Individuals & Family Plans

What are the minimum requirements to obtain coverage through the Health Insurance Marketplace?

The Marketplace was created to be very accessible to millions of people who might not have had easy access to health insurance coverage in the past. However, there are certain requirements to be met in order to purchase a plan.

  1. You must be a U.S. citizen or “lawfully present” immigrant.
  2. You must live in the United States.
  3. And you can’t be currently incarcerated serving time in a jail or prison.

What is Minimum Essential Coverage?

To avoid being charged the individual mandate (also referred to as fee, fine, penalty, or responsibility payment), employees are obligated to obtain an insurance plan that meets the requirements of “minimum essential coverage” which include the new benefits, rights, and protections laid out in the legislation, and must remain covered throughout the year, or procure and exemption.

How are my premium costs calculated?

Insurance companies are prohibited to discriminate when offering health coverage, and there have been new restrictive measures put in place to prevent this .However, there are 5 factors that may be considered when figuring out premium costs.

  1. Individual vs. Family – A plan covering an individual will generally cost less than a plan covering a family. Size of the family may also factor into the cost.
  2. Location – Where you reside may affect your coverage cost as an insurance company will consider factors such as competition, local regulations, price of living, etc.
  3. Tobacco users vs. non-users – There are many health-risks associated with tobacco use, and health insurance companies will definitely factor this into their calculations. Tobacco users will generally expect to pay a higher premium.
  4. Age – Due to health complications of aging, a younger enrollee will typically pay less than an older enrollee.
  5. Plan Category – The four metal categories in a Marketplace plan are Bronze, Silver, Gold, and Platinum. Although they offer similar coverage, they differ in premiums and deductible costs depending on the plan you go with.

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What is the penalty if I do not carry health insurance?

The fee for no having health coverage is calculated in one of two ways, whichever amount is higher. You may be charged a flat fee or a percentage fee which will be applied to your federal income tax returns for the years that you were not insured.

Below are the 2016 fee calculations:

  1. Flat Fee – You will be charged $695.00 per adult and $347.50 per dependent (under 18) to reach no more than $2,085.00 per family
  2. Percentage Fee – In this calculation you will be charged 2.5% of the annual household income above the tax filing threshold, not to exceed the national average for bronze plan premiums.

If you did not have health insurance coverage in 2015, the fees were applied as such:

  1. Flat Fee – You will be charged $325.00 per adult and $162.50 per dependent (under 18) to reach no more than $975.00 per family
  2. Percentage Fee – In this calculation you will be charged 2% of the annual household income above the tax filing threshold, not to exceed the national average for bronze plan premiums.

How would I qualify for an exemption?

If you qualify for an exemption, you will not be subject to the penalty for being uninsured. Below are some examples of exemptions that may apply to you or your family’s situation:

  • You were uninsured for under 3 months of the year
  • You don’t meet the income tax filing threshold and so are not required to file
  • You are not lawfully present in the U.S.
  • The lowest-priced plan option provided exceeds 8% of your household income
  • You are a member of tribe recognized by the federal government
  • You are a member of a federally recognized organization with religious objections to insurance, Medicare, Social Security, etc.
  • You are currently incarcerated and serving a term in jail or prison
  • You qualify for hardship exemption

You can visit online to see more examples that might qualify you for an exemption from being assessed the fee for non-coverage.

What is a Life Changing Event, and how does that will that affect how my health insurance works for me?

A life changing event would generally involve major changes in your life that would directly affect your household income, or the gaining or losing of a family member. These events must be reported, as they could directly affect how your plan is supposed to function and could result in back pay when you file your taxes, if you fail to do so.

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What if I am pregnant?

You can purchase a Marketplace coverage before or after you become pregnant. All plans will cover your pregnancy and also qualify you for a Special Enrollment Period (SEP) in which you can enroll in or change your coverage after childbirth. So should this occur outside of the Open Enrollment Period, it would not affect your ability to enroll or change to a different plan altogether. Once enrolled, coverage will take effect as soon as the child is born. This even applies if you fail to enroll for up to 60 days after the delivery date.

