FAQ's

General FAQ's

When can I enroll in new coverage?

If you have employer-provided insurance, you may enroll during your employer's annual enrollment period. Otherwise you may only enroll in new coverage during the Government Open Enrollment Period (November 1, 2016 through January 31, 2017), unless you have a qualifying life event that allows you to enroll during a Special Enrollment Period.

Can I change plans outside of the Annual Enrollment Period?

You can apply for Medicaid and CHIP at any time, but to apply for insurance coverage outside of the Government Open Enrollment period you need to have a qualifying life event (QLE). Events that are considered acceptable QLEs include:

  • permanently moving to a new state
  • job loss
  • family changes (marriage, divorce, birth of a child)
  • loss of existing health coverage because of a job loss or job change
  • loss of eligibility for Medicaid or CHIP
  • expiration of your COBRA benefits
If you have had a QLE you typically have 60 days after the event occurs to enroll and you may need to provide documentation to prove that the QLE occurred.

What happens if I miss the 60 day period to enroll after a qualifying life event?

You are not eligible to enroll in exchange-based coverage and may be subject to financial penalties. However, you can still obtain short term coverage, Medicaid (if eligible) and/or CHIP (if eligible).

What is my Modified Adjusted Gross Income (MAGI)?

Your modified adjusted gross income (MAGI) is used to determine your eligibility for a government subsidy. Your Modified Adjusted Gross Income is calculated by taking your gross income (how much money you make before taxes) and subtracting any deductions to get your Adjusted Gross Income (also on line 37 of your Form 1040), and adding back certain deductions (such as tax-free interest and student loan interest) to get your Modified Adjusted Gross Income. For most people, their Modified Adjusted Gross Income is very similar to their Adjusted Gross Income.

What if my income changes? How does that affect my subsidy?

Subsidies are based on your best estimate of your household's modified adjusted gross income for the year. If your income increases, you may have to pay the government back for any portion of the subsidy you received that you were not eligible for. This reconciliation will take place when you file your government tax return. Also note that if your income changes substantially, you may qualify for a Special Enrollment Period and may be eligible to go back to the exchange and apply for new coverage.

If I am eligible for a subsidy, can I apply that against the insurance offered by my employer?

No. Only insurance offered through the state and government marketplace are eligible for subsidies.

What is the employer mandate?

All employees with 50 or more employees will be required to offer health insurance to full time employees. That does not mean you have to buy insurance through your employer – it just means it must be made available to you if you are considered a full time employee. Generally, employees that work more than 30 hours per week are considered to be full time employees however, calculation methods may differ and you are encouraged to check with your employer to confirm eligibility for health care coverage.

What is the individual mandate?

The individual mandate is a requirement that most Americans obtain health insurance. If you don't have health insurance you'll pay a penalty. There are some exceptions to the individual mandate for people who are incarcerated, Medicaid recipients and a few others. Additionally, keep in mind that you will have to prove you're covered. After you enroll, you'll get a form from your insurance company that says you have the minimum coverage. You'll need to submit that new form with your government tax return.

Can I get help paying for health insurance?

If you're going to buy insurance through a state or government health insurance marketplace ("exchange"), financial help may be available. See our Coverage Calculator to see if you qualify for a government subsidy.

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Subsidies are based on your best estimate of your household's modified adjusted gross income for the year. If your income increases, you may have to pay the government back for any portion of the subsidy you received that you were not eligible for. This reconciliation will take place when you file your government tax return. Also note that if your income changes substantially, you may qualify for a Special Enrollment Period and may be eligible to go back to the exchange and apply for new coverage.

If I am eligible for a subsidy, can I apply that against the insurance offered by my employer?

No. Only insurance offered through the state and government marketplace are eligible for subsidies.

What is the employer mandate?

All employees with 50 or more employees will be required to offer health insurance to full time employees. That does not mean you have to buy insurance through your employer – it just means it must be made available to you if you are considered a full time employee. Generally, employees that work more than 30 hours per week are considered to be full time employees however, calculation methods may differ and you are encouraged to check with your employer to confirm eligibility for health care coverage.

What is the individual mandate?

