Frequently Asked Questions

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!

If you have any other questions, call us at 828-372-0101.

What is the health insurance Marketplace?

What is the health insurance Marketplace?

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

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How do I find my state Marketplace?

How do I find my state Marketplace?

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

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Who can buy coverage in the Marketplace?

Who can buy coverage in the Marketplace?

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

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

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

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

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

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 Marketplace coverage throughout the year, not just during Open Enrollment.

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Can I get help with my Marketplace application?

Can I get help with my Marketplace application?

Yes! Hummingbird Insurance offers free consultations and help through our certified agents. If you need help with understanding which plan is best for you, book an appointment with us today! Working with us is always free and can help you to save money.

Additionally, all state Marketplaces are required to offer Navigator programs to help consumers complete their application for  financial help, including help applying for Medicaid or CHIP.  Navigators also help people review their plan choices and appeal Marketplace decisions.  Navigators are paid by the Marketplace, not by health plans, and they must complete Marketplace training and be free from conflicts of interest.

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When can I enroll in Medicaid through the Marketplace?

When can I enroll in Medicaid through the Marketplace?

You can enroll in Medicaid or CHIP at any time during the year, not just during Open Enrollment.

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Should I buy coverage through the Marketplace in the state I live in or work in?

Should I buy coverage through the Marketplace in the state I live in or work in?

Generally, you should buy coverage in Marketplace in the state where you live.

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

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

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

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Can I buy a plan in the Marketplace if I don’t have a green card?

Can I buy a plan in the Marketplace if I don’t have a green card?

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.  

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When can small employers enroll in coverage through the SHOP Marketplace?

When can small employers enroll in coverage through the SHOP Marketplace?

Small employers can buy coverage for their employees through the SHOP Marketplace at any time during the year.  HealthCare.gov no longer operates a SHOP Marketplace website for small employers, however.  If you want to sponsor small group coverage through the Marketplace for your employees, you can contact Hummingbird Insurance to book an appointment!  In HealthCare.gov states, you can find a SHOP-certified broker using the Find Local Help tool.  Be sure to specify to the insurer or broker that you want a SHOP policy.

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

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

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

  • Loss of eligibility for other coverage (for example if you quit your job or were laid off or if your hours were reduced, or if you lose student health coverage when you graduate) Note that loss of eligibility for other coverage because you didn’t pay premiums does not trigger a special enrollment opportunity
  • Marriage (limitations apply)
  • Gaining a dependent (for example, if you give birth to or adopt a child). Note that pregnancy does NOT trigger a special enrollment opportunity in most states
  • Loss of coverage due to loss of dependent status (for example, because of divorce, legal separation, death, or “aging off” a parents’ plan when you turn 26)
  • A permanent move to another state or within a state if you move outside of your health plan service area (limitations apply)
  • Exhaustion of COBRA coverage
  • Losing eligibility for Medicaid or the Children’s Health Insurance Program
  • For people enrolled in a Marketplace plan, income increases or decreases enough to change your eligibility for subsidies
  • Change in immigration status
  • Enrollment or eligibility error made by the Marketplace or another government agency or somebody, such as an assister, acting on their behalf.

Note that some triggering events will only qualify you for a SEP in the health insurance Marketplace; they do not apply in the outside market. For example, if you gain citizenship or lawfully present status, the Marketplace must provide you with a special enrollment opportunity.

When you experience a qualifying event, your SEP will last 60 days from the date of that triggering event.  If you can foresee loss of other coverage (for example, you know the date when you will graduate and lose student health coverage) you can ask the Marketplace for a SEP up to 60 days in advance so new coverage will take effect right after your old coverage runs out.  However, in HealthCare.gov states, you cannot ask for an advance SEP if you anticipate coverage loss due to a permanent move.

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How does the “marriage” special enrollment work?

How does the “marriage” special enrollment work?

When you get married, you can qualify for a special enrollment period (SEP).  You and your spouse can sign up for coverage in the Marketplace. The special enrollment period lasts for 60 days from the date of marriage.  If you enroll in coverage through the marriage SEP, coverage will start on the first day of the following month.

If you live in a HealthCare.gov state, restrictions apply.  To be eligible for the marriage SEP, at least one of you must have been enrolled in minimum essential coverage (such as a job-based plan, Marketplace plan, or Medicaid) for at least 1 day during the 60 days preceding the date of marriage.

There are exceptions to this limit on marriage SEP eligibility:

  • If at least one spouse was living in a foreign country or U.S. territory during the 60-days prior to enrollment, the prior coverage requirement does not apply
  • If at least one spouse is a member of a federally recognized Native American tribe or an Alaskan Native, the prior coverage requirement does not apply

In addition, for people currently enrolled in the Marketplace through HealthCare.gov, the marriage SEP can only be used either to add the new spouse to the current Marketplace plan or to enroll the new spouse in a separate Marketplace plan.  The currently-enrolled spouse cannot use the marriage SEP to change plans.

This restriction on plan selection does not apply for Native Americans or Alaska Natives, or for victims of domestic abuse or spousal violence.

These restrictions on eligibility for the marriage SEP and on plan selection do not apply in the SHOP Marketplace or for people using an SEP to join an employer-sponsored group health plan.

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How does the “new dependent” special enrollment period work?

How does the “new dependent” special enrollment period work?

When you have a baby – or when you adopt a child, a child is placed with you for adoption or foster care, or if you gain a dependent through a court order – you can qualify for a new dependent special enrollment period.  You and your dependents can enroll in coverage through the Marketplace.

The new dependent SEP lasts for 60 days from the date of the child’s birth (or adoption, court order, etc.).  New coverage generally will take effect retroactive to the date of birth (adoption, court order, etc.)

If you are already enrolled in Marketplace coverage through HealthCare.gov, you can add your new dependent to your Marketplace plan or buy a different, separate policy for the child.  You cannot use the “new dependent” SEP to change health plans for already-covered family members.

This limitation on plan selection does not apply if you are an American Indian or Alaska Native.  In addition, if your current Marketplace plan doesn’t cover dependents, you and your dependents can enroll together in a new plan at the same metal level as your current Marketplace plan.

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How does the “permanent move” special enrollment work?

How does the “permanent move” special enrollment work?

If you move to or within a HealthCare.gov state, you will be eligible for a special enrollment period only if you had previously been enrolled in other coverage.  You must have been enrolled in minimum essential coverage (such as a job-based plan, Marketplace plan, or Medicaid) for at least 1 day in the 60 days preceding the date of the permanent move in order to qualify for the permanent move special enrollment period.

There are exceptions to this rule:

  • If you previously lived in a state that did not expand Medicaid eligibility and were ineligible for Marketplace coverage in that state because your income was below the poverty level, and if you move to another state where you become newly eligible for premium tax credits, you will be eligible for the permanent move special enrollment period when you move to the new state
  • If you moved from outside of the United States or a U.S. territory, you are eligible regardless of prior coverage
  • If you are newly released from incarceration, you are eligible regardless of prior coverage

The permanent move SEP lasts 60 days from the date of your move.  Coverage will start on the first day of the following month; or, if you select your new plan after the 15th of the month, new coverage will start on the first day of the second following month.  In HealthCare.gov states, you will not be able to apply for the permanent move SEP in advance of your move date.    As a result, people who move to or within HealthCare.gov states may experience a break in coverage while they wait for their new plan to take effect.

When you apply for the permanent move SEP in a HealthCare.gov state, you will be required to provide documentation of your prior address, your new address, and evidence of loss of prior coverage.

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Do I have to prove eligibility for a special enrollment period?

Do I have to prove eligibility for a special enrollment period?

Yes, in most states.  The federal Marketplace (HealthCare.gov) requires people to provide documentation of eligibility for special enrollment before you can enroll in coverage.  Pre-enrollment verification is required for the following qualifying events:

  • Loss of minimum essential coverage
  • Permanent move
  • Marriage
  • Adoption, placement for adoption, placement for foster care, or child support or other court order, and

If you experience one of these qualifying events and apply for coverage in a federal Marketplace state, HealthCare.gov will let you select a health plan, but will delay the effective date of coverage while it verifies your eligibility for the SEP.

HealthCare.gov will tell you what documents are acceptable to verify your eligibility for the SEP and how to submit them.  Once you apply for the SEP and select a health plan, you will have 30 days to provide documentation to the Marketplace.  Once the Marketplace verifies your eligibility, you will be able to complete enrollment in the plan you selected.

It is very important to act quickly to complete this verification process.  If you do not submit the required documentation within 30 days, your plan selection will be cancelled and you will no longer be eligible for the SEP.

If you submit documentation on time but the Marketplace determines it to be insufficient, you can apply for an extension of the 30-day review period to submit additional documentation.  However, you cannot apply for an extension of your special enrollment period.  If your eligibility is not verified by the end of your 60-day SEP, your plan selection will be cancelled and you will not be able to enroll until the next open enrollment period.

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Can I change plans after Open Enrollment ends if I decide I want a different plan?

Can I change plans after Open Enrollment ends if I decide I want a different plan?

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.

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I have COBRA and it’s too expensive. Can I drop it during Open Enrollment and enroll in a Marketplace plan instead?

I have COBRA and it’s too expensive. Can I drop it during Open Enrollment and enroll in a Marketplace plan instead?

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.  

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I have COBRA and am finding it difficult to afford, but Open Enrollment is over. Can I drop my COBRA and apply for non-group coverage outside of Open Enrollment?

I have COBRA and am finding it difficult to afford, but Open Enrollment is over. Can I drop my COBRA and apply for non-group coverage outside of Open Enrollment?

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.

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I’m leaving my job and will be eligible for COBRA. Can I shop for coverage and subsidies on the Marketplace instead?

I’m leaving my job and will be eligible for COBRA. Can I shop for coverage and subsidies on the Marketplace instead?

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.

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How long after I enroll in a plan will coverage take effect?

How long after I enroll in a plan will coverage take effect?

In most states if you enroll in a private health insurance plan any time between November 1 and December 15 and make your first premium payment by the due date specified by your plan, your new health coverage starts January 1.

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What happens if I want to quit a Marketplace health plan during the year?

What happens if I want to quit a Marketplace health plan during the year?

It is important that you contact both the Marketplace and the health plan and let them know you no longer need coverage.  In HealthCare.gov states, you can log into your Marketplace account, select the “terminate coverage” option, and enter the required information.

If you have a family policy and want to remove one person from the policy but keep coverage in effect for others, in HealthCare.gov states, log in to your Marketplace account, select the “reporting a life change” option, and enter the required information.

If you have questions about these changes, contact one of the agents here at Hummingbird. We will be happy to assist you in updating your information through Healthcare.gov.

Making these changes through your Marketplace account will create a written record that you tried to end coverage.

Do not simply stop paying the premium for your Marketplace health plan as a way to terminate coverage.  Nonpayment will eventually cause your coverage to end, but in the future, if you try to enroll in coverage again with that insurer, you might be prevented from doing so until you repay the missed premium.

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What health plans are offered through the Marketplace?

What health plans are offered through the Marketplace?

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.

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What health benefits are covered under Marketplace plans?

What health benefits are covered under Marketplace plans?

All qualified health plans offered in the Marketplace will cover essential health benefits. Categories of essential health benefits include:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including dental and vision care

The precise details of what is covered within these categories may vary somewhat from plan to plan.

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Will covered benefits under all Marketplace plans be the same? How can I compare?

Will covered benefits under all Marketplace plans be the same? How can I compare?

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. 

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What do the different levels of Marketplace plans mean?

What do the different levels of Marketplace plans mean?

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.

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What are Catastrophic Plans?

What are Catastrophic Plans?

Insurers can also offer “Catastrophic” plans. Catastrophic plans have the highest cost sharing. In 2019, Catastrophic plans will have an annual deductible of $7,900 ($15,800 in family plans). You will have to pay the entire cost of covered services (other than preventive care) until you’ve spent $7,900 out of pocket; after that your plan will pay 100 percent of covered in-network 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 8.3 percent of their income.

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

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

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

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

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What happens if I end up needing care from a doctor who isn’t in my plan’s network?

What happens if I end up needing care from a doctor who isn’t in my plan’s network?

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 (e.g., 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.

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How can I find out if a health plan covers the prescription drugs that I take?

How can I find out if a health plan covers the prescription drugs that I take?

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.

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Is dental coverage an essential health benefit?

Is dental coverage an essential health benefit?

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

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

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I’m buying coverage on the Marketplace for my family. I notice many health plans don’t cover pediatric dental care, but there are also stand-alone dental plans for sale. Is that allowed?

I’m buying coverage on the Marketplace for my family. I notice many health plans don’t cover pediatric dental care, but there are also stand-alone dental plans for sale. Is that allowed?

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.

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It looks like pediatric dental benefits are only offered through stand-alone plans in my state Marketplace. Will my tax credit premium cover the cost of the stand-alone dental plan?

I can’t afford the cost of a stand-alone dental plan in addition to buying major medical health insurance. Will I owe a penalty for not having Minimum Essential Coverage if I don’t buy the separate dental plan?

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

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

No. Marketplace health plans are not allowed to charge you more based on your health status or pre-existing condition.  However, some plans, such as short-term policies, that are sold off the Marketplace might turn you down or charge you more based on your health status or pre-existing condition.

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Can be charged more because of my age?

Can be charged more because of my age?

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.

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I’m 59, my spouse is 55, and our kids are 24, 17, 15, and 13. What age premium will we be charged for health insurance in the Marketplace?

I’m 59, my spouse is 55, and our kids are 24, 17, 15, and 13. What age premium will we be charged for health insurance in the Marketplace?

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.

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

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

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

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I’ve picked the plan I want. Now do I send my premium to the Marketplace?

I’ve picked the plan I want. Now do I send my premium to the Marketplace?

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.

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I don’t have a checking account. Can the insurance company require that I get one and pay my premiums through automatic monthly withdrawals?

I don’t have a checking account. Can the insurance company require that I get one and pay my premiums through automatic monthly withdrawals?

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.

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Can I pay my health insurance premium with a credit card, debit card, money order, or cash?

Can I pay my health insurance premium with a credit card, debit card, money order, or cash?

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.

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Can a third party pay my portion of the monthly health insurance premium for me?

Can a third party pay my portion of the monthly health insurance premium for me?

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.

Finally, if you are a patient with end-stage renal disease undergoing kidney dialysis, you are eligible to enroll in Medicare.  However, some dialysis facilities have offered to pay premiums for patients who elect Marketplace coverage instead of Medicare.  If a dialysis facilities offers to pay your Marketplace premium, directly or through a charity, it is required to first check with the Marketplace insurer to verify that it will accept this third party payment.  In addition, the dialysis facility must disclose other important information to you, including about the potential for gaps in coverage and penalties if Medicare enrollment is delayed.  Dialysis patients should contact a Marketplace navigator program or your state’s Senior Health Insurance Assistance Program, which provides information, counseling, and enrollment assistance for people eligible for Medicare.

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What happens if I’m late with a monthly health insurance premium payment?

What happens if I’m late with a monthly health insurance premium payment?

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.

Whether or not you are receiving premium tax credits, if you have coverage terminated for non-payment, this could affect your ability to buy coverage from that health insurer in the future.  Insurers are allowed to require people who owe back-due premiums from the past 12 months to repay the premium debt before they will renew or sell you new coverage for the year.

States can prohibit or limit this practice by insurers.  Contact the Marketplace and your state insurance regulator for more information.

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

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

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

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My income is very low, so I’m only required to pay about $30/month for my health insurance premium. The tax credit picks up the rest, which is more than 90 percent of the total premium. I’ve missed 4 premium payments in a row. Can the insurance company cancel my coverage even though they got 90 percent of the payment on time from the IRS?

My income is very low, so I’m only required to pay about $30/month for my health insurance premium. The tax credit picks up the rest, which is more than 90 percent of the total premium. I’ve missed 4 premium payments in a row. Can the insurance company cancel my coverage even though they got 90 percent of the payment on time from the IRS?

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.

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I live in State A but my small business is in State B. I want to buy group coverage for my employees through the SHOP Marketplace. In what state should I buy health benefits?

I live in State A but my small business is in State B. I want to buy group coverage for my employees through the SHOP Marketplace. In what state should I buy health benefits?

You should buy group coverage through the SHOP Marketplace in State B, where your business is located.  If your business is located in a HealthCare.gov state, there is no SHOP Marketplace website.  Instead, you should contact insurers directly or work directly with a broker to buy a small group policy.  Be sure to specify that you want a SHOP policy.

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I live in different states during the year. My summer home is in a northern state; my winter home is in a southern state. Where do I sign up for health coverage? And if I sign up for a plan in one state, how do I find in-network health providers in the other state?

I live in different states during the year. My summer home is in a northern state; my winter home is in a southern state. Where do I sign up for health coverage? And if I sign up for a plan in one state, how do I find in-network health providers in the other state?

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 “multi-state” plans have such agreements.) You could also evaluate what out-of-network coverage, if any, your plan offers.

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We buy health coverage in our state Marketplace and our son attends college in a different state. We want to cover him on our policy. Can we do that?

We buy health coverage in our state Marketplace and our son attends college in a different state. We want to cover him on our policy. Can we do that?

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 regional 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.

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I signed up for a health plan at the beginning of Open Enrollment, then changed my mind. Can I switch to a different plan as long as the Open Enrollment period hasn’t yet ended?

My employer offers a workplace wellness program that increases premiums for employees who can’t meet certain health targets, such as normal weight or blood pressure. Is this allowed?

My employer offers a workplace wellness program that increases premiums for employees who can’t meet certain health targets, such as normal weight or blood pressure. Is this allowed?

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:

  • The health plan must offer you a reasonable alternative way to avoid the penalty (for example, it might require that you participate in an exercise program, or it might require you to meet a less stringent target level for the required health measures)
  • If you are unable to meet the health targets due to a medical reason, the health plan must offer you an alternative way to avoid the penalty that is medically appropriate for you
  • The health plan must give you at least one chance every year to be re-evaluated

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My employer offers a workplace wellness program that increases premiums for employees who don’t participate. The program doesn’t require people to meet health targets or attend classes, but does require people to answer questions about personal health and lifestyle and to grant access to our medical records. Is this allowed?

My employer offers a workplace wellness program that increases premiums for employees who don’t participate. The program doesn’t require people to meet health targets or attend classes, but does require people to answer questions about personal health and lifestyle and to grant access to our medical records. Is this allowed?

It is not clear.  In 2016 the federal government published new regulations setting requirements for workplace wellness programs that ask individuals to disclose personal health information or genetic information.  These types of “medical inquiries” are allowed in “voluntary” wellness programs.  The new regulation defined “voluntary” to include programs that apply penalties as large as 30 percent of the cost of the health plan (self-only coverage) if you don’t participate.  (If participation incentives also apply to your spouse, the maximum incentive is twice that amount for the two of you, together.)  However, a federal judge later ruled that these financial incentive standards were not justified by the federal government and vacated that part of the regulation for employer plan years beginning on or after January 1, 2019.

The regulation established other requirements that remain in effect for wellness programs that collect personal health information include:

  • The program must be “reasonably designed,” meaning there must be a reasonable chance that it could promote health and wellness.
  • The wellness program can access personal health information, but it cannot share identifiable information with the employer to use for employment purposes, such as hiring or promotion.
  • The wellness program that collects personal health information must either use information to design programs to address or treat employee health problems, or provide feedback to individuals about their risk factors.
  • Wellness programs that collect personal health information must provide a notice that clearly explains what medical information will be obtained, how it will be used, who will receive it, and restrictions on disclosure that apply.
  • Wellness programs cannot, as a condition of participating in the program or earning an incentive, require people to agree to the sale, exchange, sharing, transfer, or other disclosure of medical information (except to the extent otherwise permitted under a reasonably designed program.)

For more information about workplace wellness program rules, or to file a complaint, contact the Federal Equal Employment Opportunity Commission (EEOC) at https://www.eeoc.gov/contact/index.cfm

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My employer health plan has a wellness feature that requires me to pay a higher premium if I don’t meet certain health targets or if I don’t participate at all. I can’t afford the premiums if I don’t participate or miss the mark. Can I leave my employer-sponsored plan and get one on the health insurance Marketplace?

My employer health plan has a wellness feature that requires me to pay a higher premium if I don’t meet certain health targets or if I don’t participate at all. I can’t afford the premiums if I don’t participate or miss the mark. Can I leave my employer-sponsored plan and get one on the health insurance Marketplace?

It depends. If your premium contribution with the wellness penalty would be more than 9.86% of your income in 2019, then your employer plan would be considered unaffordable 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.

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What is the Cadillac tax?

What is the Cadillac tax?

The so-called Cadillac tax is an excise tax on high cost health plans offered by employers. Beginning in 2020, 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.

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I’m uninsured. Am I required to get health care?

I’m uninsured. Am I required to get health care?

Congress eliminated the federal tax penalty for not having health insurance, effective January 1, 2019.

For 2018, 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.

While the federal tax penalty still applies for 2018, recent changes will make it easier for people to claim a hardship exemption, and so owe no penalty, when they file their 2018 federal income tax return.

Several states have adopted individual mandates with state tax penalties for not having health insurance.  These include Massachusetts, New Jersey, and the District of Columbia, effective for the 2019 calendar year.  Vermont will impose a tax penalty for not having coverage starting in 2020.  Other states are considering individual mandates; check with your tax adviser for more information.

Regardless of the penalty, it is important to have health coverage if you can.  Health insurance continues to be offered during annual Open Enrollment periods.  If you don’t sign up during Open Enrollment, you might have to wait up to one year until your next opportunity to enroll.

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What’s the penalty if I didn’t have coverage in 2018?

What’s the penalty if I didn’t have coverage in 2018?