What if I am pregnant and have a private insurance plan?

Regardless if you purchase health insurance within or outside of the Marketplace, all plans are obligated include Maternity Care and Childbirth services that cover certain essential health benefits and provide a Summary of Benefits and Coverage document explaining how the plan will cover childbirth. Again, even if you become pregnant before being enrolled in a plan, these benefits will still be available to you once you do enroll.

Medicaid and CHIP also offer these benefits and are available to low income households that meet their eligibility requirements. Both of these are state programs and will have different qualifying income levels between themselves, and from state to state. But both programs offer enrollment year round. You can apply directly through your state, or through the Marketplace.

An exception may be grandfathered individual plans that are purchased independently outside of the Marketplace or not through your employer. They may not be required to offer Maternity Care and Childbirth services.

What if I am getting married?

Getting married is also considered a life changing event and, as such, must be reported. You can enroll up to sixty days after the day you get married and coverage will take effect on the first date of the month you enrolled into a plan. But you cannot enroll until after you have become married.

What happens if I lose my current coverage? What are my options then?

You may find yourself in a situation in which your non-Marketplace grandfathered plan terminates. It is important to be familiar with these scenarios and know what options you have in the event it happens to you.

  1. Plan ends and is Cancelled – If your plan is outright cancelled, your employer may or may not offer a different plan to replace it. You have the option of purchasing this new plan. Or you may choose to purchase a Marketplace plan instead with the new rights and protections.
  1. Plan is Changed to offer the New Rights and Protections – Here once again, you have the choice of purchasing this changed plan. Or you may decide you want to look within the Marketplace and enroll for coverage there instead. In this scenario, since the original plan is changed, you will qualify for a Special Enrollment Period in which you can enroll for insurance outside of the Open Enrollment Period.
  1. Plan is Offered for Renewal Without the New Rights and protections – This situation would arise only for existing customers, not for new customers. However, this option for insurance companies to offer renewal will be decided on the state where you live. But if you do find yourself in this scenario, you may decide to opt for renewal without the new rights and protections. Or you can purchase a Marketplace plan that does offer them.

If your current coverage has been changed or cancelled, you can contact a special cancellation customer service representative to go over your options at 1-866-837-0677 Monday through Friday from 9 a.m. to 7 p.m., Saturday and Sunday from 9 a.m. to 5 p.m. Eastern Time.

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How do I enroll in a Marketplace plan?

Since the advent and implementation of the ACA legislation, much energy and focus has been put into making applying, enrolling, and purchasing health insurance coverage a simple and convenient process. Healthcare.gov was the internet portal created to answer questions, provide assistance, and allow you access to purchase a health plan. There are four ways in which you can apply for coverage through the Marketplace and any of these methods can be used, whichever is most comfortable and convenient for you.

  1. Online – When you apply for a marketplace plan online, you will be asked to set up an account and specify your state of residence before being directed to the online application where you will be asked to provide information as you’re guided through the entire application process. Once the application is completed, you can view all your plan options based on the information you provided and your eligibility results. If you are eligible for Medicaid, CHIP, savings, and premium tax credits, you will be able to view this information here too. As soon as review and decide on the plan that best suits the need for you and your family, you may now enroll in that plan and you will be provided the contact information of the insurance company to complete the process.
  1. Over the Phone – The Marketplace call center is open 24 hours a day, 7 days a week, and is there for anyone that needs assistance for questions, concerns, and complete the application and enrollment process for you over the phone. You can reach a Marketplace call center representative at any time by calling 1-866-445-9624.
  1. Mail – If you wish, you can send in a hard-copy application through the mail. Once your eligibility results are mailed back, and decide on the plan that best meets your needs, you can complete the process and enroll over the phone or online at your convenience.
  1. In Person – Some people may prefer face-to-face assistance. This is not a problem. The Marketplace have assistors to walk you through the application and enrollment procedures and answer any questions you may have along the way. Visit HealthCare.gov to locate an assister near you