State Medical 411brought to you by Darden

To make shopping for state insurance easier!
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When people talk about health care reform, they’re usually talking about the Patient Protection and Affordable Care Act (ACA), which President Obama signed into law in March 2010. It’s the biggest change to the nation’s health care system in 50 years.


The short answer is: yes. Starting in 2014, most people will have to pay a federal tax penalty if they don’t have health insurance.


People who would have to pay more than 8% of their income for health insurance and people who don’t make enough money to file federal income taxes (in 2013, $10,000 for a single person and $20,000 for a family) are exempt from the requirement.


It will vary. Maybe through their employer. Maybe through the plan of a spouse or parent. Or maybe they’re on Medicaid, Medicare or a veteran’s health program. If they need to buy health insurance, they can use a Health Insurance Marketplace in their state or use the federal Marketplace if their state doesn’t have one.


Many employees working an average of less than 30 hours per week will be eligible for subsidies, which are a type of tax credit. They’ll need to meet both of these criteria:

• Income less than 400% of federal poverty level ($45,960 for an individual or $94,200 for a family of four)

• Not on public coverage – such as Medicaid, Medicare, the Children’s Health Insurance Program (CHIP) or military coverage – and do not have access to affordable coverage through an employer.

The tax credits will be available even if the individual does not owe any federal income taxes.


Many state Medicaid programs – which provide health coverage to low-income Americans – will be expanded to cover everyone under age 65 with incomes up to 138% of the federal poverty level ($15,282 for an individual or $31,322 for a family of four).


For an individual, the penalty is $95 or 1% of the household income, whichever is greater.

For a family, the penalty is $95 for each adult and $47.50 per child, up to a maximum of $285 – or 1% of household income, whichever is greater.


Most likely. You can sign up for e-mail updates at


It’s paid on a person’s tax return, beginning with the 2014 tax return. This return is filed before April 15, 2015


It’s a new way to compare plans and buy health insurance from private companies. If your state has a Marketplace, you’ll use that one. If not, you’ll use


All U.S. citizens are eligible, unless they are currently incarcerated or living outside the United States.


All plans offered in the Marketplace are required to cover certain essential health benefits, including:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services

Preventive care will be covered at 100% in-network. The scope of benefits will be similar to that provided under a typical employer health plan.

Plans may offer additional coverage. You will see exactly what each plan offers when you compare them side-by-side in the Marketplace.


Starting in 2014, all health insurers will have to sell coverage to everyone who applies, regardless of their medical history or health status. They can’t charge more for it or exclude those conditions from their plans.


You may enroll in programs in your state until March 31, 2014.


If you enroll in medical coverage through your state Marketplace, your medical benefits will begin:

• The first day of the next month, if you enroll and pay your premium between the 1st and 15th day of the month.

• The first day of the second following month, if you enroll and pay your premium between the 16th and last day of the month.

Check out these websites:

• Darden’s State Medical 411

This free resource was created to help you, your family and even your friends to learn more about options in your state

• U.S. Government website*

• Kaiser Family Foundation*

This non-profit offers a calculator that will estimate costs and government subsidies for people who qualify for assistance

• Families USA*

* Darden has not independently reviewed the information on these websites and is not responsible for its content.

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