Skip to main content

Tag: coverage

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 ($16,753 for a single person in 2019), 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.

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

Health insurance companies, employer-sponsored health plans, and public health programs such as Medicaid are required to provide you with documentation of coverage.  In January, you should receive a form 1095-B from your health plan or insurance company indicating the months during the prior year 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 Form 1095-B.  Form 1095-C documents an offer of coverage by a large employer in addition to documenting months of coverage under the plan.) 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.

I’m behind on my payments and trying to catch up, but meanwhile I got sick and so had to make more health care claims. Does my health plan have to pay them?

If you are receiving advanced premium tax credits, the insurer is required to pay your claims during the first 30 days of the grace period.  After that, during the second and third month of the grace period, the insurer is allowed to hold your claims and only pay them if and when you get caught up in your premium payments.

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.

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 period (SEP) 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
  • Marriage (limitations apply)
  • Gaining a dependent (for example, if you give birth to or adopt a child). Note that pregnancy does NOT trigger a special enrollment opportunity in most states
  • Loss of coverage due to loss of dependent status (for example, because of divorce, legal separation, death, or “aging off” a parents’ plan when you turn 26)
  • A permanent move to another state or within a state if you move outside of your health plan service area (limitations apply)
  • 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 SEP 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 SEP will last 60 days from the date of that triggering event.  If you can foresee loss of other coverage (for example, you know the date when you will graduate and lose student health coverage) you can ask the Marketplace for a SEP up to 60 days in advance so new coverage will take effect right after your old coverage runs out.  However, in states, you cannot ask for an advance SEP if you anticipate coverage loss due to a permanent move.