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Frequently Asked Questions

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Frequently Asked Questions

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Affordable Care Act FAQs

What is the health insurance Marketplace?

Health Insurance Marketplaces (also known as Exchanges) are new organizations that will be set up to create more organized and competitive markets for buying health insurance. They will offer a choice of different health plans, certifying plans that participate and providing information to help consumers better understand their options. Through the Marketplace, individuals and families will be able to shop for coverage if they need to buy health insurance on their own. Premium and cost sharing subsidies will be available through the Marketplace to reduce the cost of coverage for individuals and families, based on their income. Individuals and families with very low incomes will also be able to find out at the Marketplace if they are eligible for coverage through Medicaid and CHIP. Finally, small businesses can also buy coverage for their employees through the Small Business Health Options Program (SHOP) Marketplace.

There will be a health insurance Marketplace in every state for individuals and families and for small businesses. Some Marketplaces will be operated by the State and have a special state name (such as CoveredCalifornia or The Maryland Health Connection.) In other states where the federal government runs the Marketplace, it will be known called The Health Insurance Marketplace of [state name.]

How do I find my state Marketplace?

Links to all state Marketplaces can be found at www.healthcare.gov

Who can buy coverage in the Marketplace?

Most people can shop for coverage in the Marketplace. To be eligible you must live in the state where your Marketplace is, you must be a citizen of the U.S. or be lawfully present in the U.S., and you must not currently be incarcerated.

Not everybody who is eligible to purchase coverage in the Marketplace will be eligible for subsidies, however. To qualify for subsidies (also called premium tax credits) people will have to meet additional requirements having to do with their income and their eligibility for other coverage.

I'm eligible for health benefits at work but want to see if I can get a better deal in the Marketplace. Can I do that?

You can always shop for coverage on the Marketplace, assuming you meet other eligibility requirements, but if you have access to job-based coverage, you might not qualify for premium tax credits.

When can I enroll in private health plan coverage through the Marketplace?

In general, you can only enroll in non-group health plan coverage during the Open Enrollment period.

For 2016 coverage, the Open Enrollment period begins November 1, 2015 and extends through January 31, 2016. Once the Open Enrollment period is over, individuals and families will not be able to enroll in Marketplace health plans until the next Open Enrollment period. However, if you experience certain changes in circumstances during the year, you will have a special 60-day opportunity to enroll in Marketplace health plans, outside of the Open Enrollment period.

For individuals and families buying non-group coverage on their own, outside of the Marketplace, you can only enroll in coverage during Open Enrollment periods and special enrollment opportunities, as well.

American Indians and Alaska Natives can enroll in coverage throughout the year, not just during Open Enrollment.

Can I buy or change private health plan coverage outside of Open Enrollment?

In general, you can have a special enrollment opportunity to sign up for private, non-group coverage during the year, other than during Open Enrollment period, if you have a qualifying life event. Events that trigger a special enrollment opportunity are:

  • Loss of eligibility for other coverage (for example if you quit your job or were laid off or if your hours were reduced, or if you lose student health coverage when you graduate) Note that loss of eligibility for other coverage because you didn't pay premiums does not trigger a special enrollment opportunity
  • Gaining a dependent (for example, if you get married or give birth to or adopt a child). Note that pregnancy does NOT trigger a special enrollment opportunity.
  • Loss of coverage due to divorce or legal separation
  • Loss of dependent status (for example, "aging off" a parents' plan when you turn 26)
  • Moving to another state or within a state if you move outside of your health plan service area
  • Exhaustion of COBRA coverage
  • Losing eligibility for Medicaid or the Children's Health Insurance Program
  • For people enrolled in a Marketplace plan, income increases or decreases enough to change your eligibility for subsidies
  • Change in immigration status
  • Enrollment or eligibility error made by the Marketplace or another government agency or somebody, such as an assister, acting on their behalf. Note that some triggering events will only qualify you for a special enrollment opportunity in the health insurance Marketplace; they do not apply in the outside market. For example, if you gain citizenship or lawfully present status, the Marketplace must provide you with a special enrollment opportunity.

When you experience a qualifying event, your special enrollment opportunity will last 60 days from the date of that triggering event. If you can foresee a qualifying event (for example, you know the date when you will graduate and lose student health coverage) you can ask the Marketplace for a special enrollment opportunity up to 60 days in advance so new coverage will take effect right after your old coverage runs out.

States have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.

How can I find out if my doctor is in a health plan's network?

Each plan sold in the Marketplace must provide a link on the Marketplace web site to its health provider directory so consumers can find out if their health providers are included.

The provider network information that insurance companies provide may or may not tell you whether a provider is accepting new patients, or whether a provider speaks your language. It is up to your Marketplace to require insurers to provide you with this information.

Is dental coverage an essential health benefit?

Under the health care law, dental insurance is treated differently for adults and children 18 and under.

Dental coverage for children is an essential health benefit. This means it must be available to you, either as a covered benefit under your health plan or as a free-standing plan. This is not the case for adults. Insurers don't have to offer adult dental coverage.

Can I be charged more if I have a pre-existing condition?

No. Health plans are not allowed to charge you more based on your health status or pre-existing condition.

I smoke cigarettes and I buy my own health insurance. Can I be charged more because I smoke?

Yes, in most states you can. Insurers are allowed to increase premiums by up to 50% more for people who use tobacco, although many insurers apply a lower surcharge for tobacco use. If you qualify for premium tax credits, this tobacco surcharge will not be covered by the tax credit. States are allowed to limit tobacco surcharges and a few have decided to prohibit tobacco rating by health insurers.

What is the Cadillac tax?

The so-called Cadillac tax is an excise tax on high cost health plans offered by employers. Beginning in 2018, health plans that cost more than $10,200 for an individual or $27,500 for a family plan will be subject to the tax, which is 40% of the amount that exceeds those thresholds. For example, if a family plan costs $30,000, the employer that offers the plan would owe 40% of $2,500 ($30,000 minus $27,500), or $1,000 for each family it covers under that plan.

The tax was intended to be a disincentive for employers to provide overly rich health benefits, and the cost of the health plan is one measure of the level of benefits. However, some plans may cost more because they cover people with higher-than-average health care costs, including retirees, older workers and workers in high-risk occupations. The cost thresholds for plans that cover a significant number of individuals in any of those categories are higher.

Individual Mandate FAQs

I'm uninsured. Am I required to get health insurance?

Everyone is required to have health insurance coverage - or more precisely, "minimum essential coverage" - or else pay a tax penalty, unless they qualify for an exemption. This requirement is called the individual responsibility requirement, or sometimes called the individual mandate.

What's the penalty if I don't have coverage?

The penalty for not having minimum essential coverage is either a flat amount, or a percentage of household income, whichever is greater. The penalty has been phased in since 2014.

In 2016, the penalty is the greater of

  • $695 for each adult and $347.50 for each child, up to $2,085 per family, or
  • 2.5% of family income above the federal tax filing threshold

In later years, the flat penalty amounts for 2016 will be indexed based on the cost of living.

In all years, the penalty is also capped at an amount equal to the national average premium for the median cost bronze health plan available through the Marketplace.

The penalty is assessed based on "coverage months." This means that each month you are uninsured, you may owe 1/12th of the annual penalty. However, short spells of uninsurance may not be subject to a penalty.

Are there exemptions to the penalty? What are they?

Yes. You may be eligible for an exemption if you:

  • Cannot afford coverage (defined as those who would pay more than 8.05 percent of their household income for the lowest cost bronze plan available to them through the Marketplace in 2015)
  • Are not a U.S. citizen, a U.S. national, or a resident alien lawfully present in the U.S.
  • Had a gap in coverage for less than 3 consecutive months during the year
  • Won't file a tax return because your income is below the tax filing threshold (For the 2015 tax year, filing threshold is $10,300 for individuals and $20,600 for married persons filing a joint return)
  • Are unable to qualify for Medicaid because your state has chosen not to expand the program
  • Participate in a health care sharing ministry or are a member of a recognized religious sect with objections to health insurance
  • Are a member of a federally recognized Indian tribe
  • Are incarcerated

Others who do not qualify through these categories but have experienced a hardship that makes it difficult to purchase insurance may apply through the health insurance Marketplace for an exemption to the individual responsibility requirement.

How do I prove that I had coverage and satisfied the mandate?

Starting in 2015, health insurance companies, employer-sponsored health plans, and public health programs such as Medicaid are required to provide you with documentation of coverage. In 2016, you should receive a form 1095-B from your health plan or insurance company indicating the months in 2015 when you were covered under the plan. If you were enrolled in family coverage, Form 1095-B will indicate the names of all family members who were covered with you under the plan. (If you worked for a large employer, with more than 50 employees, you might receive a Form 1095-C instead of or in addition to the Form 1095-B.) A copy of this form will also be reported to the Internal Revenue Service.

If you were covered by more than one plan during the year, you should receive a Form 1095-B (or 1095-C) from each plan. When you file your tax return for this calendar year (most people will do this by April 15 next year) you will have to enter information about your coverage (or your exemption) on the return.

Minimum Essential Coverage FAQs

What kinds of coverage count as Minimum Essential Coverage to satisfy the requirement to have health insurance?

Most people with health coverage today have a plan that will count as minimum essential coverage. The following types of health coverage count as minimum essential coverage:

  • Employer-sponsored group health plans
  • Union plans
  • COBRA coverage
  • Retiree health plans
  • Non-group health insurance that you buy on your own, for example, through the health insurance Marketplace
  • Student health insurance plans
  • Grandfathered health plans
  • Medicare
  • Medicaid
  • The Children's Health Insurance Program (CHIP)
  • TRICARE (military health coverage)
  • Veterans' health care programs
  • Peace Corps Volunteer plans

Be aware that outside of the Marketplace, other policies be for sale that may look like health insurance (such as short term individual policies, or policies that only cover cancer.) These kinds of products are sometimes referred to as "excepted benefits." They do not count as Minimum Essential Coverage.

Do private insurance policies have to be labeled to show whether they are Minimum Essential Coverage?

All health insurers and employer-sponsored group health plans must provide people with a Summary of Benefits and Coverage, which uses a standard format to outline the benefits, cost-sharing and coverage limits of plans. The Summary of Benefits and Coverage must also say whether the plan meets minimum value and counts as minimum essential coverage.

Renewing Marketplace Coverage FAQs

I signed up for Marketplace coverage last year and I want to continue in this plan for another year. Do I have to do anything during Open Enrollment?

Your coverage may automatically be renewed; even so, you may want to take steps to renew it yourself during Open Enrollment. If you are receiving a premium tax credit, it is wise to go through the process so that you can update your income and family information and see how much tax credit you may be eligible for based on the new premiums for 2016. Open Enrollment for 2016 plans begins on November 1, 2015 and continues through January 31, 2016.

The process for renewing coverage may be a little different depending on where you live. In federal Marketplace states that use www.healthcare.gov, if you are currently enrolled in a Marketplace policy and you don't take any action before December 15, 2015, in most cases the Marketplace will automatically renew your coverage under that policy for 2016. Insurers may not offer all of the same plans in 2016 that they offered in 2015. If your health plan is no longer being offered in 2016 and you do nothing, your insurance company will automatically enroll you in another policy that is similar to one you had in 2015.

Young Adults and Students FAQs

I'm a young adult and I need health insurance. What are my coverage options?

A number of options may be available to you:

  • If your income is below 138% of the federal poverty level ($16,242 for a single person in 2016), you may qualify for Medicaid coverage. Not all states have elected to expand Medicaid eligibility to this income level. Check with your state Marketplace to find out more about Medicaid eligibility in your state.
  • If your parents have health insurance that offers dependent coverage, you can join (or stay on) their policy as a dependent and remain covered until your 26th birthday. See below for more information about dependent coverage for young adults.
  • You can buy a policy on your own through your state health insurance Marketplace. All plans sold through the Marketplace must meet requirements for covered benefits and cost sharing. Depending on your income, you may be eligible for help to reduce the cost of plan premiums and/or cost sharing.
  • Special, catastrophic policies with very high cost sharing must be offered to young adults under the age of 30. Premium and cost sharing subsidies are not available for catastrophic plans.
  • If you are a student, you may be able to enroll in student health offered through your college or university.