The penalty for not having minimum essential coverage is either a flat amount, or a percentage of household income, whichever is greater.

For 2018 the flat amount is $695 for each uninsured adult and $347.50 for each uninsured child, up to $2,085 per family. The percentage penalty is 2.5% of family income above the federal tax filing threshold, which is $12,000 for a single filer, $24,000 for people who file jointly in 2018.  The percentage penalty is also capped at an amount equal to the national average bronze health plan premium available through the Marketplace.  That amount is updated annually in the instructions for IRS Form 8965.

The penalty is based on “coverage months.”  This means that each month you are uninsured in 2018, you may owe 1/12th of the annual penalty.  However, short spells of uninsurance may not be subject to a penalty.

For 2018, if you think you may owe a penalty for not being insured, you can claim a hardship exemption if you experienced circumstances that made it hard for you to get coverage.  With this exemption, you will not owe a tax penalty.  You can claim the hardship exemption right on your tax return by checking a box on Form 1040.  You will not be required to submit any documentation of the hardship with your tax return, though you should retain any documentation for your own records.

For more information about the penalty in 2018, also called the individual responsibility payment, see instructions for Form 8965 on the IRS web site.

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Are there exemptions to the health care penalty? What are they?

Are there exemptions to the health care penalty? What are they?

Yes. For the 2018 tax year, you can claim a hardship exemption if you experienced circumstances that prevented you from getting coverage.  You can claim this exemption directly on your federal tax return, by checking the box on Form 1040, when you file next spring.  You will not be required to provide documentation of your hardship when you file, though you should keep any documentation for your records.

In addition, you may be eligible for an exemption if you:

  • Cannot afford coverage (defined as those who would pay more than 8.05 percent of their household income for the lowest cost bronze plan available to them through the Marketplace in 2018)
  • Are not a U.S. citizen, a U.S. national, or a resident alien lawfully present in the U.S.
  • Had a gap in coverage for less than 3 consecutive months during the year
  • Won’t file a tax return because your income is below the tax filing threshold (For the 2018 tax year, the filing threshold is $12,000 for individuals and $24,000 for married persons filing a joint return)
  • Are unable to qualify for Medicaid because your state has chosen not to expand the program
  • Participate in a health care sharing ministry or are a member of a recognized religious sect with objections to health insurance
  • Are a member of a federally recognized Indian tribe
  • Are incarcerated

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On what grounds can I apply for a hardship exemption to the individual mandate?

On what grounds can I apply for a hardship exemption to the individual mandate?

For the 2018 tax year, you can claim a hardship exemption if you experienced any circumstances that prevented you from obtaining coverage.  For the 2018 tax year only, you can claim the hardship exemption directly on your tax return by checking the box on Form 1040.  You will not be required to submit documentation of the hardship with your return, but you should keep any documentation for your own records.

If you are late-filing or updating a tax return for earlier years and require a hardship exemption for that year, you can apply for a hardship exemption if you experienced difficult financial or domestic circumstances that prevent you from obtaining coverage – such as homelessness, death of a close family member, bankruptcy, substantial recent medical debt, or disasters that substantially damaged your property. In addition, a hardship exemption may be granted if you were determined ineligible for Medicaid only because your state hasn’t expanded Medicaid coverage to residents with income up to 138% of the federal poverty level.  You can also apply for a hardship exemption if obtaining coverage would have been so burdensome as to cause you to experience other serious deprivation of food, shelter, or other necessities.

For tax years before 2018, you can apply to the Marketplace for a hardship exemption.  If granted, the Marketplace will give you an exemption certificate.  You should enter that certificate number in Form 8965, which you should file with the tax return.

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I had several short coverage gaps in a year – I was uninsured in March, then again in August. Since the total gap was less than 3 months, am I exempt from the penalty?

I had several short coverage gaps in a year – I was uninsured in March, then again in August. Since the total gap was less than 3 months, am I exempt from the penalty?

The rule for short coverage gaps is that only the first short coverage gap in a year will be recognized. You wouldn’t be penalized for lacking coverage in March, but you may owe a penalty for your second gap in coverage in August if you don’t otherwise qualify for an exemption during that period.

However for 2018, if you experienced hardship that prevented you from getting coverage, you can claim a hardship exemption directly on your 2018 federal income tax return.

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I lost coverage March 15 and didn’t get new coverage until April 1. Am I considered uninsured for the month of March because I lacked coverage for part of the month?

I lost coverage March 15 and didn’t get new coverage until April 1. Am I considered uninsured for the month of March because I lacked coverage for part of the month?

No, if you are covered even one day during a month, you are considered to be insured for that month. Similarly, a person who is considered exempt from the individual responsibility requirement for even one day during a month is considered exempt for that month.

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If I live overseas, do I still have to buy coverage in the U.S.?

If I live overseas, do I still have to buy coverage in the U.S.?

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.

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

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

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

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

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If I owe a penalty, when and how do I have to pay it?

If I owe a penalty, when and how do I have to pay it?

If you did not maintain minimum essential coverage every month of this year and you don’t qualify for an exemption you will need to pay a “shared responsibility payment” to the IRS on your federal income tax return . If you are like most people, you will need to file your tax return by April 15 next year.

However, for 2018, the IRS has made it easier for people to claim a hardship exemption directly on your tax return by checking the box on Form 1040.  You can claim the hardship exemption if you experienced circumstances that made it hard for you to obtain coverage in 2018.  You will not be asked to provide documentation of the hardship when you file, though you should keep any documentation for your records.

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How do I apply for an exemption?

How do I apply for an exemption?

For the 2018 tax year, anyone can apply for a hardship exemption if they experienced circumstances that prevented them from having health insurance.  You can claim the hardship exemption directly on your 2018 federal income tax return, by checking the box on Form 1040, when you file.  You will not be required to submit documentation of the hardship with the return, though you should keep any documentation for your records.

Federal law provides other types of exemptions.  For some of these, 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 is 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 from healthcare.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 IRS Form 8965, which you will need to submit with 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 has a list of Navigators and other assisters.

The hardship exemption and other 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 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.

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I didn’t apply for a hardship exemption from the Marketplace during Open Enrollment. Is it too late to apply for a hardship exemption for this year?

I didn’t apply for a hardship exemption from the Marketplace during Open Enrollment. Is it too late to apply for a hardship exemption for this year?

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.

In addition, for the 2018 tax year, you can claim a hardship exemption directly on your tax return, by checking the box on Form 1040, without having to apply to the Marketplace.  You won’t be required to submit documentation of the hardship with your tax return, though you should retain any documents for your own records.

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I live in a state that didn’t expand Medicaid eligibility, I have low income, and I was uninsured this year. Do I have to apply to the Marketplace for an exemption?

I was in jail for 4 months awaiting trial and ultimately was exonerated. During that time I was also uninsured. Do I owe a penalty for the months I was in jail?

I was in jail for 4 months awaiting trial and ultimately was exonerated. During that time I was also uninsured. Do I owe a penalty for the months I was in jail?

There is an exemption for people who are incarcerated but it does not apply to people who were in jail awaiting trial.

However, for 2018, you could also claim a hardship exemption because you experienced circumstances that prevented you from obtaining coverage.  You can claim this exemption directly on your 2018 tax return, by checking the box on Form 1040, when you file next spring.

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

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

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

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

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

 

Starting in 2019, there is no tax penalty for people who are not covered by Minimum Essential Coverage.

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

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

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

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What is a grandfathered plan? How do I know if I have one?

What is a grandfathered plan? How do I know if I have one?

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 currently are covered under a non-group policy – whether it is grandfathered or not – you can also explore other qualified plans offered through the Marketplace and, if you prefer, you can switch to a new plan 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.

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I’m in a grandfathered plan that doesn’t cover prescription drugs. Does that count as Minimum Essential Coverage?

I notice short-term policies are for sale outside of the Marketplace and they are cheaper than many other policies. What is a short-term policy?

I notice short-term policies are for sale outside of the Marketplace and they are cheaper than many other policies. What is a short-term policy?

As the name implies, a short-term health insurance policy offers coverage for a period of less than 12 months.  Many offer coverage for just 3 to 6 months.  Beyond that term, coverage generally can only be continued if the insurance company agrees.  This is sometimes called a non-guaranteed-renewable policy.  If you’ve made claims since you bought the short-term policy, the insurer can, and likely will refuse to continue coverage once the policy term ends.

In addition, short-term policies do not offer other protections found in Marketplace plans.  For example, short-term policies can exclude coverage of pre-existing conditions.  Short-term policies also typically do not cover essential health benefits such as prescription drugs, mental health care, substance abuse treatment, or maternity care.

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Are short-term policies for sale in the Marketplace?

Are short-term policies for sale in the Marketplace?

No.  Only policies that meet ACA standards can be offered through the Marketplace.

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I am eligible for premium tax credits. Can I apply those to a short-term policy?

I am eligible for premium tax credits. Can I apply those to a short-term policy?

No.  Only polices offered through the Marketplace are eligible for premium tax credits.

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Can a short-term policy turn me down if I have a pre-existing condition?

Can a short-term policy turn me down if I have a pre-existing condition?

Yes.  In general, the application for short-term policies will ask questions about your current health status and your health history.  Depending on your answers, if you have or have had a pre-existing condition you might be turned down or charge more.  How short-term policies treat you also depends on where you live.  A few states have passed laws to prohibit short-term policies from discriminating based on health status.

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I heard about a short-term policy that has an option to renew. Does that mean I can keep it even if I get sick after buying the policy?

I heard about a short-term policy that has an option to renew. Does that mean I can keep it even if I get sick after buying the policy?

Maybe.  Under a new regulation issued by the Trump Administration, short-term policies can include renewal features that would enable people to continue coverage for up to three years.  However, before buying the policy, it would be important to know if the policy is renewable at your option or at the option of the insurance company.  If it is only renewable at the insurer’s option, you probably wouldn’t be allowed to renew after you get sick.

It would also be very important to ask about how renewal premiums will be set.  Short-term policies in most states are allowed to set premiums, including renewal premiums, based on health status.  So if you do get sick, even if you have the right to renew the policy, you might not be able to afford to keep it.

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I’m pretty healthy now. Does it make sense to buy a cheaper, short-term policy now, and then go back to a Marketplace policy if I do get sick?

I’m pretty healthy now. Does it make sense to buy a cheaper, short-term policy now, and then go back to a Marketplace policy if I do get sick?

That strategy involves some risks.  First, if you do get sick while covered under a short-term policy, it might not cover benefits for the care you need.  For example, many short-term policies don’t cover, or only provide limited coverage for prescription drugs.

Second, if you do get sick while covered under a short-term policy, the insurer can look back to see if your condition could be considered “pre-existing.”  For example, if you are diagnosed with cancer, the insurer might decide the cancer was growing in you before you bought the policy, even though you didn’t know it, and so exclude coverage for the pre-existing condition.

Third, if you become seriously ill or injured while covered under a short-term policy, the insurer will most likely refuse to sell you new coverage once your policy term ends.  At that point, you might be able to buy a comprehensive policy through the Marketplace that won’t turn you down, but these are only offered during annual Open Enrollment periods and new coverage won’t start until January 1.  That means you could be  uninsured for many weeks or months before new Marketplace coverage begins.  Loss of coverage under a short-term policy will not make you eligible for a special enrollment period to buy Marketplace coverage mid-year.

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I notice some insurers offer the option to buy two or more consecutive short-term policies with no medical underwriting required after the first application. So does that mean I’d be covered if I buy a sequence of short-term policies and then get sick?

I notice some insurers offer the option to buy two or more consecutive short-term policies with no medical underwriting required after the first application. So does that mean I’d be covered if I buy a sequence of short-term policies and then get sick?

Probably not.  Each of the consecutive policies that you would buy would likely include a pre-existing condition exclusion.  So, for example, if you are healthy enough to buy two consecutive short-term policies today, and then you get cancer while covered under the first policy, your cancer would be considered a pre-existing condition when the second policy starts and so would be excluded from coverage under the second policy.

By contrast, a qualified health plan sold through the Marketplace will never exclude pre-existing conditions.

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Are short-term policies available everywhere?

Are short-term policies available everywhere?

No.  Several states have prohibited the sale of short-term policies unless they follow all of the standards that apply to plans sold through the Marketplace — including standards prohibiting discrimination against people based on their pre-existing conditions.  These states include California, Hawaii, Massachusetts, New Jersey, New York, and Oregon; other states may consider similar action in the future.

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An agent offered to sell me a policy that pays $100 per day when you’re in the hospital. Does that count as Minimum Essential Coverage?

An agent offered to sell me a policy that pays $100 per day when you’re in the hospital. Does that count as Minimum Essential Coverage?

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, at a minimum, ask more questions about how the policy might cover pre-existing conditions or protect you from unaffordable medical bills.  Be aware that excepted benefit policies are not an equivalent substitute for Marketplace policies that meet Affordable Care Act standards.

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Can I buy health insurance outside of the Marketplace that meets all ACA standards?

Can I buy health insurance outside of the Marketplace that meets all ACA standards?

Yes.  Many insurers that offer policies through the Marketplace also offer identical policies outside of the Marketplace, in the individual health insurance market.  These ACA-compliant policies also will meet all ACA standards.  They will cover essential health benefits; and they won’t turn you down, charge you more, or limit coverage based on your pre-existing condition.  In addition, ACA-compliant policies will only be offered during Open Enrollment, or at other times during the year, only to people who are eligible for a special enrollment period (SEP).

Sometimes people prefer to buy outside of the Marketplace, for example, when they are sure they won’t qualify for financial assistance. However, many other policies that are not ACA-compliant are also for sale outside of the Marketplace, and this can make comparison-shopping more complicated.

Some signs that a health policy is not ACA-compliant include:

  • The application asks questions about your health status or health history
  • The policy doesn’t cover essential benefits, such as maternity care or prescription drugs
  • The policy has annual or lifetime dollar caps on covered benefits
  • The policy is offered for sale outside of Open Enrollment to people regardless of whether they’re eligible for an SEP, for example, because they recently lost other coverage

Plans that are not ACA-compliant, including short-term health insurance, may have lower premiums because they can exclude people with pre-existing conditions and offer more limited benefits.

If you are shopping outside of the Marketplace and you want an ACA-compliant policy, be sure to specify that to the insurer or broker you’re working with.

Finally, even if you think you won’t qualify for financial assistance, it still might be worthwhile to shop for coverage on the Marketplace.  All policies offered through the Marketplace will meet ACA standards; no other non-compliant products are sold there.   In addition, if you are not eligible for financial assistance now, but your circumstances change later during the year (for example, your income declines), you can begin receiving financial assistance right away if you are already covered under a Marketplace plan.  Or, when you file your tax return at year-end you can claim a premium tax credit to have some of the premium you paid for the Marketplace plan refunded to you.  However, if you bought an ACA-compliant policy outside of the Marketplace, and then you become eligible for financial assistance mid-year, you may have to wait until the next Open Enrollment to switch to a Marketplace plan and get financial assistance.

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Who is eligible for Marketplace premium tax credits?

Who is eligible for Marketplace premium tax credits?

Premium tax credits are 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 9.86% of the employee’s income in 2019. There is also an exception in cases where the employer plan doesn’t provide a minimum level of coverage.)

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Can I get premium tax credits for health plans sold outside of the Marketplace?

Can I get premium tax credits for health plans sold outside of the Marketplace?

No. Premium tax credits are only available for coverage purchased in the Marketplace.

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Can I use the premium tax credit to reduce the cost of any Marketplace health plan?

Can I use the premium tax credit to reduce the cost of any Marketplace health plan?

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.

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How do the premium tax credits work?

How do the premium tax credits work?

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 2019 income. If your income is near the poverty level, the expected contribution you would be required to pay toward the benchmark plan is 2.08 percent of your income in 2019. 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 9.86% 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 during Open Enrollment, you won’t necessarily know for sure what your income for the coverage year will be, so you will apply based on your best estimate. Later, when you file your 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.

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Should I claim a premium tax credit in advance or at the end of the year or some of both?

Should I claim a premium tax credit in advance or at the end of the year or some of both?

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 claim as a refund when you file your tax return at year end.

Keep in mind that when you apply for the premium tax credit during Open Enrollment, you won’t necessarily know for sure what your income for the coverage year will be, so you will apply based on your best estimate. Later, when you file your 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 income for the coming year, 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.

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How do I apply for premium tax credits?

How do I apply for premium tax credits?

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.

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When can I apply for Marketplace premium tax credits when other coverage is available?

When can I apply for Marketplace premium tax credits when other coverage is available?

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:

  • Employer-sponsored coverage, unless the coverage is unaffordable (your required contribution to the premium for self-only coverage in 2018 costs more than 9.56% of household income) or does not meet minimum value (an actuarial value of less than 60%).  Special rules apply when the affordability of family coverage is a concern.
  • Government-sponsored coverage, including Medicare Part A coverage, Medicare Advantage plans, Medicaid coverage and the Children’s Health Insurance Program coverage, Veterans health coverage and TRICARE (coverage for members of the military)
  • Coverage for Peace Corps volunteers

However, if you have access to other types of coverage, you can still be eligible for premium tax credits, assuming you meet other requirements:

  • Individual (non-group) health insurance
  • Student health coverage
  • Coverage as a dependent under your parent’s group health plan if you are under age 26 and not claimed as a tax dependent by your parent
  • Retiree health coverage offered by a former employer
  • COBRA coverage

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I’m single and I’m offered health benefits at work. Can I try to find a better deal in the Marketplace?

I’m single and I’m offered health benefits at work. Can I try to find a better deal in the Marketplace?

Usually no. If you are offered health benefits at work and your required contribution costs no more than 9.86 percent of your 2019 household income, you will not be eligible for premium tax credits through the Marketplace. If you are required to pay more than 9.86% 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 2019.

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 $7,900 per person, or if it doesn’t cover hospitalization), 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.

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I’m married. I work full-time for a large employer that offers me health benefits, but won’t cover spouses. Is that allowed? Can my spouse apply for coverage and subsidies in the Marketplace?

I’m married. I work full-time for a large employer that offers me health benefits, but won’t cover spouses. Is that allowed? Can my spouse apply for coverage and subsidies in the Marketplace?

Large employers are required to offer health benefits to full-time workers and to their dependent children, or face a penalty. However, large employers are not required to offer health benefits to the spouses of full-time workers, so your employer would not have to pay a penalty for refusing to offer coverage to your spouse.  A large employer is one that employees at least 50 workers.

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.

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

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

You can always shop for coverage on the Marketplace, but your family members won’t be eligible for tax credits to help pay the premium. When people are eligible for employer-sponsored coverage, they can only qualify for Marketplace premium tax credits if the employer-sponsored coverage is considered unaffordable. Coverage is considered unaffordable only if your cost for coverage for yourself, alone, under the employer plan is more than 9.86% of your income in 2019. 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.  Sometimes this situation is referred to as “the family glitch.”

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If I’m eligible for other coverage but haven’t enrolled in it yet, can I qualify for premium tax credits in the Marketplace?

If I’m eligible for other coverage but haven’t enrolled in it yet, can I qualify for premium tax credits in the Marketplace?

For certain types of coverage, if you are eligible but not enrolled, then you can still qualify for premium tax credits. These include:

  • Retiree health coverage offered by a former employer
  • COBRA coverage
  • Student health plan coverage
  • Medicare Part A coverage requiring payment of premiums

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.

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My kids are eligible for the Children’s Health Insurance Program. Can I enroll them in our Marketplace health plan and get premium tax credits for them instead?

My kids are eligible for the Children’s Health Insurance Program. Can I enroll them in our Marketplace health plan and get premium tax credits for them instead?

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.

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I have an individual health insurance policy that I buy on my own. Can I drop it and go into the Marketplace and qualify for premium tax credits?

I have an individual health insurance policy that I buy on my own. Can I drop it and go into the Marketplace and qualify for premium tax credits?

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.

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

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

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

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

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

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

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How much can I earn and qualify for premium tax credits in the Marketplace?

How much can I earn and qualify for premium tax credits in the Marketplace?

Premium tax credits are available to people who buy Marketplace coverage and whose income is between 100% and 400% of the federal poverty level.

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Is the value of my house counted in determining my eligibility for premium tax credits in the Marketplace?

Is the value of my house counted in determining my eligibility for premium tax credits in the Marketplace?

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.

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My income is below the federal poverty level and my state has not elected to expand Medicaid eligibility. Can I qualify for premium tax credits?

What income is counted in determining my eligibility for premium tax credits?

What income is counted in determining my eligibility for premium tax credits?

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.

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I get Social Security benefits and don’t make enough to pay federal income taxes on them. Do I count my tax-free Social Security benefits when I apply for premium tax credits?

I’m divorced and receive child support payments from my ex-spouse. Do I count that in determining eligibility for subsidies?

I’m divorced and I pay alimony to my ex-spouse. Should I deduct that from my income in determining my eligibility for subsidies?

I’m divorced and I pay alimony to my ex-spouse. Should I deduct that from my income in determining my eligibility for subsidies?

For divorces after December 31, 2018, alimony payments are no longer deductible for the paying spouse and alimony is not included as income for the recipient spouse.

For pre-2019 divorces, old tax rules apply.  The paying spouse can deduct alimony payments from income and the recipient spouse must report alimony payments as income on the federal tax return.  However, divorced couples have the option of modifying their pre-2019 divorce agreement to adopt the new tax rules.

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My income is very low, but I just inherited $10,000 in cash from my aunt. Will that affect my eligibility for subsidies?

I’m currently collecting workers’ compensation benefits. Are those counted in determining my eligibility for subsidies?

I’m currently collecting workers’ compensation benefits. Are those counted in determining my eligibility for subsidies?

Worker’s compensation payments are generally not taxable, so they would not be counted in determining your eligibility.

