FAQS

Will everyone need to have health insurance? What happens if I don't?

Yes, with some exceptions. Most people will need to have insurance—either purchase it on their own, receive it through an employer, or receive it through Medicaid or Medicare. If you can afford health insurance but did not get coverage for 2014, you may have to pay a fee. The fee in 2014 is either 1% of your adjusted yearly income or $95 per person for the year—whichever is more. The fee increases year after year. For more information, please refer to the FAQ "Is there any way I can be uninsured and exempt from having to pay a fee?"

Is there any way I can be uninsured and exempt from having to pay a fee?

Maybe. Some uninsured people won't have to pay a fee. This includes people who:

  • Are uninsured for less than three months of the year
  • Have very low income
  • Cannot afford insurance because it costs more than 8% of their income
  • Are not required to file a tax return because their income is too low
  • Are able to qualify for Medicaid under the new income limits but their state has chosen not to expand Medicaid eligibility
  • Are a member of a federally recognized Tribe
  • Are participating in a health care sharing ministry
  • Are a member of a recognized religious group with religious objections to health insurance

Will I have to prove that I have health insurance?

Yes. Your health insurance carrier will provide documents to you to prove that you have the minimum coverage required by law.

Will I be eligible for tax credits—or free or low-cost coverage—to make health insurance more affordable?

Maybe. Financial assistance is available only to people who get coverage through an exchange and are not eligible for Medicare or employer coverage. Depending on your income, you may be eligible for premium tax credits to help pay for monthly premiums. For example, an individual earning up to $45,900 a year or a family of four earning up to $94,200 a year may get a tax credit to help cover the cost of their premiums. You may also be eligible for cost-sharing assistance to help pay for copays, deductibles, and other out-of-pocket costs. And you may also be eligible for free or low-cost coverage through Medicaid or the Children's Health Insurance Program (CHIP). For more information, see the tax credit calculator.

What is a health insurance marketplace?

A health insurance marketplace, or exchange, is a website where individuals and employers can compare insurance plans and sign up for plans during open enrollment periods. These marketplaces also provide a place to learn more about tax credit, cost-sharing assistance, and other free or low-cost options to help pay for coverage. Health insurance marketplaces are required by the Affordable Care Act. Some states have opted to establish their own health insurance marketplaces, while others have chosen to use the federally facilitated exchange.

Is mental health care covered under the Affordable Care Act?

Mental health programs are offered through both public health coverage programs, as well as private health plans you'd buy through an exchange or receive from your employer. New private health plans are required to cover mental health and substance abuse treatment as an essential health benefit. Public programs—including Medicaid and the Children's Health Insurance Program (CHIP)—typically cover a broad array of community-based services and mental health programs. Private health plans offer wide-ranging benefits, and typically offer a limited variety of mental health services.

Can I get coverage if I have a pre-existing condition such as diabetes or heart disease?

Yes. For plan years beginning in 2014, carriers can't turn you down or charge you more because you're sick or have a pre-existing condition. The only exception is for grandfathered health plans, which are individual health insurance policies purchased on or before March 23, 2010.

What is a grandfathered plan? How do I know if I have one, and how is it impacted by the Affordable Care Act?

A grandfathered health plan is a group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Check your plan's materials or ask your employer or benefits administrator to find out if your health plan is grandfathered. Grandfathered plans are exempt from many changes required under the Affordable Care Act

What are essential health benefits, and why should I care about them?

Essential health benefits are a set of 10 health care service categories defined by the Affordable Care Act that must be covered by certain non-grandfathered plans both inside and outside health insurance marketplaces beginning in 2014. These benefits must include items and services within the following categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance-use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services.

How are the essential health benefits I've heard about different from preventive health services?

Essential health benefits could require payment as part of private plans, while for most people, preventive health services—such as shots and screening tests—are available at no cost. (If you purchased a health plan before March 23, 2010, your plan may not cover the full cost of preventative health services. Check your plan details to be sure.)

If I have insurance, will I have to pay anything for preventive health services?

It depends. Most plans cover the cost of preventative health services. The requirement to cover these services doesn't apply to health plans created or purchased before March 23, 2010. Check your plan details or ask your employer or benefits administrator to find out more.

When can I sign up for coverage, and what is the deadline for applying?

If you're purchasing health coverage, you can sign up at any time between October 1, 2013, and March 31, 2014. If you're eligible, you may apply for free or low-cost health coverage—including Medicaid and the Children's Health Insurance Program (CHIP)—at any time throughout the year.

When will my coverage go into effect?

