Affordable Care Act

The health care environment in the metropolitan Washington region is robust. There are numerous hospitals, health care systems, Federally Qualified Health Centers and primary and specialty health care providers located in the District of Columbia, Northern Virginia and suburban Maryland.  Health care resources are not equally distributed throughout the region, requiring some residents to travel to receive health care that is appropriate and affordable. For the most part, people with health coverage and financial resources can access health care services more easily than those without adequate health coverage, financial resources and social capital.

There are federal, state and local programs to assist low-income individuals and households obtain health coverage. Medicaid is a combined federal/state program that provides health coverage for low-income children, pregnant women, parents of minor children, the elderly, blind, and disabled, and optional populations including people in hospice care, women with breast and cervical cancer, and low-income adults. In order to participate, states must comply with mandatory federal requirements, but can establish their own eligibility requirements and benefits packages. Medicaid eligibility and benefits in the District, Maryland and Virginia are substantially different. The District and Maryland expanded Medicaid to cover all eligible, low-income adults when the ACA became law. Virginia expanded Medicaid to cover U.S. citizens with incomes becomes below 138% of the Federal Poverty Level beginning January 1, 2019.

The Affordable Care Act is the law despite efforts to repeal.

The implementation of the Affordable Care Act substantially increased health coverage for low and moderate income Americans through Medicaid expansion and the availability of subsidies for the purchase of qualified health care plans on state or federal insurance exchanges.  Under the ACA, consumers with incomes up to 400% of the Federal Poverty Level are eligible for cost-sharing subsidies and tax credits when they purchase health insurance no matter where they live.

Individuals with pre-existing conditions cannot be denied health insurance or charged more for health insurance because of their health status. Parents can continue to keep adult children up to the age of 26 on their health insurance plans. Qualified health plans available in the Marketplace must cover essential health benefits. Health coverage plans offered outside the Marketplace are not required to meet the same benefits and standards.

The ACA was not implemented uniformly in all states. Cost and coverage, as well as eligibility requirements, vary from state-to-state. In this region, the District of Columbia and Maryland fully implemented the ACA early on, expanding Medicaid to cover all adults with incomes under 138% of the Federal Poverty Level.  Each also created state-run insurance marketplaces where eligible consumers can purchase qualified health plans and apply for tax credits and cost sharing subsidies.

Virginia’s Medicaid program covers low-income children and their parents if the household meets income eligibility guidelines as well as very low-income adults and those who are blind or disabled. Virginia expanded its Medicaid program in January 2019. Under this expansion, eligibility is based on income and immigration status. A single adult citizen making less than $17,256 a year is now qualified to apply for coverage. Virginia consumers are able to purchase qualified health plans on the federal exchange as well.

Some changes to the Affordable Care Act occured in 2019.

Beginning in 2019, there will no longer be a federal penalty for not having coverage. However, several states  have passed or are considering passing legislation to establish statewide health coverage mandates including financial penalties for individuals without health care coverage. The District of Columbia passed the Individual Responsibility Requirement in 2019 that requires residents to have qualifying health coverage, get an exemption, or pay a penalty on their DC taxes.

Individuals are advised to shop for the plans that best meet their needs, both within and outside of state and federal Marketplaces. Most individuals with incomes below 400 percent of the Federal Poverty Level are eligible for tax credits and cost-sharing subsidies when they purchase qualified insurance plans through state and federal Marketplaces. Cost-sharing reductions are only available on Silver plans and will increase at the same rate that the cost of the plans increases. Non-qualified health plans, including short-term, limited duration (STLD) plans, are also available for consumers to purchase. STLD plans only provide coverage for a limited time period. Additional information on these non-qualified health plans can be found at the Commonwealth Institute and the Kaiser Family Foundation.

According to the Centers for Medicare & Medicaid Services (CMS), the average premium for the second lowest cost silver plan on the federal marketplace will drop by 4 percent for the 2020 coverage year. However, rates are influenced by a number of market factors and will vary by state and within specific geographic areas. In all cases, the cost of individual or family coverage will vary depending on eligibility for subsidies. The Kaiser Family Foundation provides detailed estimates of variations in insurance premiums, tax credits and cost-sharing subsidies by county and state. The Kaiser Family Foundation also provides a Health Insurance Marketplace Calculator and a list of frequently asked questions (FAQs).

IMPORTANT ENROLLMENT INFORMATION FOR 2020

Open enrollment for purchasing health insurance varies by state. In Maryland and Virginia, the open enrollment period runs from Friday, November 1, 2019 to Sunday, December 15, 2019. Plans purchased during this enrollment period begin January 1, 2020. Open enrollment in the District of Columbia is November 1, 2019 to January 31, 2020. However, in order to begin coverage on January 1, 2019, enrollment needs to be completed by December 15, 2019.

Individuals with a qualifying life event such as loss of employment, birth/adoption of a child, marriage, divorce, death of a spouse or other qualifying circumstances can enroll at any time within 60 days of the qualifying event.

Access to in-person enrollment assistance will be more limited due to reductions in federal funding. The District, Maryland and Virginia all have state programs that provide in-person enrollment assistance. Federally Qualified Health Centers also have financial counselors and certified enrollment staff to aide with purchasing insurance or enrolling in Medicaid.

For more information about enrollment in your state, check out the resources below:

In Washington, DC visit DC Health Link or Call 1-855-532-5465. There are many enrollment sites with hours and directions listed on the website.

Maryland residents can visit Maryland Health Connection or call 1-855-642-8572 (Toll Free) or TTY: 1-855-642-8573. Montgomery County and Prince George’s County residents can obtain assistance on local websites and at enrollment in their respective counties.

In Montgomery County, in-person enrollment assistance is available at the following locations:

In Prince George’s County, residents can call the PGC Health Connect Call Center at 301-927-4500. In-person enrollment assistance is available at the following locations:

In Virginia, residents are eligible to purchase subsidized health coverage through the federal marketplace at Healthcare.gov. For information about eligibility for all of Virginia’s health care programs visit Cover Virginia or call 1-855-242-8282. For help finding in-person assistance with insurance options and enrollment visit Cover Virginia’s Marketplace Assistance Map or call 1-855-242-8282.

The following organizations provide in-person enrollment assistance in Northern Virginia: