Insurance is complicated. There are plenty of questions our customers have about insurance that we want to answer! Let Hummingbird help you out and read through our insurance FAQs!
All Marketplace insurance plans cover mental health and substance abuse services as an essential health benefit.
Health insurance plans available in the Marketplace must cover 10 categories of essential health benefits. One of these categories is mental health and substance abuse services. (Substance abuse is also known as substance use disorder.)
These services include behavioral health treatment, such as psychotherapy and counseling. They also include mental and behavioral health inpatient services and substance use disorder treatment.
Your specific behavioral health benefits will depend on the state you live in and the particular health plan you choose. You’ll see a full list of what each plan covers when you compare plans in the Marketplace.
Marketplace plans can’t deny you coverage or charge you more just because you have a pre-existing condition. This includes mental health and substance use disorder conditions.
Coverage for treatment of pre-existing conditions begins as soon as your Marketplace coverage starts.
There’s no waiting period for coverage of these services.
Marketplace plans can’t apply yearly or lifetime dollar limits on coverage of essential health benefits. This includes benefits for mental health and substance use disorder services.
Marketplace plans must provide certain “parity” protections between mental health and substance abuse benefits on the one hand, and medical and surgical benefits on the other.
This means that in general, limits applied to mental health and substance abuse services can’t be more restrictive than limits applied to medical and surgical services. The kinds of limits covered by the parity protections include:
The health care law requires most health insurance plans to provide breastfeeding equipment and counseling for pregnant and nursing women.
Health insurance plans must provide breastfeeding support, counseling, and equipment for the duration of breastfeeding. These services may be provided before and after you have your baby.
These rules apply to Health Insurance Marketplace plans and all other health insurance plans, except for grandfathered plans.
Your health insurance plan must cover the cost of a breast pump – and may offer to cover either a rental or a new one for you to keep.
Your plan may have guidelines on whether the covered pump is manual or electric, how long the coverage of a rented pump lasts, and when they’ll provide the pump (before or after you have the baby).
But it’s up to you and your doctor to decide what’s right for you.
In many cases, your insurance plan will follow your doctor’s recommendations on what is medically appropriate. Some insurance plans may require pre-authorization from your doctor to ensure the proper services are provided. Talk to your doctor to find out what this means for you.
Contact your insurance plan for questions about your breastfeeding benefits.
Plans in the Health Insurance Marketplace must cover contraceptive methods and counseling for all women, as prescribed by a health care provider.
These plans must cover the services without charging a copayment or coinsurance when they’re provided by an in-network provider. This is true even if you haven’t met your deductible.
All Food and Drug Administration-approved contraceptive methods prescribed by a woman’s doctor are covered, including:
Plans aren’t required to cover:
For more information about specific contraceptive services your plan covers, check your plan’s materials or ask your employer or benefits administrator.
Health plans sponsored by certain exempt “religious employers,” like churches and other houses of worship, don’t have to cover contraceptive methods and counseling. If you work for an exempt religious employer and use contraceptive services, you may have to pay for them out-of-pocket. Contact your employer or benefits administrator for more information.
Some non-profit religious organizations (like non-profit religious hospitals and institutions of higher education that certify they have religious objections to contraceptive coverage) don’t have to contract, arrange, pay, or refer for contraceptive coverage.
Contact your employer or health plan for more information.
In the Health Insurance Marketplace, you can get dental coverage 2 ways: as part of a health plan, or by itself through a separate, stand-alone dental plan.
You can buy a dental plan through the federal Marketplace only when you enroll in a health plan.
Health plans that include dental coverage. In the Marketplace, dental coverage is included in some health plans. You can see which plans include dental coverage when you compare them.
If a health plan includes dental coverage, you’ll pay one monthly premium for everything. The premium shown for the plan includes both health and dental coverage.
Separate, stand-alone dental plans. In some cases separate, stand-alone plans are offered. You may want this if the health coverage you choose doesn’t include dental coverage, or if you want different dental coverage.
If you choose a separate dental plan, you’ll pay a separate, additional premium.
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 if you’re getting coverage for someone 18 or younger, dental coverage must be available as part of a health plan or as a stand-alone plan. While it must be available to you, youdon’t have to buy it.
This is not the case for adults. Insurers don’t have to offer adult dental coverage.
Under the health care law, most people must have health coverage or pay a fee. But this isn’t true for dental coverage. You don’t need to have dental coverage, even for children, to avoid the penalty.
Essential health benefits for pre-existing medical conditions are covered under all Marketplace plans.
All private health insurance plans offered in the Marketplace offer the same set of essential health benefits. These are services all plans must cover.
The essential health benefits include at least the following items and services:
Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. You will see exactly what each plan offers when you compare them side-by-side in the Marketplace.
Additional benefits include:
People under 30 and people with “hardship exemptions” may buy a “catastrophic” health plan. This type of plan has lower monthly premiums and mainly protects you from very high medical costs.
A catastrophic plan generally requires you to pay all of your medical costs up to a certain amount, usually several thousand dollars. This limit is known as a deductible. After you reach your deductible, costs for essential health benefits are generally paid by the catastrophic plan.
Catastrophic plans usually have lower monthly premiums than a comprehensive plan. But they cover your costs only after you’ve used a lot of care. These plans basically protect you from worst-case scenarios like serious accidents or illnesses.
In the Marketplace, catastrophic plans cover 3 primary care visits per year at no cost, even before you’ve met your deductible. They also cover free preventive services.
If you buy a catastrophic plan in the Marketplace, you can’t get premium tax credits or lower out-of-pocket costs based on your income. Regardless of your income, you pay the standard price for the catastrophic plan.
After you fill out a Marketplace application you’ll get an eligibility notice. It will tell you what programs and savings you’re eligible for, including catastrophic plans. If you’re eligible to enroll in a catastrophic plan, you’ll see these plans listed when you compare your coverage options.
You can then choose to enroll in a catastrophic plan or any other plan available to you.
Many tools are available to help you search, compare, and assess providers, hospitals, and other care facilities so you can make better decisions.
Different plan types provide different levels of coverage for care you get inside and outside of the plan’s network of doctors, hospitals, pharmacies, and other medical service providers. There are other differences between plan types too.
When comparing your options in the Marketplace, you’ll see health plan details. Make sure to note the type of each plan you’re considering.
To get details about the plan you can also view a summary of benefits, a plan brochure, a provider directory, and a list of covered drugs. If staying with your current doctors is important to you, check to see if they’re included in the provider directory before choosing a plan.
You can find quality information about doctors, hospitals, and other care providers by using our quality compare tools.
The category of plan you choose affects how much you spend on out-of-pocket costs. Generally, Bronze and Silver plans have lower monthly premiums, but you’ll pay higher out-of-pocket costs when you need care. Gold and Platinum plans generally have higher premiums but lower out-of-pocket costs.
The maximum out-of-pocket costs for any Marketplace plan for 2015 are $6,600 for an individual plan and $13,200 for a family plan. This means when the amount you’ve paid in deductibles, copayments, and coinsurance reaches these limits, the insurance company pays 100% of your costs for covered care. Even if you choose a catastrophic coverage planyour out-of-pocket costs shouldn’t exceed this limit.
If you qualify for lower out-of-pocket costs based on your household size and income and choose a Silver plan, you can save more. This called a “cost-saving reduction.”
With a cost-sharing reduction, you’ll pay lower deductibles, copayments, and coinsurance. You’ll basically get the lower out-of-pocket costs of a Gold or Platinum plan while paying a Silver plan premium. You can choose any category of plan, but you get these savings on out-of-pocket costs only if you enroll in a Silver plan.
If you make $11,670 to $29,175 for individuals or $23,850 to $59,625 for a family of 4, you may be eligible for a cost-sharing reduction. The lower your income within these ranges, the more you’ll save on out-of-pocket costs.
Get more information about cost sharing reductions for American Indians and Alaska Natives.
Monthly premiums are important, but they’re not all you need to think about. Picking a plan only because its premium is low may not be the best decision for you.
If your plan has a lower monthly premium, your out-of-pocket costs may be higher when you need care.
If your plan has a higher premium, your out-of-pocket costs may be lower when you need care.
Generally speaking, the lower your monthly premium the higher your out-of-pocket costs will be. It’s important to keep this in mind when you compare plans.
If you make $11,670 to $46,680 for individuals or $23,850 to $95,400 for a family of 4, you may qualify for premium tax credits that can lower your monthly premiums. The lower your income is within these ranges, the bigger your tax credit and the more you save.
The health plan category you choose determines how you and your plan share the costs of care. These categories have nothing to do with the quality or amount of care you get.
There are 5 categories or “metal levels” of coverage in the Marketplace. Plans in each category pay different amounts of the total costs of an average person’s care. This takes into account the plans’ monthly premiums, deductibles, copayments, coinsurance, and out-of-pocket maximums. The actual percentage you’ll pay in total or per service will depend on the services you use during the year.
Think about your health care needs when choosing a category of Marketplace plan.
If you expect a lot of doctor visits or need regular prescriptions: You may want a Gold plan or Platinum plan. These plans generally have higher monthly premiums but pay more of your costs when you need care.
If you don’t expect to use regular medical services and don’t take regular prescriptions: You may want a Silver, Bronze, or Catastrophic plan. These plans cost you less per month, but pay less of your costs when you need care.
If you qualify to save on out-of-pocket costs: Silver plans may offer the best value. You may qualify for lower out-of-pocket costs based on your household size and income. If you do, you can get these out-of-pocket savings only if you enroll a Silver plan. If you make this choice you’ll basically get the lower out-of-pocket costs of a Gold or Platinum plan while paying a Silver plan premium.
If you’re under 30 or have a hardship exemption and want low monthly premiums: You may want to choose a catastrophic plan designed to protect you from worst-case scenarios, like serious accidents or diseases.
Of course, it’s impossible to predict all your health care needs for the year ahead. Pick a plan that fits your budget and meets your and your family’s expected needs.
Choosing a health plan can be complicated. There are a lot of things to take into account.
There are several important things to consider when you compare Marketplace plans.
Plan category: There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic. Plans in these categories differ based on how you and the plan share the costs of your care. The categories have nothing to do with the amount or quality of care you get.
Monthly premiums: This is the amount you pay your insurance company for your plan, usually monthly, whether you use medical services or not.
Type of insurance plan and provider network: Some types of plans allow you to see almost any doctor or health care facility. Others limit your choices to a network of doctors and facilities, or require you to pay more if you use providers outside the network.
Benefits: All plans sold through the Marketplace provide the same essential health benefits and cover pre-existing conditions and offer free preventive services. But some plans offer additional benefits.
If you can’t afford any health plan and don’t qualify for coverage through Medicaid and the Children’s Health Insurance Program (CHIP), you can get low-cost health care at a nearby community health center.
How much you pay depends on your income. Community health centers are located in both urban and rural areas. They provide:
When you apply for health coverage in the Marketplace, you or some members of your household could be eligible for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP).
This will depend on your household size and income, and on whether your state is expanding its Medicaid program to cover more people.
Learn more about Medicaid and CHIP coverage.
Five factors can affect Marketplace plan prices: location, age, family size, tobacco use, and plan category. Health status and gender don’t affect pricing.
Under the health care law, insurance companies can take into account only 5 things when setting premium costs.
States may limit how much these factors can affect premiums.
All Marketplace health plans cover the same list of essential health benefits. Insurance companies may offer more benefits than the minimum, which could also affect costs.
Insurance companies can’t charge women more than men for the same policy.
They also can’t take health status into account when setting rates. All Marketplace policies must cover treatment for pre-existing conditions from the first day coverage begins.
When you enroll in coverage through the Marketplace, you may be able to save money on out-of-pocket costs, including deductibles, copayments, and coinsurance. This is sometimes called “cost-sharing reductions.”
Whether you qualify to save on out-of-pocket costs will depend on your household size and income.
Very important: You can get these savings on out-of-pocket costs only if you enroll in a plan in the Silver category.
When you apply for coverage in the Marketplace, you’ll learn if you’re eligible for savings on out-of-pocket costs.
If your household income falls between the following amounts, health insurance companies must lower how much you pay out of pocket when you get medical care. They do this only for Silver plans.
The lower your income within these ranges, the more you’ll save on out-of-pocket costs.
Incomes that qualify for cost-sharing reductions are higher in Alaska and Hawaii. See Alaska and Hawaii information.
If your income falls between the amounts shown, you also qualify forpremium tax credits that lower your monthly premiums.
Plans in the Marketplace are grouped into 4 categories: Bronze, Silver, Gold, and Platinum.Learn more about plan categories and what they mean.
If you qualify for out-of-pocket savings, you must choose a Silver plan to get the savings. You can choose any category of plan, but you’ll get the out-of-pocket savings only if you enroll in a Silver plan.
Get more information about cost sharing reductions for American Indians and Alaska Natives.
When you buy health insurance coverage in the Marketplace, you may be able to get a premium tax credit that lowers what you pay in monthly premiums.
This will depend on your 2015 household size and income.
You can apply part or all of this tax credit each month to your premium payments. The Marketplace will send your tax credit directly to your insurance company, so you pay less for your premiums each month. This is called “advance payment of the premium tax credit.”
If your 2015 income falls within the following ranges you’ll generally qualify for a premium tax credit. The lower your income is within these ranges, the bigger your credit.
Incomes that qualify for tax credits are higher in Alaska and Hawaii. See Alaska and Hawaii information.
If your 2015 income falls below the amounts shown on the chart, you may qualify for coverage under your state’s Medicaid program. This is true if you live in a state that’s decided to expand Medicaid to cover more people.
But if ALL of the following apply, you can’t get premium tax credits when you buy a private insurance plan through the Marketplace:
Learn if your state is expanding Medicaid and what this means for you.
To learn if you qualify for lower costs on health insurance coverage, find your estimated 2015 household income and household size on the chart below.
The column on the left tells you if you may qualify for premium tax credits, lower out-of-pocket costs, or low-cost health care through Medicaid.
Higher incomes qualify for lower costs in Alaska and Hawaii. See Alaska and Hawaii information.
If you’re applying for coverage for the rest of 2014 with a Special Enrollment Period (SEP), the figures will be slightly different. When you apply with an SEP, the Marketplace application will use the 2014 dollar amounts.
If you bought a health plan through the Marketplace in 2014, you’ll probably be automatically enrolled for 2015. If you don’t take any action, your coverage will start January 1, 2015. But you should update your income and household information to be sure you get the right amount of savings for 2015.
When you get your notice from your health insurance company, you’ll know if you’ll be enrolled automatically.
You can change plans for 2015 coverage, even if you’ll be automatically enrolled in your current plan or a similar plan. Preview 2015 plans and prices to compare available plans with your current coverage.
If your insurance company notice says you’ll be enrolled automatically, it will tell you if:
If you’ll be automatically enrolled in a similar plan: Insurance companies sometimes decide to change which plans they offer in the Marketplace. This is a normal part of their business cycle. If you’re being automatically enrolled in a different plan, your company has decided not to offer your particular Marketplace plan to anyone in your area in 2015.
An insurance company can’t move you to a different plan based on your health or how much care you use. It can move you only if it’s no longer offering the plan you had to anyone in your area.
You can accept the automatic enrollment in the similar plan or change plans.
If you want to change, you must enroll in the new plan by December 15, 2014, for your new plan to start January 1, 2015.
If you will be automatically enrolled, your Marketplace notice will tell you if:
If you will be enrolled without savings, here are two possible reasons:
You must update the information you provided on your 2014 Marketplace application, like your income, who’s in your household, and whether you can get coverage through a job. This is true even if you accept your automatic enrollment.
No matter what health plan you had in 2014, you can change plans for 2015.
You can change plans even if your notice says you’ll be enrolled automatically for 2015.
You can change plans even after you’ve been automatically enrolled in a plan.
Preview 2015 plans and prices to compare available plans with your current coverage. See how to preview 2015 plans & prices.
Starting November 15, 2014, you can change health plans for 2015. Here’s how:
Important: After you get new eligibility results, you must continue all the steps in the process and enroll in a plan. If you don’t, your new information won’t get to your insurance company.
Be sure to enroll by December 15, 2014, for coverage to start January 1, 2015.
If you bought a health insurance plan through the Marketplace in 2014, you can renew your current plan or enroll in a different plan for 2015.
See a quick list of 5 Steps to Staying Covered through the Marketplace (PDF).
Preview 2015 plans and prices to compare available plans with your current coverage.
Before November 15, 2014, you’ll get two important notices about your health coverage. One will come from your health insurance company. One will come from the Marketplace. These notices help you understand your choices for 2015, so it’s important to review them carefully and keep them in a safe place. Learn more about these notices.
If you have 2014 Marketplace coverage, your notices will explain which one of these will apply to you:
Important: You can always pick a different plan for 2015. This is true even if we enroll you in a plan automatically. You can choose any plan available to you in 2015, no matter what kind of plan you had in 2014.
You can apply for 2015 Marketplace coverage starting November 15, 2014. Until then, there’s a lot you can do to get ready.
Here are the most important dates for 2015 coverage:
November 15, 2014: Open Enrollment starts — the first day you can apply for 2015 coverage
December 15, 2014: The last date to enroll for coverage that starts January 1, 2015
December 31, 2014: Date when all 2014 Marketplace coverage ends, no matter when you enrolled
January 1, 2015: The date 2015 coverage can start if you apply by December 15, 2014, or if you accept automatic enrollment in your 2014 plan or a similar plan
February 15, 2015: The last day to enroll in 2015 coverage. If you miss this deadline, you can’t sign up for a health plan inside or outside the Marketplace for the rest of 2015. The only exception is if you qualify for a Special Enrollment Period.
Most people are eligible to use the Health Insurance Marketplace.
To be eligible for health coverage through the Marketplace, you:
If you have Medicare coverage, you’re not eligible to use the Marketplace to buy a health or dental plan. Learn more about Medicare and the Marketplace.
U.S. citizens living in a foreign country for at least 330 days of a 12-month period are not required to get health insurance coverage for that 12-month period. If you’re uninsured and living abroad under this definition, you don’t have to pay the fee that other uninsured U.S. citizens may have to pay.
See question 12 on this IRS document to learn more about the rules for people living abroad.
Generally, health insurance coverage in the Marketplace covers health care provided by doctors, hospitals, and other providers within the United States. If you’re living abroad, it’s important to know this before you consider buying Marketplace insurance.
Take action for 2015
Here’s a quick rundown on the most important things to know about the Health Insurance Marketplace, sometimes known as the health insurance “exchange.”
The Health Insurance Marketplace helps uninsured people enroll in health coverage. Fill out a Marketplace application and we’ll tell you if you qualify for:
Private health insurance with savings based on your income. Plans cover essential health benefits, pre-existing conditions, and preventive care. Most people who apply through the Marketplace qualify for premium tax credits and savings on out-of-pocket costs based on household size and income.
Medicaid and the Children’s Health Insurance Program (CHIP). These programs provide free or low-cost coverage to millions of families with limited income. Many states are expanding Medicaid to cover more people. Find out what Medicaid expansion means for you.
Where you live can affect what health coverage you’re eligible for as well as your eligibility to get help paying for coverage. When you log in to your account and fill out your Marketplace application, you’ll need to know certain things about reporting where you live.
Generally, people must live in a state to be considered residents and get help paying for health coverage there. If someone is living out of the state temporarily, they can still be considered a resident of the state.
You’ll be asked if everyone on your application lives at the same permanent home address in your state.
When you apply, you’ll be asked to enter your permanent home address. Give the permanent home address where everyone on your application lives. This can’t be a P.O. box. We’ll use this address to determine if you’re a resident of the state where you’re seeking health coverage.
When you log in to your account and fill out a Marketplace application, you’ll need to know which members of your household to include.
To learn about who qualifies as a dependent, refer to IRS Publication 501 (PDF).
If you want to find out if you qualify for lower costs on Marketplace coverage, you’ll need to provide information about your household members and estimated 2015 income.
The Marketplace application includes detailed instructions. It makes calculations using the information you provide to determine if you’re eligible for premium tax credits and other savings that can lower the cost of health insurance.
When you log in to your account and fill out a Marketplace application, you’ll also find out if you qualify for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP) in your state.
If you provide inaccurate information about your household or estimated 2015 income, you could wind up with the wrong amount of premium tax credits and other savings. If you make more money than you estimate, you could wind up having to pay back some of those savings when you file your next tax return.
When you apply for premium tax credits and other savings in the Marketplace, you’ll need to estimate your income for 2015. You’ll provide this information on your Marketplace application.
You can start by adding up the following items for:
For each of the following sources, estimate what your income will be in 2015—the year for which you’re applying for insurance. If you’re not sure what your income will be, make your best estimate.
Other items to include when estimating your 2015 income are: retirement income, investment income, pension income, rental income, and other taxable income such as prizes, awards, and gambling winnings.
Don’t include the following kinds of income:
Don’t include as income any money that an employer takes out of your paycheck for child care, health insurance, or retirement plans that is “not taxable.” Sometimes these are called “pre-tax deductions.” Your pay stub should list these deductions individually.
The pay stub may list your “federal taxable wages.” If it does, use that figure to report your pay.
For more information on reporting your income, see IRS Publication 525.
You can also report certain deductions from your income by logging in to your account and updating your application.
Scholarship and fellowship payments for tuition and fees and course-related expenses required of all students are not counted as income in determining your eligibility. Payments for room and board are included.
Worker’s compensation payments are generally not taxable, so they would not be counted in determining your eligibility.
No. Inheritances are not counted.
Alimony that is paid is deducted from gross income to determine adjusted gross Income. It will be excluded from income in determining your eligibility for subsidies.
No, child support payments you receive are not counted.
Yes, all of your Social Security benefits will be counted as income in determining your eligibility.
Eligibility for premium tax credits is based on your Modified Adjusted Gross Income, or MAGI. When you file a federal income tax return, you must report your adjusted gross income (which includes wages and salaries, interest and dividends, unemployment benefits, and several other sources of income.) MAGI modifies your adjusted gross income by adding to it any non-taxable Social Security benefits you receive, any tax-exempt interest you earn, and any foreign income you earned that was excluded from your income for tax purposes. Note that eligibility for Medicaid and CHIP is also based on MAGI, although some additional modifications may be made in determining eligibility for these programs. Contact your Marketplace or your state Medicaid program for more information.
No, your income is too low to qualify for premium tax credits.
No, assets are not counted. So the value of your house, car, retirement savings, etc. will not affect your eligibility for premium tax credits. Only your income is considered.
Premium tax credits are available to people who buy Marketplace coverage and whose income is between 100% and 400% of the federal poverty level.
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.
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.
Yes, having an individual policy does not disqualify you from buying Marketplace coverage and qualifying for premium tax credits. However, remember that you can only drop your existing policy and buy a new one during the Open Enrollment period.
You can add your children to your Marketplace plan, but because they are eligible for your state’s Children’s Health Insurance Program (CHIP), they are not eligible for premium tax credits. The exception to that is if you live in a state that has a waiting period for enrolling in CHIP. During the waiting period, your children are eligible for a premium tax credit; when the waiting period has ended they can enroll in CHIP and will become ineligible for the tax credit.
For certain types of coverage, if you are eligible but not enrolled, then you can still qualify for premium tax credits. These include:
In addition, during Open Enrollment, if you are already enrolled in these types of coverage, you can apply for Marketplace coverage and subsidies and then drop your other coverage as of the date your new Marketplace coverage will take effect. However, if you are eligible for job-based coverage (that is affordable and meets minimum value) or for Medicaid or CHIP, but you didn’t enroll, then you are not eligible for premium tax credits.
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 9.56% of your income in 2015. 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.”
Beginning in 2015, large employers will be required to offer health benefits to full-time workers and to their dependent children, or face a penalty. Large employers are not required to offer health benefits to the spouses of full-time workers. A large employer is one that employees at least 50 workers. Once the provision takes effect in 2015, your employer would not have to pay a penalty for refusing to offer coverage to your spouse. Meanwhile, because your spouse is not offered health benefits through your job, s/he may be eligible to apply for coverage and premium tax credits through the Marketplace.
Usually no. If you are offered health benefits at work and your required contribution costs no more than 9.56 percent of your 2015 household income, you will not be eligible for premium tax credits through the Marketplace. If you are required to pay more than 9.56% of your income to enroll in coverage for a single person under your job-based health plan, then you could qualify for premium tax credits in the Marketplace in 2015.
In addition, if your job based health plan doesn’t meet the standards for minimum value (for example, if it has an annual deductible higher than $6,600 per person), then you could also qualify for premium tax credits.
When you apply for a premium tax credit in the Marketplace, the application will include a form with questions about the affordability and minimum value of any job-based coverage you may be eligible for. Take that form to your employer and ask them to fill it out. The Marketplace will review the information and let you know whether you qualify for premium tax credit.
In general, if you have, or are eligible for, any of the following types of coverage, you would be ineligible for premium tax credits through the Marketplace:
However, if you have access to other types of coverage, you can still be eligible for premium tax credits, assuming you meet other requirements:
On the health insurance Marketplace web site, you will find an Application for Health Coverage and Help Paying Costs. Filling out the application online is the fastest, though you can also submit a paper application or call your Marketplace call center and apply over the phone. The Application will ask you basic information about yourself (and any family members who are applying for coverage with you) including your Social Security number and information about your citizenship or immigration status. It will also ask employment and income information, including what’s on your most recent income tax return. Once you’ve submitted the application, the Marketplace will let you know if you qualify for help paying for Qualified Health Plans it offers. It will also let you know if you (or any members of your family) may be eligible for coverage through Medicaid or the Children’s Health Insurance Program. To complete the Application for Health Coverage and Help Paying Costs online, you will need to create a secure personal account with a login ID and password.
That’s up to you. You can have 1/12 of your annual premium tax credit paid directly to your health plan each month to reduce your monthly premium right away. Or, if you can afford to, you can pay the entire health plan premium yourself up front and collect the premium tax credit in a lump sum next year when your file your tax return. Or you can have some of the tax credit paid directly to your insurer in advance but save some to be collected at year end. Keep in mind that when you apply for the premium tax credit this fall, during Open Enrollment, you won’t necessarily know for sure what your 2015 income will be, so you will apply based on your best estimate of your 2015 income. Later, when you file your 2015 tax return, the IRS will compare your actual income to the amount of premium tax credit you claimed in advance. If you underestimated your income and claimed too much premium tax credit, you might have to pay back some or all of the difference. If you didn’t receive all of the premium tax credit you’re entitled to during the year, you can claim the difference when you file your tax return. If you’re uncertain about your 2015 income, it’s also important to remember that you can modify the amount of premium tax credit during the year if your income changes. So, for example, if you are unemployed now, you can apply for a premium tax credit based on your current low income; then if you get a new job during the year, you can report this increase in income to the Marketplace and reduce the amount of premium tax credit you’re receiving at that time.
Premium tax credits reduce your premium for most Marketplace policies. The amount of the tax credit you may receive depends on your income and the cost of Marketplace health plans in your area. The Marketplace will determine the expected contribution you are required to pay toward the premium for a mid-range (Silver) benchmark plan. The expected contribution will increase on a sliding scale based on your 2015 income. If your income is near the poverty level, the expected contribution you would be required to pay toward the benchmark plan is 2.01 percent of your income in 2015. As your income gets closer to 400% of the poverty level, the expected contribution you would be required to pay toward the benchmark plan is 9.56% of your income. The difference between the premium for the benchmark plan and your expected contribution equals the amount of your tax credit. (You do not have to pay more than the actual premium for the plan.) The Marketplace will tell you what that dollar amount is. You can use that amount to help pay the premium for any Bronze, Silver, Gold, or Platinum plan offered in the Marketplace. The credit cannot be used to pay for a Catastrophic plan. Premium tax credits may be claimed at the end of the year, or you can apply for an advanced premium tax credit based on your estimated income for the up-coming year. If you elect to receive an advanced credit, the government will pay 1/12 of the credit directly to your insurance company each month and the insurer will bill you for the rest of the premium. It’s important to keep in mind that when you apply for the premium tax credit this fall, during Open Enrollment, you won’t necessarily know for sure what your 2015 income will be, so you will apply based on your best estimate of your 2015 income. Later, when you file your 2015 tax return, the IRS will compare your actual income to the amount of premium tax credit you claimed in advance. If you underestimated your income and claimed too much premium tax credit, you might have to pay back some or all of the difference. If you didn’t receive all of the premium tax credit you’re entitled to during the year, you can claim the difference when you file your tax return. You should report any changes in your income during the year to the Marketplace, so your credit can be adjusted and you can avoid any significant repayments at the end of the year.
You can apply the premium tax credit to any Bronze, Silver, Gold, or Platinum plan offered through the Marketplace. Premium tax credits cannot be applied to Catastrophic plans or to stand-alone dental plans. If you are also eligible for cost sharing reductions, be aware that these can only be obtained through Silver plans offered in the Marketplace.
No. Premium tax credits are only available for coverage purchased in the Marketplace.
Premium tax credits will be available to U.S. citizens and lawfully present immigrants who purchase coverage in the Marketplace and who have income between 100% and 400% of the federal poverty level. Premium tax credits are also available to lawfully residing immigrants with incomes below 100 percent of the poverty line who are not eligible for Medicaid because of their immigration status. (Generally, immigrants must lawfully reside in the U.S. for five years before they can become eligible for Medicaid.) In addition, to be eligible for the premium tax credits, individuals must not be eligible for public coverage—including Medicaid, the Children’s Health Insurance Program, Medicare, or military coverage—and must not have access to health insurance through an employer. (There is an exception in cases when the employer plan is unaffordable because the employee share of the premium exceeds 9.56% of the employee’s income in 2015. There is also an exception in cases where the employer plan doesn’t provide a minimum level of coverage.)
As the name implies, a short-term health insurance policy offers coverage for a period of less than 12 months (e.g., many offer coverage for just 6 months) and are renewable at the option of the insurance company. Though you may be given an opportunity to request to renew the policy, if you’ve made claims since you bought it, the insurer can refuse to renew it. This is also called a non-guaranteed-renewable policy. Short-term policies are not considered minimum essential coverage. Insurance companies that sell such policies are required to notify you that they do not constitute minimum essential coverage.
Yes, grandfathered plans count as minimum essential coverage.
Grandfathered plans are those that were in existence on March 23, 2010 and have stayed basically the same. If you buy coverage on your own and you first purchased your policy prior to March 23, 2010, it may be a grandfathered plan. If you first purchased the policy after that date, it is not grandfathered. As your non-grandfathered policy comes up for renewal in 2014, it will have to change to follow all the new rules required of other health plans. If you currently are covered under a non-group policy – whether it is grandfathered or not – starting October 1, 2013, you can also explore other qualified plans offered through the Marketplace and, if you prefer, you can switch to one of the new plans during Open Enrollment. To be eligible for a tax credit to help pay your premium – which will be based on your income – you would have to switch to a plan offered through the Marketplace. Some group plans offered by employers may also be grandfathered plans. A grandfathered group plan also must have been first established prior to March 23, 2010. To retain grandfather status, the group plan cannot be significantly changed (that is, the employer can’t significantly change covered benefits or cost sharing or the share of the plan premium that you are required to contribute.) Because employer plans tend to change from year to year, most have already lost grandfather status or will lose it over time. Meanwhile, however, grandfathered plans are not required to provide all of the benefits and consumer protections required of other health plans. For example, a grandfathered health plan might not cover preventive health services. Employers with grandfathered group health plans are allowed to enroll new employees in the grandfathered plan. So even if you first joined a group health plan after March 23, 2010, you should ask about its grandfathered status. Your employer or your insurer must let you know if your health plan is grandfathered.
No. Some types of coverage do not qualify as minimum essential coverage. These include hospital indemnity policies (that pay a fixed dollar amount per day when you are hospitalized), discount plans, short-term nonrenewable policies, or plans that provide coverage only for a specific disease (i.e., cancer-only policies). Companies that sell these products, also called “excepted benefits,” are required to notify you if they don’t qualify as minimum essential coverage. If you receive such a notice, and don’t obtain other coverage that is minimum essential coverage, you may have to pay a tax penalty.
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, although in 2014, that information may be provided separately in a cover letter.
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:
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.
You should contact the Marketplace to call the mistake to their attention and request a corrected form 1095-A. Information on 1095-A is also reported to the IRS, so it is important that you get a corrected form before you file your income tax return.
Form 1095-A gives you information about the amount of advanced premium tax credit (APTC) that was paid during the year to your health plan in order to reduce your monthly premium. This information was also reported to the IRS. The APTC paid on your behalf during the year was based on the 2014 income you estimated you would earn when you signed up for Marketplace coverage. Now you must file a 2014 federal income tax return to compute your actual 2014 income. You will have to include Form 8962 with your return. Instructions for this form will help you calculate how the 2014 APTC compares to the amount of premium tax credit you were eligible for. If your actual 2014 income was lower than what you estimated, you are eligible for a larger premium tax credit and can claim the difference as a refund when you file your 2014 return. If your 2014 income was higher than what you estimated, you are eligible for less premium tax credit and will have to pay back some or all of the difference when you file your 2014 return.
