks at how “risky” their health profile is. However, even most healthy people have something—a bad ankle from a teenage injury or allergies that sometimes require medication—in their medical history. When it comes to health insurance, rather minor medical issues like these can end up costing even the healthiest people. Insurers can jack up rates for any blip in an applicant’s medical history, no matter how small. Therefore, while it may seem appealing to healthy people to pay a premium based on their health status, in the end they might not get what they bargained for.

In addition, when premiums are based on health status, those who are sicker find themselves in big—and expensive—trouble. People who fall ill are often charged exorbitant premiums. This concerns us all, because although we may be healthy now, the fact is, someday we might not be. The point of insurance is to share the risks of medical costs with others, which provides the security that if you face large expenses in the future, you will be protected from costs you can’t afford. This can’t happen if people with greater medical needs are charged drastically more for coverage than healthier people.

Under health reform, premium rates will no longer be based on health status. Insurers will not be able to charge healthy people more for the ailments that affected them long ago. They will also be prohibited from drastically hiking up rates for people who are sicker. These prohibitions, along with many other new rules to keep premiums fair and reasonable, will make health coverage affordable for everyone, healthy or sick.

Wellness Incentive Programs
Currently, and also under health reform, insurers and employers may offer premium discounts to health plan enrollees who meet certain goals in “wellness incentive programs.” These goals may be based on participation in a program, or they may be based on actual health outcomes.

Unfortunately, wellness programs are not always fair or effective. When wellness programs are based on health outcomes, such as a lowering blood pressure or cholesterol, the programs may end up punishing people for medical problems that they can’t control. In this case, the result of a wellness program is really no different than an insurer looking at peoples’ health status to find reasons to charge them higher premiums. In addition, many wellness programs don’t provide any supports (like coaching services, weight loss interventions, or even just a convenient location where people can participate) to help people achieve the goals. In these cases, wellness programs function more like a system of surcharges than a real tool to help people stay or become healthy.

Health reform will create new rules to make sure that wellness programs are effective and based on evidence. However, groups representing consumers are concerned because health reform also allows the premium incentives in wellness plans to be larger than they are now. For people with lower incomes or people whose life situations make it impossible for them to participate, the higher premiums they may face if they can’t meet wellness plan goals could make it hard or impossible for them to afford health coverage. When it comes to wellness programs, insurers, employers, and consumers—even those who are relatively healthy—must proceed with caution.

Conclusion
The main takeaway on health status and insurance premiums is that things are not always as they seem. While it may seem like a good idea for healthy people to be charged lower premiums than sicker people, this defeats the purpose of health insurance. Health insurance is meant to be a safeguard that is there for people during the unpredictable times when they most need it—whether it’s for a sudden emergency or for when they are older and in less than perfect health. Only by sharing risks throughout our lifetime can we all have quality, affordable coverage and the peace of mind that it will be there for us when we need it.

Claire McAndrew is a Health Policy Analyst at Families USA, a nonprofit, nonpartisan organization striving to achieve quality, affordable health coverage for all Americans. For more information, visit www.familiesusa.org.

Under reform, insurers will have to submit transparent information to regulators on how they calculate their premium rates, justifying any rates that seem unreasonable. Health reform also provides new funding for states to implement or enhance oversight of health insurers’ proposed rate increases. And, plans that impose unreasonable rate hikes in the next few years may be prohibited from participating in the new health insurance exchanges once they’re up and running in 2014.

Health reform does not mandate that small employers offer coverage to their workers. However, it does make it easier for small employers to offer coverage. Health reform provides employers with up to 25 workers with tax credits to make coverage more affordable—increasing the likelihood that they will offer coverage. Starting this year, small employers can get tax credits for up to 35 percent of their share of the premiums for their workers’ health coverage. In 2014, they will be eligible for credits of up to 50 percent of the premiums they pay.

In addition, starting in 2014, small employers will have a new marketplace (also referred to as an “exchange”) in which they can shop for coverage for their workers. In the new health insurance exchanges, insurers will provide small employers with clear, comparable information on the costs and benefits of different health plans, which will help small employers find quality coverage that meets their workers’ needs.

If your husband’s employer decides not to offer coverage to his/her workers, you and your family will still be able to get coverage starting in 2014 through the new health insurance exchange. Moreover, many low- and middle-income workers will get significant help affording coverage through a new tax credit subsidy.

Under health reform, health plans will cover standardized, comprehensive benefit packages. The law sets out general categories of benefits that must be covered, and these categories include maternity and newborn care. The details of the specific services that will be covered under each category will be determined by future regulations from the Secretary of Health and Human Services. The law specifically requires the Secretary to consider the health care needs of women when determining the services that the benefits package will include. There will also be a public input process for people to express which benefits they believe are necessary for the Secretary to include in the required benefits package.

Answer: Health reform does not mandate that small employers offer coverage to their workers. However, it does make it easier for small employers to offer coverage. Health reform provides employers with up to 25 workers with tax credits to make coverage more affordable—increasing the likelihood that they will offer coverage. Starting this year, small employers can get tax credits for up to 35 percent of their share of the premiums for their workers’ health coverage. In 2014, they will be eligible for credits of up to 50 percent of the premiums they pay.

In addition, starting in 2014, small employers will have a new marketplace (also referred to as an “exchange”) in which they can shop for coverage for their workers. In the new health insurance exchanges, insurers will provide small employers with clear, comparable information on the costs and benefits of different health plans, which will help small employers find quality coverage that meets their workers’ needs.

If your husband’s employer decides not to offer coverage to his/her workers, you and your family will still be able to get coverage starting in 2014 through the new health insurance exchange. Moreover, many low- and middle-income workers will get significant help affording coverage through a new tax credit subsidy.