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I have a college scholarship that covers my tuition and fees. Do I count that as income in determining my eligibility for subsidies?

I have a college scholarship that covers my tuition and fees. Do I count that as income in determining my eligibility for subsidies?

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.

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My spouse and I have a teenage daughter who has a part-time job. Do we count her income as part of our household income when we apply for Marketplace subsidies?

My spouse and I have a teenage daughter who has a part-time job. Do we count her income as part of our household income when we apply for Marketplace subsidies?

The answer depends on whether she earned enough income to be required to file a federal income tax return on her own. Generally, kids who qualify as tax dependents aren’t required to file a federal income tax return or pay taxes on their income if they earned less than a threshold amount ($12,000 in 2018.) If your daughter earned less than that, you would not count her income as part of your household income.

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I understand eligibility for premium tax credits is based on our household income. Who counts as being in my household?

I understand eligibility for premium tax credits is based on our household income. Who counts as being in my household?

A household, for purposes of determining eligibility for premium tax credits, includes any individuals whom you list on the federal tax form. That includes yourself, your spouse, and dependents. Dependents include children who meet certain requirements:

  • U.S. citizen or resident of the U.S, Mexico or Canada
  • Live with you for more than half the year
  • Under age 19 at the end of the year (or under age 24 if a full-time student); a child is considered to live with the taxpayer while he or she is temporarily away from home due to education, illness, business, vacation or military service.
  • Doesn’t provide more than 50% of his or her own support

Other adults who can count as dependents include relatives, in-laws or full-time members of your household who:

  • Are a U.S. citizen or resident of the U.S, Mexico or Canada
  • Receive more than 50% of their support from you
  • Are related to you or live in your home all year
  • Make less than $4,150 (in 2018), generally excluding Social Security

A household can include individuals even if they are ineligible for tax credits (for example, individuals who are not lawfully present). Your household size can change during a year due to family changes, including the birth or adoption of a child, a child moving out of the house, and divorce or legal separation. When such changes take place you should report them to the Marketplace as they may affect your eligibility for subsidies. Family changes also can trigger a special enrollment opportunity when you can change health plans, even outside of the regular Open Enrollment period.

Note that the definition of household for determining eligibility for premium tax credits sometimes differs from the definition of household for determining Medicaid eligibility. Ask your Marketplace for more information about who should be counted in your household.

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I’m raising my grandchild and claim her as a dependent. If I apply for Marketplace subsidies, will we be considered a household of two?

I’m raising my grandchild and claim her as a dependent. If I apply for Marketplace subsidies, will we be considered a household of two?

Yes, you will be considered as a household of two for both Medicaid and premium tax credits. However, your grandchild will be considered as her own household for Medicaid and CHIP and your income will not count in determining her eligibility for these programs. Assuming she does not have her own income she will likely be eligible for Medicaid or CHIP and not eligible for premium tax credits for coverage in the Marketplace. You could of course purchase coverage for her in the Marketplace but you would not be eligible for a premium tax credit to help pay for her plan.  Whether you could include her on your policy would depend on what insurers offer in your Marketplace.

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What if I don’t know what my income will be next year?

What if I don’t know what my income will be next year?

When you apply for the premium tax credit, you will be asked to estimate your expected income for the upcoming year. Often a good place to start is to consider what your income is this year, or what income you reported on your tax return last year. However, if your circumstances have changed since then, for example, if you recently lost your job, you should make your best estimate of what your income will be next year. The health insurance Marketplace will compare your income estimates against records at the Internal Revenue Service, Social Security Administration and other sources. If your estimate and official records don’t match, or aren’t sufficiently close, but you meet all other eligibility requirements, you might be asked to provide documentation to support your income projections.

In general, if the income amount shown on that official record is more than 25% or $6,000 (whichever is greater) higher than the amount you put on your application, you might receive a data match inconsistency notice from the Marketplace and you’ll need to provide more documentation.

If you don’t have that documentation handy, the Marketplace will provide subsidies for up to 90 days while you gather and submit your documentation for verification. It is very important that you provide any documentation requested by the Marketplace in a timely manner; if you don’t your subsidies might be reduced or terminated.

Keep in mind that if you estimate your income incorrectly and end up claiming more help than you are eligible for, you may have to pay back some or all of the premium tax credit you received. If you over-estimate your income and end up claiming less help than you are entitled to, the difference will be refunded to you when you file your income taxes the following year.

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My income is uneven during the year. Some months I earn very little, other months are much better. I think my annual income will be low enough to qualify for subsidies next year, but I’m not sure. What if I’m wrong?

My income is uneven during the year. Some months I earn very little, other months are much better. I think my annual income will be low enough to qualify for subsidies next year, but I’m not sure. What if I’m wrong?

It’s common for income to fluctuate, particularly if you are self-employed, perform seasonal work or have multiple jobs. To achieve the most accurate premium tax credit amount, you should report income changes to the health insurance Marketplace during the year, as they happen. Otherwise, if you claim a premium tax credit during the year based on estimated income and your actual income for the year edges over 400% FPL, you will need to pay back the full credit amount. To avoid this result, if you estimate your annual income will be close to 400% FPL, you could also consider waiting until you file your taxes to take all or a portion of the premium tax credit on your tax return instead of receiving advance payments.

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What’s the most I would have to repay the IRS?

What’s the most I would have to repay the IRS?

That depends on what your actual annual income turns out to be. If your income goes over 400% FPL you will have to repay the full advance premium tax credit amount you received. If your actual annual modified adjusted gross income is higher than what you projected but less than 400% FPL, there are repayment limits based on income. On your tax return, you will compare the actual amount of advance premium tax credit you received during the year to the amount you should have received based on your modified adjusted gross income, and then pay back the excess up to the repayment limit.

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I estimate my income next year will be 140% of the federal poverty level, so I need a premium tax credit and I need to have it all paid in advance. If, by the end of the year, it turns out my annual income was even lower – 130% of the federal poverty level – so I could have enrolled in Medicaid, will I have to pay back the premium subsidy?

I estimate my income next year will be 140% of the federal poverty level, so I need a premium tax credit and I need to have it all paid in advance. If, by the end of the year, it turns out my annual income was even lower – 130% of the federal poverty level – so I could have enrolled in Medicaid, will I have to pay back the premium subsidy?

No, your final premium credit amount will be determined based on your income for the year as reported on your tax return. The fact that it ended up being 130% of the poverty line does not mean you have to pay back the premium tax credit you received. In fact, your final credit amount will likely be larger than the amount you received in advance.

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How often during the year can I adjust my premium tax credit amount? What documentation is required to make an adjustment? How long after I request the adjustment will it take effect?

How often during the year can I adjust my premium tax credit amount? What documentation is required to make an adjustment? How long after I request the adjustment will it take effect?

There is no limit to the number of times a person may report income, family or insurance-eligibility changes to the Marketplace. Changes that are reported by enrollees will be verified by the Marketplace. Then the Marketplace will send you a notice (called a redetermination notice) showing your revised eligibility for premium tax credits and cost-sharing reductions. In addition, people can always ask the Marketplace to provide them with a monthly advance premium credit below the amount the Marketplace determines based on the household’s income if they want to minimize the chance of needing to owe money at the end of the year.

The adjustment will take effect by the first day of the month following the date of the redetermination notice. For example, if an enrollee reports a change in income on June 25 and the Marketplace verifies the change and sends a redetermination notice to the enrollee on July 3, the change will be implemented on August 1.

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I never filed an income tax return before. Can I claim a premium tax credit this year?

I never filed an income tax return before. Can I claim a premium tax credit this year?

Yes in most cases. People who have not filed a tax return before can qualify for a premium tax credit. However, there is a requirement to file a return for the tax year in which you receive a premium tax credit.  If you got an advanced premium tax credit last year, you must file a federal income tax return for that year to be eligible to receive an advance premium tax credit next year.

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I got a premium tax credit in 2017, but I usually don’t file a tax return and didn’t realize I was supposed to file a 2017 return this year. Now I’m trying to renew my premium tax credit for next year and the Marketplace says I can’t. What do I do now?

I got a premium tax credit in 2017, but I usually don’t file a tax return and didn’t realize I was supposed to file a 2017 return this year. Now I’m trying to renew my premium tax credit for next year and the Marketplace says I can’t. What do I do now?

You should file your federal income tax return for 2017 as soon as possible.  Then log into your Marketplace account, update your application information, and tell the Marketplace that you have filed your taxes by attesting to that question on the application.  Keep in mind that the Marketplace will check with the IRS during the coverage year to verify your return was filed and, if it cannot verify, will terminate your premium tax credit.

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I got health insurance last year through a Marketplace plan and also received advanced premium tax credits to reduce my monthly premium. What happens if I don’t file my federal income tax return this spring? What if I file but don’t include Form 8962?

I got health insurance last year through a Marketplace plan and also received advanced premium tax credits to reduce my monthly premium. What happens if I don’t file my federal income tax return this spring? What if I file but don’t include Form 8962?

For any year when you received advanced premium tax credits, you are required to file a federal income tax return, including Form 8962.  If you fail to do this — it is called “failure to reconcile” — you may be unable to apply for premium tax credits for the following year.  If you file a federal income tax return but don’t include Form 8962, that is also considered a failure to reconcile and you may be prevented from applying for premium tax credits at the next Open Enrollment.
If this happens to you, be sure to remedy this failure as soon as you can.  You can still sign up for health insurance coverage for the coming year, but you won’t be able to get advance premium tax credits until you have filed your prior-year tax return with Form 8962.

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What happens to a young adult who applies for premium tax credits the first year she is independent, and so she hasn’t filed a return in prior years?

What happens to a young adult who applies for premium tax credits the first year she is independent, and so she hasn’t filed a return in prior years?

One challenge a young adult may face in her first year of independent tax filing is verifying income, since one of the prime sources of income data is a prior year tax return. However, other methods of verification are available; for instance, the Marketplace will have access to monthly wage data that can verify current income. In the case of someone who is self-employed or who has fluctuating income, additional documentation of income may be accepted.

The fact that a young adult has not filed in the past will not prevent her from receiving premium tax credits.  When she applies, if the Marketplace cannot verify her income right away, she will receive a provisional (temporary) eligibility determination based on the income information she puts in her application.  The Marketplace will then give her a period of time (usually 90 days) to provide additional documentation of income.  Current pay stubs, bank deposit records, or other documentation may be appropriate, depending on her situation.

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If I’ve not filed taxes in a prior year, how will the Marketplace determine my income?

If I’ve not filed taxes in a prior year, how will the Marketplace determine my income?

If an applicant did not file taxes in a prior year, income will be verified by the Marketplace through use of electronic wage data. If the information cannot be verified electronically, the applicant may be asked to submit additional paper documentation within 90 days, such as pay stubs, a work contract or other verification of income.

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My partner and I live together but are unmarried. Is our combined household income what we should report?

My partner and I live together but are unmarried. Is our combined household income what we should report?

Because you are not married, you will be considered two separate households for the purposes of determining eligibility for premium tax credits and Medicaid. Assuming that neither of you are claiming any dependents on your tax returns, you will each be considered as a household of one and your own income will be used to determine eligibility for premium tax credits and Medicaid as well as the amount of any premium tax credit and cost-sharing reduction you may qualify for. If you are eligible for premium tax credits, you will each receive a separate determination of the amount of your credit and whether you are eligible for a cost-sharing reduction. Whether you can use your credits to buy a family policy rather than two individual policies will depend on the offerings in your state Marketplace.

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I’m under 26 and eligible to be covered as a dependent under my mom’s job-based policy. Mom no longer claims me as a tax dependent – I file my own taxes, though my income isn’t very high. If subsidized Marketplace coverage would be even more affordable to me can I sign up for that instead?

I’m under 26 and eligible to be covered as a dependent under my mom’s job-based policy. Mom no longer claims me as a tax dependent – I file my own taxes, though my income isn’t very high. If subsidized Marketplace coverage would be even more affordable to me can I sign up for that instead?

Yes. Although the general rule is that people are not eligible for Marketplace subsidies when they are also eligible for affordable job-based health coverage, there is a special rule for young adults. As long as a young adult is not claimed as a tax dependent by her parents, the availability of dependent coverage under her parents’ health plan does not affect her eligibility for premium tax credits in the Marketplace.

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My spouse and I qualify for a premium tax credit, but our doctors participate in different health plan networks so we want to sign up for two separate plans. Can we do that?

My spouse and I qualify for a premium tax credit, but our doctors participate in different health plan networks so we want to sign up for two separate plans. Can we do that?

Yes. The Marketplace will allocate the monthly advance payment across the two plans. In most cases the Marketplace will allocate the monthly advance payment in proportion to the premiums for the two plans.

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My 24-year-old daughter, who is working, lives near me and my spouse. We do not claim her as a tax dependent. She is eligible for premium tax credits and a cost-sharing reduction. We are not eligible for any subsidies, but we would all like to enroll in the same plan. Can we do that?

My 24-year-old daughter, who is working, lives near me and my spouse. We do not claim her as a tax dependent. She is eligible for premium tax credits and a cost-sharing reduction. We are not eligible for any subsidies, but we would all like to enroll in the same plan. Can we do that?

You can all enroll in the same family plan, and your daughter can apply her premium tax credit to reduce her share of the premium for that family plan, but your daughter would lose her eligibility for cost-sharing reductions. If two individuals (or two separate households) qualify for different levels of cost-sharing assistance, or if one qualifies and the other doesn’t, and if they want to be covered under the same plan, they must select a plan that provides the level of cost-sharing reduction that they all would qualify for. In this case, since you do not qualify for any help with cost sharing, the three of you could only enroll together in a plan without cost sharing subsidies.

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My 24-year-old son, who is working, lives near me and my spouse. My spouse and I are eligible for a silver plan with a 73 percent actuarial value, but my son is eligible for a plan with an 87 percent actuarial value. What happens if we all enroll in one family policy?

My 24-year-old son, who is working, lives near me and my spouse. My spouse and I are eligible for a silver plan with a 73 percent actuarial value, but my son is eligible for a plan with an 87 percent actuarial value. What happens if we all enroll in one family policy?

If you all enroll in the same plan, you would only be eligible for a plan with a 73 percent actuarial value; that is the lowest-value plan for which all of you would qualify in this situation.

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I’m low income and enrolled in subsidized Marketplace coverage now. I just found out I’m pregnant. Under my state’s rules, I now qualify for Medicaid. Do I have to drop out of the Marketplace coverage and enroll in Medicaid? If I don’t will I have to pay back the premium tax credit subsidy?

I’m low income and enrolled in subsidized Marketplace coverage now. I just found out I’m pregnant. Under my state’s rules, I now qualify for Medicaid. Do I have to drop out of the Marketplace coverage and enroll in Medicaid? If I don’t will I have to pay back the premium tax credit subsidy?

In nearly all states, pregnancy-related Medicaid provides the same (or similar) benefits as Medicaid for other adults and so is considered minimum essential coverage (MEC).  (In 3 states – Arkansas, Idaho, and South Dakota – pregnancy-related Medicaid only covers maternity care and is not recognized as MEC).  The general rule requires that people eligible for other MEC are not eligible for premium tax credits.  However, a special rule allows women who are already receiving APTC and who become pregnant and eligible for pregnancy-related Medicaid to choose whether to stay in their marketplace plan with APTC or enroll in the pregnancy-related Medicaid.   For example, women might choose pregnancy-related Medicaid because it does not charge monthly premiums or cost sharing for covered services.

If you decide to enroll in the pregnancy-related Medicaid (in all but 3 states), you will no longer be eligible for APTC while you are enrolled in Medicaid.    If you decide to enroll in the pregnancy-related Medicaid and live in one of 3 states offering limited benefits, you can apply for an exemption from the individual mandate and won’t owe a penalty for lacking MEC coverage during those months.  In all states, when your pregnancy and pregnancy-related Medicaid ends, you will be eligible for a special enrollment period (SEP) and can sign up for marketplace coverage and APTC at that time.

But if you prefer to stay in your marketplace plan you can continue receiving APTC and won’t be required to pay it back later just because you were eligible for pregnancy-related Medicaid.

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I am married but my spouse and I live apart and we do not file a joint tax return. Instead, I use the “married filing separately” tax filing status. I have low income and need help paying health insurance premiums. Can I qualify for premium tax credits?

I am married but my spouse and I live apart and we do not file a joint tax return. Instead, I use the “married filing separately” tax filing status. I have low income and need help paying health insurance premiums. Can I qualify for premium tax credits?

Generally no. Married taxpayers are required to file a joint tax return in order to qualify for premium tax credits. People who use the “married filing separately” status are not eligible to receive premium tax credits (and also cannot claim certain other tax breaks, such as the child and dependent care tax credit, tuition deductions, or the earned income tax credit.)  There is a special exception, however, for individuals who must file separately because of domestic abuse or spousal abandonment.

For other married individuals who do not file a joint return, there may be other options.

If you have a dependent and meet certain conditions, you may be able to use the “head of household” filing status. People who file a tax return using this filing status can qualify for premium tax credits.

In addition, if you expect to be divorced by the end of the tax year, you will be able to file as a single taxpayer for that year and could qualify for subsidies under that filing status when you file your taxes.  However, you may not be able to receive all of the premium tax credit that you’re entitled to in advance if you are not yet divorced with you make your Marketplace application.  Except in cases of domestic abuse or spousal abandonment you should not say on your application that you are unmarried when you are still married.

Check with your tax adviser or a health insurance Marketplace Navigator for more information.

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I am still legally married, but live apart from my spouse because of domestic abuse or abandonment. I cannot file a joint tax return. Can I qualify for premium tax credits if I file as married-filing-separately and don’t take into account my spouse’s income?

I am still legally married, but live apart from my spouse because of domestic abuse or abandonment. I cannot file a joint tax return. Can I qualify for premium tax credits if I file as married-filing-separately and don’t take into account my spouse’s income?

Yes.  If you are married but unable to file a joint return because of domestic abuse, you can file as married-filing-separately and claim the premium tax credit.  Similarly, if you cannot file a join return because you are unable to locate your spouse due to spousal abandonment, you can file as married-filing-separately and claim the premium tax credit.  In either instance, you will need to check the “Relief” box in the top right-hand corner of Form 8962 and file that with your tax return.  You are not required to submit documentation of the abuse or abandonment with your tax return, but should keep any documentation for your records.

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I can’t afford to pay much for deductibles and co-pays. Is there help for me in the Marketplace for cost sharing?

I can’t afford to pay much for deductibles and co-pays. Is there help for me in the Marketplace for cost sharing?

Yes. If your income is between 100% and 250% of the federal poverty level, you can also qualify for cost-sharing reductions. These will reduce the deductibles, copays, and other cost sharing that would otherwise apply to covered services.

The cost-sharing reductions will be available through modified versions of Silver plans that are offered on the Marketplace. These plans will have lower deductibles, copays, coinsurance and out-of-pocket limits compared to regular Silver plans. Once the Marketplace determines you are eligible for cost sharing reductions, you will be able to select one of these modified Silver plans, based on your income level.

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I heard the cost-sharing reduction payments ended. Does that mean I won’t be able to get this help?

I heard the cost-sharing reduction payments ended. Does that mean I won’t be able to get this help?

No.  Cost-sharing subsidies did not end.  They continue to be available in the Marketplace.  By law, insurers offering coverage on the Marketplace are still required to offer cost-sharing reductions to consumers with income between 100% and 250% of the poverty level.

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If I use my premium subsidy for a Bronze plan, I can save even more money on the premium. Can I get also get my cost-sharing reduction through a Bronze plan?

If I use my premium subsidy for a Bronze plan, I can save even more money on the premium. Can I get also get my cost-sharing reduction through a Bronze plan?

No, you can only get cost-sharing reductions by enrolling in a Silver Marketplace plan. You will not receive cost-sharing reductions if you enroll in a Bronze, Gold, or Platinum plan. Note that this is different from the rule for premium tax credits. You can apply premium tax credits to all four types of plan. However, if you are eligible for both kinds of help (that is, if your income is between 100% and 250% of the federal poverty level), you can only receive both types of subsidies if you enroll in a Silver plan.

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How much are the cost-sharing subsidies?

How much are the cost-sharing subsidies?

That depends on your income and where you live. To give a general idea, a typical Silver plan might have an annual deductible of $4,000, for example, and an annual out of pocket limit on all cost sharing of $7,900. But if your income is between 100% and 150% of the federal poverty level, the cost-sharing reductions will modify a Silver plan so that the annual deductible might be closer to $250 and the annual out-of-pocket limit on all cost sharing would be no more than $2,600.

If your income is between 150% and 200% of the federal poverty level, the cost-sharing reductions will modify the Silver plan so that the annual deductible might be around $800 and the annual out-of-pocket limit would be no more than $2,600.

If your income is between 200% and 250% of the federal poverty level, the cost-sharing reductions will be more modest. At this income level, your annual out-of-pocket limit will be reduced to no more than $6,300.

Check the Marketplace website for more information about cost sharing reductions in Silver plans in your area based on your level of income.

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If I mis-estimate my income and end up earning more than 250% of the federal poverty level next year, will I have to pay back the cost sharing subsidies?

If I mis-estimate my income and end up earning more than 250% of the federal poverty level next year, will I have to pay back the cost sharing subsidies?

No. Unlike premium tax credits, which are reconciled each year based on the income you actually earned, cost-sharing reductions are not reconciled.

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

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

In reviewing your application, the Marketplace will compare the amount of income you estimate for next year to the most recent information about your income that is available (usually, that will be the tax return you filed this year reporting last year’s income.)  Generally, if that amount differs from the amount you put on your application by more than 25% or $6,000 (whichever is greater), you might receive a data match inconsistency notice from the Marketplace and you’ll need to provide more documentation.

