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For consumers, the new year brings changes in the Affordable Care Act ranging from limits on itemized deductions and flexible spending accounts to Medicare-related tax increases and standardized forms that describe benefits in plain English.
In many ways, Connecticut leads the nation in implementing reform from establishing an online marketplace to purchase health insurance and expanding Medicaid coverage to low-income adults to generating millions of dollars in savings for consumers with coverage issues. Changes coming in 2013 and 2014 include:
Limits On Itemized Tax Deductions: The rules for itemizing deductions on federal income tax returns have changed. Beginning 2013, taxpayers can claim deductions for medical expenses not covered by health insurance when they reach 10 percent of adjusted gross income, up from 7.5 percent. The law waives the increase for those 65 years and older for tax years 2013 through 2016.
Changes In Flexible Spending Accounts: Starting in 2013, there is a new cap of $2,500 on flexible spending accounts (FSA), which permit taxpayers to set aside tax-free dollars for medical expenses (eye glasses, orthodontic work, speech therapy, etc.) that aren't reimbursed. In future years, the $2,500 cap will increase by the annual inflation rate. You also can no longer use an FAA account to cover the cost of over-the-counter drugs unless prescribed by a doctor.
Medicare-Related Tax Increases: Two new Medicare-related taxes impact earners with adjusted gross income above $200,000 for individuals or $250,000 for married couples who file jointly. Effective 2013, employees will pay an extra 0.9 percent Medicare payroll tax on wages. There's also a new 3.8 percent tax on unearned income, including investments, interest, dividends, annuities, rent, royalties, certain capital gains, and inactive businesses. Some exemptions apply, including income from tax-exempt bonds, veteran's benefits, and qualified plan distributions from an IRA or 401(k). The new tax does not apply to the sale of a principal residence, except in rare cases.
Standard Benefit Explanations: Health insurers must provide policyholders with standard disclosure forms (no more than four pages) summarizing benefits and coverage, including information about deductibles, co-payments, out-of-pocket limits and excluded services. The standard format allows consumers to make informed decisions based on apples-to-apples comparisons of health plans. Insurers must also disclose typical out-of-pocket costs for two scenarios: having a baby and treating type 2 diabetes. Future years will include coverage estimates for other conditions, such as heart attack or breast cancer.
Phasing Out Annual Dollar Limits: In 2013, an insurance company must pay no less than $2 million a year for an individual's medical expenses. The law eliminates all annual limits in 2014.
Health Insurance Exchanges: Connecticut is among a handful of states taking the lead in implementing health care reform with the establishment of the Connecticut Health Insurance Exchange, which recently adopted "Access Health CT" as its new consumer-friendly name. The exchange is an online marketplace where individuals and small businesses can compare and buy health plans. The law requires most Americans to buy health insurance or pay a tax beginning in 2014.
In Connecticut, nine insurance carriers intend to offer either medical insurance or dental coverage on the state exchange. The Connecticut Insurance Department, which regulates insurance in the state, must approve all the health plans. The Exchange will announce later this year which carriers meet the requirements to sell health plans on the online marketplace. Open enrollment begins Oct. 1 for coverage beginning January 2014.
Essential Benefits: Insurers must provide a minimum level of coverage known as "essential benefits" beginning 2014, including dental care for children and maternity services. The Connecticut Health Insurance Exchange has chosen ConnecticutCare's HMO plan as the benchmark plan for "essential benefits" for health plans sold on the exchange. Also chosen as benchmarks were the Children's Health Insurance Program for pediatric dental coverage and the Federal Employee Vision Plan for pediatric vision coverage. The law applies to non-grandfathered health plans sold to individuals and small businesses in the private market or state exchange. Health plans must cover emergency services, hospitalizations, maternity services, laboratory services, mental health and substance abuse treatment, outpatient care, pediatric care, prescription drugs, preventive care, vision and dental care for children, and rehabilitative services.
Prescription Drug Savings For Older Adults: In 2013, Medicare recipients who reach the prescription coverage gap - known as the "donut hole" - will get a 52.5 percent discount on prescription drugs and a 21 percent discount on generic drugs. Since the law's passage, Connecticut residents with Medicare have saved $62.9 million on prescription drugs. A total of 32,451 state residents with Medicare saved $26 million on brand-name prescription drugs during the first nine months of 2012, for an average savings of $803 per person. The "doughnut hole," in which people must start paying for their medications, disappears by 2020.