The individual mandate is a requirement that most Americans obtain health insurance. If you don't have health insurance you'll pay a penalty. There are some exceptions to the individual mandate for people who are incarcerated, Medicaid recipients and a few others. Additionally, keep in mind that you will have to prove you're covered. After you enroll, you'll get a form from your insurance company that says you have the minimum coverage. You'll need to submit that new form with your government tax return.

Can I get help paying for health insurance?

If you're going to buy insurance through a state or government health insurance marketplace ("exchange"), financial help may be available. See our Coverage Calculator to see if you qualify for a government subsidy.

How do the government subsidies work?

Government subsidies are available to help individuals with the cost of purchasing health insurance coverage through a marketplace. To qualify for a subsidy your income must be between 100% and 400% of the federal poverty level (less than $47,000 for a single person or $97,000 for a family of four). Subsidies are paid directly to the insurers to help lower premium costs. However, subsidies are structured so that the most qualifying individuals or families will have to pay towards their premiums will range from 2.0% to 9.5%.

Do I have to purchase insurance through healthcare.gov to receive a subsidy?

No. You may purchase insurance through any state sponsored exchange, government certified web based entity (such as eHealth) or healthcare.gov.

How will I prove I have health insurance?

The individual government income tax return rules will tell you what documentation you need to submit as proof of your health coverage. Starting in 2015, you'll get a certificate from your insurance company that says you have minimum coverage. You'll have to submit that certificate with your government income tax return to prove you have insurance

Think about the cost. Is your employer insurance "affordable?" That is, is your cost for "you only" coverage less than or equal to 9.5% of your income?

If your employer offers qualified health insurance coverage that is affordable, you are not eligible for a government subsidy. You may still elect to purchase insurance anywhere, however you will not be eligible for a government subsidy. The choice is yours. Before you choose a plan:

  • Think about the cost. Is your employer insurance "affordable?" That is, is your cost for "you only" coverage less than or equal to 9.5% of your income?
    • If it is, and the insurance meets coverage standards as required by law, you can still buy insurance through a marketplace, but you will not qualify for financial help. If you can't afford the health insurance offered to you through your employer or in a marketplace, you may qualify for Medicaid, or your children may qualify for the Children's Health Insurance Program. Each state has its own eligibility requirements for these programs.
  • Think about the insurance coverage. What does your insurance "buy" you? That is, how much will you pay out of your own pocket when you use medical services?
    • How often do you expect to use your insurance? Do you see the doctor fairly often and take one or more prescription drugs for an ongoing condition, like high blood pressure or diabetes? Or do you only see the doctor once or twice a year for checkups and the occasional illness?
  • Think about the network. If you have a doctor, it is important that you continue to see him or her? You'll pay less for care you get from in-network providers. So if you want to keep your doctor and pay lower, in-network rates, make sure that he or she is in your plan's network. If you need to find a doctor, does the plan's network have a wide selection of nearby doctors for you to choose from?

What if I lose my coverage during the year?

If you lose coverage due to involuntary reasons (i.e., loss of your job) you qualify for a Special Enrollment Period and have 60 days to enroll in new coverage in the marketplace.

Exchange Related FAQ's

What is an exchange?

A health insurance marketplace, or "exchange," is a website where health insurance companies come together to give you a place to shop for health insurance. Just like shopping for a flight on a travel website, you can see all of your options and prices in one place. That makes it easier to compare your options and find the best fit for your family's needs. Many states offer their own health marketplaces. For states that don't offer their own exchange, you may access the health insurance marketplace operated by the federal government or utilize a web based entity such as eHealth.

What can I do through a health insurance marketplace?

A marketplace or exchange allows you to:

  • Shop for health insurance offered by well-known insurance companies.
  • Choose from health plans grouped by metallic levels: Bronze, Silver, Gold, and Platinum. The different plans will offer you choices in:
    • How much you'll pay for insurance (premium amounts)
    • How much you'll pay out of your own pocket for medical care and prescription drugs (deductibles, coinsurance, copays, and out-of-pocket maximums)
    • Networks of participating doctors, hospitals, labs, and other health care providers
  • Find out if you qualify for financial help.
  • Enroll in health insurance that's right for you or your family. The government and state health insurance marketplaces will begin enrollment November 1, 2016 for insurance starting January 31, 2017.