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

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I am self-employed with uneven income. When I applied for premium tax credits during Open Enrollment, I said I expect to earn much less next year than I did last year. The Marketplace said I must provide more documentation but didn’t say what to send. How can I find out?

I am self-employed with uneven income. When I applied for premium tax credits during Open Enrollment, I said I expect to earn much less next year than I did last year. The Marketplace said I must provide more documentation but didn’t say what to send. How can I find out?

Unfortunately, in most states so far, the data match inconsistency notices are not very specific in describing the additional documentation that is required.  Instead, notices list generic types of types of income documentation without specifying the documentation appropriate for you.  If you are self-employed and estimate your income next year will be significantly less than what you reported on your most recent tax return, you should provide copies of any documents that support your estimate.  Make sure to provide copies and not original documents.  If you don’t have documents, a signed statement explaining your estimate may be accepted.  Be sure to include your name and ID number, a description of the income you expect to earn next year, a description of how you arrived at your estimated income amount, and an explanation of why other documentation is not available.

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My income is uneven during the year. Some months I don’t earn anything, other months are better. I’m pretty sure my income for the coming year will be less than 400% of the FPL so I’d like to apply for premium subsidies. But what if I’m wrong and my income ends up being more than 400% FPL?

My income is uneven during the year. Some months I don’t earn anything, other months are better. I’m pretty sure my income for the coming year will be less than 400% of the FPL so I’d like to apply for premium subsidies. But what if I’m wrong and my income ends up being more than 400% FPL?

It’s common for income to fluctuate, particularly if you are self-employed, perform seasonal work or have multiple jobs. To achieve the most accurate premium tax credit amount, you should report income changes to the health insurance Marketplace during the year, as they happen. Otherwise, if you claim a premium tax credit during the year and your actual income for the entire year edges over 400% FPL, you will need to pay back the full credit amount. To avoid this result, if you estimate your annual income will be close to 400% FPL, you could also consider waiting until you file your taxes to take all or a portion of the premium tax credit on your tax return instead of receiving advance payments.

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Can I adjust the level of subsidy I collect in advance during the year when my income goes up or down? How often during the year can I make adjustments?

Can I adjust the level of subsidy I collect in advance during the year when my income goes up or down? How often during the year can I make adjustments?

Yes, you can make adjustments during the year whenever you need to. There is no limit to the number of times a person may report income, family or insurance-eligibility changes to the Marketplace. Changes that are reported by enrollees will be verified by the Marketplace. Then the Marketplace will send you a notice (called a redetermination notice) showing your revised eligibility for premium tax credits and cost-sharing reductions. In addition, people can always ask the Marketplace to provide them with a monthly advance premium credit below the amount the Marketplace determines based on the household’s income if they want to minimize the chance of owing money at the end of the year.

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If I request an adjustment in my Marketplace premium subsidy, how long before that takes effect?

If I request an adjustment in my Marketplace premium subsidy, how long before that takes effect?

The adjustment will take effect by the first day of the month following the date of the redetermination notice. For example, if an enrollee reports a change in income on June 25 and the Marketplace verifies the change and sends a redetermination notice to the enrollee on July 3, the change will be implemented on August 1.

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I live in a state that has chosen not to expand Medicaid. When I applied for Marketplace coverage, my income was just above the poverty level, so I applied for and received an advance premium tax credit. What happens if I lose my job toward the end of the year so my annual income will be just under the poverty level? Will I have to pay back the advanced subsidies I’ve received?

How often during the year can I adjust my premium tax credit amount? What documentation is required to make an adjustment? How long after I request the adjustment will it take effect?

How often during the year can I adjust my premium tax credit amount? What documentation is required to make an adjustment? How long after I request the adjustment will it take effect?

There is no limit to the number of times a person may report income, family or insurance-eligibility changes to the Marketplace. Changes that are reported by enrollees will be verified by the Marketplace. Then the Marketplace will send you a notice (called a redetermination notice) showing your revised eligibility for premium tax credits and cost-sharing reductions. In addition, people can always ask the Marketplace to provide them with a monthly advance premium credit below the amount the Marketplace determines based on the household’s income if they want to minimize the chance of needing to owe money at the end of the year.

The adjustment will take effect by the first day of the month following the date of the redetermination notice. For example, if an enrollee reports a change in income on June 25 and the Marketplace verifies the change and sends a redetermination notice to the enrollee on July 3, the change will be implemented on August 1.

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

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

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

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I enrolled in a Marketplace policy with premium tax credits in 2018, even though my employer offers health benefits, because the employer coverage was unaffordable (more than 9.56% of my income in 2018). Then mid-year I started a second part-time job. As a result my annual income will be higher than I originally estimated, and, at this higher income, the cost of enrolling in my job-based plan would be less than 9.56% of my income. Unfortunately, I can’t sign up for my employer plan until the next open season. What should I do? When I file my taxes will I be required to pay back my premium tax credits because I had access to affordable job-based coverage after all?

I enrolled in a Marketplace policy with premium tax credits in 2018, even though my employer offers health benefits, because the employer coverage was unaffordable (more than 9.56% of my income in 2018). Then mid-year I started a second part-time job. As a result my annual income will be higher than I originally estimated, and, at this higher income, the cost of enrolling in my job-based plan would be less than 9.56% of my income. Unfortunately, I can’t sign up for my employer plan until the next open season. What should I do? When I file my taxes will I be required to pay back my premium tax credits because I had access to affordable job-based coverage after all?

First, you should report your income change to the Marketplace. The Marketplace will determine your new eligibility for premium tax credits, based on your higher income, and adjust the level of subsidy going forward. If you make this adjustment promptly, it’s likely you won’t receive any more advanced premium tax credit during the entire year than you’re eligible for based on your annual income.

As for the new “affordability” of your job-based coverage option, that won’t be taken into account when you file your taxes. As long as the Marketplace determined you were not eligible for affordable job-based coverage when you initially applied for Marketplace coverage and subsidies, that determination will hold for the remainder of the year. The IRS refers to this as a “safe harbor,” and won’t require you to go back and re-compute the affordability of your job-based coverage at year end when you file your taxes.

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Can I be charged higher premiums in the Marketplace if I smoke?

Can I be charged higher premiums in the Marketplace if I smoke?

In most states, yes. Generally, an insurer can charge as much as 50% more for a person who uses tobacco products. For example, if the premium for somebody your age (before any tax credits are applied) would otherwise be $200 per month, if you are a tobacco user your premium could be increased to $300 per month. States can prohibit insurers from applying a tobacco surcharge or further limit the tobacco penalty and some have done so. (For example, California, Massachusetts, Rhode Island, Vermont and the District of Columbia prohibit tobacco rating for their Marketplace plans.] Also, some insurers who do charge more for tobacco users are charging the less than maximum amount they can under the law. Check with your state Marketplace to learn more about tobacco surcharges and how they work.

If you qualify for premium tax credits to reduce the cost of Marketplace coverage, this tax credit amount will be based on the premium before the tobacco surcharge is applied, which means that a smoker must pay the full cost of the surcharge.

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What does it mean to “use tobacco?” I’m pretty sure my teenager has smoked at least a couple of times. Do I have to pay a higher rate because of her?

What does it mean to “use tobacco?” I’m pretty sure my teenager has smoked at least a couple of times. Do I have to pay a higher rate because of her?

“Tobacco use” means a person has used a tobacco product an average or four or more times per week for the past six months. A state can increase the number of times per week or reduce the “look-back” period to less than six months. Check with your state Marketplace to learn more about tobacco surcharges and how they work.

The surcharge on tobacco users can only be applied to an individual who can legally purchase a tobacco product in the state. Thus, the surcharge does not generally apply to a person under age 18.

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My income is less than 400% of the FPL and I smoke. Will the tobacco surcharge to the premium be covered by my premium tax credit?

My income is less than 400% of the FPL and I smoke. Will the tobacco surcharge to the premium be covered by my premium tax credit?

No. A tobacco surcharge is not covered by the health insurance premium tax credits. The premium tax credit will reduce what you have to pay for the regular health insurance premium, but you will have to pay the entire additional tobacco surcharge. For example, if the regular premium for a policy is $200 per month and you qualify for a premium tax credit of $75 but you also use tobacco and so would be subject to a 50% tobacco use surcharge, you would have to pay $225 for that policy ($200 for the regular premium minus $75 for your premium tax credit plus $100 for the tobacco surcharge.)

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The tobacco surcharge makes my health insurance unaffordable so I can’t buy coverage. Even after taking into account the tax credit, my premium will cost more than 8.16 percent of my income. Will I owe a penalty?

The tobacco surcharge makes my health insurance unaffordable so I can’t buy coverage. Even after taking into account the tax credit, my premium will cost more than 8.16 percent of my income. Will I owe a penalty?

No. If the cost of health insurance, taking into account both your premium tax credit and the tobacco surcharge, exceeds 8.16 percent of your income in 2017, you will not be subject to the penalty for failure to obtain insurance that year.

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I smoke but I’m trying to quit. What happens if I don’t disclose to an insurance company that I use tobacco?

I smoke but I’m trying to quit. What happens if I don’t disclose to an insurance company that I use tobacco?

If you report inaccurate or false information about your tobacco use on an application, an insurer is allowed to retroactively impose the tobacco surcharge to the beginning of the plan year. However, the insurer is not allowed to cancel your coverage because of the false or incorrect information.

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What happens if I take up smoking after I bought the policy?

What happens if I take up smoking after I bought the policy?

You would be subject to the tobacco surcharge when you renew your plan the following year.

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What happens if I disclosed that I smoked when I bought the policy, but now I’ve successfully quit?

What happens if I disclosed that I smoked when I bought the policy, but now I’ve successfully quit?

The insurer is not required to lower your premium until you renew your policy the following year.

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I work for a small business who buys health insurance in the Marketplace and I smoke. Can my company be charged more because of me?

I work for a small business who buys health insurance in the Marketplace and I smoke. Can my company be charged more because of me?

Yes, assuming your coverage is purchased in a state that allows the tobacco surcharge. An insurer can adjust the premiums of health plans sold to small businesses based on the number of workers who use tobacco.

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The Marketplace said I must submit additional information to document my eligibility (to buy coverage or to qualify for premium tax credits or to receive an exemption). They gave me 90 days, but I missed the deadline. Can I request an extension?

The Marketplace said I must submit additional information to document my eligibility (to buy coverage or to qualify for premium tax credits or to receive an exemption). They gave me 90 days, but I missed the deadline. Can I request an extension?

Generally, if the Marketplace hasn’t received the requested information within 90 days and you didn’t already ask for an extension, the Marketplace will make a determination based on the information it has.

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The Marketplace said I must submit additional information to document my eligibility for premium tax credits. I submitted the information, but kept getting more notices to send information. Now 90 days have passed and my tax credit has been reduced. What should I do?

The Marketplace said I must submit additional information to document my eligibility for premium tax credits. I submitted the information, but kept getting more notices to send information. Now 90 days have passed and my tax credit has been reduced. What should I do?

You can appeal the Marketplace’s decision to reduce your tax credit.  Information on how to appeal will be included on the final determination notice.  If your appeal is successful, your tax credit will be restored retroactively.

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How do I appeal a Marketplace decision?

How do I appeal a Marketplace decision?

You can request an appeal of any Marketplace decision, including decisions about

  • Your eligibility to buy coverage in the Marketplace
  • Your eligibility for, or the amount of, premium tax credits or cost sharing reductions
  • Your eligibility for an exemption from the penalty for not having health insurance
  • Untimely (late) notice from the Marketplace about a decision

To make your appeal, start by reviewing the Marketplace’s decision. You will have received the decision (called a determination notice) online if you initially applied online, or in the mail if you submitted a paper application. So far, in the federal Marketplace, the notice will not provide much detail to explain the reasons for the decision, but it will describe the process you should follow if you want to appeal.

If you have questions about what the notice says or if you want to appeal, consider asking for help from a Navigator or other in-person assister program.  The Marketplace website will have a link to programs in your area.

Generally you have 90 days from the date on your eligibility decision notice to request an appeal.  If you need health services right away and a delay could jeopardize your health, you can request an expedited appeal.

To request an appeal in federal Marketplace states, you’ll have to submit the appeal in writing.  You can write a letter or use appeal forms available on healthcare.gov and submit your appeal by mail or by fax.  Your written appeal should provide your name and contact information and an explanation of what you are appealing and why. If you are requesting an expedited appeal, indicate that on the form or state it in your letter.

You can submit documents to the Marketplace that support your case. You can submit documents along with your initial appeal request or at any time during the appeal process, up until a hearing.

The Marketplace may offer you the option of receiving temporary benefits while your appeal is pending. You can accept the temporary benefits or waive them. If you accept temporary benefits during the appeals process and then lose your appeal, you might have to pay back the benefits you weren’t eligible for.

The Marketplace will review your completed appeal once it is submitted. Then the Marketplace will let you know its decision.  If you still disagree with the decision, you can request a hearing. While you are waiting for the hearing to take place, the Marketplace may contact you to try to resolve the dispute informally.

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How long will a Marketplace decision appeal take?

How long will a Marketplace decision appeal take?

This will depend on the reason for your appeal and the documentation needed to decide your appeal. Contact the Marketplace for more information about your appeal.

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My employer won’t fill out the form that asks about the affordability of our job-based health plan. I think my job-based plan is unaffordable and that’s why I’m not enrolled in it. Can I go ahead and apply for Marketplace coverage and subsidies without that form?

My employer won’t fill out the form that asks about the affordability of our job-based health plan. I think my job-based plan is unaffordable and that’s why I’m not enrolled in it. Can I go ahead and apply for Marketplace coverage and subsidies without that form?

Your employer is not required to fill out the form that asks about affordability of your job-based health plan. If for any reason you cannot obtain this information from your employer, you should report to the Marketplace what you know, yourself, about your eligibility for employer sponsored coverage, the cost of that coverage, and whether it meets minimum value. The Marketplace may try to follow up with your employer and collect or verify this information. The Marketplace will determine your eligibility for subsidies based on the information you provided or based on any information the Marketplace was able to obtain on its own through other follow up with your employer.

Although employers aren’t required to provide you this information up front, most are expected to do so.  All employers are required to provide you with this information at year end.  In January, your employer will be required to provide you with a Form 1095-C that indicates whether health benefits they offered to you in the prior calendar year meet the requirements for affordability and minimum value.

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I expect my income next year will be much lower than it is currently. Do I have to provide documentation to prove my income will be less? What counts as valid documentation?

I expect my income next year will be much lower than it is currently. Do I have to provide documentation to prove my income will be less? What counts as valid documentation?

You may be asked for additional information about your projected income. The Marketplace will compare your estimated income to other available data on your most recent income (for example, with tax return data.) If you estimate your annual income will be substantially less — by 25% or $6,000, whichever is greater — than the amount you earned in previous years the Marketplace will ask you to provide documentation to support your estimate. This may include a letter from your employer, a pay stub from your new job or other documents. In some cases, just explaining your changed circumstances may be enough.

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What documentation is required to request a hardship exemption from the requirement that I have health insurance or pay a penalty?

What documentation is required to request a hardship exemption from the requirement that I have health insurance or pay a penalty?

For the 2018 tax year, you can claim a hardship exemption directly on your tax return instead of applying to the Marketplace for a hardship exemption.  If you experienced a hardship that prevented you from obtaining health insurance in 2018, you can simply check the box on the front of the federal Form 1040 indicating that you qualify for an exemption.  You will not be required to submit documentation with your tax return, but should retain any documentation of the hardship for your own records.

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What happens if I just make up an income level that I know will qualify me for financial assistance?

What happens if I just make up an income level that I know will qualify me for financial assistance?

That’s not advisable. The Marketplace will check the information you provide against a number of databases (including IRS data, Social Security data, wage databases, and others). If the information you provide is very different from what’s in these databases, you may be asked to provide additional documentation. In addition, at the end of the Application for Health Coverage and Help Paying Costs, you will have to sign that you have provided true answers to all questions to the best of your ability. Knowingly providing untrue information is against the law and could even result in civil money fines.

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I signed up for Marketplace coverage this year. I am sure I never missed a payment, but the insurer says I didn’t pay the October premium and won’t let me renew coverage for next year unless I repay it. Can I appeal this decision?

I signed up for Marketplace coverage this year. I am sure I never missed a payment, but the insurer says I didn’t pay the October premium and won’t let me renew coverage for next year unless I repay it. Can I appeal this decision?

This is unclear.  So far, the federal government has not established a clear appeals process for problems that arise under the rule that permits insurers to refuse to renew Marketplace coverage for nonpayment.  It is important that you sign up for coverage before the end of Open Enrollment.  At this point, options to consider include:

  • Ask your insurer to reconsider. Be sure to present your cancelled check or other proof that you paid.
  • Report this problem to the Marketplace and to your state insurance regulator and ask their help resolving the problem
  • Review Marketplace plan options offered by any other insurers and consider signing up for one of those if you can’t get this problem resolved before December 15.

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

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

A number of options may be available to you:

  • If your income is below 138% of the federal poverty level ($16,753 for a single person in 2019), you may qualify for Medicaid coverage. Not all states have elected to expand Medicaid eligibility to this income level. Check with your state Marketplace to find out more about Medicaid eligibility in your state.
  • If your parents have health insurance that offers dependent coverage, you can join (or stay on) their policy as a dependent and remain covered until your 26th birthday. See below for more information about dependent coverage for young adults.
  • You can buy a policy on your own through your state health insurance Marketplace. All plans sold through the Marketplace must meet requirements for covered benefits and cost sharing. Depending on your income, you may be eligible for help to reduce the cost of plan premiums and/or cost sharing.
  • Special, catastrophic policies with very high cost sharing must be offered to young adults under the age of 30. Premium and cost sharing subsidies are not available for catastrophic plans.
  • If you are a student, you may be able to enroll in student health offered through your college or university.

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What is a student health plan?

What is a student health plan?

“Student health plan” refers to a special policy of health coverage that colleges and universities make available to their enrolled students. Typically the student health plan is different from the employer-sponsored group coverage that colleges and universities offer their faculty and staff.

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Does a student health plan count as Minimum Essential Coverage?

Does a student health plan have to cover essential health benefits?

Does a student health plan have to cover essential health benefits?

It does if it is a “fully insured” student health plan. A fully insured plan is one that your college or university purchases from a health insurance company. If your student health plan is fully insured, it must cover essential health benefits, which include

  • 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
  • Pediatric services including oral and vision care

However, if the student health plan is “self-insured,” it might not be required to cover essential health benefits. It’s up to states to regulate self-insured student health plans.  Check with your college or university to find out what type of student health plan they offer, or check with your state insurance regulator to find out what rules apply to your student health coverage.

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Does my student health plan have to cover contraceptives?

Does my student health plan have to cover contraceptives?

Generally, yes it does, if it is a fully insured plan. A fully insured plan is one that your college or university purchases from a health insurance company. These plans are required to provide, without cost sharing, access to all FDA-approved contraceptive methods, sterilization procedures, patient education and counseling prescribed by a health care provider.

However, exceptions are made for institutions of higher education that have religious objections to providing contraceptive services. If you attend such a college or university, the college or university can opt to have the insurance company provide the contraceptive coverage directly to you, separate from the student health plan. Some universities have legally challenged this contraceptive coverage rule. While the litigation is ongoing, some universities may have excluded contraceptive coverage from their fully-insured health plan.

If your student health plan is a self-insured plan, it might not be required to cover contraceptive services. It’s up to states to regulate self-insured student health plans.  Check with your college or university to find out what type of student health plan they offer, or check with your state insurance regulator to find out what rules apply to your student health coverage.

You may have other options as well. If you are under 26, you should check if you are eligible as a dependent in your parent’s health plan. You can also consider buying coverage on your own through the Marketplace. If your income is between 100% and 400% of the federal poverty level and you meet other requirements, you can qualify for premium tax credits; if your income is between 100% and 250% of the federal poverty level you can also qualify for cost-sharing reductions. In addition, if your income is low you might be eligible for Medicaid. Check with your state Marketplace to see if you may be eligible for Marketplace subsidies or Medicaid.

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I’m a part-time student. Does my college have to let me enroll in the student health plan?

I’m a part-time student. Does my college have to let me enroll in the student health plan?

It is up to the college or university to establish eligibility rules for student health plans.

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

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

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

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

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I’m enrolled in student health coverage now, but now I think I can get a better deal in the Marketplace. Can I drop student health plan coverage and go to the Marketplace instead?

I’m enrolled in student health coverage now, but now I think I can get a better deal in the Marketplace. Can I drop student health plan coverage and go to the Marketplace instead?

If you are currently enrolled in a student health plan, you can still qualify for Marketplace policies and subsidies if you apply during Open Enrollment. During Open Enrollment, you can sign up for a Marketplace plan and, if your income is between 100% and 400% of the poverty level you can also apply for premium tax credits. You will have to drop your student health coverage by December 31 in order to remain eligible for premium tax credits for the following year.

Outside of Open Enrollment, you cannot voluntarily drop your student health plan coverage in order to qualify for Marketplace coverage and premium tax credits. However, if you involuntarily lose eligibility for student health plan coverage mid-year – for example, if you drop out of school and so lose eligibility for the student health plan – you will qualify for a “coverage loss” special enrollment opportunity and be able to apply for Marketplace coverage and premium tax credits. The “coverage loss” special enrollment period (SEP) will last 60 days from the date your student health coverage ends.  If you know in advance when coverage will end, you can also apply for the SEP up to 60 days in advance.  If you apply in advance, you can elect to have new coverage begin the following day and avoid a gap in coverage.

If you live in a HealthCare.gov state, you will need to provide proof of coverage loss to qualify for this SEP — for example, a letter or notice from the school stating when coverage will end.

Log into your HealthCare.gov account to apply for the SEP and select a new health plan.  You will then have 30 days to provide documentation to the Marketplace  Once the Marketplace verifies your eligibility, you will be able to complete enrollment in the plan you selected.

It is very important to act quickly to complete this verification process.  If you do not submit the required documentation within 30 days, your plan selection will be cancelled and you will no longer be eligible for the SEP.  If you submit documentation on time but the Marketplace determines it to be insufficient, you can apply for an extension of the 30-day review period to submit additional documentation.  However, you cannot apply for an extension of your SEP.  If your eligibility is not verified by the end of your 60-day SEP, your plan selection will be cancelled and you will not be able to enroll until the next Open Enrollment Period.

If you have questions contact a Navigator or other Marketplace assister program for help.

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I’m a foreign student studying in the U.S. Does the requirement to have health coverage apply to me?

I’m a foreign student studying in the U.S. Does the requirement to have health coverage apply to me?

In general, yes, through 2018.  Starting in 2019, there will be no tax penalty for not having health insurance.

For 2018, people who might otherwise owe a tax penalty can claim an exemption from the penalty directly on their tax return if they experienced a hardship that prevented them from getting coverage.  No documentation is required to be submitted with the tax return, though taxpayers should retain any documentation of the hardship for their own records

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I’m an American college student and I plan to study abroad next semester. Am I required to have U.S. health insurance while I’m living in another country?

I’m an American college student and I plan to study abroad next semester. Am I required to have U.S. health insurance while I’m living in another country?

Beginning in 2019 there is no tax penalty for not having health insurance.  Even so, it is important to have coverage in case you get sick or injured, so it would be worthwhile to explore what coverage options you may have while studying abroad.

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I’m about to turn 19 and I’m covered under my parent’s health plan as a dependent. How long can I stay covered as a dependent?

I’m about to turn 19 and I’m covered under my parent’s health plan as a dependent. How long can I stay covered as a dependent?

Health plans that offer dependent coverage must cover dependents up to their 26th birthday.

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I’m going to a college that offers a student health plan. Can I stay covered as a dependent on my parent’s policy or do I have to take the student health coverage?

I’m going to a college that offers a student health plan. Can I stay covered as a dependent on my parent’s policy or do I have to take the student health coverage?

You can stay on your parent’s plan. Eligibility for student health coverage does not make you ineligible to be covered as a dependent on your parent’s policy up to the age of 26.

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

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

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

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I’m 24 and I used to be covered as a dependent on my parent’s policy. I dropped off last year when I found other coverage, but now I’ve lost that other coverage and want to get back on my parent’s policy. Can I do that?

I’m 24 and I used to be covered as a dependent on my parent’s policy. I dropped off last year when I found other coverage, but now I’ve lost that other coverage and want to get back on my parent’s policy. Can I do that?

Yes. You are still eligible to be covered as a dependent. Your parent’s plan must offer you a special opportunity to re-enroll because you lost other coverage. That special enrollment opportunity must last at least 30 days from the date you lost other coverage.

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

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

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

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

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

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

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I’m covered under my parent’s policy but I’m moving to another state. Can I remain covered as a dependent?

I’m covered under my parent’s policy but I’m moving to another state. Can I remain covered as a dependent?

Yes, you are eligible to be covered as a dependent up to age 26 regardless of where you actually live. However, your parent’s health plan probably has a network of participating providers and it may be difficult for you to find in-network care when you are living in another state. If you find that your parent’s plan doesn’t cover health providers in the state where you live, you can also explore the option of signing up for coverage on your own. Moving will qualify you for a special enrollment opportunity to enroll in other coverage. You might not be able to sign up for new coverage until after you have moved; Marketplaces are no longer required to make the permanent move special enrollment period available to you in advance of your move.  Check the Marketplace web site in your state for more information about permanent move special enrollment period, qualified health plan options and your eligibility for premium tax credits.

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My spouse and I want to cover our 25-year-old son as a dependent on our policy. We have no other children. We don’t claim him as a dependent, he doesn’t live with us, and he has a job. We also have modest income and hope we can qualify for premium tax credits in the Marketplace. Do we have to count our son as a member of our household when we apply? Do we have to count his income when we apply?

My spouse and I want to cover our 25-year-old son as a dependent on our policy. We have no other children. We don’t claim him as a dependent, he doesn’t live with us, and he has a job. We also have modest income and hope we can qualify for premium tax credits in the Marketplace. Do we have to count our son as a member of our household when we apply? Do we have to count his income when we apply?

No. You and your spouse will be counted as a household of two and the income you and he report on your joint tax return will be counted for purposes of determining your eligibility. Your son will be counted separately as a household of one, and his income will be counted separately to determine his eligibility. After the Marketplace decides the amount of premium tax credit each of your “households” are eligible for, the three of you can apply for a family policy offered on the Marketplace and you can apply your combined premium tax credits to reduce what your family has to pay for that policy.

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Can I be covered under my parent’s plan if I’m married?

Can I be covered under my parent’s plan if I’m married?

Yes, as long as you are younger than 26. Being married does not affect your eligibility to be covered as a dependent under your parent’s plan.

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I’m under age 26, covered on my parent’s plan as a dependent, and I’m getting married. Does my parent’s plan have to cover my spouse?

I’m covered as a dependent under my parent’s plan and I’m pregnant. Will my parent’s plan cover my prenatal care and delivery? Will my parent’s plan cover my baby after he’s born?

I’m covered as a dependent under my parent’s plan and I’m pregnant. Will my parent’s plan cover my prenatal care and delivery? Will my parent’s plan cover my baby after he’s born?

The rules are somewhat different depending on the plan your parents have.

If your parents are covered under a small employer plan (less than 50 workers) provided by an insurance company through the Marketplace or outside of the Marketplace, or if your parents are covered under a nongroup policy they bought themselves, then your parent’s plan is required to cover your prenatal care and delivery.

However, if your parents are covered under a group health plan offered by a large employer (50 or more workers), then your parent’s plan is only required to cover your prenatal care, but is not required to cover the delivery. Medicaid covers prenatal and delivery services in all states. You could see if you can qualify for Medicaid on your own.

Your parent’s plan, regardless of the source, generally won’t be required to cover your child as a dependent. You will be responsible for obtaining coverage for your baby. Depending on your income, your child may be eligible for coverage under the Medicaid/CHIP program in your state. Or, you can buy a family policy through the Marketplace and, depending on your income, you may be eligible for a premium tax credit to reduce your cost of that coverage.

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I’m covered as a young adult dependent on my parent’s policy now, but my 26th birthday is next summer, at which point I won’t be eligible for dependent coverage any longer. Should I apply for Marketplace health plans and subsidies now, during Open Enrollment?

I’m covered as a young adult dependent on my parent’s policy now, but my 26th birthday is next summer, at which point I won’t be eligible for dependent coverage any longer. Should I apply for Marketplace health plans and subsidies now, during Open Enrollment?

You can remain covered as a dependent on your parent’s policy until you turn 26. Once you lose eligibility as a dependent, you will qualify for a special enrollment opportunity. At that point, you will also be able to apply for health coverage and assistance through the Marketplace, even though it won’t be during a regular Open Enrollment period.  In addition, if your parent’s policy is a group plan offered by an employer with at least 20 workers, you would also be able to continue coverage under the policy through COBRA for up to 3 years.  However, the employer contribution to the premium would end and Marketplace subsidies cannot be applied to the COBRA coverage.

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My 26th birthday is next week and I will lose coverage under my parent’s plan at the end of this month. Open Enrollment has closed. What do I do now?

My 26th birthday is next week and I will lose coverage under my parent’s plan at the end of this month. Open Enrollment has closed. What do I do now?

You should act now to review your coverage options and sign up for new coverage. You may have more than one option.

If your parent’s plan was offered by an employer with more than 20 workers, you will probably be offered COBRA.  This is an option to continue coverage under the plan for up to 36 months.  COBRA coverage is typically an expensive option because your parent’s employer is no longer required to contribute to the premium, but it may be important option for some young adults, for example, if you are currently in treatment for a condition and prefer not to change coverage now.

You should have or will soon receive a notice from your parent’s plan that your dependent status is about to end and informing you of your right to elect COBRA.  You have 60 days from the latter of that notice or the date dependent coverage ends to elect or decline COBRA coverage.  If you elect COBRA, you have up to 45 days to pay the first premium (COBRA coverage will be effective on the first day after your dependent coverage ended, so the first premium will cover the time retroactive to that date.)  If you don’t make the first payment on time, your COBRA election will not take effect.

Once you elect COBRA and pay the first premium, you will not be eligible to apply for a Marketplace plan with tax credits until the next Open Enrollment period.  Even though COBRA lasts 36 months, you do have the option during each Open Enrollment period to drop COBRA and apply instead for subsidized Marketplace coverage.

The Marketplace is another option to consider.  Premium tax credits subsidize the cost of Marketplace coverage if your income is between 100% and 400% of the federal poverty level, so for many young adults, this option may be more affordable.  Generally people can only apply for Marketplace coverage during Open Enrollment.  However, loss of dependent status under your parent’s plan is a qualifying event that makes you eligible for a special enrollment period (SEP).  Your SEP lasts 60 days from the date of your qualifying event (the day your parent’s coverage ends) but when the coverage loss can be anticipated, you can also apply for new coverage up to 60 days before your qualifying event.  Acting early makes it more likely you won’t have a gap in coverage.

You can apply for Marketplace coverage on your own or ask for help from a Navigator or other Marketplace assister program.  Indicate on the Marketplace website that you are applying for coverage during a SEP and make your plan selection.  In federal Marketplace states, you will be required to provide proof of your qualifying event before your new coverage will take effect.   For example, if you were also eligible for COBRA under your parent’s plan, submitting a copy of your COBRA notice can document your eligibility for the SEP.  Healthcare.gov will give you 30 days from the date you select your new plan to provide proof of your other coverage loss.  It is very important to act quickly to complete this verification process.  If you do not submit the required documentation within 30 days, your plan selection will be cancelled and you will no longer be eligible for the SEP.

Finally, if your income is very low, you might qualify for Medicaid.  Medicaid is open for enrollment year round and, in more than half of the states, will cover adults with income up to 138% of the poverty level (about $16,753 for a single person in 2019.)  You can also apply for Medicaid through the Marketplace and can get help with your application from a Navigator or other in-person assistance program.

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My parents are self-employed and buy coverage through the Marketplace. They earn too much to qualify for subsidies. I’m 24 and only earn $30,000 a year (about 255% of FPL.) My parents don’t claim me as a tax dependent, I file my own return. Can I be covered as a dependent under their Marketplace policy? If so, can I qualify for a premium tax credit and apply that to their premium?

My parents are self-employed and buy coverage through the Marketplace. They earn too much to qualify for subsidies. I’m 24 and only earn $30,000 a year (about 255% of FPL.) My parents don’t claim me as a tax dependent, I file my own return. Can I be covered as a dependent under their Marketplace policy? If so, can I qualify for a premium tax credit and apply that to their premium?

Yes, you can be covered as a dependent up to age 26 on your parent’s Marketplace policy. If your parents don’t claim you as a tax dependent (and you file independently), then your eligibility for premium tax credits will be based on your income alone. With your income at roughly 250% FPL, you will qualify for a premium tax credit. Once you know the amount, you can decide to sign up for a Marketplace policy on your own, or be covered as a dependent on your parent’s policy until you are 26. If you enroll in your parents’ plan, you can elect to have your premium tax credit paid directly to your parents’ insurer each month, or you can claim it on your tax return later when you file.

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What is a Catastrophic Health Plan?

What is a Catastrophic Health Plan?

A “Catastrophic plan” is a qualified health plan offered through the Marketplace that covers essential health benefits and requires the highest level of cost sharing allowable for essential health benefits. In 2019, under a “catastrophic policy,” the annual deductible for covered services is $7,900 for an individual (twice that amount for a family policy.) After you have satisfied the deductible, the plan will pay 100% for covered essential health benefit services that you receive from in-network providers for the remainder of the year. “Catastrophic policies” may also be sold by insurers outside of the health insurance Marketplace.

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Who can buy a Catastrophic Plan?

Who can buy a Catastrophic Plan?

In general, only young adults under the age of 30 are eligible to buy a catastrophic plan. However, older adults can buy a catastrophic plan if no other qualified health plan offered through the Marketplace in 2019 would cost less than 8.3% of income.

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If I qualify for a premium tax credit, can I use that to reduce my cost of a Catastrophic Plan?

If I qualify for a premium tax credit, can I use that to reduce my cost of a Catastrophic Plan?

No. Catastrophic health plans are not eligible for premium tax credits or cost sharing reductions.

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I heard that plans have to cover preventive services without cost sharing. Does this include every preventive service and are there any limits to what is covered?

I heard that plans have to cover preventive services without cost sharing. Does this include every preventive service and are there any limits to what is covered?

Your plan is required to cover a wide range of preventive services and may not impose cost-sharing charges (such as copayments, deductibles, or co-insurance) If you are enrolled in an ACA-compliant, non-grandfathered plan, including plans offered through the Marketplace.  The ACA requires private plans to provide coverage for services under four broad categories: evidence-based screenings and counseling, routine immunizations, childhood preventive services, and preventive services for women. So long as the preventive service is performed by an in-network provider, is not billed separately from the office visit, and is the main reason for the office visit, then the visit and the preventive service will be covered by the insurer without cost-sharing.

If you buy coverage on your own and you first purchased your policy prior to March 23, 2010, it may be a grandfathered plan. These plans are not required to cover preventive services without cost sharing. If you are not sure if your plan is grandfathered, check with your employer or your insurance plan.

In addition, short-term health insurance policies do not have to provide benefits required by the ACA and may not cover preventive services.

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Are there any preventive services for women specifically?

Are there any preventive services for women specifically?

The ACA includes a number of preventive services for women that ACA-compliant, “non-grandfathered” private plans are required to cover without cost sharing. For example, these include counseling and screening services including prenatal and preconception care; breast and cervical cancer screening; genetic counseling and testing for women at high risk of breast cancer; Chlamydia and Gonorrhea screening and counseling for high risk women; at least one well woman visit a year; contraceptive counseling, services and supplies including prescriptions for FDA approved contraceptives; breastfeeding counseling and support services including breast pump rental; and intimate partner violence screening and counseling. So long as the preventive service is performed by an in-network provider, is not billed separately from the office visit, and is the main reason for the office visit, then the visit and the preventive service will be covered by the insurer without cost sharing.

Short-term health insurance policies do not have to provide benefits required by the ACA and may not cover preventive services.

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I am 35 and I think that I am at higher risk for breast cancer because my mother had it. What services must my insurer cover?

I am 35 and I think that I am at higher risk for breast cancer because my mother had it. What services must my insurer cover?

If you believe you are at higher risk, you should discuss with your provider. There are a number of breast cancer screenings and preventive services that insurers must cover for women. If you are enrolled in an ACA-compliant, non-grandfathered plan, your insurance must pay for your provider to assess whether you have a have a family history that makes you at higher risk for certain genetic mutations that are associated with increased risk of breast cancer (BRCA1 and BRCA2). If your provider determines that your family history makes you at increased risk for genetic mutations, your plan must cover the full cost of genetic counseling and genetic testing if recommended. If you end up having one of these genetic mutations, your insurer is also required to cover the full cost of certain preventive medications which can greatly reduce your risk of getting breast or ovarian cancer.

The coverage rule for mammography is based on the Women’s Preventive Services Initiative, adopted by HRSA, that recommends screening mammography every one to two years for women age 40 – 74 years. Since you are under age 40, federal rules do not specify whether your plan must cover the costs of the screening mammogram without cost sharing.

Short-term health insurance policies do not have to provide benefits required by the ACA, including preventive services such as mammography.

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I am purchasing health insurance in my state’s health insurance Marketplace. Is my plan required to cover contraceptives without cost?

I am purchasing health insurance in my state’s health insurance Marketplace. Is my plan required to cover contraceptives without cost?

Yes, your plan must cover the full range of FDA-approved contraceptive methods, but can impose some restrictions on the contraceptives offered at no cost to you. For example, the plan may require that you choose a provider within the network, and use generic rather than brand name contraceptives, unless the brand name is medically necessary. If the generic drug or device does not work for you, you can ask your doctor to request a waiver from the insurance plan to receive the brand name drug or device without cost sharing.

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I would like to get an IUD. Is my plan required to cover the full cost of the brand I would like get?

I would like to get an IUD. Is my plan required to cover the full cost of the brand I would like get?

There are two kinds of IUDs: Hormonal and Copper. The federal law requires most ACA-compliant, “non-grandfathered” plans to cover at least one hormonal IUD (marketed as Mirena, Skyla, Lilleta or Kyleena) as well as the copper IUD (brand name ParaGard) with no cost sharing. The plans must also cover the provider visits for insertion and removal, with no cost sharing. You should talk to your provider about which IUD is best for you. If your plan will not initially cover the hormonal IUD your provider recommends, you should ask your provider to request a “waiver” or “exception” from your insurance plan. However, there are certain types of employers with religious objections to contraception that are not required to provide contraceptive services to their workers and dependents.

Short-term health insurance policies do not have to provide benefits required by the ACA, including contraceptive services.

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I would like to get a NuvaRing but my insurer says that they do not have to cover it since they cover other hormonal methods. I thought all FDA approved contraceptives for women are covered.

I would like to get a NuvaRing but my insurer says that they do not have to cover it since they cover other hormonal methods. I thought all FDA approved contraceptives for women are covered.

In May 2015, the federal government clarified that ACA-compliant plans must cover at least one type of each of the 18 FDA approved methods for women. The NuvaRing is the only available vaginal ring, so plans must cover the NuvaRing without cost sharing.

If your plan does not cover the NuvaRing without a co-payment, you should file an appeal with your insurance plan or check with your State Department of Insurance if you are on an individual plan or with the Federal Department of Labor if you are on a group plan.

Short-term health insurance policies do not have to provide benefits required by the ACA and may not cover preventive services, including contraceptive services.

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I have employer-based coverage and I know my plan is not “grandfathered.” Yet, when I recently filled my prescription for birth control pills, I was charged a co-payment. Aren’t those plans required to cover all contraceptives without cost sharing now?

I have employer-based coverage and I know my plan is not “grandfathered.” Yet, when I recently filled my prescription for birth control pills, I was charged a co-payment. Aren’t those plans required to cover all contraceptives without cost sharing now?

Most non-grandfathered plans (plans that started or made changes after March 23, 2010) must provide contraceptives and related services with no cost sharing when they are obtained through an in-network provider. Plans must cover at least one type of each of the 18 FDA approved methods for women. There are three categories of birth control pills that must be covered: combined hormone, progestin only, and extended/continuous use. However, plans may use reasonable medical management to limit the scope of oral contraceptive coverage within each of these three categories. For example, plans may cover generic oral contraceptives without cost sharing but impose some out-of-pocket charges for equivalent branded drugs. Check with your provider if there is a generic birth control pill available that will work for you. If there is no generic alternative or there is a medical reason you need to use a brand name birth control pill or device, ask your provider to help you request a “waiver” or “exception” from the insurance company. The “waiver” or “exception” would allow you to use the brand name drug or device with no co-payment.

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I was told that my college insurance plan does not pay for contraceptives. Can that be right?

I was told that my college insurance plan does not pay for contraceptives. Can that be right?

The rules affecting student health plans are complicated and depend on the type of plan your college or university may offer.  If your student health plan is fully-insured, it should cover all 18 FDA-approved contraceptive methods for women as prescribed, without cost sharing.  However, if your college or university has a religious objection to providing contraceptive coverage, then it may have opted to have the insurance company provide the coverage directly to policyholders.  Some universities have legally challenged the contraceptive coverage rule.  While this litigation is ongoing, some universities may have excluded contraceptive coverage from their student health plan.

If your college has a self-funded health plan, then it is not subject to requirements under the Affordable Care Act, including covering contraceptives with no cost sharing. Ask your college if the plan is self-funded. If it is self-funded, state laws that may require some coverage of contraceptives. Check with your State Insurance Department about the state law. You may have other options as well. If you are under 26, you should check if you are eligible as a dependent in your parent’s health plan.  You can also consider buying coverage on your own through the Marketplace. If your income is between 100% and 400% of the federal poverty level and you meet other requirements, you can qualify for premium tax credits; if you income is between 100% and 250% of the federal poverty level, you can also qualify for cost sharing reductions. In addition, you might be eligible for Medicaid. Check with your state Marketplace to find out if you meet the income and other eligibility standards to enroll in Medicaid coverage.

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I’ve been uninsured and just enrolled in a health plan through my Marketplace. I’ve been getting my birth control at a Family Planning Clinic. Will I still be able go there to get my birth control for free?

I’ve been uninsured and just enrolled in a health plan through my Marketplace. I’ve been getting my birth control at a Family Planning Clinic. Will I still be able go there to get my birth control for free?

It depends. Your Family Planning Clinic may be a covered provider in your new health plan network. If so, you can continue to go there for your birth control without cost-sharing. If your Family Planning Clinic is not in the network, you may still qualify for free or reduced cost services from the clinic. Check with your clinic for more information.

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My husband would like to get a vasectomy but when I checked with our insurer, they told me that the plan would cover my sterilization without cost sharing but we would have to pay part of the costs for his procedure. What is the reason for that?

My husband would like to get a vasectomy but when I checked with our insurer, they told me that the plan would cover my sterilization without cost sharing but we would have to pay part of the costs for his procedure. What is the reason for that?

Contraceptives, including sterilization, are covered only for women as preventive services by ACA-compliant plans. Since sterilization for men is not considered a preventive service under the Affordable Care Act, federal law does not require plans to cover vasectomies.  However, seven states (Colorado, Illinois, Maine, Maryland, Oregon, Vermont and Washington) require individual and fully-insured group health plans to cover vasectomies.  State laws vary on cost-sharing requirements.  Check with your State Department of Insurance for more information.

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When can plans limit coverage of particular contraceptives?

When can plans limit coverage of particular contraceptives?

There are a number of ways that plans or employers can limit contraceptive services.  Federal law requires that ACA-compliant plans must cover at least one form of each the 18 contraceptive methods for women identified by the FDA. But, a plan may apply reasonable medical management techniques such as prior authorization or step-therapy, and require cost-sharing for certain contraceptive drugs or devices to encourage an individual to use specific services or items within a chosen FDA approved contraceptive method. However, the plan must have a process in place to ensure that your particular contraceptive service or product is covered without cost sharing when your specific provider recommends it based on medical necessity.  In addition, you must get your contraceptive care from an in-network provider.  Insurers may charge cost sharing if you go to an out-of-network provider for contraceptive care.

In addition, if your employer is affiliated with a faith-based organization, they can limit the types of contraceptives they wish to cover based on religious objections.  Specifically, all houses of worship are exempt.  Other employers and universities that are affiliated with faith-based organizations that oppose some or all contraceptive methods may also opt to exclude coverage, and have the insurance company provide the contraceptive coverage directly to policyholders.  There is ongoing litigation about which employers are exempt and can exclude contraceptive services.

Short-term health insurance policies do not have to provide benefits required by the ACA and may not cover preventive services including contraceptive services.

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Do I need a referral to go to my OBGYN if I am enrolled in a non-grandfathered plan?

Do I need a referral to go to my OBGYN if I am enrolled in a non-grandfathered plan?

If you are enrolled in a non-grandfathered plan, then you must be allowed to see your OBGYN without a referral. Women in grandfathered plans and Medicaid may be able to schedule a visit with an OBGYN without a referral. Check with your plan.

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What services do plans have to cover for pregnant women?

What services do plans have to cover for pregnant women?

Federal law requires most employer and all ACA-compliant individual insurance plans, including those available through the Marketplaces, to cover maternity services including child birth and newborn care. These plans also must cover prenatal visits and screenings, folic acid supplements, tobacco cessation counseling and interventions, and breastfeeding services without any co-pay because they are considered preventive services. All state Medicaid programs cover maternity care without cost-sharing to low-income women who qualify for coverage.

Short-term health insurance policies do not have to provide benefits required by the ACA, such as preventive and maternity care, and most short-term plans will likely exclude maternity services.

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I’m covered as a dependent under my parent’s plan and I’m pregnant. Will my parent’s plan cover my prenatal care and delivery? Will my parent’s plan cover my baby after he’s born?

I’m covered as a dependent under my parent’s plan and I’m pregnant. Will my parent’s plan cover my prenatal care and delivery? Will my parent’s plan cover my baby after he’s born?

The rules are somewhat different depending on the plan your parents have.

If your parents are covered under a small employer plan (less than 50 workers) provided by an insurance company through the Marketplace or outside of the Marketplace, or if your parents are covered under a nongroup policy they bought themselves, then your parent’s plan is required to cover your prenatal care and delivery.

However, if your parents are covered under a group health plan offered by a large employer (50 or more workers), then your parent’s plan is only required to cover your prenatal care, but is not required to cover the delivery. Medicaid covers prenatal and delivery services in all states. You could see if you can qualify for Medicaid on your own.

Your parent’s plan, regardless of the source, generally won’t be required to cover your child as a dependent. You will be responsible for obtaining coverage for your baby. Depending on your income, your child may be eligible for coverage under the Medicaid/CHIP program in your state. Or, you can buy a family policy through the Marketplace and, depending on your income, you may be eligible for a premium tax credit to reduce your cost of that coverage.

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I just found out that I’m pregnant and my baby is due in March. Can I enroll in a plan though the health insurance Marketplace?

I just found out that I’m pregnant and my baby is due in March. Can I enroll in a plan though the health insurance Marketplace?

Yes.  However, you may only enroll during Open Enrollment period (November 1, 2016 – January 31, 2017).  Once enrolled, your plan will be required to cover maternity services.  You may also qualify for a premium subsidy, depending on your family income and your eligibility for employer coverage.  Once born, you can add the baby to the plan.  You will also be allowed to change plans at that time.  Birth of a child is a qualifying event that allows you to enroll in or change your coverage, no matter when during the year the baby is born.  Your special enrollment period will last for 60 days from the date of birth.  Adding the baby will change the plan premium and also your subsidy, assuming you qualify for premium tax credits. Depending on your income and the state you reside in, you might also qualify for Medicaid and there is not a limited open enrollment period for Medicaid.

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I am pregnant and plan to breastfeed my baby. How does the ACA affect breastfeeding services?

I am pregnant and plan to breastfeed my baby. How does the ACA affect breastfeeding services?

The ACA requires that all new ACA-compliant plans, including those in the employer market, individual market, and health insurance Marketplaces, cover lactation counseling and breast pump rental without any charge. Check your plan details to find out the specific number of counseling sessions and type of breast pump that it covers, or if your plan covers purchase of a breast pump. If you are nursing and work for a large employer (50 or more employees), your employer must provide access to a private room (that is not a bathroom) and break time for you to express milk.

Short-term health insurance policies do not have to provide benefits required by the ACA, including breastfeeding services.

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I have been trying to get pregnant. Will the plans on the exchanges cover infertility services?

I have been trying to get pregnant. Will the plans on the exchanges cover infertility services?

This will vary by state. Some states have requirements that plans cover some infertility services, but there is no national requirement for coverage of infertility services. If you need these services and are shopping for coverage, check the plan details about coverage and out of pocket charges for infertility care.

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How do I project my household size/income for next year if I’m pregnant now? I’m married and this pregnancy will be our first child. We want to find subsidized coverage in the Marketplace.

How do I project my household size/income for next year if I’m pregnant now? I’m married and this pregnancy will be our first child. We want to find subsidized coverage in the Marketplace.

During Open Enrollment, you and your spouse will apply as a household of two. When the baby is born, you can update your family information with the Marketplace to reflect that you have become a household of three. At that point, you may qualify for a larger premium tax credit. (For example, if you and your spouse together expect to earn a 2019 income that is twice the federal poverty level for a household of two ($32,920), you would be required to contribute about 6.54% of your household income toward the premium for the benchmark plan in the Marketplace. Once the baby is born and you are a household of three, that income would constitute just 158% of the federal poverty level for a family of three and you would only be required to contribute about 4.15% of your income. When you report your new family status to the Marketplace you will also have a 60-day special enrollment opportunity to add the baby to your plan and increase your advanced premium tax credit amount.  You will also have the option of enrolling your baby in a different plan.  However, you and your spouse generally will not be able to change health plans as a result of the “newborn” special enrollment period.

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I am currently uninsured and plan to purchase coverage through the health insurance Marketplace. Do the insurance plans in the Marketplace cover abortions?

I am currently uninsured and plan to purchase coverage through the health insurance Marketplace. Do the insurance plans in the Marketplace cover abortions?

It depends on where you live and the specific plan you choose. Some states allow plans in the Marketplace to cover all abortions and some states prohibit or limit plans’ coverage of abortion to certain cases. In half the states, Marketplace plans are prohibited from offering coverage that includes abortions, or are restricted to covering abortions in very limited circumstances. You should check the plan details to find out whether your plan covers abortion services.

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Does Medicaid cover abortions?

Does Medicaid cover abortions?

In general, Medicaid coverage for abortion is very limited. In most states, Medicaid covers abortions only when the pregnancy is the result of rape or incest or if the woman’s life is endangered because federal law limits the use of federal funds to these circumstances. However, 16 states do go beyond this limit and use state funds to cover other abortions.

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My partner and I are unmarried and we have two children. How do we count our household size and income when we apply for subsidies in the Marketplace? Can we buy one policy to cover the whole family?

My partner and I are unmarried and we have two children. How do we count our household size and income when we apply for subsidies in the Marketplace? Can we buy one policy to cover the whole family?

Assuming you are eligible for premium tax credits, the amount of your credit will be calculated based on how you file your taxes. If for example, you each claim one of your children, you each will be considered as a household of two. The income of each household would be evaluated separately to calculate eligibility for and the amount of premium tax credits and cost-sharing reductions.  Using a different example, if you claim both children as dependents on your tax return, then you and your children will be considered a household of 3, your income will be the basis for determining subsidy eligibility for the 3 of you. Your partner will be a household of one and his/her eligibility for premium tax credits will be determined separately. As for the type of coverage your family can purchase, that may vary based on the Marketplace rules where you live. For example, some insurers may offer family coverage only to married couples. If you buy one policy for the entire family, all the tax credits you are eligible for can be used to reduce the premium for that policy. If you buy separate policies, you can allocate the premium tax credits across two plans.

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My partner and I are unmarried. Can we buy a policy that covers us both? Are we counted as a household of two?

My partner and I are unmarried. Can we buy a policy that covers us both? Are we counted as a household of two?

The rules for premium tax credit eligibility will be the same in all states; however the type of policy you can buy will depend on where you live.

Because you are not married, you will be considered two separate households for the purposes of determining eligibility for premium tax credits and Medicaid. Assuming that neither of you are claiming any dependents on your tax returns, you will each be considered as a household of one and your own income will be used to determine eligibility for premium tax credits and Medicaid as well as the amount of any premium tax credit and cost-sharing reduction you may qualify for. If you are eligible for premium tax credits, you will each receive a separate determination of the amount of your credit and whether you are eligible for a cost-sharing reduction. Whether you can use your credits to buy a family policy rather than two individual policies will depend on the offerings in your state Marketplace.

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Does being lesbian, gay, bisexual, or transgender (LGBT) affect my health insurance coverage and options? What if I am legally married to my same-sex partner?

Does being lesbian, gay, bisexual, or transgender (LGBT) affect my health insurance coverage and options? What if I am legally married to my same-sex partner?

The Affordable Care Act (ACA) and other federal policies provide protections for LGBT individuals and their families.

Health insurance Marketplaces, which are organizations set up in every state to create more organized and competitive markets for buying coverage, are prohibited from discriminating on the basis of sexual orientation and gender identity. You cannot be turned away or charged more for being lesbian, gay, bisexual, or transgendered. You also can’t be denied coverage or charged more because of any pre-existing health condition, such as your HIV status.  Insurers can’t limit how much they’ll spend on your medical care – over a year or over a lifetime.

Under the ACA, these protections extend to the health benefits provided in the Marketplace plans, which cannot discriminate based on sexual orientation, gender identity, or health status in how they design their essential health benefits.

In addition to these Marketplace protections, the ACA prohibits discrimination based on gender identity and sex-stereotyping (which in some cases may include sexual orientation) in all health programs that receive federal funding, such as Medicaid and Medicare, among other programs.

There are also other federal policies designed to protect you and your family.  Virtually all hospitals must now allow visitation by a same-sex partner (whether or not you are married) and same-sex partners must be afforded the same treatment as other spouses for long-term care, such as nursing home care under Medicaid.  In addition, same-sex couples (whether or not you are married) now have the same rights as others to name a representative to make medical decisions on a patient’s behalf.

Supreme Court Rulings and What They Mean for Your Insurance Options if you are Legally Married to a Same-Sex Partner:

Beyond the protections under the ACA, the Supreme Court’s June 2013 ruling (overturning part of the Defense of Marriage Act (DOMA) in United States v. Windsor) and subsequent June 2015 ruling (in Obergefell v. Hodges that same-sex couples have the right to marry in all states) mean that same-sex marriages are  recognized under federal and state law.  This has implications for the health care Marketplaces as well as for Medicaid and CHIP, Medicare, and coverage through your employer:

Health Care Marketplace: Legally married same-sex couples can apply jointly for tax credits in the Marketplace.  These tax credits help you pay the costs of your health plan.  Tax credits are calculated based on your federal income tax filing, so marketplaces must recognize same-sex marriages and base eligibility on a married couple’s income.  In fact, legally married couples, including same-sex couples, must file a joint tax return to gain access to these tax credits. If you are not legally married – if you are in a domestic partnership, a civil union, or another relationship –you may still be able to get these credits but will need to apply for them separately as individuals instead of as a couple; depending on your state Marketplace, you may be able to use your individual credits to buy a family policy rather than two individual policies.

Medicaid and CHIP: All states must recognize same-sex marriages when determining whether or not you meet your state’s income eligibility requirement for Medicaid and CHIP.

Medicare: If you are married to your same-sex partner, you may now qualify for Medicare coverage based on your spouse’s work history.

Health coverage through an employer: All federal employees, federal contractors, members of the military, veterans, and state employees who are legally married to a same-sex partner may now obtain spousal health benefits for their partner. In addition, all health insurance issuers who offer coverage to opposite-sex spouses must also offer coverage to same-sex spouses.  However, there remains some question about whether private employers can legally limit spousal coverage to opposite-sex spouses only, many experts believe that an employer who does so would likely found to be in violation of federal Civil Rights law.

Department of Veterans Affairs:  The VA recognizes same-sex marriages and will extend benefits to same-sex spouses of Veterans, including CHAMPVA health coverage, survivor compensation, and burial benefits

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Can immigrants enroll in Medicaid or Children’s Health Insurance Program (CHIP) coverage?

Can immigrants enroll in Medicaid or Children’s Health Insurance Program (CHIP) coverage?

Most lawfully present immigrants who meet Medicaid and CHIP program requirements, such as income and state residency, can enroll in Medicaid or CHIP after they have been in the United States for 5 years or more.

Some groups of lawfully present immigrants do not have to wait five years before they may enroll in Medicaid and CHIP. These include refugees, asylees, and other humanitarian immigrants; veterans and military families; and pregnant women and children in some states.

Some lawfully present immigrants who are authorized to work in the United States cannot enroll in Medicaid, even if they have been in the country for five or more years.

Undocumented immigrants may not enroll in Medicaid or CHIP coverage.

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Can immigrants buy health insurance through the Health Insurance Marketplaces?

Can immigrants buy health insurance through the Health Insurance Marketplaces?

Most lawfully present immigrants can buy health insurance through the Health Insurance Marketplaces. This group includes lawfully present immigrants who cannot enroll in Medicaid based on immigration status.

Undocumented immigrants may not purchase coverage through the Health Insurance Marketplaces.

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Can immigrants get help paying premiums and/or cost-sharing for health insurance in the Marketplaces?

Can immigrants get help paying premiums and/or cost-sharing for health insurance in the Marketplaces?

Lawfully present immigrants can get tax credits to help pay premiums and cost-sharing for health insurance through the Marketplaces. Like citizens, they can get tax credits to help pay premiums if they make between 100% and 400% of the federal poverty level. They can also qualify for cost sharing reductions if they make between 100% and 250% of the federal poverty level.  To get this help, they cannot be offered affordable health insurance through their job or be eligible for Medicaid.

Lawfully-present immigrants who make less than 100% of the federal poverty level  also can get help paying premiums and cost sharing if they cannot enroll in Medicaid due to immigration status. Many lawfully-present immigrants cannot enroll in Medicaid until they have been in the United States for five or more years.

Undocumented immigrants cannot receive help paying for premiums or cost sharing for Marketplace coverage and may not buy health insurance through the Marketplaces even at full cost.

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Can family members in families with mixed immigration status, where some family members are citizens or lawfully present and others are undocumented, enroll in Medicaid or CHIP or receive help buying coverage through the Marketplaces?

Can family members in families with mixed immigration status, where some family members are citizens or lawfully present and others are undocumented, enroll in Medicaid or CHIP or receive help buying coverage through the Marketplaces?

Citizen and lawfully present family members can get health insurance coverage through Medicaid, CHIP, and Marketplaces even if other family members are not lawfully present. Family members who are not lawfully present, including undocumented immigrants, may apply for health insurance for citizen and lawfully present family members. For example, an undocumented immigrant parent may apply for health insurance for a citizen child.

When a family with mixed immigration status applies for health insurance, it only has to give citizenship and immigration status for those family members applying for coverage. Non-applicants, such as a parent applying for a child, do not have to provide citizenship or immigration status. Non-applicants will be asked to provide a Social Security Number, but do not have to provide one unless the family is applying for help with costs for Marketplace coverage and the individual is the tax-filer for the household, and the individual has a SSN.  Information provided by applicants will not be used for immigration enforcement purposes.

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How will an individual’s citizenship and immigration status be checked?

How will an individual’s citizenship and immigration status be checked?

Only those individuals in a family who are applying for health insurance are required to provide citizenship and immigration status. Applicants also must provide a Social Security Number if they have one.  Information provided by applicants will not be used for immigration enforcement.

Citizenship and immigration status for those applying for health insurance will be checked electronically with several systems, including the Social Security Administration, the Department of Homeland Security, and SAVE (Systematic Alien Verification for Entitlements).

If an individual’s status cannot be checked through an electronic match, the individual can give other documentation of his or her status.

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Will getting health insurance through Medicaid, CHIP, or Health Insurance Marketplaces affect an individual’s ability to obtain lawful permanent resident status or citizenship?

Will getting health insurance through Medicaid, CHIP, or Health Insurance Marketplaces affect an individual’s ability to obtain lawful permanent resident status or citizenship?

Currently, getting health insurance through Medicaid, CHIP, or the Marketplaces generally will not prevent an individual from obtaining lawful permanent resident status (get a green card) or citizenship.  One exception would be if an individual is receiving long-term care in an institution that is financed by Medicaid.

The rules may change for people seeking a green card in the future, but those changes are not yet final.  If you are living in the U.S. and applying for a green card here, you can still get health insurance through Medicaid, CHIP, or a Health Insurance Marketplace without affecting your application.  Get help deciding what is best for your family and consult with an immigration attorney if you can.  You can use this online directory to search for local nonprofit organizations that provide legal help and advice:  http://www.immigrationlawhelp.org

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Will getting health insurance through Medicaid, CHIP, or Health Insurance Marketplaces put undocumented family members at risk?

Will getting health insurance through Medicaid, CHIP, or Health Insurance Marketplaces put undocumented family members at risk?

Medicaid, CHIP, and the Marketplaces must protect individuals’ information and keep it private. Information can be used only for eligibility and enrollment purposes.  Information provided by applicants will not be used for immigration enforcement purposes.

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Are immigrants required to have health insurance coverage under the Affordable Care Act’s individual mandate?

Are immigrants required to have health insurance coverage under the Affordable Care Act’s individual mandate?

Most immigrants who are residents lawfully present in the U.S., including “green card holders,” are subject to the ACA’s individual mandate.

However, for 2018, people who lack coverage during the year can claim an exemption from the tax penalty directly on their tax return if they experienced circumstances that prevented them from obtaining coverage.  No documentation of the hardship is required to be submitted with the tax return, though taxpayers should retain all documentation for their files.

Starting in 2019, there will be no tax penalty for failing to have health insurance coverage.

Immigrants who are not lawfully present in the U.S. will not pay a tax penalty if they do not have health insurance.

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Who is a lawfully present immigrant for health insurance purposes?

Who is a lawfully present immigrant for health insurance purposes?

Lawfully present immigrants generally include:

  • lawful permanent residents (or “green card holders”);
  • persons fleeing persecution, including refugees and asylees;
  • other humanitarian immigrants, including those granted temporary protected status;
  • Cuban/Haitian entrants; and
  • survivors of domestic violence, trafficking, and other serious crimes.

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Are individuals granted deferred action under “Deferred Action for Childhood Arrivals” eligible for Medicaid, CHIP, and the Health Insurance Marketplaces?

Are individuals granted deferred action under “Deferred Action for Childhood Arrivals” eligible for Medicaid, CHIP, and the Health Insurance Marketplaces?

Some undocumented youth have been given temporary permission to stay in the United States under a program called Deferred Action for Childhood Arrivals. These individuals are lawfully present in the United States and can be granted work authorization and Social Security numbers. However, they are not eligible for Medicaid, CHIP, or the Marketplaces.

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Where can immigrants get health care or health coverage when they cannot enroll in Medicaid or CHIP or get coverage through the Marketplaces?

Where can immigrants get health care or health coverage when they cannot enroll in Medicaid or CHIP or get coverage through the Marketplaces?

Hospitals are required to provide emergency care and treatment to all individuals regardless of immigration or insurance status, though afterwards they can bill for their services. In addition, individuals may get low-cost care at community health centers.

Individuals may purchase health coverage through an employer or a spouse’s employer or the individual insurance market outside of the Marketplace. Some states and counties also offer health programs for immigrants.

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I entered the U.S. lawfully and I’m over 65, but I don’t qualify for Medicare. Can I apply for coverage and subsidies in the Marketplace? I hear premiums can be higher based on age. How much higher can my premium be if I’m over age 65?

I entered the U.S. lawfully and I’m over 65, but I don’t qualify for Medicare. Can I apply for coverage and subsidies in the Marketplace? I hear premiums can be higher based on age. How much higher can my premium be if I’m over age 65?

Yes, you can purchase Marketplace coverage and qualify for subsidies based on your income. Premiums for Marketplace plans can vary by age unless States decide otherwise. In most states, your premium (before taking into account tax credits) could be up to three times that charged for somebody in their early 20s. Several states prohibit age adjustments to premiums or require lower age adjustments.

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Am I required to have health insurance?

Am I required to have health insurance?

Congress eliminated the federal tax penalty for not having health insurance, effective January 1, 2019.

For 2018, most people are required to have health insurance or else pay a tax penalty, unless they qualify for an exemption.  This is called the individual responsibility requirement, or the individual mandate.

While the federal tax penalty continues to apply for 2018, recent changes will make it easier for people to claim a hardship exemption, and so owe no penalty, when they file their 2018 federal income tax return.  If you experienced a hardship that prevented you from getting coverage in 2018, just check the box on the front of Form 1040, indicating that you qualify for a hardship exemption.  You will not be required to submit proof of the hardship with your tax return, though you should retain any documentation for your own records.

Several states have adopted individual mandates with state tax penalties for not having health insurance.  These include Massachusetts, New Jersey, and the District of Columbia, effective for the 2019 calendar year.  Vermont will impose a tax penalty for not having health insurance starting in 2020.  Other states are considering state individual mandates.  Check with your tax adviser for more information.

Regardless of the penalty, it is important to have health coverage if you can.  Health insurance continues to be offered during annual Open Enrollment periods.  If you don’t sign up during Open Enrollment you might have to wait up to one year until your next opportunity to enroll.

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Will my employer be required to provide health insurance benefits to me?

Will my employer be required to provide health insurance benefits to me?

If you’re a full-time worker and work for a large employer, your employer will face a penalty if they don’t provide coverage. Some employers may opt to take the penalty and not offer coverage. Check with your employer to see what they offer.

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I’m a migrant seasonal worker. Can I buy health insurance in the Marketplace where I live now? If I move to another state during the year, can I keep the plan I bought here or will I have to buy different coverage?

I’m a migrant seasonal worker. Can I buy health insurance in the Marketplace where I live now? If I move to another state during the year, can I keep the plan I bought here or will I have to buy different coverage?

Eligibility to buy coverage in the Marketplace is based on where you establish your permanent residence. Some health insurers will offer larger networks than other plans and may offer regional or national provider networks. Once Open Enrollment begins, check the plans available in your Marketplace to see if there is a plan with provider coverage in the areas you work.  If your move during the year is a permanent move, not just a temporary one, you may qualify for a special enrollment period following the permanent move.

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I’m working on an H-2A visa. Am I eligible for coverage in the Marketplace?

I’m working on an H-2A visa. Am I eligible for coverage in the Marketplace?

Yes. All lawfully-present immigrants – including “nonimmigrants” like H-2A workers and those on student visas – may purchase insurance in the Marketplace. Those who are low-income and otherwise eligible may also receive premium assistance and cost-sharing reductions to lower the cost of coverage in Marketplace plans.

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I’m undocumented. Will I be required to have health insurance? Can I buy health insurance or apply for subsidies on the Marketplace?

I’m undocumented. Will I be required to have health insurance? Can I buy health insurance or apply for subsidies on the Marketplace?

No, you are not required to have health insurance. Undocumented immigrants are not eligible to buy coverage in the Marketplace.

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I’m an employer with agricultural workers. Am I required to provide health benefits to all of my workers?

I’m an employer with agricultural workers. Am I required to provide health benefits to all of my workers?

If you are a large employer (you have more than 50 full-time equivalent employees), you may owe a penalty if you do not provide affordable and minimum essential coverage to all of your full-time employees. A full-time employee is one that averages more than 30 hours per week of work, although there are special rules for employees with variable hours.

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My workers are seasonal employees. Do I count them in determining whether I am a large employer?

My workers are seasonal employees. Do I count them in determining whether I am a large employer?

In general, an employer is considered a “large” employer for the purposes of the Affordable Care Act if the employer has more than 50 full-time-equivalent workers per year. Seasonal workers do count among your full-time employees unless your business qualifies for the seasonal worker exemption. The seasonal worker exemption applies if: a) you had more than 50 employees for fewer than 120 days, and b) during the 120 period you would have had fewer than 50 employees if you excluded your seasonal workers. The 120 days (or 4 months) do not need to be consecutive. For example, Farm A has 30 full-time, year round employees, and hires 25 workers to work 50 hours per week during a 2-month planting season in the winter, and then invites the same crew back for a 3-month harvest season in the fall. Farm A is a “large” employer because the Farm employs more than 50 full-time workers for more than 120 days.

Farm B has 30 full-time, year round employees, and hires 25 workers to work 50 hours per week during a 3 month harvest only. This employer is a “small” employer because the number of full-time employees exceeded 50 during a period that is less than 120 days, and during that time the seasonal worker exemption applies, because after excluding the seasonal employees you had fewer than 50 full-time workers.

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What are the penalties for me, as an employer, if I don’t provide health benefits to my seasonal workers?

What are the penalties for me, as an employer, if I don’t provide health benefits to my seasonal workers?

If you are a large employer, you will face a penalty if you do not offer affordable coverage that meets minimum value to all of your full-time employees and their dependent children. If, as an employer, you’re unsure whether or not your seasonal workers are full-time employees, you can use a special measurement period (a three- to twelve-month look back, at your discretion) to decide if your employees are in fact seasonal or full-time. During this measurement period, you don’t have to offer coverage, but if it turns out an employee did work full-time during that measurement period, you must treat that employee as full time during a subsequent “stability” period (which must be the longer of six months or the length of the measurement period that you chose) and offer that worker health benefits regardless of their actual hours worked during the stability period. Full-time means the employee worked on average 30 hours a week over the measurement period.

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I run a small farm (less than 50 employees) with a mix of full-time and part-time workers. Am I required to offer coverage?

I run a small farm (less than 50 employees) with a mix of full-time and part-time workers. Am I required to offer coverage?

No, there is no requirement for small employers to offer health benefits to their workers.

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I use a farm labor contractor to provide most of the workers for my farm. Is the contractor required to provide health benefits or am I?

I use a farm labor contractor to provide most of the workers for my farm. Is the contractor required to provide health benefits or am I?

The proposed IRS rules governing employer responsibilities utilize the common law standard to identify whether an individual is an “employee” of a business, for the purposes of assigning employer responsibility to provide coverage. In general, this means that an employer has the right to direct what an employee does and how it is done. Whether a farm labor contractor or a farm itself is responsible for providing coverage thus depends on which entity “directs what an employee does and how it is done.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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I work for a large employer (more than 50 full time employees) but my hours vary during the year. I work full-time during the summer but part-time the rest of the year. Does my employer have to offer me health benefits?

I work for a large employer (more than 50 full time employees) but my hours vary during the year. I work full-time during the summer but part-time the rest of the year. Does my employer have to offer me health benefits?

Large employers must offer health benefits to employees who work, on average, at least 30 hours per week, or else pay a tax penalty. Check with your employer/human resources department to find out if your hours worked over the year meet this threshold. If your hours vary during the year, your employer may have some options in determining your status as a full-time or part-time worker. Your employer can tell you whether you are a full or part-time worker.

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I work full time for a small business (fewer than 50 employees). Does my employer have to offer me health benefits?

I work full time for a small business (fewer than 50 employees). Does my employer have to offer me health benefits?

No, small businesses are not required to offer health benefits to either full-time or part-time employees, or to their dependents. Small businesses are not subject to tax penalties when they don’t offer health benefits. If your small employer doesn’t offer health benefits, you (and your family) can apply for coverage in the Marketplace; and, if your income is between 100% and 400% of the federal poverty level, you can apply for a premium tax credit that may reduce the cost of coverage in the Marketplace.

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When can I enroll in my employer health plan?

When can I enroll in my employer health plan?

Usually, you can sign up for health benefits when you are first hired. Most employers also have an annual open enrollment period, or open season, when you can sign up for coverage or (if your employer offers a choice of plans) change your enrollment to a different health plan. In addition, there are special circumstances, called “qualifying events” that trigger a “special enrollment opportunity” outside of the normally scheduled annual open season. These qualifying events include loss of eligibility for other coverage (for example, because of job loss or reduction in hours worked, death, divorce or legal separation, or loss of dependent status) and certain life events such as marriage, or the birth or adoption of a child. In general, you must be offered a special enrollment opportunity of at least 30 days following these qualifying events to enroll in your job-based health plan.

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We just had a baby. Can I add my baby to the family health plan offered by my employer?

We just had a baby. Can I add my baby to the family health plan offered by my employer?

Yes. Having a baby is one of the special circumstances that allow you to add dependents to your health plan even outside of the regular open season. You have 30 days from the date of your child’s birth to notify your employer and request that the baby be enrolled in your coverage.

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We just had a baby. Before that my spouse and I were each covered under our own health plans at our own jobs, but now we want the family covered under one policy. Can we all switch to my employer plan now?

We just had a baby. Before that my spouse and I were each covered under our own health plans at our own jobs, but now we want the family covered under one policy. Can we all switch to my employer plan now?

Yes. Having a baby is one of the special circumstances that allow you to add dependents to your health plan even outside of the regular open season. You have 30 days from the date of your child’s birth to notify your employer and request that your spouse and your baby be enrolled in your coverage.

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I was just hired and told I’m not eligible for health benefits right away. New employees have to satisfy a waiting period. Is that allowed?

I was just hired and told I’m not eligible for health benefits right away. New employees have to satisfy a waiting period. Is that allowed?

Yes, employers can require a waiting period before new employees are eligible to enroll in a group health plan. These waiting periods are not allowed to be longer than 90 days. If you are concerned that your employer requires a waiting period longer than 90 days, you can contact the US Department of Labor at 1-866-444-3272.

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I work and am eligible for health benefits. Do I have to sign up for my job-based plan or will my employer do that for me?

I work and am eligible for health benefits. Do I have to sign up for my job-based plan or will my employer do that for me?

You generally are responsible for enrolling in a health plan offered by an employer, so it’s up to you to sign up for coverage under the rules and procedures established by your employer health plan.

Some employers may use auto-enrollment, which means that your employer will enroll you in a plan and you must opt-out of the plan if you do not want to be covered. If your employer auto-enrolls you in the group health plan, you must be given the opportunity to disenroll if you want or to change plans if your employer offers more than one option. If you have concerns with the way auto-enrollment in health coverage is handled at your job, you can contact the US Department of Labor at 1-866-444-3272.

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My employer offers health benefits but doesn’t contribute much toward the premium. I can’t afford my share. Can I apply for coverage and subsidies in the Marketplace instead?

My employer offers health benefits but doesn’t contribute much toward the premium. I can’t afford my share. Can I apply for coverage and subsidies in the Marketplace instead?

You can always shop for health coverage in the Marketplace. However, if you’re offered employer health benefits, you can’t qualify for premium tax credits in the Marketplace unless your employer coverage is considered unaffordable. If your share of the premium for self-only coverage in your employer plan is 9.86% or more of your 2019 household income, it is considered unaffordable, and you can apply for premium tax credits in the Marketplace.

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My employer offers health benefits to me and my family. The company pays the entire cost of my coverage but contributes nothing toward the cost of covering my family. We can’t afford to enroll my spouse and kids. Can they get coverage and subsidies in the Marketplace instead?

My employer offers health benefits to me and my family. The company pays the entire cost of my coverage but contributes nothing toward the cost of covering my family. We can’t afford to enroll my spouse and kids. Can they get coverage and subsidies in the Marketplace instead?

You can always shop for health coverage in the Marketplace. However, your employer-provided coverage is considered “affordable.” That’s because the affordability of employer sponsored coverage is only measured with respect to self-only coverage. Because your employer pays the entire cost of the employee-only coverage, you are technically considered to have affordable coverage (even though practically speaking, it was unaffordable to you.) As a result, neither you nor your spouse and children are eligible to apply for premium tax credits in the Marketplace. Sometimes this rule is referred to as “the family glitch.”

There are some other things you should know. First, depending on your family income, your children might qualify for the Children’s Health Insurance Program in your state. Check with your state Marketplace to find out if your children may be eligible for CHIP.

Second, if you find you cannot afford to get coverage for your spouse and/or children, you should know that starting in 2019, there is no tax penalty for not having health insurance.

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Apparently my family isn’t eligible for subsidies in the Marketplace because I am eligible for self-only coverage at work that is considered affordable and my family is also offered coverage but the cost of family coverage is not affordable. But we can’t afford to buy Marketplace coverage on our own. Will I have to pay a penalty because my family members are uninsured?

I’m offered health benefits at work, but they’re not very good. I’m applying for better coverage and subsidies in the Marketplace. The application asks whether I’m offered job-based health coverage that meets minimum value. What does that mean?

I’m offered health benefits at work, but they’re not very good. I’m applying for better coverage and subsidies in the Marketplace. The application asks whether I’m offered job-based health coverage that meets minimum value. What does that mean?

The term “minimum value” means that your job-based plan would cover at least 60% of an average group of people’s covered health costs.   In addition, employer plans must provide substantial coverage for hospitalization and for physician care to meet the “minimum value” test.  Most employer plans will meet this test, but some may not.  The Marketplace application includes a form with questions about job-based coverage.  You should take this form to your employer and ask them to fill it out.  With that information the Marketplace will determine whether the plan meets minimum value.  If it doesn’t, you may be able to qualify for premium tax credits to help pay for Marketplace coverage.

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My employer offers a health plan that covers preventive services and some other benefits, but it doesn’t cover inpatient hospital care (or only pays $100 per day for hospitalization). Because I’m offered this policy, does that mean I can’t qualify for subsidized coverage through the Marketplace?

My employer offers a health plan that covers preventive services and some other benefits, but it doesn’t cover inpatient hospital care (or only pays $100 per day for hospitalization). Because I’m offered this policy, does that mean I can’t qualify for subsidized coverage through the Marketplace?

The standard for “minimum value” has been clarified to also require plans to provide substantial coverage for hospitalization and for physician care.  The plan your employer offers would not meet this standard.  If that is the only plan your employer offers to you, then you would be eligible to apply for Marketplace coverage with premium tax credits.  However, if this so-called skinny plan is only one option offered to you, and if other plan choices offered to you by your employer do meet the “minimum value” standard and the affordability standard, then you would not be eligible for premium tax credits through the Marketplace.

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The prescription drug benefit under my employer’s health plan only covers generic drugs. Does that mean it doesn’t have minimum value? Can I shop for better coverage and subsidies on the Marketplace?

The prescription drug benefit under my employer’s health plan only covers generic drugs. Does that mean it doesn’t have minimum value? Can I shop for better coverage and subsidies on the Marketplace?

Whether your employer’s health plan meets minimum value will depend on a number of factors. Some employer plans might be able to meet the minimum value standard even if they don’t provide coverage for brand name prescription drugs.  The Marketplace application includes a form with questions about job-based coverage. You should take this form to your employer and ask them to fill it out. With that information the Marketplace will determine whether the plan meets minimum value. If it doesn’t, you may be able to qualify for premium tax credits to help pay for Marketplace coverage.

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My employer’s plan is grandfathered so it doesn’t cover preventive services. Can I shop for better coverage in the Marketplace if my job-based plan is grandfathered?

My employer’s plan is grandfathered so it doesn’t cover preventive services. Can I shop for better coverage in the Marketplace if my job-based plan is grandfathered?

You can always shop for coverage in the Marketplace. However, you can only apply for premium tax credits if your job-based plan – whether it is a grandfathered plan or not – is unaffordable or if it doesn’t meet minimum value. Whether your employer’s health plan meets minimum value will depend on a number of factors. The Marketplace application includes a form with questions about job-based coverage. You should take this form to your employer and has them to fill it out. With that information the Marketplace will determine whether the plan meets minimum value. If it doesn’t, you may be able to qualify for premium tax credits to help pay for Marketplace coverage.

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I have COBRA and it’s too expensive. Can I drop it during Open Enrollment and enroll in a Marketplace plan instead?

I have COBRA and it’s too expensive. Can I drop it during Open Enrollment and enroll in a Marketplace plan instead?

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.

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I have COBRA and am finding it hard to afford, but Open Enrollment is over. Can I drop my COBRA and apply for non-group coverage outside of Open Enrollment?

I have COBRA and am finding it hard to afford, but Open Enrollment is over. Can I drop my COBRA and apply for non-group coverage outside of Open Enrollment?

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.

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I’m leaving my job and will be eligible for COBRA. Can I shop for coverage on the Marketplace instead?

I’m leaving my job and will be eligible for COBRA. Can I shop for coverage on the Marketplace instead?

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 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.

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Does my eligibility for COBRA or other continuation coverage affect my eligibility for premium tax credits or cost-sharing assistance in the Marketplace?

Does my eligibility for COBRA or other continuation coverage affect my eligibility for premium tax credits or cost-sharing assistance in the Marketplace?

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.

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I’m eligible for health benefits at work. However, unfortunately, I forgot to turn in my enrollment papers on time during the company open season, so now I’m not covered. Can I get policy in the Marketplace instead? Can I apply for subsidies?

I’m eligible for health benefits at work. However, unfortunately, I forgot to turn in my enrollment papers on time during the company open season, so now I’m not covered. Can I get policy in the Marketplace instead? Can I apply for subsidies?

If you missed your opportunity to enroll in your employer plan during the company’s open enrollment season, you can still apply for coverage in the Marketplace during open enrollment. You can also apply for subsidies but you will have to provide information on the health coverage you are eligible for at work, even if you’re not enrolled in the plan. If the plan employer offered meets standards for affordability and minimum value, you will not be eligible for premium tax credits or cost-sharing reductions.

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My large employer offers health benefits to me. My spouse works and has coverage through her job. To figure out whether my coverage is affordable, do I just count my income or do I count my spouse’s salary, as well?

My large employer offers health benefits to me. My spouse works and has coverage through her job. To figure out whether my coverage is affordable, do I just count my income or do I count my spouse’s salary, as well?

If you are considering applying for premium tax credits for coverage in the Marketplace, the test for whether your employer coverage is affordable is based on the cost of self-only coverage in the lowest cost plan your employer offers, compared to your household income (and not just your salary).

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My employer offers a plan with very limited benefits. It only covers preventive services and a few doctor visits each year. I want better coverage. Can I apply for coverage and subsidies in the Marketplace?

My employer offers a plan with very limited benefits. It only covers preventive services and a few doctor visits each year. I want better coverage. Can I apply for coverage and subsidies in the Marketplace?

You can apply for coverage in the Marketplace and you may qualify for premium tax credits if your employer plan doesn’t meet the Affordable Care Act’s standard for minimum value. If your employer plan only covers preventive services and a few doctor visits, it probably doesn’t meet the minimum value standard, and so you could be eligible for premium tax credits to help buy a Marketplace plan. However, if the mini-med plan is only one choice that your employer offers, and if another plan your employer offers would be affordable and meet the minimum value standard, then you will not qualify for premium tax credits in the Marketplace.

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My employer offers a plan with very limited benefits. It only covers preventive services and a few doctor visits each year. However, this plan option is free. If I sign up for it, will that satisfy the individual mandate to have coverage?

My employer offers a plan with very limited benefits. It only covers preventive services and a few doctor visits each year. However, this plan option is free. If I sign up for it, will that satisfy the individual mandate to have coverage?

Yes, most group health plans offered by an employer are considered “minimum essential coverage.” Some limited benefit plans (for example, dental only plans) are not considered minimum essential coverage.  Your group health plan materials should indicate whether the plan is considered “minimum essential coverage.”  If it is and if you enroll in the plan, you will have met the requirement to have coverage and won’t owe a tax penalty.  However, the plan you described probably does not meet the standard for “minimum value.”  If this is the only plan your employer offers, you may be able to qualify for premium tax credits to help pay for Marketplace coverage.  The premium tax credits could help you afford coverage that would be more comprehensive.

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I received a Form 1095-C in the mail. What’s that?

I received a Form 1095-C in the mail. What’s that?

Large employers must offer health insurance to their full time workers or pay a penalty.  These employers also must provide their employees with Form 1095-C to document that health coverage was offered.   Every employee of a large employer who was eligible for health coverage this year should receive a form 1095-C next year in January.  Even if you declined to sign up for your health plan at work, you will still receive a form 1095-C.  Information on this form will also be reported to the IRS.

Form 1095-C will indicate your name and the name of your large employer, the months during the prior calendar year when you were eligible for coverage, and the cost of the cheapest monthly premium you could have paid for coverage under your employer’s health plan. If you worked for a large employer that did not offer its full time employees health coverage, Form 1095-C will also indicate that.

Keep this form with your tax records.  You may need this form if you were offered health coverage by your employer and you did not sign up for it.  If you signed up for Marketplace coverage instead and received a premium tax credit, information on Form 1095-C will help you determine whether you were eligible for the tax credit (for example, if the cost of your employer health plan was more than 9.56% of your income in 2018.)

If you were uninsured during the year even though your employer offered you health coverage that year, you will be eligible for an exemption from the tax penalty in 2018 if you experienced a hardship that prevented you from enrolling in coverage.  You can claim the hardship exemption directly on your 2018 tax return when you file.  You will not be required to submit documentation of the hardship with your tax return, though you should retain any documentation for your own tax records.

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I’m 62 and already collecting Social Security. Are my Social Security benefits counted in determining my eligibility for subsidies in the Marketplace?

I’m 62 and already collecting Social Security. Are my Social Security benefits counted in determining my eligibility for subsidies in the Marketplace?

Yes, Social Security benefits are counted as income in determining eligibility for premium tax credits in the Marketplace.

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I’m a retired Veteran collecting VA disability pension and benefits. Are those benefits counted in determining my eligibility for subsidies in the Marketplace?

I’m a retired Veteran collecting VA disability pension and benefits. Are those benefits counted in determining my eligibility for subsidies in the Marketplace?

No. VA disability pension benefits generally are not subject to federal income tax and so are not counted as income in determining eligibility for premium tax credits.

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I’m 63 and enrolled in a retiree health plan from my former employer. Can I look for better coverage and subsidies in the Marketplace?

I’m 63 and enrolled in a retiree health plan from my former employer. Can I look for better coverage and subsidies in the Marketplace?

Yes, as long as you do so during the Open Enrollment period.

People with employer-provided retiree health benefits should know that most early retiree health plans are considered minimum essential coverage, and thus meet an individual’s requirement for coverage.

If you are enrolled in such coverage, you can also look at coverage options through the Marketplace, and if your income is between 100% and 400% of the Federal Poverty Level, you may qualify for premium tax credits. However, there’s one exception. Some employers may provide retired employees with access to an account, called a health reimbursement arrangement (or HRA) that the retiree may use to reimburse medical expenses, including an individual policy through a Marketplace or in the non-group market. A retiree that signs up for an HRA offered by a former employer is considered to have minimum essential coverage from an employer and would therefore would not be eligible to claim a premium tax credit if he or she enrolled in a Marketplace plan.

Remember that outside of Open Enrollment, you cannot voluntarily drop your retiree coverage and replace it with other Marketplace coverage.

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I’m 63 and about to retire. I’ll be offered a retiree health plan. Can I look for better coverage and subsidies in the Marketplace instead?

I’m 63 and about to retire. I’ll be offered a retiree health plan. Can I look for better coverage and subsidies in the Marketplace instead?

Yes. Most early retiree health plans are considered minimum essential coverage, and thus meet an individual’s requirement for coverage. However, if you want to obtain coverage through the Marketplace, you may do so, and if your income is at or below 400% of the Federal Poverty Level, you are eligible for premium tax credits. Eligibility for retiree coverage will not affect your eligibility for Marketplace coverage and subsidies.

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My spouse is an early retiree with affordable retiree health benefits from his former employer, but I’m not eligible to be on his plan. Can I apply for coverage and subsidies in the Marketplace?

My spouse is an early retiree with affordable retiree health benefits from his former employer, but I’m not eligible to be on his plan. Can I apply for coverage and subsidies in the Marketplace?

Yes, assuming you meet the other requirements, you can apply for health plans and premium tax credits in the Marketplace. Your spouse’s eligibility for early retiree coverage will not affect your ability to seek coverage and financial help in the Marketplace.

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I’m 63 and my spouse is 65 and on Medicare. Our income is less than 400% of FPL so I need help affording the premium in the Marketplace. Can we count what my spouse has to pay for his Medicare premiums and supplemental and Part D premiums against what I will be required to contribute toward coverage in the Marketplace?

I’m 63 and my spouse is 65 and on Medicare. Our income is less than 400% of FPL so I need help affording the premium in the Marketplace. Can we count what my spouse has to pay for his Medicare premiums and supplemental and Part D premiums against what I will be required to contribute toward coverage in the Marketplace?

No. Your eligibility for premium tax credit subsidies and the amount of your premium tax credit will be based on your family income. The amount your spouse pays for his Medicare, Part D, and supplemental insurance premium costs will not be taken into account.

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

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

Yes, you can keep your Medicare and you do not need to make any changes to your coverage because of the ACA.

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I am over age 65 and covered by Medicare, but I’m wondering if I can purchase one of the health plans offered through the Marketplace and drop my Medicare coverage? Is that an option for me or should I keep my Medicare?

I am over age 65 and covered by Medicare, but I’m wondering if I can purchase one of the health plans offered through the Marketplace and drop my Medicare coverage? Is that an option for me or should I keep my Medicare?

If you have Medicare, you should keep it.  In fact, companies that sell Marketplace plans are prohibited from selling these plans to you if they know you are covered by Medicare.  If you do drop Medicare, and choose to re-enroll later, you can only re-enroll during the Medicare general enrollment period (from January 1 to March 31), and your coverage would not begin until July of that year.  You also may face a penalty for late enrollment.  If you don’t sign up for Part B when you’re first eligible or if you drop Part B and then sign up again later, your monthly Part B premium may go up 10% for each year that you could have had Part B, but didn’t.  You may also owe a late enrollment penalty for Part D drug coverage, which is equal to 1% of the national average premium amount for every month you didn’t have coverage as good as the standard Part D benefit.

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Are Medicare Advantage plans, Medicare Part D drug plans, or Medigap policies sold through the Marketplace?

Are Medicare Advantage plans, Medicare Part D drug plans, or Medigap policies sold through the Marketplace?

No.  Medicare Advantage plans (such as Medicare HMOs and PPOs), Medicare Part D prescription drug plans, and Medigap policies are not sold through the federal or state Marketplaces.  You can enroll in a Medicare Advantage plan or a Medicare Part D plan on the Medicare website (www.Medicare.gov) or by signing up directly with the company that offers the plan.  To learn more about your coverage options under Medicare, including the Medicare Advantage plans, Part D drug plans, and Medigap supplemental policies available in your area, and how to enroll, you can go to the Medicare Plan Finder on www.Medicare.gov or call 1-800-MEDICARE.

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Is the open enrollment period the same for Medicare and the Marketplaces?

Is the open enrollment period the same for Medicare and the Marketplaces?

There is some overlap in the enrollment periods for Medicare and the Marketplaces, but this year they are not the same.  The Medicare open enrollment period runs from October 15 through December 7 each year.  For Marketplace coverage in 2019, the open enrollment period will run from November 1, 2018 through December 15, 2018 in states that use the HealthCare.gov website.  Some states that run their own Marketplaces will have a somewhat longer Open Enrollment period for 2019 coverage.  Check with your state Marketplace for more information.

If you are covered by Medicare, and you are interested in reviewing and comparing your Medicare coverage options, make sure the plans you are considering during the open enrollment period are Medicare plans, not Marketplace plans.  Medicare plans are not sold through the federal or state Marketplace websites.  You can review and compare your Medicare options on the Medicare website (www.Medicare.gov) or by calling 1-800-MEDICARE.

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I am about to turn 65 and go on Medicare, and my income is $120,000. I am not married. I know that people with higher incomes are required to pay higher premiums for Medicare Part B and Part D. To avoid paying these higher Medicare premiums, can I sign up for health insurance from a Marketplace plan now instead of enrolling in Medicare when I turn 65?

I am about to turn 65 and go on Medicare, and my income is $120,000. I am not married. I know that people with higher incomes are required to pay higher premiums for Medicare Part B and Part D. To avoid paying these higher Medicare premiums, can I sign up for health insurance from a Marketplace plan now instead of enrolling in Medicare when I turn 65?

If you are not yet enrolled in Medicare, you can buy health insurance coverage through the Marketplace before you turn 65, and if you have a Marketplace plan, you can choose to renew it after you turn 65.  But once you turn 65 and become entitled to Medicare coverage, you cannot buy a new Marketplace plan.  This is because insurers are prohibited from selling health insurance coverage that duplicates what you have under Medicare, if they know you are covered by Medicare.

If you are considering renewing a Marketplace policy after you turn 65 and become eligible for Medicare, there may be downsides to this choice.

First, your total costs could be higher with a Marketplace plan than with Medicare, even if your income is high enough that you are required to pay income-related premiums for Medicare coverage.  At your current income level in 2018, you would pay about $4,000 in annual Medicare premiums ($3,215 for Part B and around $823, on average, for Part D.)  You would also likely buy a Medigap supplemental policy to help cover Medicare deductibles and limit annual cost sharing.  The average cost of Medigap is roughly $2,000, though premiums can vary widely depending on the plan you choose, your age, and where you live.

By comparison, premium for a Marketplace policy will vary depending on where you live, your age, and the plan you choose.  In 2018, the national average premium for the lowest cost bronze plan for a 64-year-old was about $9,500 and the average annual deductible under bronze plans was about $6,000.  Most Marketplace participants pick silver plans. On average, the premium for the benchmark silver plan for a 64-year-old was about $13,500 in 2018 – much higher than the total premiums for Medicare – and the average silver plan deductible was about $4,000.  Also keep in mind that the combination of Medicare plus a Medigap policy would offer you more comprehensive coverage with lower overall out-of-pocket costs than a Marketplace plan.

Second, you should also be aware there would likely be differences in access to doctors, hospitals, and prescription drugs between Marketplace plans and Medicare.

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

Finally, if you have Marketplace coverage when you become eligible for Medicare, and decide to drop your Marketplace plan, you need to contact your plan to terminate your Marketplace plan yourself.  It will not happen automatically when your Medicare coverage begins. Your insurer cannot terminate your Marketplace coverage unless you tell them you want this coverage to end.

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I am covered by Medicare and my annual income is $30,000. Can I qualify for a premium tax credit to help me pay for my health insurance coverage through Medicare?

My mom is an 83-year-old widow with an income of about $12,000 and almost no savings. She is covered by Medicare. Does she qualify for the new Medicaid expansion under the ACA?

My mom is an 83-year-old widow with an income of about $12,000 and almost no savings. She is covered by Medicare. Does she qualify for the new Medicaid expansion under the ACA?

No.  The Medicaid expansion provided under the Affordable Care Act is for adults who are under the age of 65 with incomes up to 138% of poverty (about $16,753 for an individual in 2019).  The law explicitly excludes people ages 65 and older from this Medicaid eligibility category.  So even if your mom’s income is low enough to qualify for Medicaid under these rules, she is not eligible for it because she is over age 65.

However, your mom might qualify for Medicaid under the current eligibility rules if her income and assets are low enough.  Under the current rules, Medicaid helps many low income people on Medicare with their Medicare premiums and cost-sharing requirements, and may also cover some benefits that are not covered by Medicare, such as dental services and long-term services and supports.  Also, your mom might qualify for extra financial assistance to help with the cost of Medicare Part D prescription drug coverage.  To find out if she qualifies for these programs, you can contact the State Health Insurance Assistance Program in your state, the State Medical Assistance Office (for Medicaid), or the Social Security Administration (for Part D extra help).  Medicare provides links and phone numbers for these and other organizations at the following website: http://www.medicare.gov/contacts/.

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I am 54 and living with a permanent disability, and for the past 12 months I have been receiving Social Security disability insurance (SSDI) payments. But I do not have health insurance. I am required to wait another 12 months before I can go on Medicare due to the two-year waiting period for people receiving SSDI payments. Am I eligible to purchase health insurance coverage from a marketplace plan under the ACA? Am I eligible for a premium tax credit? And what about Medicaid?

I am 54 and living with a permanent disability, and for the past 12 months I have been receiving Social Security disability insurance (SSDI) payments. But I do not have health insurance. I am required to wait another 12 months before I can go on Medicare due to the two-year waiting period for people receiving SSDI payments. Am I eligible to purchase health insurance coverage from a marketplace plan under the ACA? Am I eligible for a premium tax credit? And what about Medicaid?

Yes, you are eligible to purchase coverage through the Marketplace, and if your income is between 100% and 400% of poverty ($12,140 to $48,560 for an individual in 2019) you will qualify for premium tax credits to help make Marketplace coverage more affordable.  If you live in a state that has expanded its Medicaid program to cover adults under age 65 with incomes up to 138% of poverty (about $16,753 for an individual in 2019), you might also be eligible for this coverage, depending on your income.

If you apply for and receive Marketplace coverage and subsidies, keep in mind that your eligibility for Marketplace subsidies will end when your Medicare Part A and Part B coverage automatically begins after the two-year waiting period.  At that point, you will have to pay the full price for your Marketplace coverage, but you could instead drop your Marketplace coverage and enroll in Medicare Part A, Part B and Part D.  If you keep both Medicare and Marketplace coverage, Medicare will be the primary payer.

Once your Medicare coverage begins, depending on your income, you may qualify for Medicaid in addition to Medicare or for extra help with premiums and cost sharing for your Part D prescription drug benefits.  A good place to turn for information about these programs and whether you might qualify is your local Social Security Administration office or the State Health Insurance Assistance Program in your state.  Medicare provides links and phone numbers for these and other organizations at the following website: http://www.medicare.gov/contacts/.

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My husband and I are retired. He just turned 65 and is now covered by Medicare, but I am 62 and I don’t have health insurance. Can I enroll in Medicare as his spouse?

My husband and I are retired. He just turned 65 and is now covered by Medicare, but I am 62 and I don’t have health insurance. Can I enroll in Medicare as his spouse?

No.  Although your husband now qualifies for Medicare, you will not qualify for Medicare until you turn 65.  If you do not have health insurance now, you can consider signing up for health insurance coverage through a Marketplace plan.  If your household income is less than 400% of the federal poverty level ($65,840 for a couple in 2019), you may qualify for premium tax credits to reduce your cost of a Marketplace policy.  If your household income is at or below 138% of poverty ($22,715 for a couple in 2019), you might be eligible for Medicaid if you live in a state that has expanded its Medicaid program.

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I am 66 years old, work for a large employer, and have excellent health insurance coverage through my job. I am planning to keep working for a few more years and would like to keep the coverage that my employer offers. How does the Marketplace affect me?

I am 66 years old, work for a large employer, and have excellent health insurance coverage through my job. I am planning to keep working for a few more years and would like to keep the coverage that my employer offers. How does the Marketplace affect me?

It doesn’t.  You can keep your employer-sponsored health insurance coverage as long as that is an option for you.  Since you are already eligible for Medicare because you are over age 65, you should sign up for Medicare when you stop working or if you lose your employer coverage before then.  Once you decide when you want to stop working, you should contact the Social Security Administration about how and when to enroll in Medicare to be sure you don’t have a gap in coverage.

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I am turning 65 years old next month, but I am not entitled to Medicare without having to pay a premium for Part A because I have not worked long enough to qualify. Can I sign up for a Marketplace plan?

I am turning 65 years old next month, but I am not entitled to Medicare without having to pay a premium for Part A because I have not worked long enough to qualify. Can I sign up for a Marketplace plan?

Yes, in general, people age 65 or older who are not entitled to premium-free Medicare can purchase health insurance coverage in the Marketplace (except undocumented immigrants).  If you sign up for a Marketplace plan, you will be eligible for premium tax credits to make the coverage in the Marketplace more affordable if your income is between 100% and 400% of the federal poverty level ($12,140 to $48,560 for an individual in 2019).

Keep in mind that if you are able to continue working, you may be able to earn enough work history to qualify for premium-free Medicare in the future.  So another option for you to consider would be to sign up for Part A and Part B coverage when you turn 65 (you will have to pay a premium for both Part A and for Part B), and when you become eligible for premium-free Part A through your work history, you will then only have to pay a premium for Part B.

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I am in my early 60s and have signed up for a Marketplace plan so that I have health insurance coverage until I qualify for Medicare at age 65. What happens when I go on Medicare?

I am in my early 60s and have signed up for a Marketplace plan so that I have health insurance coverage until I qualify for Medicare at age 65. What happens when I go on Medicare?

When you turn 65, you should sign up for Medicare and notify your Marketplace plan that you now qualify for Medicare coverage.  Your Marketplace coverage will not be cancelled automatically by your plan when you turn 65 and sign up for Medicare, but if you receive premium tax credits to help you pay for your Marketplace plan premium, your eligibility for these tax credits will end when your Medicare Part A coverage starts (people with Medicare are not eligible for these tax credits, and the premium tax credit can only be used for the purchase of Marketplace coverage, not Medicare).

If you choose to enroll in Medicare Part A and keep your Marketplace coverage, you will have to pay the full price for your Marketplace plan, and Medicare will be the primary payer.  If you were receiving financial assistance for your Marketplace coverage prior to signing up for Medicare, you will receive a letter in the mail from the Marketplace informing you that you are no longer eligible to receive this financial assistance since you are enrolled in Medicare Part A. You should contact your Marketplace plan to make sure that your financial assistance is stopped when your Medicare coverage begins. If you do not stop receiving the premium tax credit and other financial assistance for your Marketplace plan when your Medicare coverage begins, you may have to repay some or all of the amount of financial assistance you received for the months you had both types of coverage.

If you decide to drop your Marketplace coverage when you become eligible for Medicare, make sure your Medicare coverage has started before you cancel your Marketplace plan so that you avoid any gaps in coverage.  You can start signing up for Medicare three months before your 65th birthday.

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I am enrolled in a Medicare Part D drug plan. Did the ACA make changes to my Medicare drug coverage?

I am enrolled in a Medicare Part D drug plan. Did the ACA make changes to my Medicare drug coverage?

Yes, the law included changes that could save you money if you have very high prescription drug costs.  If you are enrolled in a Medicare Part D plan and you have very high drug costs, the law is helping to reduce the costs you pay when you reach a gap in coverage that is sometimes referred to as the “doughnut hole.”  This gap in coverage is being phased out between now and 2019 for brand-name drugs.  If your total drug costs are more than $3,820 in 2019, after that point you will pay 25% of the cost of your brand-name drugs and 37% of the cost of your generic drugs.  In 2020, you will pay 25% for both brand-name and generic drugs.

The law also included a new requirement that people on Medicare with higher incomes pay a higher premium for Part D coverage.  These higher premiums are paid by single beneficiaries enrolled in Part D plans with incomes greater than $85,000 and married couples with incomes greater than $170,000.

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I am enrolled in a Medicare Advantage plan. Did the ACA make changes to this program?

I am enrolled in a Medicare Advantage plan. Did the ACA make changes to this program?

Yes, the law did make some changes to the Medicare Advantage program.  This program is an alternative to traditional Medicare, where people on Medicare can choose a private plan, such as an HMO or PPO, to receive Medicare-covered benefits.  The law reduced federal payments to these plans to bring them closer to the average costs of traditional Medicare.  The law also provided additional payments to plans that earn high quality ratings.

In addition, the law limited how much cost sharing plans can charge enrollees for certain services, and limited how much plans can spend on administrative expenses and profits (referred to as “medical loss ratio” requirements.)

To learn more about how your coverage options under Medicare, including all of the Medicare Advantage plans, Part D drug plans, and Medigap supplemental policies available in your area, you can go to the Medicare Plan Finder on www.Medicare.gov or call 1-800-MEDICARE.

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Did the ACA change how much my doctor is paid by Medicare?

Did the ACA change how much my doctor is paid by Medicare?

The ACA temporarily increased Medicare payments by 10% for certain services provided by primary care practitioners (including doctors, nurse practitioners, and physician assistants) as well as general surgeons practicing in underserved areas.  These increases were in place from 2011 through the end of 2015.

Until April 2015, Medicare was required to pay doctors based on a certain formula.  The ACA did not make any changes to that formula, but Congress repealed it in the Medicare Access and CHIP Reauthorization Act (MACRA).   Among other things, this law created a new method for determining how Medicare pays physicians. Specifically, Medicare payments to physicians will be based on either their participation in an alternative payment model that assumes financial risk, or their performance on quality and spending measures. Medicare is currently working on implementing this new system, which will begin to affect physician payments in 2019.

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I am age 60 and have been receiving Social Security disability insurance (SSDI) payments for two years. I recently received my Medicare card, and I would like to get coverage to supplement my Medicare Part A and Part B coverage. I live in a state that does not require insurance companies to sell Medigap supplemental policies to people under age 65. Can I purchase a Marketplace plan to supplement Medicare?

I am age 60 and have been receiving Social Security disability insurance (SSDI) payments for two years. I recently received my Medicare card, and I would like to get coverage to supplement my Medicare Part A and Part B coverage. I live in a state that does not require insurance companies to sell Medigap supplemental policies to people under age 65. Can I purchase a Marketplace plan to supplement Medicare?

No, companies that sell Marketplace plans are prohibited from selling these plans to you if they know you are covered by Medicare.  If you do not live in a state that requires insurance companies to sell Medigap policies to people under age 65, some insurance companies still may voluntarily sell Medigap policies to people under 65, although they will probably cost you more than Medigap policies sold to people age 65 and older.  If you want prescription drug coverage to supplement your Medicare Part A and Part B benefits, you can purchase a Part D prescription drug plan.  You can also look into receiving your Medicare-covered benefits through a Medicare Advantage private plan, such as an HMO or PPO.  Medicare Advantage plans are not allowed to turn down people with Medicare based on your health status or having a pre-existing condition, but access to providers is generally more limited than in traditional Medicare.
Keep in mind that when you turn 65 and are enrolled in Part B, you will get a six-month opportunity to enroll in any Medigap policy you want.

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I am about to turn 65 and sign up for Medicare but am not sure what my options are for coverage. Where can I go for more information?

I am about to turn 65 and sign up for Medicare but am not sure what my options are for coverage. Where can I go for more information?

To learn more about your coverage options under Medicare, including the Medicare Advantage plans, Part D prescription drug plans, and Medigap supplemental policies available in your area, and how to enroll, you can go to the Medicare Plan Finder on www.Medicare.gov or call 1-800-MEDICARE.  You can also contact the State Health Insurance Assistance Program in your state or the Social Security Administration.  Medicare provides links and phone numbers for these and other organizations at the following website: http://www.medicare.gov/contacts/.  Information about Medicare Advantage plans, Part D drug plans, and Medigap policies is not available through the federal or state Marketplaces.

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

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

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

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

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If I have a Marketplace plan and then become eligible for Medicare, will my Marketplace plan be cancelled automatically when my Medicare coverage starts?

If I have a Marketplace plan and then become eligible for Medicare, will my Marketplace plan be cancelled automatically when my Medicare coverage starts?

No, your Marketplace plan will not be canceled automatically when your Medicare coverage starts. You must contact your Marketplace insurer directly to cancel your Marketplace policy.

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I am covered by traditional Medicare and was recently notified by my doctor that she is participating in an “ACO” created by the ACA. What is an ACO and how does this affect me?

I am covered by traditional Medicare and was recently notified by my doctor that she is participating in an “ACO” created by the ACA. What is an ACO and how does this affect me?

The ACA created a new Medicare payment model, called the Accountable Care Organization, or ACO, as part of an ongoing effort to try to lower costs and improve the quality of care in Medicare.  ACOs are groups of doctors, hospitals, and other health care providers that form partnerships to collaborate and share accountability for the quality and cost of care delivered to their patients.  There are several types of ACOs, and Medicare’s payments to them vary based on their success in meeting quality and spending goals.  If any of your doctors or clinical practitioners are participating in a Medicare ACO, you still have access to all your Medicare benefits and may continue to see any Medicare provider that you choose.  All providers are required to notify you of their participation in a Medicare ACO.

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