If you purchased a plan before December 31, 2013, and have submitted the first payment for your monthly premium(s), your coverage will go into effect January 1, 2014. Coverage for Medicaid or the Children's Health Insurance Program (CHIP) generally begins on the date you complete an application. If you purchased a plan after December 31, 2013, your coverage will go into effect after your first payment for your monthly premium.

What happens if I missed enrollment?

If you miss the deadline for applying, you could be required to pay a fee for not having health insurance. Also, there are special enrollment periods to accommodate changes in life circumstances. For example, if you lose your job, get married, or lose your insurance, you can apply for coverage through an exchange outside of the open enrollment period.

How and when will I receive tax credits to help me pay for my plan?

You can only receive tax credits if you purchase a health plan through a health insurance marketplace. To apply for and receive tax credits, you will need to provide information about your current job(s) and income level. If you are eligible for tax credits, they can either be applied right away (directly to an insurance company to reduce a monthly premium) or when you file a federal income tax return.

When I search the health insurance marketplace, will I know which insurance company is offering health coverage?

Yes. Health insurance plans in the marketplace are offered by private companies, and you will be able to see who offers coverage and what type of health coverage options are available from each carrier.

Can I get dental coverage in the health insurance marketplace?

In many states, you can get dental coverage if you also buy medical insurance. However some states allow people to just purchase a dental plan. To see what options are available in your state, check in with your state marketplace.

If I have health coverage through COBRA, can I cancel it and find a cheaper plan through the health insurance marketplace?

Yes, you may change from COBRA continuation coverage to health insurance coverage during open enrollment or when you've exhausted COBRA.

If I have insurance through my employer, will I be able to find a better deal shopping as an individual through the health insurance marketplace?

It's possible. You can choose not to participate in your employer-offered health plan if you don't think the plan fits your budget. If you opt out, you can then shop for health coverage through the marketplace as an individual. However, to qualify for tax credits, you must to demonstrate that your employer coverage was unaffordable.

How long can I stay on my parents' insurance? Does it matter if I live with them or if I'm married?

If a health plan covers children, they can be added or kept on the health insurance policy until they turn 26 years old. Children can join or remain on a plan even if they are married, attending school, eligible to enroll in their employer's plan, not living with their parents, or not financially dependent on their parents.

I'm on my parents' health insurance, but I will turn 26 outside of an open enrollment period. What are my coverage options?

You have a couple of options. First, check with your current insurance company. Private health insurance companies have volunteered to provide coverage for young adults losing coverage as a result of aging out of dependent coverage on a family policy. Second, watch for open enrollment. Young adults may qualify for an special open enrollment period to purchase their own coverage. Insurers and employers are required to provide notice for this special open enrollment period.

What are the various types of plans available through the health insurance marketplace?

There are a variety of health insurance plans that meet different needs and budgets that may be available through a health insurance marketplace:

When can I get a plan's Summary of Benefits and Coverage (SBC)?

You have the right to get this summary when shopping for or enrolling in coverage. The Summary of Benefits and Coverage (SBC) is available for every plan in the
health insurance marketplace. You'll find a link to the SBC on the plan website during sign-up. You can also ask to receive a copy from your insurance company or group health plan at any time.

Will I receive a Summary of Benefits and Coverage (SBC) if I use COBRA continuation coverage?

Yes. You can get a Summary of Benefits and Coverage (SBC) for most health plans whether you get coverage through your employer or buy it yourself.

How can I get an estimate of costs on health plans offered through the health insurance marketplace?

You should be able to get an estimate of health plan costs and savings through the health insurance marketplace prior to applying for coverage. You can find a cost calculator on your state's health insurance marketplace or on the federal health insurance marketplace, and through the tax credit calculator.

What are my health coverage options if I'm unemployed?

If you're unemployed you may qualify for Medicaid, the Children's Health Insurance Program (CHIP), or tax credits and cost-sharing assistance on plans offered through the marketplace. You also have the option to stay on COBRA. Your household size and income—and not your employment status—will determine which health coverage options you're eligible for and how much help you get paying for coverage.

What are my health coverage options if I'm a part-time employee without health coverage?

If you're a part-time employee without health coverage, you may qualify for Medicaid, the Children's Health Insurance Program (CHIP), or tax credits and
cost-sharing assistance on plans offered through the marketplace. Your household size and income—and not your employment status—will determine which health coverage options you're eligible for and how much help you get paying for coverage.

Can I keep my own doctor?

If staying with your current doctor is important to you, check to see if your doctor is included before choosing a plan. Most health insurance plans offered in the marketplace have networks of hospitals, doctors, specialists, pharmacies, and other health care providers. Depending on the type of policy you buy, care may be covered only when you get it from a network provider.

