Health Insurance Marketplace FAQs

The Health Insurance Marketplaces make it easier and cheaper to buy health insurance so you can take charge of your hematology care. Find out how the Marketplaces work, what types of plans are available, who qualifies for financial assistance and more.

The Health Insurance Marketplace FAQs are provided courtesy of The Kaiser Family Foundation.

Marketplace Eligibility, Enrollment Periods, Plans and Premiums

What is the health insurance Marketplace?

Health Insurance Marketplaces (also known as Exchanges) are organizations that... More

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 the Small Business Health Options Program (SHOP) Marketplace.

There is a health insurance Marketplace in every state for individuals and families and for small businesses. Some are operated by the State and have a special state name (such as CoveredCalifornia or The Maryland Health Connection.) In other states where the federal government runs the Marketplace, it is called HealthCare.gov. Less

Source:

The Kaiser Family Foundation. Health Reform FAQs.
http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-what-is-the-health-insurance-marketplace. Accessed November 23, 2016.

How do I find my state Marketplace?

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

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

Source:

The Kaiser Family Foundation. Health Reform FAQs.
http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-how-do-i-find-my-state-marketplace. Accessed November 23, 2016.

Who can buy coverage in the Marketplace?

Most people can shop for coverage in the Marketplace. To be eligible you must live in... More

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. Less

Source:

The Kaiser Family Foundation. Health Reform FAQs.
http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-who-can-buy-coverage-in-the-marketplace. Accessed November 23, 2016.

I notice Marketplace plans are labeled “Bronze,” “Silver,” “Gold,” and “Platinum.” What does that mean?

Plans in the Marketplace are separated into categories — Bronze, Silver, Gold, or Platinum... More

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. Less

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... More

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. Less

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?

If you are in a non-grandfathered, or a new private plan, including those available through...More

If you are in a non-grandfathered, or a new private plan, including those available through health insurance Marketplaces, then 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). 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. Less

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... More

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

  • Loss of eligibility for other coverage (for example if you quit your job or were laid off or if your hours were reduced, or if you lose student health coverage when you graduate) Note that loss of eligibility for other coverage because you didn’t pay premiums does not trigger a special enrollment opportunity
  • Gaining a dependent (for example, if you get married or give birth to or adopt a child). Note that pregnancy does NOT trigger a special enrollment opportunity
  • Loss of coverage due to a loss of dependent status (for example, because of divorce, legal separation, death, or “aging off” of 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 (starting July 11, 2016, if you move to or within a federal Marketplace state, you will only be eligible if you had previously been enrolled in other coverage, or meet other exceptions)
  • Exhaustion of COBRA coverage
  • Losing eligibility for Medicaid or the Children’s Health Insurance Program
  • For people enrolled in a Marketplace plan, income increases or decreases enough to change your eligibility for subsidies
  • Change in immigration status
  • Enrollment or eligibility error made by the Marketplace or another government agency or somebody, such as an assister, acting on their behalf

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

When you experience a qualifying event, your special enrollment opportunity will last 60 days from the date of that triggering event. If you can foresee a qualifying event (for example, you know the date when you will graduate and lose student health coverage) you can ask the Marketplace for a special enrollment opportunity up to 60 days in advance so new coverage will take effect right after your old coverage runs out. However, under new federal rules, Marketplaces are not required to offer advanced availability of special enrollment periods to people who anticipate a permanent move.

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

Health Insurance Requirements and Penalties

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

Everyone is required to have health insurance coverage More

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. Less

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

The penalty for not having minimum essential coverage More

The penalty for not having minimum essential coverage is either a flat amount, or a percentage of household income, whichever is greater. The penalty has been phased in and will be adjusted in the future for inflation.

For 2016 and 2017, the penalty is the greater of:

  • $695 for each adult and $347.50 for each child, up to $2,085 per family, or
  • 2.5% of family income above the federal tax filing threshold, which is $10,350 for a single filer, $20,700 for people who file jointly in 2016

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

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

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

For more information about the penalty, also called the individual responsibility payment, see the IRS web site.

Source:

The Kaiser Family Foundation. Health Reform FAQs.
http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-whats-the-penalty-if-i-dont-have-coverage. Accessed November 23, 2016.

Are there exemptions to the penalty? What are they?

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

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

  • Cannot afford coverage (defined as those who would pay more than 8.16 percent of their household income for the lowest cost bronze plan available to them through the Marketplace in 2017)
  • 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 2016 tax year, the filing threshold is $10,350 for individuals and $20,700 for married persons filing a joint return)
  • Are unable to qualify for Medicaid because your state has chosen not to expand the program
  • Participate in a health care sharing ministry or are a member of a recognized religious sect with objections to health insurance
  • Are a member of a federally recognized Indian tribe
  • Are incarcerated

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

I had health insurance coverage throughout this year, so I shouldn't have to pay a penalty for being uninsured? Do I have to do anything else to make sure?

When you file your return for this tax year (usually people do this next spring), there will be a space More

When you file your return for this tax year (usually people do this next spring), there will be a space for you to indicate that you had health insurance coverage for the full year. If you did not have health coverage for the entire year, there will be directions to help you calculate the tax penalty or to indicate that you owe no penalty if you qualify for an exemption. Less

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 More

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. Less

Help Paying for Private Health Insurance

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, More

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. Less

Who is eligible for Marketplace premium tax credits?

Premium tax credits will be available to U.S. citizens and lawfully More

Premium tax credits will be available to U.S. citizens and lawfully present immigrants who purchase coverage in the Marketplace and who have income between 100% and 400% of the federal poverty level. Premium tax credits are also available to lawfully residing immigrants with incomes below 100 percent of the poverty line who are not eligible for Medicaid because of their immigration status. (Generally, immigrants must lawfully reside in the U.S. for five years before they can become eligible for Medicaid.)

In addition, to be eligible for the premium tax credits, individuals must not be eligible for public coverage—including Medicaid, the Children's Health Insurance Program, Medicare, or military coverage—and must not have access to health insurance through an employer. (There is an exception in cases when the employer plan is unaffordable because the employee share of the premium exceeds 9.69% of the employee's income in 2017. There is also an exception in cases where the employer plan doesn’t provide a minimum level of coverage.) Less

Young Adults and Students

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

A number of options may be available to you: More

A number of options may be available to you:

  • If your income is below 138% of the federal poverty level ($16,394 for a single person in 2017), 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. Less

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 More

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. Less

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 More

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. Less

Employer-Sponsored Health Coverage

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, More

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. Less

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