Do I need to purchase insurance through a public exchange?

No. If you have access to health insurance through your employer or your spouse's employer you can purchase insurance there. The Federal Exchange is just one exchange available to individuals who don't have coverage available elsewhere. You can also utilize private exchanges or insurance agents who should be able to help identify the most appropriate coverage offerings available to you.

What type of insurance is available on an exchange?

The State and Federal exchanges feature the four metallic plan levels: Bronze, Silver, Gold, and Platinum. Each plan type provides different levels of insurance, at different costs, to fit different needs. All the plans offered in a marketplace must meet certain rules relating to affordability, required benefits, and market standards. You can also choose from a variety of insurance companies. Shopping on a health insurance marketplace makes it easier to compare all of your options. No matter which plan you choose, the new law requires that a core package of items and services is covered. That way you can rest assured that you will have insurance for the basics, also known as the Minimum Essential Benefits.

What are the "metallic plans"?

The four types of plans available on the public exchanges are referred to as "metallic plans" because they are named after four types of metals:

  • Bronze - pays for 60% of all covered costs
  • Silver - pays for 70% of all covered costs
  • Gold - pays for 80% of all covered costs
  • Platinum - pays for 90% of all covered costs

Do I have to buy one of the metallic plans?

No. However, unless you are exempted from insurance coverage requirements, the individual insurance mandate requires that you maintain minimum essential coverage for yourself and your dependents.

Who's exempted from purchasing health insurance?

Not everyone needs to purchase the full plan. Several groups, including the following, are exempted from required coverage:

  • Individuals under the age of 30
  • American Indians/Alaskan Natives
  • Prisoners
  • Undocumented immigrants
  • Members of certain religious groups opposed to accepting benefits from a health insurance plan
  • Most people already covered by a governmental program or by employer-sponsored coverage
  • People with low income
  • People for whom insurance would cost more than 8 percent of their income
  • People who earn too little to file a tax return
  • People who are in a state where Medicaid wasn't expanded and their income isn't high enough to qualify for government tax credits and subsidies
  • People who have had a gap in coverage for three months or less
  • People who have suffered a hardship
  • US Citizens who live outside the United States

What kind of coverage will I receive from insurance purchased on the marketplace?

All the plans in the marketplace must cover the same health care services. These services are called "the 10 essential health benefits" or "the Minimum Essential Benefits" and they are:

  • Emergency care
  • Hospital care
  • Prescription drugs
  • Lab services
  • Medical, dental, and eye care for children
  • Mental Health and substance abuse services
  • Maternity and newborn care
  • Preventive care and wellness services
  • Ambulatory or "outpatient" care
  • Rehabilitative services and devices
Your costs-both how much you'll pay for insurance and how much you'll pay when you get medical care-will depend on the plan you choose (bronze, silver, gold or platinum).

Keep in mind though, that all the plans in the marketplace cover preventive care services at no cost to you. This means that you won't pay anything for these services as long as you get them from a doctor, lab, or other provider who is part of your health plan's network.

What types of health plans do not meet the Minimum Essential Benefits requirement?

Examples of health plans that don't meet the Minimum Essential Benefits requirement are:

  • Coverage for only vision or dental
  • Worker's compensation
  • Coverage for a specific disease
  • Discount plans

How much is the penalty if my plan doesn't cover the Minimum Essential Benefits?

In 2016 the penalty increases to the higher of:

  • 2.5% of your household income OR
  • $695 per person plus $347.50 per child (under the age of 18), subject to a maximum of $2,085.

What preventive health services must be covered by exchange plans?