Yes. You will need to file a 2014 federal income tax return and Form 8962. Follow the instructions on Form 8962 to determine the amount of tax credit you should receive as a tax refund when you file your taxes.
Yes. You are required to file a 2014 federal income tax return and calculate how much tax credit you were actually eligible for in 2014. The Marketplace determination you received last year was based on your good faith estimate of what your 2014 income would be. When you file your tax return, you will report your actual 2014 income. If your actual 2014 income turned out to be higher than you had estimated, you may have to repay some or all of the advanced premium tax credit (APTC) that was paid on your behalf during the year. If your actual 2014 income turned out to be lower than you had estimated, you will be able to claim additional tax credit amounts as a tax refund. To calculate this, you will need two new tax forms. In January you will receive a form 1095-A in the mail from your health insurance Marketplace. This form will indicate the amount of APTC that was paid to your health plan in 2014. When you file your federal income tax return, you will also need to file Form 8962. The instructions for Form 8962 will walk you through the steps to calculate the amount of tax credit that you were eligible for based on a final calculation of your 2014 income. Once you’ve completed this form, you will know whether you are required to repay some of the 2014 APTC or whether you are owed additional premium tax credit.
There are several options to consider. Some people with very low incomes are automatically exempt from the individual responsibility requirement. If your 2014 income was below the tax filing threshold ($10,150 in 2014 for single taxpayers, $20,300 for married taxpayers who file a joint return), you don’t need to file a 2014 tax return and you won’t be assessed a penalty for not having coverage during the year. If you do intend to file a 2014 return anyway (for example, to get a refund of any income taxes that were withheld during 2014), you will need to include Form 8965 with your tax return and check the box indicating that your income is below the filing threshold.
If your income is above the tax filing threshold, you will have to file a 2014 federal income tax return and claim an affordability exemption from the individual responsibility requirement. You can qualify for this exemption if the lowest cost plan that was available to you through the Marketplace in 2014 would have cost more than 8% of your household income, taking into account any premium tax credit that you were eligible for. Or, if you were offered coverage by an employer in 2014, you would be eligible for the affordability exemption if your share of the premium for that plan would have cost more than 8% of your household income. You can apply for this exemption from the Marketplace in your state, before you file your 2014 federal income tax return, or you can apply for it on the tax return when you file. Either way, you will need to file Form 8965 with your 2014 federal income tax return.
To apply for an exemption from the Marketplace, in most states you would have to fill out a paper application, providing information about your expected 2014 income, members of your household, and any employer-sponsored coverage that may have been offered to you. If the Marketplace grants the exemption, you will receive an exemption certificate. Include the exemption certificate number on Form 8965 and include that with your income tax return.
If you haven’t received a Marketplace affordability exemption, the instructions for Form 8965 will explain the steps you must follow to determine whether you are eligible for an affordability exemption. If so, you will enter that information on Form 8965 and include it when you file your 2014 income tax return.
There are several other exemptions from the individual responsibility penalty that you may qualify for.
You should contact your health plan to call the mistake to their attention and request a corrected form 1095-B before you file your 2014 tax return.
When you file your 2014 tax return, there will be a space for you to indicate that you had health insurance coverage for the full year. In January, you will receive a form 1095-B in the mail from your health plan or health insurance company. If you were covered under Medicare, Medicaid or CHIP, you will receive a form 1095-B from that program. This form will indicate the name of your health plan or program and the month(s) during the year you were covered under it. If family members were also covered under your plan, form 1095-B will also show their information. Keep it for your records. You should use the information from the 1095-B to help you fill out your tax return. If you did not have health coverage for the entire year, there will be directions to help you calculate the tax penalty or to indicate that you owe no penalty if you qualify for an exemption.
Yes, unless you qualify for another exemption. There is an exemption for people who are incarcerated but it does not apply to people who were in jail awaiting trial.
No, you can apply to the Marketplace for a hardship exemption at any time during the year. Most hardship exemptions will be granted for the month before the hardship, the months of the hardship, and the month after the hardship. You will need to document the timing of the hardship in your application. For people ineligible for Medicaid only because their state hasn’t expanded Medicaid eligibility, the hardship exemption will be granted for the entire calendar year. If you are applying for this type of hardship exemption, you will have to apply for Medicaid coverage and be denied, then submit the Medicaid denial to the Marketplace with your hardship exemption application. If you need help applying for an exemption, you can contact the Marketplace call center or a Navigator or other in-person assister. Your Marketplace website will have a listing of Navigators and other assisters.
For some types of exemptions, you must apply through the health insurance Marketplace; for other types, you must apply when you file your taxes; some types of exemptions can be claimed either way.
The religious conscience exemption and most hardship exemptions are available only by going to a health insurance Marketplace and applying for an exemption certificate. In the federal Marketplace, you cannot apply for an exemption online. Instead, you can download a paper application for an exemption fromhealthcare.gov, fill it out and mail it in. You will receive a response by mail and, if the exemption is approved, it will include an exemption certificate number. Save this document, you will need to include the exemption certificate number on your tax return when you file your federal income taxes. If you need help applying for an exemption, you can contact the Marketplace call center or a Navigator or other in-person assister. Your Marketplace website will have a listing of Navigators and other assisters.
The exemptions for unaffordable coverage, members of Indian tribes, members of health care sharing ministries, and individuals who are incarcerated are available either by going to a Marketplace and applying for an exemption certificate or by claiming the exemption as part of filing a federal income tax return.
The exemptions for short coverage gaps, certain hardships and individuals who are not lawfully present in the United States can be claimed only as part of filing a federal income tax return. You will need to file a 2014 federal income tax return and include with it Form 8965. If you already received an exemption from the Marketplace, you will include the Marketplace exemption certificate number on this form. Otherwise, instructions for this form will explain the steps you must take and information you must enter on your federal tax return so that you won’t owe a tax penalty.
The exemption for having income under the federal income tax return filing threshold is available automatically. No special action is needed. However, if you are filing a tax return anyway (for example, to have refunded taxes that were withheld during the year), you should include Form 8965 with your tax return and check the special box indicating that your income is below the tax filing threshold.
If you did not maintain minimum essential coverage in 2014 and you don’t qualify for an exemption you will need to pay a “shared responsibility payment” to the IRS on your 2014 tax return. If you are like most people, you will need to file your tax return by April 15, 2015.
When you file your 2014 tax return (most people will do this by April 15, 2015) you will have to enter information about your coverage (or your exemption) on the return. You should get a form (called Form 1095-B) from your insurance provider(s) by January 31, 2015, describing your coverage status during each month of the previous year.
If you are a resident of a foreign country for the full calendar year, you will not have to pay a tax penalty, even if you don’t have minimum essential coverage.
People may apply for a hardship exemption if they have experienced difficult financial or domestic circumstances that prevent them from obtaining coverage – such as homelessness, death of a close family member, bankruptcy, substantial recent medical debt, or disasters that substantially damage a person’s property. In addition, a hardship exemption may be granted to people who were determined ineligible for Medicaid only because their state hasn’t expanded Medicaid coverage to residents with income up to 138% of the federal poverty level. People may also apply for a hardship exemption if obtaining coverage would be so burdensome as to cause the applicant to experience other serious deprivation of food, shelter, or other necessities. Consult your Marketplace for more information about hardship exemptions.
The penalty for not having minimum essential coverage is either a flat amount, or a percentage of household income, whichever is greater. The penalty will be phased in. In 2014, the penalty is the greater of
In 2015, the penalty is the greater of
In 2016, the penalty is the greater of
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 lowest 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.
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.
No. When you go back to the Marketplace you will need to do both. In federal Marketplace states, healthcare.gov will show you the information you entered last year when you applied for financial assistance. If nothing has changed, you will be able to indicate that on the website. The Marketplace will then provide you with an updated eligibility decision, and then you can continue to select a new plan for next year.
No. When you re-apply for financial assistance, the Marketplace will determine the new amount of your financial assistance, and then you will need to re-select your current plan in order for the updated premium tax credit amount to be applied to your 2015 premium. If you want the new premium tax credit to take effect on January 1, you will have to update your application for financial assistance on or before December 15, 2014.