Expanded Medicaid Coverage: Connecticut was the first state to receive federal approval to expand Medicaid enrollment even before the Affordable Care Act takes effect. States must decide whether to expand Medicaid by 2014, with the federal government paying 90 to 100 percent of the costs. In Connecticut, the number of low-income adults receiving Medicaid has grown from an estimated 47,000 to about 86,800 from July 2010 to December 2012, reports the Connecticut Department of Social Services. Some lawmakers question whether the increase stems from a bad economy or if people are deliberately moving to Connecticut to receive benefits. For now, the Centers for Medicare & Medicaid Services is reviewing a request by Connecticut to institute a $10,000 asset test and parental income reporting for applicants.
Coverage For Pre-Existing Conditions: As of August 2012, a total of 484 previously uninsured Connecticut residents locked out of the coverage system for more than six months because of a pre-existing condition are now insured through the Pre-Existing Condition Insurance Plan created by the law. Although insurers cannot deny coverage to children under 19 with a pre-existing condition, discrimination against adults with pre-existing conditions doesn't kick in until 2014.
Expanded Coverage For Young Adults: Young adults up to age 26 who do not have job-based health insurance can stay on their parent's plan whether or not they live at home or attend school. The law applies to all health plans, even those that are self-insured.
Free Preventative Care: With its emphasis on prevention and primary care, the law requires new private health pans to cover wellness visits and evidence-based preventive measures (such as immunizations and cancer screenings) without charging a deductible, co-pay or co-insurance. Additional preventive measures for women since August 2012 include free screening for gestational diabetes, breast-feeding supplies, domestic violence screening and contraception. Although workplaces run by religious organizations that object to birth control do not have to pay for contraception, insurers must pick up the cost.
In the first nine months of 2012, a total of 277,412 Connecticut residents with Medicare received free preventive services. A total of 710,000 state residents were among the 54 million Americans with private health insurance who gained coverage for free preventive services in 2011.
In addition, Connecticut will receive $493,891 each year for five years in "community transformation grants" to address chronic disease and health disparities in five rural counties (Litchfield, Middlesex, New London, Tolland and Windham).
Consumer Rebates: Consumers whose private insurance carriers do not spend at least 80 percent of premium dollars on health care and quality improvements can expect to receive a rebate in August. Last year, 137,452 Connecticut consumers (individuals, small businesses and large employers) received nearly $13 million in rebates (for an average of $168 per person) from insurers that spent too much money on administrative costs rather than on health care. The rebates do not apply to people with self-insured health plans.
Scrutinizing Premium Increases: Insurance companies seeking premium increase rates of 10 percent or more trigger an automatic review by the Connecticut Insurance Department to determine if the request is reasonable. The state has received $1 million under the new law to fight unreasonable premium increases.
Banning Lifetime Dollar Limits: Lifetime dollar limits on health benefits are banned. Already, 1.4 million Connecticut residents with insurance, including 525,000 women and 367,000 children, no longer need to worry about going into debt when coverage runs out.
Consumer Protection: The Connecticut Office of the Healthcare Advocate (OHA), the independent state agency that helps consumers with insurance issues, generated $6.3 million in savings for consumers in 2012. OHA received federal funds to assist additional residents. Insurers can no longer cancel coverage if you get sick or make an honest mistake on your application. You can also appeal insurance company decisions to an independent reviewer.
Tax Credits For Small Business Owners: Connecticut small businesses can apply for a 35 percent tax credit (50 percent by 2014), while nonprofit organizations can receive a 25 percent credit (35 percent by 2014). About 36,620 small businesses employing 192,400 state residents are eligible to receive up to $166 million in tax credits to defray the cost of insuring employees. To qualify, a small business must pay at least half of their employees' health insurance costs and have fewer than 25 people earning an average of less than $50,000 a year.
Community Health Centers: Connecticut health centers that serve the state's most vulnerable residents have received $56 million under the health care reform law to support ongoing operations, establish new sites, expand services and fund capital improvements. In Connecticut, 13 health centers operate 184 sites, providing preventive and primary health care services to 315,992 people.
Information for this report came from the U.S. Department of Health and Human Services, Kaiser Family Foundation, Connecticut Department of Social Services, Connecticut Health Insurance Exchange, Connecticut Insurance Department, Connecticut Office of the Healthcare Advocate and Connecticut Office of Health Reform and Innovation.
This story was reported under a partnership with the Connecticut Health I-Team.