The preventive services are specific services that must be covered without charging you a copayment and regardless of whether you have met your deductible. These services include:

  • Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  • Alcohol Misuse screening and counseling
  • Aspirin use to prevent cardiovascular disease for men and women of certain ages
  • Blood Pressure screening for all adults
  • Cholesterol screening for adults of certain ages or at higher risk
  • Colorectal Cancer screening for adults over 50
  • Depression screening for adults
  • Diabetes (Type 2) screening for adults with high blood pressure
  • Diet counseling for adults at higher risk for chronic disease
  • HIV screening for everyone ages 15 to 65, and other ages at increased risk
  • Immunization vaccines for adults--doses, recommended ages, and recommended populations vary-for the following:
    • - Hepatitis A
    • - Hepatitis B
    • - Herpes Zoster
    • - Human Papillomavirus
    • - Influenza (Flu Shot)
    • - Measles, Mumps, Rubella
    • - Meningococcal
    • - Pneumococcal
    • - Tetanus, Diphtheria, Pertussis
    • - Varicella
  • Obesity screening and counseling
  • Sexually Transmitted Infection (STI) prevention counseling
  • Syphilis screening
  • Tobacco Use screening

Which states have state-run exchanges?

In 2016, 13 states elected to host their own marketplaces. Those electing to run their own marketplace include: California, Colorado, Connecticut, District of Columbia, Idaho, Kentucky, Maryland, Massachusetts, Minnesota, New York, Rhode Island, Vermont, and Washington. The remaining states elected either to forge a partnership or participate in the Federally Facilitated Marketplace (Healthcare.gov).

Insurance Related FAQ's

What is Catastrophic Insurance?

A catastrophic insurance plans meets the insurance mandate for those 30 years of age and younger (and those with a "hardship exemption"). These plans cost a little less than traditional insurance as they do not provide the full scope of services and are limited to, as it sounds, protection in the case of a more catastrophic situation. These plans cover three primary care visits per year at no cost, as well as preventive services. However, catastrophic plans are not eligible for a government subsidy.

What is the deductible on a health insurance plan?

The deductible is what you pay out of pocket before your insurance starts paying its share of your costs. How the deductible works depends on the plan you choose.

Please explain out-of-pocket costs.

"Out-of-pocket" costs refers to the amount you and your covered family members must pay out of your own pocket for medical services and prescription drugs. Generally, your out-of-pocket costs include the deductible, copayments, and the portion of any eligible expenses that insurance doesn't pay. It doesn't include the amounts you pay in premiums.

What does out-of-pocket maximum refer to?

The out-of-pocket maximum is the most you and your covered family members would have to pay in a year for medical and prescription drug costs. Generally it includes the deductible, applicable copayments, and the portion of any eligible expenses that insurance doesn't pay. It doesn't include amounts you pay for premiums.

What are preventive and wellness services?

Preventive and wellness services including tests and immunizations that can help you avoid illness and improve your health. Under the Affordable Care Act, preventive care services recommended by the U.S. Preventive Services Task Force must be covered at no cost to you. That means you won't pay anything for these services as long as you get them from a doctor, lab, or other provider who is part of your health plan's network.

What does Guaranteed Issue refer to?

Guaranteed issue refers to the concept that insurers are prohibited from denying coverage to individuals due to pre-existing conditions. Similarly, insurers must offer insurance coverage to individuals in the same geographic area at the same price.

What is Co-Insurance?

Coinsurance is your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan's allowed amount for an office visit is $100 and you've met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Medicaid FAQ's

What is Medicaid and how does it work?

Medicaid is government-provided health insurance for low income individuals and families. Medicaid also seeks to help other disadvantaged individuals including the elderly, the blind, pregnant women and the disabled. While the program is sponsored by the federal government, eligibility limits are set by each state. So, some people may be eligible to participate in Medicaid in one state but not another. The Affordable Care Act was intended make the requirements identical across all states and cover individuals earning up to 100% of the Federal Poverty Level (FPL) with Marketplace subsidies covering those earning between 100% of 400% of the FPL. However, not all states have agreed to extend Medicaid to all individuals earning up to 100% of the FPL, so implementation of this concept varies by state.

I heard that some states made Medicaid available to more people. What states are those?

The Affordable Care Act sought to make Medicaid available to all individuals earning up to 100% of the Federal Poverty Level (FPL). However, not all states have expanded their Medicaid programs accordingly. Currently, 28 States and the District of Columbia have expanded their Medicaid program to cover those earning up to 100% of the FPL. These states include Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania Rhode Island, Utah Vermont, Washington, and West Virginia.

Twenty-two (22) States have determined that they are not going to expand their Medicaid offering at this point. Those states include Alabama, Alaska, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.

If I am on Medicaid could I switch to an exchange plan and receive a subsidy?