Both notices are important and you should read them carefully. The notice from your health insurer should state whether your 2014 plan is being offered again in 2015. If it is, the notice should describe any changes to that plan and the monthly premium for 2015. The insurer notice will also advise you that, if you do nothing before December 15, 2014, you will automatically be re-enrolled in your current plan for 2015. If your 2014 plan is not being offered again but your insurance company is offering similar plans in 2015, the notice from your health insurer will explain that your policy is not being continued. The notice will also describe another similar policy that will be offered next year and advise that if you do nothing before December 15, 2014, you will automatically be enrolled in that similar plan for 2015. The insurer notice will also remind you that, whether or not your current plan will be offered next year, you are free to shop for new coverage and change plans during Open Enrollment. The notice from your insurer should also describe the amount of APTC that you received in 2014 and explain that, unless you update your application for financial assistance, in most cases you will continue to receive the same dollar amount of APTC for 2015. If your 2014 plan is not being offered again and your insurance company will not offer any other plans in 2015, the notice from your health insurer will explain that your policy is not being continued. The notice will also advise that you cannot be automatically renewed into another policy. You will have to apply for a new plan during Open Enrollment. The notice from the Marketplace will provide additional information about renewing your application for financial assistance. That notice will let you know whether you are eligible to have your 2014 financial assistance continued automatically into 2015 without you having to take any action. That notice should also remind you to update your application for financial assistance to ensure that your eligibility determination reflects the most current information possible.
Yes. In the federal marketplace, on your 2014 application for coverage, you had the opportunity to authorize the Marketplace to check online income data about you, including from your tax returns, for another 1 to 5 years. If you did not authorize this (note that most people did give authorization), your financial assistance will NOT be automatically continued for 2015. You must re-apply for financial assistance if you want the APTC for 2015. In addition, if you did authorize the Marketplace to check income information about you, it will check the most recently available information, which for most people will be your 2013 federal income tax return. If the income you reported on your 2013 tax return was more than 500% of the federal poverty level ($58,350 for a single person, $117,750 for a family of 4), your financial assistance will not automatically be continued for 2015. Instead, to continue receiving an APTC in 2015, you will have to re-apply for financial assistance and provide information about your expected 2015 income. Note that the process for renewing financial assistance may vary in other states. In Maryland, for example, all residents who received premium tax credits in 2014 must reapply for financial assistance. Otherwise, their advance premium tax credit will be discontinued for 2015. Maryland residents who don’t reapply but are eligible for financial assistance would still be able to receive the tax credit at the end of the year when filing their 2015 tax return. All state Marketplaces will send consumers notices prior to the start of Open Enrollment explaining the process for continuing or re-applying for financial assistance in 2015.
If you live in a federal Marketplace state and you don’t update your application, in most cases, healthcare.gov will automatically continue the amount of your 2014 premium tax credit for 2015. If that turns out to be less than the amount you’re actually eligible for in 2015, you will have to pay more premium each month than you otherwise would have had to, although you can receive a refund for the rest when you file your 2015 tax return. If the 2014 premium tax credit amount turns out to be more than you are actually eligible for in 2015, you will have to repay all or part of the difference when you file your 2015 tax return.
You should return to the Marketplace to update your application for financial assistance. You can do this on your own, either by logging in to your account on the web site or by calling the Marketplace call center. Or you can visit a Navigator or other in person assister in your community. Your Marketplace web site and call center will have contact information for in person assisters near you.
If you don’t update your application by December 15, in most cases and in most states, the marketplace will automatically continue the amount of your 2014 premium tax credit for 2015.
Updating your application is a good idea because, chances are, the amount of premium tax credit you will be eligible for in 2015 will be at least slightly different from what you were eligible for last year. The amount of premium tax credit you are eligible for is based on two things: your household income and the cost of a benchmark plan in your Marketplace. It is important to report any changes in your household income and your family status so your eligibility determination will be up to date. Even if your circumstances haven’t changed, the cost of the benchmark plan in your area may have changed, and this would also change the amount of your premium tax credit. Therefore, to be sure you are receiving the correct amount of financial assistance in 2015, you can return to the Marketplace and obtain an updated eligibility determination for premium tax credits.
Your coverage may automatically be renewed; even so, you may want to take steps to renew it yourself during Open Enrollment this fall. 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 2015. Open Enrollment for 2015 plans begins on November 15, 2014 and continues through February 15, 2015. 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, 2014, in most cases the Marketplace will automatically renew your coverage under that policy for 2015. Insurers may not offer all of the same plans next year that they offered in 2014. If your health plan is no longer being offered in 2015 and you do nothing, your insurance company will automatically enroll you in another policy that is similar to one you have now.
It depends. Insurers are allowed to make changes to policies each year. Most likely, the premium for your 2014 policy will change in 2015. There may be other changes as well, for example, changes in the deductible or copays for some services. In some cases an insurer may stop offering a particular policy and offer you new choices, instead. Shortly before Open Enrollment begins, you should receive a notice from your insurance company describing any changes to your policy and the new monthly premium. If you want to continue the policy you can renew coverage for another year. If you prefer to shop for other coverage, you can do that during Open Enrollment.
All Marketplace health plans provide coverage based on a calendar year. Even if you signed up mid-year, coverage under your current plan continues through December. Open Enrollment (November 15, 2014 through February 15, 2015) is the time to renew coverage. You can return to the Marketplace website or call the Marketplace call center to renew coverage yourself so that it continues in 2015. In most states if you don’t act to renew your coverage by December 15, 2014, the Marketplace will automatically renew coverage for you. If your coverage is automatically renewed but you would still like to change plans, you can still do so until the last day of Open Enrollment, February 15, 2015.
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.
It depends. If your premium contribution with the wellness penalty would be more than 9.56% of your income in 2015, then your employer plan would be considered un-affordable and you would be eligible to apply for premium tax credits in the Marketplace. This test applies whether you are actually penalized or not, and in advance of the penalty being applied (for example, if your employer gives you time to try to meet the health standard that triggers a penalty or reward). Similarly, if your employer wellness program applies the penalty to the plan cost sharing (for example, people who don’t participate or who can’t meet the health targets have a higher deductible than would otherwise be the case), and if penalty is high enough to reduce the value of your plan below the “minimum value,” then you would be eligible to apply for premium tax credits in the Marketplace. Again, this test applies whether you are actually penalized or not and in advance of the penalty ever being applied.
Yes, as long as your employer workplace wellness program meets certain requirements, it can increase your premium by as much as 30 percent of the cost of the health plan if you don’t participate or meet required health targets. (Or, if one of the health targets involves tobacco use, the penalty can be as much as 50 percent of the cost of the health plan.) Some of the key requirements include:
Not necessarily. In 2014, multi-state plans are offered through the Blue Cross Blue Shield Association. Some multi-state plans will reimburse as “in-network” care rendered by providers in other state Blue Cross Blue Shield plan networks, but others may not. This information should be provided in the description of the multi-state plan’s features on your state’s health insurance marketplace.
No. multi-state plans may only be sold through the health insurance Marketplace.
In 2014, there will be multi-state plans in 30 states, but by 2017 the law requires that all 50 states have multi-state plans.
The multi-state plan program was established under the Affordable Care Act to provide people with additional coverage options in the health insurance Marketplace. A multi-state plan is one that has been approved to participate on the health insurance Marketplace by a federal government agency, the U.S. Office of Personnel Management. This is the same agency that administers the health plan for federal government employees.
Yes, you can. One key consideration, though, will be whether he can access in-network services while he is away at school. Some insurers sell coverage in many states and offer a multi-state or national provider network. In addition, some health plans may have agreements with insurers in other states to cover their providers as though they were in-network. If you can’t find a plan that offers network providers in both states, you could consider buying a separate plan for your son. You could also evaluate what out-of-network coverage, if any, your plan offers.
You should buy coverage in the state where you officially reside. Most states consider you a resident if you intend to make that state your permanent home. So-called “snowbirds” may own a second home and live part of the year in another state, but their official state of residence is where they spend most of the year, where they pay taxes, where they register their cars, or are registered to vote. If you are buying coverage in your state of residency but spend a significant amount of time in a different state, you may want to explore plans offered by insurers that use a national provider network so that you could find participating providers in more than one state. You could also explore insurers that arrange to cover as in-network other insurers’ network providers. (For example, some, though not all “multi-state plans, and some, though not all Blue Cross plans have such agreements.) You could also evaluate what out-of-network coverage, if any, your plan offers.
You should buy group coverage through the SHOP Marketplace in State B, where your business is located.
