The Affordable Care Act (ACA) is changing the healthcare industry. We’re here to help you make sense of what these changes mean for you. Here are the 10 key terms and topics you should know.

  • Guaranteed issue

    As of January 1, 2014, health insurance issuers must accept every individual in the state that applies for coverage regardless of health, age, gender, or other factors (including pre-existing conditions).

  • The Individual Mandate

    Starting in January 2014, individuals will be required to have health insurance that qualifies as minimum essential coverage or risk paying a tax penalty for every month they are uninsured.

    YEAR FLAT DOLLAR AMOUNT PERCENTAGE OF INCOME (OVER TAX FILLING THRESHOLD)
    2014 $95 1.0%
    2015 $325 2.0%
    2016 $695 2.5%
    Beyond $695 2.5%

    Starting in January 2014, individuals will be required to have health insurance that qualifies as minimum essential coverage or risk paying a tax penalty for every month they are uninsured.

  • Grandfathered plans

    When the Affordable Care Act (ACA) was enacted on March 23, 2010, President Obama said that if Americans liked their coverage, they could keep it.  Therefore, the ACA allows carriers to distinguish plans that existed prior to March 23, 2010 (Grandfathered Plans) and those that came afterward (Non-Grandfathered Plans). Since Grandfathered Plans were intended to stay as they existed as of March 23, 2010, they are not subject to many of the ACA’s requirements.

    Learn more about Grandfathered Plans and why they are important:

  • New marketplaces

    The Affordable Care Act (ACA) creates new ‘marketplaces’ (also known as ‘exchanges’) where individuals and small businesses will be able to purchase health insurance for coverage beginning in 2014. California’s health insurance marketplace is known as Covered California. In addition to buying coverage via Covered California, individuals and small business will be able to purchase health care the way they do today through brokers and directly through health insurance carriers.

    Blue Shield is planning to participate on Covered California in both the Individual and Small Business markets.

    Learn more about Covered California:

  • Open Enrollment

    Individual Open Enrollment

    Annual open enrollment periods for individuals and families purchasing their own health coverage is held November 1 – January 31 of each year with an initial effective date of January 1st of the following year. There are exceptions for “special enrollment” within 60 days of a life-changing event, such as the loss of a job, death of a spouse or birth of a child.


    Small Business Open Enrollment

    Small business employers have an annual election period prior to the group’s annual open enrollment period. Employees can only enroll or change plans once a year, during annual election period, unless they qualify for a special enrollment period.

  • Essential health benefits

    All non-grandfathered health plans offered in the individual and small business markets, both inside and outside of Covered California, will be required to offer a core package of benefits and services known as "essential health benefits," which must include coverage within at least the following 10 categories:

    Ambulatory patient services Prescription drugs
    Emergency services Rehabilitative and habilitative services and devices
    Hospitalization Laboratory services
    Maternity and newborn care Preventive and wellness services and chronic disease management
    Mental health and substance use disorder services, including behavioral health treatment Pediatric services, including oral and vision care
  • Metal level plans

    Under the Affordable Care Act, all non-grandfathered, health plans offered in the individual and small business markets, both inside and outside of Covered California, will be required to provide coverage at a "metal level" – Platinum, Gold, Silver and Bronze. The metal levels are based on the actuarial value (AV): Bronze (60 percent AV), Silver (70 percent AV), Gold (80 percent AV) or Platinum (90 percent AV). What this means is that someone who buys a silver plan would have to pay 30 percent of health care costs, while the plan covers 70 percent.

    There is also a catastrophic plan for the individual market only that will cover the essential health benefits plus three primary care visits per year. The catastrophic plan can only be sold to consumers under age 30 and consumers who are exempt from the individual mandate as a result of low income or hardship.

  • Federal subsidies

    Starting in 2014, subsidies will be available for consumers whose annual income is between 134% and 400% of the Federal Poverty Level (FPL) and who meet other applicable guidelines. These cost-sharing reductions and advanced premium tax credits will lower the cost of premiums and out-of-pocket expenses for health coverage purchased through Covered California. Those with an FPL under 134% may be eligible for Medi-Cal.

    Tax credits will also continue to be available to small businesses with no more than 25 full-time equivalent employees to help offset the cost of providing coverage. Learn more about the small business tax credit.

  • ACA taxes

    The ACA requires that certain taxes be collected to fund aspects of the law, including Covered California—the statewide healthcare marketplace (aka the Exchange).  
    For an overview of taxes beginning January 1, 2014, download our ACA tax fact sheet (PDF, 24KB).

  • Play-or-Pay

    Starting on January 1, 2014, the Affordable Care Act (ACA) will require companies over a certain size to offer affordable health plan coverage to full-time employees and their dependents or face a penalty if an employee receives federally-subsidized coverage from Covered California (aka: The Marketplace/Exchange).