What is ObamaCare (Affordable Care Act)

So What Is The Affordable Care Act (Obamacare, HEALTHCARE.GOV, Covered CA, etc.)?

family health

The Affordable Care Act (ACA), affectionately known as Obamacare is our current health care reform law in America. It was signed into federal law by President Obama on March 23, 2010.  No matter what you call it, or what political side of the fence you are on, it’s important that you know what it can do for you and how to avoid some of the pitfalls we’ve seen.

…it originally was put into place to provide more Americans with access to affordable quality health insurance.  It also gives access to people with pre-existing conditions and allows low-income people under age 65 to be on MediCaid.  However, affordability is being debated now because if your Modified Adjusted Gross Income (MAGI – see below for quick calculation) is too high for help with the premium, rates have gone through the roof.  Plus, many medical providers are dropping individual and family plans (IFP) plans, left and right.  We can help minimize the blow as much as possible with a personalized insurance design.   We also work with your tax professionals to make sure you’re minimizing your MAGI to maximize the subsidy or look for alternatives.

And a few more facts that you should know about the ACA:

  • Those who make less, pay less:  2023 Federal Poverty Limit Chart (as of 3/15/2023)
  • Health plans must cover maternity, pediatric dental/vision and certain birth control pills
  • There are NO lifetime limits on ACA Compliant plans
  • All new plans sold ‘ON’ or ‘OFF’ the Health Exchanges (Covered CA or Healthcare.gov for instance) must include a wide range of new benefits including wellness visits and preventative tests and treatments at NO additional out-of-pocket costs

CA HEALTH INSURANCE UPDATE…The new health insurance kid on the block is a company called OSCAR.  It’s an EPO and now available in AZ, NY, NJ, Cleveland, Columbus, FL, Memphis, Nashville, Austin, San Antonio, LA, Orange Cty and San Francisco.  In So CA, UCLA and Hoag accept a couple of OSCAR plans.  OSCAR is proactive on promoting wellness and using technology.  Need to Skype a Doctor in the middle of the night?  No problem and no charge with OSCAR!

Deadlines to Apply for a Health Plan


Open enrollment begins on November 1st and continues until December 31st.  (some states, CA, NY and Wash DC, etc., tend to extend past deadlines to 1/31…check with your individual State).

***After Open Enrollment ends (January 31st), you can only obtain an ACA compliant plan with a qualfying event.

Qualifying Events

If you need a health plan and you missed Open Enrollment, there are MANY qualifying events that will allow you to obtain a plan. Here are some of the events (click the link for the current events):

– Turning 26
– Losing current insurance
– Move to a new area
– Getting married
– Birth of a baby
– Getting divorced
– Death in the family
– Becoming a citizen


What is the Health Exchange?

What is The Exchange?

The exchange is an online marketplace for health insurance. This is where you can go to find and apply for coverage from competing private health care providers.  You have the option of buying a plan ON the Exchange or OFF the Exchange (direct with the carrier). Many States have Health Exchanges. If your State does not, you can buy through Healthcare.gov.


Should I Apply On of Off the Exchange?
Whether you apply with the Health Exchange or direct to the carrier depends on a couple of factors:

1) Your MAGI (Modified Adjusted Gross Income). If your MAGI is within certain parameters, you are eligible for a ‘subsidy’ (the government helps to pay for some or most of your insurance premium).

2) Some plans have a wider network of Providers ‘OFF’ the Exchanges (direct to the insurance company). Always check to see if your Drs, medications, and hospitals are ‘in-network’.

Working with an INDEPENDENT Insurance Agent (LIKE US😉) that is certified with the Exchange, will be able to figure out:

1) If you can receive a subsidy
2) Maximize the subsidy
3) Ensure your Providers are in-network
4) Educate you
5) Guide you to the right plan FOR YOU!

And the cherry on top of the already delicious ice cream? At HIR Insurance, you won’t pay any more for our services than if you did this yourself!

Type of Health Insurance Plans

What is the Metal-Tier System?

This is a way to compare health plans and figure out which is best for you and gives you the most Bang for your Buck! It’s all about how much you’re willing to pay in premiums and how much coverage you need.
Just remember the METALS:

  1. BRONZE – Insurance pays 60% you pay 40%
  2. SILVER – Insurance pays 70% you pay 30%
  3. GOLD – Insurance pays 80% you pay 20%
  4. PLATINUM – Insurance pays 90% you pay 10%

MAGI – you won’t find anything labeled MAGI on your tax form.  For most people, MAGI will be:

  • Line 7 on your tax form (Adjusted Gross Income)
  • Plus lots of things but the two main additions are ‘un-taxed’ Social Security and tax-exempt income

Check with your tax professional if you want to be 100% sure of your MAGI

How Can I Get Help With My Premiums?

Whether you can get help with your insurance premiums from the government (subsidy) and how much it will be, depends on a few factors:

1) What is your MAGI (Modified Adjusted Gross Income)? It’s basically your AGI (Line 7 on your taxes) plus a few extra things (tax-exempt interest and untaxed Social Security benefits) but always best to contact your tax accountant.

2) Your location. Yes, your zip code matters and it can be a dramatic difference.