No. Medicaid-eligible individuals are not eligible to receive subsidies.

Special Enrollment Period FAQ's

When can I enroll in a new plan?

Under the ACA rules, you can only enroll in a new coverage plan during open enrollment (note: you can apply for Medicaid and CHIP at any time). This year the open enrollment period will run from November 1, 2016 through January 31, 2017. For the remainder of the year you may only enroll during the Special Enrollment Period if you experience a qualifying life event (QLE).

What are qualifying life events?

Qualifying Life Events (QLEs) are special occurrences that would allow you to purchase coverage outside of open enrollment. Events that are considered acceptable QLEs include:

  • involuntary loss of coverage
  • birth or adoption of a child
  • marriage
  • divorce
  • loss of existing health coverage because of a job loss or job change
  • permanently moving to a new state
  • loss of eligibility for Medicaid or CHIP
  • expiration of your COBRA benefits

How long do I have to obtain coverage after I have a qualifying life event?

You typically have 60 days from the date of the QLE to obtain coverage and you may need to provide documentation to prove that the QLE occurred.

What happens if I miss the 60 day period?

You could be subject to a tax penalty and will only be able to purchase short-term coverage (or retain your existing coverage) until the next open enrollment period begins.

Why is it necessary to experience a qualifying life event to buy insurance outside of open enrollment?

The Affordable Care Act prohibits health insurance companies from declining any applicant based on his or her personal medical history. If people were allowed to enroll at any time of the year they might wait until they fall ill before enrolling. If only sick people were to enroll in coverage, the cost would skyrocket. To prevent this situation, the open enrollment period was created and everyone is encouraged to enroll at that time.

Will a qualifying life event allow me to purchase coverage only on government-run exchanges?

No. Just like during open enrollment, you can purchase coverage through government-run exchanges or through private exchanges or even directly from an insurance agent.

If I stop paying for my insurance, would that be considered involuntary loss of coverage, making me eligible to switch coverage during the special enrollment period?

No. Your loss of coverage must have been involuntary on your part (i.e., brought about by your employer or something outside of your control). Additionally, the coverage you lost must have provided what the law considers "minimum essential coverage." This means that it must have met the coverage requirements of the Affordable Care Act. Losing your dental plan or a short-term health insurance will not qualify you to go out and shop for a new major medical health insurance plan outside of open enrollment.

If I'm not happy with my current plan and I decide to cancel it, would that be a qualifying life event allowing me to go out and shop for a new plan?

No. Voluntarily ending your coverage like this does not count as a qualifying life event.

I am expecting a child but am uninsured, is this considered a qualifying life event?

No. Unfortunately, while the birth of your child will be considered a qualifying life event, pregnancy is not considered a qualifying life event under the ACA.

We just had a baby and need a new health insurance plan. Can we go out and buy one now?

Yes. The birth or adoption of a child is considered a qualifying life event and will allow you to shop for and enroll in a new health insurance plan outside of open enrollment. You'll typically have 60 days to purchase your coverage, starting from the date your child was born or adopted.

Is graduation from college a qualifying life event?

No. Graduation isn't considered a qualifying life event but you may have a qualifying life event if your graduation caused you to lose coverage through a school-sponsored plan (note: the school-sponsored plan must have met the coverage requirements of the ACA), or if you move to a new city or state.

What if my qualifying life event changes my eligibility for subsidies? Can I get subsidies outside of open enrollment?

If you experience a qualifying life event that changes your eligibility for a subsidy (for example, a significant decrease in your income), that is considered a qualifying life event and you are eligible to enroll in a new health insurance plan and receive the associated subsidy.

What can I do if I'm not happy with my coverage but open enrollment is still months away?

Unfortunately, your options are limited. Unless you have a qualifying life event you are not eligible to switch plans outside of open enrollment.

Tax Information

Will my employer send me anything confirming that I had health coverage?

Yes, the Affordable Care Act requires large employers to send statements regarding the health care coverage offered to full-time employees.

I only had qualifying health coverage for part of 2016; what does this mean?

If you only had qualifying health coverage for part of the year, you may be subject to a tax penalty for any months in which you did not have qualifying health coverage.