I'm eligible for the student health plan but haven't signed up yet. Do I have to take that or can I apply for coverage and subsidies in the Marketplace?

Eligibility for a student health plan does not make you ineligible for Marketplace coverage and subsidies. Even if you are eligible for student health coverage, you can get coverage through the Marketplace. In addition, if your income is between 100% and 400% of the federal poverty level and you meet other requirements, you can qualify for premium tax credits; if you income is between 100% and 250% of the federal poverty level, you can also qualify for cost sharing reductions.

In addition, eligibility for a student health plan does not make you ineligible for Medicaid. Check with your state Marketplace to find out if you meet the income and other eligibility standards to enroll in Medicaid coverage.

I just got a job that offers health benefits, but my parent's policy is better and less expensive to me. Can I stay on my parent's policy?

Yes. Eligibility for group health benefits through your own job does not make you ineligible to be covered as a dependent on your parent's policy up to the age of 26.

Do my parents have to claim me as a tax dependent for me to be on their health plan to age 26?

No. You do not need to be a tax dependent of your parents to continue to be covered as a dependent on their health plan.

Do I have to live in my parents' home to be covered as a dependent under their policy?

No, living in your parents' home is not a requirement for eligibility to be covered as a dependent under their policy.

Uneven Incomes FAQs

My income is uneven and hard to predict because I am self-employed. Most years I make between $20,000 and $30,000, though two years ago I did especially well and earned $35,000. How will this affect my application for premium tax credits for the coming year?

In reviewing your application, the Marketplace will compare the amount of income you estimate for next year to the most recent information about your income that is available (usually, that will be the tax return you filed this year reporting last year's income.) If that amount is more than 10% different from the amount you put on your application, you might receive a data match inconsistency notice from the Marketplace and you'll need to provide more documentation.

In cases of an income data match inconsistency, the Marketplace will ask you to provide documentation within 90 days. During that period, you can get premium tax credits based on the income you attested to in your application. However, if you have not resolved the data match inconsistency within 90 days, the Marketplace will adjust or end your advance premium tax credit based on the most recent income information it can find.

My spouse and I earn so little we are not required to file an income tax return. Do we have to file anyway to receive premium tax credits?

Yes, even if you don't earn enough to owe taxes, you must file a tax return in order to receive a premium tax credit.

Medicare FAQs

I am covered by Medicare. Can I keep my Medicare coverage even though these Marketplace plans are available, or do I need to make a change?

Yes, you can keep your Medicare and you do not need to make any changes to your coverage because of Obamacare. You may have heard about the requirement that all adults need to have health insurance coverage (known as the "individual mandate") or have to pay a penalty if they go without health insurance, but your Medicare coverage satisfies this requirement. If you have Medicare Part A, or Part A and Part B, this penalty won't apply to you. Having Part B only doesn't satisfy this requirement.

I recently turned 65 and I am eligible for Medicare Part A without having to pay a premium. But I have not yet signed up for Medicare Part A or Part B. Can I purchase a Marketplace plan?

Yes, if you are not covered by Medicare, an insurer can sell you a Marketplace plan. But because you are eligible for premium-free Medicare Part A, you are not eligible to receive the premium tax credit to help reduce the cost of a Marketplace policy, even if you would qualify based on your income.

Also keep in mind that if you sign up for a Marketplace plan, rather than enroll in Medicare Part B when you are first eligible to do so, and then later you decide to sign up for Medicare, you may be required to pay a penalty for delaying enrollment in Medicare Part B. Your monthly Part B premium may go up 10% for each year that you could have had Part B, but didn't. You may also owe a late enrollment penalty for Part D drug coverage, which is equal to 1% of the national average premium amount for every month you didn't have coverage as good as the standard Part D benefit.

