William Avendaño

The ACA (Affordable Care Act, Affordable Care Act) presents developments regarding the standards and opportunities to access health care in the United States. This law was approved by Congress in March 2010; it establishes the new health care guidelines for all people. We want to help you understand what this law means to you. Here we highlight some important aspects of the law:

- Almost everyone must now have health insurance.

- Deny health insurance coverage to anyone is prohibited. - Most health plans must also offer you preventive care at no cost.

- The out-of-pocket cost for health services, in most health plans, should not exceed a fixed amount.

- You must be given a written document in plain language that contains a summary of your benefits and coverage

- The maximum age for your children to remain in the family health plan is 26 years.

- You can purchase a health plan through the Public Insurance Market, also called the "Insurance Market", or you can also purchase it without resorting to it. You should know that there are a number of stipulated benefits that these plans must cover

- If you buy your plan through the Public Insurance Marketplace, you can choose to receive help from the government to pay for it.

You need to know that the law covers almost all health plans currently on the market. However, some sections of the law are not applicable to plans that were sold prior to the passing of the law. These plans are called "plans governed by the previous law."

The Affordable Care Act is founded on the principle that everyone should have health insurance. From a financial perspective, this would not be profitable if people bought coverage only when they were sick. Therefore, the law determines that everyone has to have health insurance coverage, which is called an individual mandate and is applicable to all US citizens and legal residents. To obtain coverage you can use any of the following options:

- An individual plan

- A plan through your employer

- A government program

Your health plan must follow certain guidelines to meet the minimum coverage requirements. Find out which plans qualify. https://www.healthcare.gov/fees/plans-thatcount-as-coverage/

If you do not have coverage, there is a possibility that you will have to pay a forfeiture. You must pay the applicable penalty when you file your federal income tax return. Calculate it here. https://www.healthcare.gov/fees/

There is a possibility that those who cannot afford coverage are not required to pay the penalty. Receive information regarding exceptions to penalties. https://www.healthcare.gov/exemptionstool/#/

The Affordable Care Act mandates that health insurance companies have a duty to offer coverage to all people. It is forbidden for them to reject it due to their health or to a pre-existing illness; Nor can they reject you because of your gender or age. This law is called an assured issue.

This rule is not applicable to plans governed by the previous law.

The Affordable Care Act expands civil rights protections for health care and health insurance. The section of the law in which this is stipulated is Section 1557 also called the Nondiscrimination Law, which determines that you cannot be treated differently because of your:

- Nationality

- Race

- Skin color

- Sex (includes gender, pregnancy, as well as gender identity)

- Age

- Disability

This section of the ACA (Affordable Care Act) must apply to all health care programs and activities of any entity that receives federal funds, including companies that offer plans in the insurance market.

In addition, the law also has regulations dedicated to helping people with disabilities access care and, in turn, requires that people with limited knowledge of English have the opportunity to receive help in their native language at no cost.

More information regarding the no-discrimination law at your fingertips. https://es.aetna.com/legalnotices/nondiscrimination-notice.html

Now most of the health plans have to cover preventive care. If you go to a doctor that’s in your plan's network, you won't have to pay anything for preventive care. There will be no copayment, no coinsurance, or any other extra costs to you even if you did not meet the plan deductible.

The U.S. government made the list of what should cover preventive care, which includes these types of providers:

- Screening tests for some conditions;

- Recommended vaccines for children;

- Certain women's health services, including birth control.

You can also learn more about the following:

- Preventive Care for Adults (https://www.healthcare.gov/preventive-care-adults/)

- Preventive Care for Women (https://www.healthcare.gov/preventive-care-women/)

- Preventive Care for Children (https://www.healthcare.gov/preventive-care-children/)

Some organizations or employers who adhere to certain religious beliefs are not required to cover any costs related to birth control or some related services.

Get more information about religious exemptions https://www.healthcare.gov/coverage/birth-control-benefits/

Plans governed by the law above do not follow preventive care requirements.

Generally, you and your health plan split the costs of your use of health care services. The part you pay is called out-of-pocket costs, which include deductibles, copayments, and coinsurance.

The ACA has set a limit on the total amount that you can be required to pay as expenditure. Once this amount is paid, the plan must pay 100% of the covered costs. Likewise, the out-ofpocket limit or maximum is renewed annually.

Plans governed by the previous law are not affected by out-of-pocket limits.

Learn more about out-of-pocket cost limits. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/

The ACA (Affordable Care Act) states that health insurance companies have to use most of the money from premiums on health care and/or quality improvement. For large company plans, 85% of the premium payments must be invested in health care and quality improvement. If, on the other hand, you purchase insurance through a small employer or on your own, we must use at least 80% of the premium payments. In case of using less than that percentage, we must implement discounts.

These percentages are called MLR (medical loss ratio, which is the loss rate for the health insurance industry). The way our MLRs are calculated is by grouping the policyholders of each state together and thus calculating the MLR for each group. We do not calculate an MLR separately for each individual or employer.

Assuming that the MLR for a group is only 75% of the premiums, in this situation, discounts apply. It should be noted that most aircraft do not receive discounts. Those workers who receive discounts have the option of using them to reduce premiums or improve benefits.

Those employers who insure their own aircraft will not be able to receive discounts.

