September 17, 2019
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Little-known facts about the Affordable Care Act

So, let’s say you’re pregnant. (Fellas, bear with me here.)

You’re thinking you’d like to breastfeed your new bundle of joy. You’re sure. Pretty sure. But how to work and nurse?

Under the Affordable Care Act, you’ll get some help figuring that out. (Plus a free breast pump for just that purpose.)

If you’re not pregnant and don’t want to be, insurance companies will pay for your birth control under the ACA. If you have little ones, you’ll have access to dental and vision care for them.

Haven’t heard about all that? You aren’t alone.

A lot of attention has been paid to the big parts of the ACA — the fact that large businesses will have to provide health insurance to workers, that almost all Americans will have to have health insurance or pay a penalty, and that the federal government will help some people pay for insurance. But the ACA is 900-plus pages long, with regulations that take up thousands of pages more.

It’s easy to miss things.

Things like these.

Breast pumps for all!

All ACA-compliant health insurance plans must provide breastfeeding support, counseling and equipment. Help may be provided before the baby’s born; it must be provided for the duration of breastfeeding.

That doesn’t mean your insurance company has to hand over a new, $1,000 hospital-grade breast pump. Pumps can be manual or electric, used and rented or new and yours to keep. That depends on your insurance plan.

Also dependent on your plan: Whether your doctor must sign off on it. Some insurance companies require preauthorization. Talk to your doctor or insurance company to find out more.

But let’s say your doctor’s on board, your insurance company has handed over the Cadillac of breast pumps (or maybe the Ford of breast pumps) and little Juniper is happily taking a bottle with Daddy, at Grandma’s or in day care.

How are you supposed to find time for all this pumping while you work? The ACA also requires many employers to provide reasonable break time — and a private location other than a bathroom — for pumping.

There are exceptions. For example, companies with fewer than 50 employees don’t have to comply if they prove such a break would impose an “undue hardship” on them. And the company doesn’t have to pay you for the time unless you’re pumping during a break that would be paid for other employees.

But if your employer fits the requirement, these accommodations must be made for as long as you are breastfeeding, for up to a year after the baby’s birth.

Birth control

If you have an ACA-compliant health plan — generally, any full health insurance bought after March 2010 (see below) — the insurance company must pay for prescribed contraceptives, patient education and birth control counseling.

You may have heard something about this; it’s been pretty controversial. But even though some people have tried to get it removed from the ACA, it’s still there for the moment and still law.

The caveats: You have to be a woman to get this benefit. Certain religious employers don’t have to offer it to their employees. And the contraceptives have to be approved by the Food and Drug Administration.

What kind of birth control does this include? Barrier methods, such as diaphragms and sponges. Hormonal methods, such as birth control pills and vaginal rings. Implanted devices, such as intrauterine devices, or IUDs. Emergency contraception, such as “Plan B.” Sterilization procedures.

Your insurance company doesn’t have to provide any and all birth control for free, just a selection from each category. However, it does have to give you a specific contraceptive if your doctor says you need that one.

Insurance companies aren’t required to cover drugs to induce abortion or services related to a man’s, er, reproductive ability. Such as vasectomies. (Sorry, guys.)

The birth control part of the ACA has been challenged by a number of religious groups and employers who don’t want to provide contraceptives. The U.S. Supreme Court is likely to take up the issue soon. But, for now, the rule stands.

Dental and vision for kids

To the ACA, dental and vision care are an essential part of children’s health care the same way ER visits, medications and blood tests are.

That means they must be available to kids as part of your insurance plan or alone as a free-standing plan. (This isn’t true for grown-ups. Insurers don’t have to offer dental and vision care to you.)

In Maine, all health plans in the marketplace include vision care, but most don’t include dental. Standalone dental plans will likely be offered in the marketplace by Anthem Blue Cross and Blue Shield and Delta Dental, with rates ranging from about $26 a month to about $39 a month, according to the Maine Bureau of Insurance. All plans cap your out-of-pocket expenses at $700 a year for one child and $1,400 a year for two children or more.

Off the marketplace, according to the bureau, a variety of insurers will offer dental plans, with rates ranging from about $26 a month to about $50 a month, depending on whether you’re buying for your family only or through a small group, such as your employer.

FYI: Dental and vision have to be offered for kids, but you don’t have to take them. If dental or vision are not part of your insurance plan, the ACA won’t make you buy a standalone policy to get them.

Coverage counts

Starting Jan. 1, 2014, most Americans will have to have health insurance or pay a penalty.

But you can’t just go buy a $50 plan from a sketchy Internet site and call it good. (Not that you would.)

Under the ACA, insurance plans have to limit patient costs and provide essential coverage. Think hospitalization, doctor’s visits, lab tests and preventive care.

Sure, that sounds like most health insurance, so what doesn’t count? Plans that cover only vision or dental care. Workers’ compensation. Coverage only for a specific disease or condition. Plans that offer only discounts on medical services.

If you or your employer bought health insurance before the law was signed on March 23, 2010, you may be able to keep it. That’s called a grandfathered plan.

But be careful. If there’s a significant change that reduces the plan’s benefits or raises patient costs — such as if you ask to increase your deductible — that grandfathered status could vanish. (Check out our story today on preventive care for more on that.)

Percentage rules

Let’s say you can get insurance through work, but it’s expensive. Life would really be so much sweeter if you could buy it on your own through the marketplace and get a subsidy from the feds to help.

You can.


The ACA also has something called a 9.5 percent rule.

The feds say employer insurance is unaffordable if it’ll cost you more than 9.5 percent of your family income to insure you. Unaffordable work insurance means you might qualify for a subsidy to go to the marketplace and buy insurance on your own.

The key words there: “family income” and “insure YOU.” There’s the rub.

The 9.5 percent is based on family income, but your employer only has to insure you. Not your spouse. Not your children. So as long as you pay less than 9.5 percent of your family income for your own insurance — even if you have to pay more to add your kids to the policy — you don’t qualify for a subsidy.

Starting in 2015, the feds will penalize large employers who offer unaffordable insurance, so companies will ultimately have an incentive to provide you with coverage you can afford. But the 9.5 percent rule applies to that, too.

As long as the company offers ACA-compliant insurance that costs less than 9.5 percent of your family income to insure just you, they’re penalty-free.

It’s a loophole that has experts worried that companies will pull back on dependent coverage and sink that money into employee-only coverage. Only time will tell what employers will do and whether that loophole will be closed.

Wonder about your situation? Ask your employer about coverage for next year and check the Kaiser Family Foundation’s online calculator for more information on subsidies and premium estimates.

Still concerned about cost? You and your family may be able to get an exemption to the insurance requirement if your household earns less than the poverty level in Maine (because Maine didn’t expand Medicaid) or if your family income is so small that you don’t have to file taxes. You may also be able to get an exemption if you can show it would be a hardship for you to get insurance.

Have feedback? Want to know more? Send us ideas for follow-up stories.

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