The fact that you don’t have a permanent home should not affect your eligibility in State B as long as you are currently residing there and intend to remain there. In most cases, the Marketplace will accept an applicant’s statement regarding their state of residence without other verification. In situations where other information available to the Marketplace suggests that the applicant may live in a different state, it may ask for verification. This could happen in your case if records available to the Marketplace show your prior address in State A. You will need to provide a statement or other documentation showing that you have moved and now intend to reside in State B.
Yes. A person receiving an advanced premium tax credit has a 90-day grace period to pay all premiums that are owed. If the amount owed for all outstanding premium payments is not paid in full by the end of the grace period, the insurer can terminate coverage. The insurer would then have to return funds it received from the federal government for all but the first 30 days of the grace period.
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.
The answer depends on whether you are receiving advanced premium tax credits. For people receiving advanced premium tax credits, if a payment due date is missed, insurers must provide a 90-day grace period during which consumers can bring their premium payments up to date and avoid having their coverage terminated. However, the grace period only applies if an individual has paid at least one month’s premium. If, by the end of the 90-day grace period, the amount owed for all outstanding premium payments is not paid in full, the insurer can terminate coverage. In addition, during the first 30 days of the grace period, the insurer must continue to pay claims. However, after the first 30 days of the grace period, the insurer can hold off paying any health care claims for care received during the grace period, which means the enrollee may be responsible to cover any health care services they receive during the second and third months if they fail to catch up on the amounts they owe before the end of the grace period. Insurers are supposed to inform health care providers when someone’s claims are being held. This could mean that providers will not provide care until the premiums are paid up so that they know they will be paid. People not receiving advanced premium tax credits are expected to get a much shorter grace period; currently, the general practice is 31 days but it may vary in each state.
Possibly. Federal rules require health plans offered through the Marketplace to accept premium and cost-sharing payments made on behalf of enrollees by the Ryan White HIV/AIDS Program, other Federal and State government programs that provide premium and cost-sharing support for specific individuals, and Indian tribes and tribal organizations. Federal rules discourage Marketplace plans from accepting third-party payments from hospitals, other healthcare providers, and other commercial entities. Check with your health plan for more information.
At least within the individual-market Marketplace, insurers are required to accept money orders and pre-paid debit cards. They do not have to accept credit card or debit card payments unless states make that a requirement, although many insurers currently accept all of these forms of payment. Therefore, it may vary from state to state and between insurers.
No. Insurers offering coverage in the individual-market exchange or Marketplace are required to provide a variety of payment methods and cannot require a consumer to pay by automatic bank withdrawals (sometimes called electronic funds transfers, or EFT.) Federal rules require the insurer to accept paper checks, cashier’s checks, money orders, and all general-purpose pre-paid debit cards, as well as EFT. These methods must be available to consumers for both the initial premium payment (at enrollment) and ongoing payments.
No, in most states you will make your premium payments directly to the health insurance company. Once you’ve selected your plan, the Marketplace will direct you to your insurance company’s website to make the initial premium payment. Insurance companies must accept different forms of payment and they cannot discriminate against consumers who do not have credit cards or bank accounts. The insurance company must receive and process your payment at least one day before coverage begins. Make sure you understand your insurance company’s payment requirements and deadlines and follow them so your coverage begins on time. Your enrollment in the health plan is not complete until the insurance company receives your first premium payment. Note that if you have qualified to receive an advanced premium tax credit, the government will pay the credit directly to your insurer and you will pay the remainder of the premium directly to the insurer.
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.
Family premiums will reflect the composition of family members, their ages and their tobacco use. To compute a “family premium,” insurers will add together a separate premium for each adult age 21 and older. In addition, insurers can charge a separate premium for up to three children under age 21. In your example, your family premium will reflect three adult premiums and three child premiums.
Yes, in most states you can, within limits. Federal rules allow insurers to charge older adults (e.g., in their sixties) up to three times the premium they would charge younger adults (e.g., in their early twenties). This limit on age rating applies to all non-group and small-group health insurance policies, whether sold in the Marketplace or outside of the Marketplace. Some states prohibit insurers from adjusting premiums for age, or limit the age adjustment to less than three-to-one.
No. Starting in 2014, as insurance policies are sold or renewed, health plans are not allowed to charge you more based on your health status or pre-existing condition.
No. You do not need to have pediatric dental coverage to avoid the penalty.
No, the premium tax credit will not be increased to also cover the cost of a stand-alone dental plan.
Each health insurance Marketplace can decide whether to require all insurers to cover pediatric dental benefits or whether to allow the sale of stand-alone dental policies. When stand-alone dental policies are allowed, health insurers in the Marketplace might not be required to cover pediatric dental benefits. If your health plan covers dental benefits, you will pay one premium for everything. If you get dental benefits through a stand-alone plan, you will have to pay a separate premium for the dental benefits.
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.
Health plans in the Marketplace must include a link to their prescription drug “formulary” with other on-line information about the plan. The “formulary” is a list of prescription drugs the plan will cover. If you don’t find your drug on the formulary but your doctor says it’s medically necessary for you to take that specific drug, you can appeal for an exception to the plan formulary. If there is a Consumer Assistance Program in your state, staff in this program can help you file your appeal.
Plans are not required to cover any care received from a non-network provider, though many plans today do, at least to some extent. If you do receive care out of network, it could be costly to you. Generally plans that provide an out-of-network option cover such care at a lower rate (eg, 80% of in-network costs might be reimbursed but only 60% of non-network care.) In addition, when you get care out of network, insurers may apply a separate deductible and are not required to apply your costs to the annual out-of-pocket limit on cost sharing. Non-network providers also are not contracted to limit their charges to an amount the insurer says is reasonable, so you might also owe “balance billing” expenses. If you went out of network because you felt it was medically necessary to receive care from a specific professional or facility – for example, if you felt your plan’s network didn’t include providers able to provide the care you need – or if you inadvertently got non network care while hospitalized if the anesthesiologist or other physicians working in the hospital don’t participate in your plan network – you can appeal the insurer’s decision. If there is a Consumer Assistance Program in your state, staff in this program can help you file your appeal.
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.
Insurers can also offer “Catastrophic” plans. Catastrophic plans have the highest cost sharing. In 2015, Catastrophic plans will have an annual deductible of $6,600 ($13,200 in family plans). You will have to pay the entire cost of covered services (other than preventive care) until you’ve spent $6,600 out of pocket; after that your plan will pay 100 percent of covered services for the rest of the year. Not everybody will be allowed to buy Catastrophic plans. They are only for adults up to age 30, and for older people who can’t find any other Marketplace policy that costs less than 8 percent of their income.
Plans in the Marketplace are separated into categories — Bronze, Silver, Gold, or Platinum — based on the amount of cost sharing they require. Cost sharing refers to health plan deductibles, co-pays and co-insurance. For most covered services, you will have to pay (or share) some of the cost, at least until you reach the annual out of pocket limit on cost sharing. The exception is for preventive health services, which health plans must cover entirely. In the Marketplace, Bronze plans will have the highest deductibles and other cost sharing. Silver plans will require somewhat lower cost sharing. Gold plans will have even lower cost sharing. And Platinum plans will have the lowest deductibles, co-pays and other cost sharing. In general, plans with lower cost sharing will have higher premiums, and vice versa.
Not necessarily. All Marketplace health plans are required to cover the ten categories of essential health benefits. However, insurers in many states will have flexibility to modify coverage for some of the specific services within each category. Any modifications must be approved by the Marketplace before plans can be offered. All health plans must provide consumers with a Summary of Benefits and Coverage (SBC). This is a brief, understandable description of what a plan covers and how it works. The SBC will also be posted for each plan on the Marketplace web site. The SBC will make it easier for you to compare differences in health plan benefits and cost sharing.
Plans might differ in other ways, too. For example, the network of health providers might be different from plan to plan.
All qualified health plans offered in the Marketplace will cover essential health benefits. Categories of essential health benefits include:
The precise details of what is covered within these categories may vary somewhat from plan to plan.
All health plans offered through the Marketplace must meet the requirements of “qualified health plans.” This means they will cover essential health benefits, limit the amount of cost sharing (such as deductibles and co-pays) for covered benefits, and satisfy all other consumer protections required under the Affordable Care Act.
Health plans may vary somewhat in the benefits they cover. Health plans also will vary based on the level of cost sharing required. Plans will be labeled Bronze, Silver, Gold, and Platinum to indicate the overall amount of cost sharing they require. Bronze plans will have the highest deductibles and other cost sharing, while Platinum plans will have the lowest. Health plans will also vary based on the networks of hospitals and other health care providers they offer. Some plans will require you to get all non-emergency care in-network, while others will provide some coverage when you receive out-of-network care.