What is a catastrophic plan, and how do I know if I'm able to buy one?

Catastrophic plans are available to individuals who are under age 30 prior to the start of the plan year, or who have received an exemption from the individual mandate because they do not have an affordable coverage option or because they qualify for a hardship exemption. A catastrophic plan is designed to provide you with an emergency safety net to protect against unexpected medical costs. Catastrophic plans provide you with coverage for essential health benefits once your cost-sharing expenses, such as copayments, have equaled your out-of-pocket maximum.

What key dates do I need to know?

For 2014, open enrollment for health plans begins October 1, 2013. Health coverage can begin on January 1, 2014. Open enrollment closes on March 31, 2014.

How are small businesses affected by the Affordable Care Act?

Starting in 2014, businesses with 50 or fewer full-time equivalent (FTE) employees can use the health insurance marketplace to offer coverage to their employees (although doing so is not required until 2015). As a business owner, you control the coverage you offer and how much you pay toward premium costs. Insurance carriers can't turn you down based on the health status of your employees or their dependents. Plans also can't charge you higher premiums for women or increase your group's premium for employees with high medical costs. You may even qualify for tax credits if you purchase a plan through the marketplace. If you have fewer than 25 FTEs making an average of about $50,000 or less a year, you may also qualify for a Small Business Health Care Tax Credit. Click here for more information.

Will employers that don't provide health coverage have to pay a penalty?

Small businesses with fewer than 50 full-time equivalent employees (FTEs) are not required to offer health coverage. Starting in 2015, only large employers—with 50 or more FTEs—are required to provide insurance to their employees. The penalty for large employers is based on the number of FTEs (30 hours or more per week) that were not offered affordable health insurance. Click here for more information.

How does the Affordable Care Act apply to companies with self-funded plans?

The Affordable Care Act contains many provisions that apply nationally to
self-funded plans, including the extension of dependent coverage until age 26, no cost-sharing for preventive services, the limit on waiting periods to no more than 90 days, maximum patient out-of-pocket costs, and no lifetime or annual limits on coverage. However, self-funded plans will not be subject to meeting the minimum essential health benefit requirements.

When can I access the marketplace to offer health insurance to my employees?

Small businesses can start shopping for health insurance through the marketplace when open enrollment begins on October 1, 2013. Coverage would start as soon as January 1, 2014. You can sign up and begin offering coverage any time during the year.

What companies can I use to offer health insurance?

You can use any health insurance carrier that offers a
qualified health plan—regardless of whether you buy directly from the carrier or through the health insurance marketplace.

Do I have to provide insurance to all my full-time and part-time employees?

Starting in 2015, large employers with at least 50 full-time equivalent employees (FTEs) will have to pay penalties if they do not offer coverage to their FTEs.

If I own a small business, where should I go to get started?

To learn more about what you'll need to prepare, you can go to www.HealthCare.gov or check in with your state marketplace.

Do I qualify for Medicaid?

You can qualify for Medicaid based on your household income and size of your family. The rules for Medicaid eligibility are different from state to state. Most states offer coverage for adults with children below a certain income level, as well as pregnant women, some seniors, and people with disabilities. Under the Affordable Care Act, Medicaid eligibility is expanding in many states. Even if you didn't qualify for Medicaid in the past, you may qualify under the new rules. To see if your state decided to expand Medicaid eligibility, check in with your state marketplace.

How do I sign up for Medicaid?

You can visit your state's Medicaid website to find out if you qualify. You can apply for Medicaid coverage through your state's marketplace. If it looks like anyone in your household is eligible for Medicaid, the marketplace will let the Medicaid agency know so your coverage can start right away. For more information on Medicaid expansion, see the state-by-state map.

When will I receive Medicaid benefits?

If you qualify, coverage for Medicaid or the Children's Health Insurance Program (CHIP) generally begins on the date you complete an application for qualification.

What if my state isn't expanding Medicaid?

You can still apply for Medicaid. Your medical needs or unique circumstances might mean you qualify. If you don't qualify, you might be able to receive
cost-sharing assistance or a premium tax credit to help you pay for private insurance through the health insurance marketplace.

Will employees be taxed for the portion of the health insurance premium that is paid by the employer?

No, employer-provided health coverage will not be taxable.

What will happen to Medicare Advantage plans?

Nothing. The Affordable Care Act and the marketplace won't affect your Medicare choices or your benefits. No matter how you receive Medicare—through Original Medicare or a Medicare Advantage Plan—you'll still have the same benefits and security you have now. There's no need to make any changes.