Employer Sponsored Coverage FAQs

My family and I are offered health benefits through my job, but we can't afford to enroll. My employer pays 100% of the premium for workers, but contributes nothing toward the cost of adding my wife spouse and kids. Can we try to find a better deal in the Marketplace?

You can always shop for coverage on the Marketplace, but your family members won't be eligible for tax credits to help pay the premium. When people are eligible for employer-sponsored coverage, they can only qualify for Marketplace premium tax credits if the employer-sponsored coverage is considered unaffordable. Coverage is considered unaffordable only if your cost for coverage for yourself, alone, under the employer plan is more than 9.78% of your income in 2016. The cost of adding your spouse and children to family coverage is not taken into consideration. So although you may feel your family coverage is unaffordable in practical terms, it is considered technically affordable.

If your family members end up uninsured because family coverage is unaffordable, they will not have to pay a tax penalty under the "individual mandate."

I work full time for a large employer (more than 50 full time employees). Is my employer required to offer me health benefits?

Your employer is not required to offer health benefits. However, large employers that don't offer health benefits to their full-time employees and to their dependent children may be liable for a tax penalty. If your employer doesn't offer you health benefits, you can apply for coverage in the Marketplace; and, if your income is between 100% and 400% of the federal poverty level, you may apply for a premium tax credit that may reduce the cost of coverage in the Marketplace.

Note that a full-time employee is one who works, on average, at least 30 hours per week. If your hours vary during the year, your employer may have some options in determining your status as a full-time or part-time worker. Your employer can tell you whether you are a full or part-time

I work full time for a large employer (more than 50 full time employees) and I'm married and we have kids. Is my employer required to offer health benefits that cover my spouse and kids?

Your employer is not required to offer health benefits. However, large employers that don't offer health benefits to their full-time employees and to their dependent children may be liable for a tax penalty. Large employers do not face a tax penalty if they don't offer health benefits to the spouses of their workers.

If your employer doesn't offer coverage to your spouse or children, they can apply for coverage in the Marketplace and, if your family income is between 100% and 400% of the federal poverty level, a premium tax credit that may reduce the cost of coverage in the Marketplace.

If your employer offers health benefits (that are affordable and meet minimum value) to you and your spouse and children, you still may choose to purchase coverage through a Marketplace, but your family will not be eligible for premium tax credits to help pay for the coverage.

I work part-time for a large employer. Is my employer required to offer me health benefits? What about benefits for my spouse and kids?

No, large employers are not required to offer health benefits to part time employees and there is no penalty for large employers that don't offer health benefits to part-time employees or their dependents. If you work part-time and you are not offered health benefits, you (and your family) can apply for coverage in the Marketplace; and, if your income is between 100% and 400% of the federal poverty level, you can apply for a premium tax credit that may reduce the cost of coverage in the Marketplace.

Note that a part-time employee is one that works, on average, fewer than 30 hours per week. If your hours vary during the year, your employer may have some options in determining your status as a full-time or part-time worker. Your employer can tell you whether you are a full or part-time worker.

COBRA FAQs

I'm eligible for COBRA but haven't elected it yet. Does that affect my eligibility for Marketplace subsidies?

No, Just being eligible for COBRA doesn't affect your eligibility for premium tax credits or cost-sharing assistance if you enroll in a Marketplace plan.

I'm enrolled in COBRA now but I want to drop it. Does that affect my eligibility for Marketplace subsidies?

No, having COBRA doesn't affect your eligibility for premium tax credits. However, you can only drop COBRA and sign up for a Marketplace plan and premium tax credits during Open Enrollment. You will have to drop your COBRA coverage effective on the date your new Marketplace plan coverage begins. After Open Enrollment ends, however, if you voluntarily drop your COBRA coverage or stop paying premiums, you will not be eligible for a special enrollment opportunity and will have to wait until the next Open Enrollment period.


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