If you enroll in a private health insurance plan any time between November 15, 2014 and December 15, 2014 and make your first premium payment by the due date specified by your plan, your new health coverage starts January 1, 2015.
After that, if you enroll between the 1st and 15th day of the month and pay your premium by the due date, your coverage begins the first day of the next month. So if you enroll on January 10, 2015, your coverage begins February 1, 2015.
If you enroll between the 16th and the last day of the month and pay your premium by the due date, your effective date of coverage will be the first day of the second following month. So if you enroll on January 16, 2015, your coverage starts on March 1, 2015.
Yes, leaving your job and losing eligibility for job-based health coverage will trigger a special enrollment opportunity that lasts for 60 days. You can apply for Marketplace health plans and (depending on your income) for premium tax credits and cost sharing reductions during that period. If you enroll in COBRA coverage through your former employer, however, you will need to wait to the next Marketplace Open Enrollment period if you want to switch to a Marketplace plan.
No, voluntarily dropping your COBRA coverage or ceasing to pay your COBRA premiums will not trigger a special enrollment opportunity. You will have to wait until you exhaust your COBRA coverage or until the next Open Enrollment (whichever comes first) to sign up for other non-group coverage.
During Open Enrollment, you can sign up for a Marketplace plan even if you already have COBRA. 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. Only exhaustion of your COBRA coverage triggers a special enrollment opportunity.
No, in general, once you sign up for a plan, you are locked into that coverage for 12 months, or until the next Open Enrollment period. A change in health status doesn’t make you eligible for a special enrollment opportunity.
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:
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.
States have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.
Small employers can buy coverage for their employees through the SHOP Marketplace at any time during the year.
You can enroll in Medicaid or CHIP at any time during the year, not just during Open Enrollment.
In general, you can only enroll in non-group health plan coverage during the Open Enrollment period.
For 2015 coverage, the Open Enrollment period begins November 15, 2014 and extends through February 15, 2015. 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.
If you are not a U.S. citizen, a U.S. national, or an alien lawfully present in the U.S., you are not eligible to buy a plan on the health insurance Marketplace. However, you can shop for health insurance outside of the Marketplace in the non-group market. Insurers outside of the Marketplace are prohibited from turning you down based on your health status or your immigration status and must follow generally the same rules as plans in the Marketplace. To obtain coverage, contact a state-licensed health insurance company or a licensed agent or broker. Your state Department of Insurance can help you find one.
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.
Generally, you should buy coverage in Marketplace in the state where you live.
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.
Links to all state Marketplaces can be found at www.healthcare.gov
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.]
A set of health care service categories that must be covered by certain plans, starting in 2014.
The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid.
Open Enrollment for 2014 Marketplace coverage is over. Outside the Open Enrollment period, you can enroll in a private health plan through the Marketplace only if you qualify for a special enrollment period.
You have a qualifying life event like having a baby, getting married, or losing other coverage. Learn more about special enrollment periods and other coverage options outside Open Enrollment.
You have other complicated situations, as described on this page.
Below are cases and examples that may also qualify you for a special enrollment period.
You faced a serious medical condition or natural disaster that kept you from enrolling. For example:
An unexpected hospitalization or temporary cognitive disability
A natural disaster, such as an earthquake, massive flooding, or hurricane
Misinformation or misrepresentation
Misconduct by a non-Marketplace enrollment assister (like an insurance company, navigator, certified application counselor, or agent or broker) resulted in you:
Not getting enrolled in a plan
Being enrolled in the wrong plan
Not getting the premium tax credit or cost-sharing reduction you were eligible for
The insurance company was unable to process your enrollment because of a technical error between the Marketplace and the insurance company.
System errors related to immigration status
An error in the processing of applications or system caused you to get an incorrect immigration eligibility result when you tried to apply for coverage.
Display errors on HealthCare.gov
Incorrect plan data was displayed at the time that you selected your health plan, such as benefit or cost-sharing information. This includes issues where some consumers were allowed to enroll in plans offered in a different area, or enroll in plans that don’t allow certain categories of family relationships to enroll together.
If you applied for Medicaid through your state, or were sent to Medicaid from the Marketplace, but you weren’t eligible for Medicaid.
Your state transferred your information to the Marketplace but you didn’t get an answer about your eligibility and/or didn’t get enrolled before March 31.
Your application was stopped due to specific error messages. For example, you received a “data sources down” error message or another error message that didn’t allow you to enroll.
You’re working with a caseworker on an enrollment issue that didn’t get resolved before March 31.
Victims of domestic abuse
You’re a victim of domestic abuse and weren’t previously allowed to enroll and receive advance payments of the premium tax credit separately from your spouse. You’ll be able to do so now.
Other system errors
Other system errors that kept you from enrolling, as determined by the Centers for Medicare & Medicaid Services
The representative will ask for information about your situation to determine if your circumstances qualify you for a special enrollment period. The representative will help you apply and enroll in coverage.
If you’re already enrolled in a plan and you get a special enrollment period, you can stay in your current plan in most cases, or you can switch plans. In some limited cases, you may qualify for an earlier effective date of coverage. Remember, you must make the first premium payment before your coverage becomes effective.
Filing an appeal
If your request for a special enrollment period is denied, you can file an appeal. If the denial is found incorrect, you can get coverage back to the date your special enrollment period was denied.
How to file an appeal:
Select your state’s appeal form, download it, and fill it out
Mail your appeal to:
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061
When possible, include a copy of any eligibility determination notice or other official notice you received. This isn’t required, but will help us process your appeal.
When mailing the appeal request to the Health Insurance Marketplace, be sure to include the last 4 digits of the London, KY Zip code (40750-0061). This will help your appeal arrive faster.
You can preview Marketplace health plans and prices available in your area by using a simple tool. It lets you see plans and estimates of the prices you pay without filling out an application.
The prices shown reflect any lower costs you may be eligible for based on your income and household size.
Important: Marketplace Open Enrollment ended March 31. You can still buy a Marketplace health plan only if you qualify for a special enrollment period. You can apply for Medicaid and CHIP any time. Learn about special enrollment periods and other coverage options after Open Enrollment. Open Enrollment for 2015 coverage starts November 15, 2014.
Select the link below and answer a few questions.
You’ll see Marketplace health plans available in your area, with premium estimates based on your income and household size. You’ll also get important details like deductibles, copayments, and out-of-pocket maximums, plus links to a summary of benefits, the provider network, drug coverage rules, and customer service contacts.
The premiums shown apply to people who don’t use tobacco.
The tool also provides:
You can apply for and enroll in Medicaid or CHIP any time of year. There’s no limited enrollment period for either Medicaid or the Children’s Health Insurance Program (CHIP). If you qualify, your coverage can begin immediately.
Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under North Carolina’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace, or healthcare.gov
Some states haven’t expanded their Medicaid programs. If you live in one of these states, you may not have as many options for health coverage. It will depend on where your income falls.
When the health care law was passed, it required states to provide Medicaid coverage for adults between ages 18 and 65 with incomes up to 133% of the federal poverty level, regardless of their age, family status, or health.
It also provides tax credits for people with incomes between 100% and 400% of the federal poverty level to buy private insurance plans in the Marketplace.
Under the law, the federal government will pay states all of the costs for newly eligible people for the first three years. It will pay no less than 90% of the costs in the future.
The U.S. Supreme Court later ruled that the Medicaid expansion is voluntary with states. As a result, some states have not expanded their Medicaid programs.
Many adults in those states with incomes below 100% of the federal poverty level fall into a gap. Their incomes are too high to get Medicaid under their state’s current rules. But their incomes are too low to qualify for help buying private coverage in the Marketplace.
Even if your state hasn’t expanded Medicaid, you should apply for coverage to see if you qualify. Each state has coverage options that could work for you – particularly if you have children, are pregnant, or have a disability.
You can apply today by contacting your state Medicaid office. Use the “Get State Information” menu at the bottom this page to get the contact information.
You can also apply by filling out an application in the Marketplace online or by contacting the call center at 1-800-318-2596 (TTY: 1-855-889-4325), 24 hours a day, 7 days a week.
Remember, you can apply for Medicaid and CHIP at any time. There’s no limited enrollment period for either program.
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