Cuando corresponda aplicar un descuento para determinado año, se le notificará antes del 30 de septiembre del siguiente año. El cheque por el valor del descuento le será enviado al empleador en la mayoría de los casos y también se informará a los empleados. Por otro lado, si le correspondiera un descuento relacionado a algún plan que usted adquirió por su cuenta, le enviaremos el cheque personalmente a usted.

In order to facilitate the comparison of different plansAll health plans are required to provide a Summary of Benefits and Coverage (SBC) following a standard format

The SBC must be simple. This document should contain a description of what the plan covers and what costs you would be responsible for paying. Your health insurance company or your employer is required to provide you with a copy of your plan's SBC:

- When you want to buy a plan;

- After registering;

- When renewing your previous plan;

- If there are any changes to the plan;

- When you require a copy

This is how you can get the Summary of Benefits and Coverage. https://es.aetna.com/health-carereform/summary-benefits-and-coverage-individuals.html

Here's an example of a Summary of Benefits and Coverage. https://www.dol.gov/ebsa/pdf/SampleCompleted-SBC2-nal.pdf

If your health plan has coverage for your dependents, your children can stay in that plan until they are 26 years old. They can be covered even if:

- They are not students;

- Do not live with you;

- They are not dependents according to your tax return.

Learn more about coverage for young adult dependents on.
https://www.healthcare.gov/young-adults/children-under-26/

The Affordable Care Act launched a proposal for a new way to shop for health plans. If you do not have coverage through an employer, you can buy it in the Public Insurance Market. Some states run their own marketplaces, but if your state does not yet have a Health Insurance Marketplace, you have the ability to purchase one on the federal government's Health Insurance Marketplace website.

Go to healthcare.gov. https://www.healthcare.gov/

By accessing the insurance market, you will be able to:

- Purchase a plan

- Renew your plan

- Change plan

If you want to register for health coverage after the open enrollment period, you must meet the requirements for the special enrollment period. To be able to do this, you must present your reasons, which must include important life events, for example, the birth of a child or a change in employment.

Receive information about special enrollment periods. https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/

Any health plan that you access on your own or through a small employer must cover "essential health benefits." Plans sold on the Health Insurance Marketplace are also subject to this. In this sense, the essential health benefits include:

- Outpatient services
- Emergency services
- Hospitalization care
- Care during pregnancy, childbirth and newborns
- Mental and behavioral health care and substance abuse services;
- Prescription drugs
- Services that enable an adult or child to learn, maintain and improve abilities and performance in daily life (habilitation services);
- Services to help people who have lost abilities and performance due to illness, injury or disability (rehabilitation services);
- Laboratory services;
- Preventive and wellness care;
- Management of chronic diseases;
- Health care for children (including dental and vision care).

To define essential health benefits, each state relies on a specific referral plan

See more information about state referral plans. https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html

You can save on monthly premiums when you buy a health plan on the Public Insurance Marketplace, because if you qualify, the government will pay a portion of your premium. This is called a premium tax credit. Based on your estimated income and the number of people in your household, the amount of this payment will be calculated

When you receive a premium tax credit, you must file Form 8962 with your federal income tax.

Some people may even be able to get help with out-of-pocket costs for care

You can see if you qualify for these savings on. https://www.healthcare.gov/lower-costs/

The Affordable Care Act affects your federal income tax return in three ways:

1. Proof of Health Insurance Coverage: When filing your tax return, you must mark the checkbox that says you have the required health insurance coverage for the tax year. Your Marketplace, your health insurance company or your employer will send the Internal Revenue Service (IRS) the corresponding form stating that you have coverage. These forms are 1095-A, 1095-B, and 1095-C, and you should receive a copy of their records.

2. Penalty for lack of coverage: If you have not had some level of health insurance coverage for all or part of the fiscal year, there is a possibility that you will have to pay a penalty. Said penalty must be paid at the time of filing your federal income tax return.

3. Premium Tax Credit: If you purchased a plan on the marketplace and paid reduced premiums, you will need to file a different form in addition to your federal income tax return. To access reduced premiums, you need to meet the requirements according to your income estimate and the number of people in your household; the government will pay the insurance company the rest of the premium. This is considered an advance tax credit for premiums.

When filing your tax return, you will need to attach a copy of Form 8962. This form is used to show whether your income matches your estimate. If this is not the case, you can compile the requirements to apply for an even larger loan or you may have to pay part of the current one.

También podría realizar el pago del monto total de su prima para todo el año y posteriormente, al llegar la temporada de impuestos, consultar si reúne los requisitos para obtener un crédito fiscal.

Sepa más sobre los formularios de impuestos. https://es.aetna.com/health-carereform/tax-forms-affordable-care-act.html

Some of the sections of the new Affordable Care Act do not affect certain health plans, which are known as health plans governed by the old law. These plans must have been offered before March 2010. In addition, they must not have been modified in some aspects, for example:

- Increased costs;
- Significant cut in benefits.

There are other changes that also influence the plans governed by the previous law.

Also, your insurance company or employer must tell you if your plan is governed by the above law.

On the other hand, plans governed by the previous law must also comply with some of the provisions of the ACA (Affordable Care Act), such as:

- They are obliged to provide you with the Summary of benefits and coverage corresponding to your plan.
- If your plan includes your dependents, coverage must be offered until they turn 26 years old.

There are other requirements that also apply.

On the other hand, the plans governed by the previous law are not obliged to cover preventive services at no cost to you, nor are they obliged to cover pre-existing conditions; among other.

Find more information about the health plans governed by the above law. https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/