Will a pregnancy in my household affect my ability to get health coverage?

No. A pregnancy in your household will not affect your ability to get health coverage.

Will plans cover my birth control benefits?

All non-grandfathered plans, including all plans available through the marketplace, must cover contraceptive methods and counseling for all women, as prescribed by a health care provider. These plans must cover the services without charging a copayment, coinsurance, or deductible when they are provided by an in-network provider.

Will plans cover my breastfeeding equipment and counseling?

The Affordable Care Act requires most health insurance plans to provide breastfeeding equipment and counseling for pregnant and nursing women. You may be able to access these benefits at no cost to you.

If I'm an American Indian or Alaska Native, what do I need to know about the health insurance marketplace?

If you are an American Indian or Alaska Native and an enrolled member of a
federally recognized Tribe, you have access to additional benefits through the Affordable Care Act. These additional benefits include:

  • No required fee payment if you don't have health coverage
  • Access to special cost and eligibility rules for Medicaid and the Children's Health Insurance Program (CHIP)
  • No cost-sharing if your income is at or below a certain range
  • No cost-sharing for Tribal members who get services from a Tribal or Urban Indian Clinic
  • Special monthly enrollment periods to sign up for or change plans

To get these benefits, individuals must be enrolled Tribal members and provide documentation within 90 days. Individuals are responsible for documentation, but the Tribe can help with the process.

If I'm a military veteran, what do I need to know about the health insurance marketplace?

If you're enrolled in TRICARE or the Veterans Affairs (VA) health care program, you're considered covered under the health care law. You don't need to make any changes. If you're not enrolled in VA benefits or other veterans health coverage, you can get coverage through the health insurance marketplace. You may be able to get lower costs on monthly premiums and out-of-pocket costs, or you may qualify for free or low-cost coverage through Medicaid or the Children's Health Insurance Program (CHIP).

Can I purchase insurance if I'm not a U.S. citizen, or if I'm an undocumented immigrant?

Yes, but only directly from an insurance carrier. You are not eligible to purchase insurance through the marketplace.

Will students who are enrolled in a student health plan need additional health insurance?

Student health plans are a type of individual health insurance and must offer preventive health services without any cost to you. However, if your student health plan is grandfathered, it does not have to cover preventive health services. Self-funded student health plans are also exempt from the requirement.

What is the difference between buying an insurance plan through a health insurance marketplace and buying a plan directly from an insurance company?

Individuals and small employers who shop through a health insurance marketplace can access unique benefits. Individuals will be able to check their eligibility and apply for public health care programs, such as Medicaid. Financial assistance to make health coverage more affordable—including tax credits—is available only to individuals who purchase insurance through the marketplace. Small employers that offer coverage through the marketplace will be able to provide their employees with more plan choices. Only small employers that purchase coverage through the marketplace may be eligible for the Small Business Health Care Tax Credit.

I need assistance enrolling for coverage through the exchange. What are my options?

Affiliated health insurance agents and community partners are available to assist you with the application process at no cost. The Affordable Care Act refers to these assisters as "navigators." Visit HealthCare.gov, or call 800-318-2596 for more information.

Will my health coverage through the exchange cost more just because I make a certain amount of money?

No. The amount of income you make annually may determine how much financial assistance you qualify for, but not the cost of specific plans.

What are the differences between bronze, silver, gold, and platinum health plans? How do I know which metal level is the right choice for me?

The different metal level plans available in the health insurance marketplace are defined by how much a plan pays for essential health benefits. Bronze plans cover 60 percent of costs on average, silver plans cover 70 percent of costs on average, gold plans cover 80 percent of costs on average, and platinum plans cover 90 percent of costs on average. Premium costs rise as you move up from bronze to platinum. You can choose the level that meets your specific needs. If you'd rather pay more each month in premiums and less costs when you visit your provider, the platinum plan is probably your best option. Likewise, if you'd rather pay less each month in premiums and more costs when you visit your provider, the bronze plan is probably your best option.

How does a business qualify to receive a tax credit to help cover the cost of premiums?

The Small Business Health Care Tax Credit is available through the IRS to help cover the cost of premiums. For more information on how to qualify, contact a CPA or a tax professional, or visit www.irs.gov/uac/Small-Business-Health-Care-Tax-Credit-for-Small-Employers.

If I provide insurance to my employees now, will the plans automatically roll over to the health insurance marketplace in 2014?

No. In order to offer coverage through the health insurance marketplace, small employers will need to complete the application and enrollment process.