3) Whether your Providers are ‘in-network’ with the Health Exchanges. Yes, the network can be vastly different if you get your plan ‘on’ the Health Exchange or ‘off’ the Exchange (direct to the insurance companies).

All in all, contact an independent insurance agent that is certified with the Exchange you will use. With HIR Insurance agents, you’ll always receive non-biased guidance and will NEVER cost you any more than if you did it yourself!

What happens When My Income Falls Below the Income Limits

FEDERAL POVERTY LIMIT (FPL):  This is the barometer that the government uses to see if you qualify for help with your premiums and/or benefits.  The issue is, if your income falls below certain amounts, you may be pushed into MediCaid (MediCal in CA).  Now, if you are ok on Medicaid, then it’s no issue.  If you don’t want to be on MediCaid however, you’ll want to be on top of this because it’s easier to get ON to MediCaid than it is to get OFF.  We’ve had to go through the ‘appeals’ process for many of our clients to get them off of MediCaid.  It’s no problem for us to do this, it’s just part of our customer service.  However, many times it takes months to get you completely out of the States’ computer systems.  To avoid this mess,  your insurance agent should be keeping an eye on this for you.  If they aren’t, change the Broker of Record to us and we’ll take care of the making the changes for you!  Remember, it doesn’t cost you one extra penny to have us as your advocate  🙂

Does My Dr. Accept ObamaCare plans?
Many Doctors do not accept the new individual and family (IFP) plans or they have aligned with one or two insurance companies only.  These networks change daily.  You’ll need to check EACH insurance company and sometimes call the Doctors’ offices to confirm.

TIP:  If you Doctor doesn’t accept any IFP plans, consider a high-deductible, Bronze, Health Savings Account (HSA) plan.  They used to be more affordable than they are now but it’s not what it is, it’s what it does.  It allows you to put money away in an account (tax-deductible going in and tax-free coming out when used for qualified medical expenses).  You can then use the HSA to pay for those Doctors’ bills.

Is there a Penalty for Being Uninsured?
PENALTY FOR BEING UNINSURED:  We know what you’re thinking…President Trump signed an Executive Order eliminating the penalty, right?  Well, he did however several states have brought it back including California.

In CA, the penalty applies if you are without an ACA Compliant plan for more than three months and will be assessed on your State income tax return.

Starting in 2020, California residents will be penalized unless you have an ‘Exemption’. Call us and we’ll discuss whether you will be exempt and what you will have to do to prove it.

What is the Penalty for Being Uninsured?
If you don’t have health insurance for more than 3 months, you may be penalized on your state taxes. As of 2022, there are penalties for being uninsured in the following states: Massachusetts, New Jersey, California, Rhode Island, and the District of Columbia. Check with your State Exchange for the exact penalty. Click here for information about the penalty in CA, including the amount your family could owe for not having coverage:

NOTE:  There are many exemptions from the penalty available.  However, you must apply and be approved in advance for the exemption. Click here for more info: https://www.coveredca.com/learning-center/tax-penalty-details-and-exemptions/exemptions/

HINT -Remember, it is ok to reduce your MAGI by legal means so if you’re close to a plan being unaffordable, consider putting more money into your retirement account. We’ve seen where putting $500 in an IRA has saved our clients $2,000 because they were able to get a higher subsidy or get their MAGI so that they are in the ‘unaffordable’ area and not pay the penalty. Of course, check with your tax professional to see what else you can do to reduce your MAGI.

Exemptions From the CA Health Insurance Penalty?

What are the exemptions from the CA health insurance penalty?

Click here for a full list:  CoveredCA Penaties and exemptions

What Happens When My Child Turns 26?

The Affordable Care Act increased the age that children can stay on your health plan from 21 to 26. Then it’s time to move them to their own health insurance plan. If your child is disabled and you claim them on your taxes, they can stay on your plan.

Call your health plan and ask when the child will be terminated off the parents’ plan. Look for options a couple of months before they that date and apply for a new plan the month before it is terminated.

HIR Insurance agents are well versed in finding the right plan for young adults turning 26. And we won’t charge any more than if you had to search for yourself!

Where Can I Find Help?

This is all just the…
TIP OF THE ICEBERG when it comes to Obamacare!

All pretty confusing, right?  We’re sure you have a lot more questions like…

  • Have a child turning 26?
  • When and how do I apply?
  • Do I go On or Off the exchange?
  • Will I be penalized for not obtaining health insurance?
  • What do I do if I can’t afford my employers’ insurance?
  • Can I get help with my premium?
  • What happens if my premiums cost too much?  What are my options?
  • Who can assist me with all of this?
  • What is the penalty for not being insured?

That is where we come in!

You know that ole’ saying, “we just don’t know what we don’t know”.  The biggest issue nowadays?  Most people have no idea what questions to ask.  We will help easily guide you to the strategy and plan that is right for you.  Or if your current plan is the right one, we’ll let you know that too!

For more information please give us a call at:

Also keep up to date with valuable Obamacare hints, tips and deadlines:
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Check out some of the reviews posted by our clients on Yelp and Google.  You may see yourself in those stories!

For more information on Obamacare visit this helpful resource: