Looking for information on the new health care law? Here are some frequently asked questions that may be helpful. If you are an organization helping people find information on new insurance options, please visit our Advocates page.
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Q. I wasn’t eligible for Medicaid or Marketplace tax credits, because my income was below the poverty level and my state did not expand Medicaid. What happens if my income increases – will I be eligible for coverage now?
- If you have a pre-existing health condition, you can no longer be denied coverage or charged more based on your condition.
- Insurance companies are required to spend at least 80% of the monthly premiums you pay on health care services. If you got a refund check in the mail from your insurance company, they are paying you back for spending too much of your premium payments on other items, such as administrative costs or profits.
- Most insurance plans are now required to cover specific categories of basic health services, known as Essential Health Benefits (EHBs).
- Many preventive services must now be provided for free, including certain vaccines, cancer and disease screenings, services for pregnant women, and contraceptive methods like birth control pills.
- Insurance companies can no longer put yearly or lifetime limits on the amount of health care services they will cover if you get really sick.
- Each state has an online Health Insurance Marketplace (AKA “Exchange”) where people can compare plan rates and benefits side-by-side and purchase the health insurance that’s right for them. Depending on your income, you may be eligible for new tax credits and cost-sharing subsidies to lower the cost of coverage when you buy a plan on the marketplace. Go to HealthCare.gov to find the marketplace in your state.
- If your parent’s insurance plan offers dependent coverage, you can stay on your parent’s plan until you are 26 years old. Former foster care youth can stay on Medicaid until age 26 as well.
- States now have the option of expanding Medicaid, a free or low-cost insurance plan offered by the government, to cover all low-income adults. Before the ACA, Medicaid in most states was only available to low-income adults with children, pregnant women, seniors, and people with disabilities. Visit HealthCare.gov to find out if you’re eligible for Medicaid in your state.
- Almost everyone is now required to have health insurance coverage in 2014. If you do not have qualifying insurance coverage and do not fall under an exception to the law, you may have to pay a fee when you file your taxes.
- If you work full-time for a business that employs over 100 full-time employees, your employer has to provide the majority of it’s employees with insurance coverage or pay a fine. Starting in 2016, employers with more than 50 full-time employees will also have to meet this requirement.
The individual mandate is the requirement that everyone who can afford health insurance has coverage or pays a fee. You will provide information on any health insurance you had the previous year when you file your taxes for that year. You may have to pay a fee if you did not have insurance coverage and do not qualify for an exemption.
Starting in 2014, if you don’t have health insurance and don’t qualify for an exemption, you’ll pay a fee when you file your taxes in 2015. You’ll also have to pay out-of-pocket for all of your health care. There are a few exceptions, or situations under which you would not have to pay the fee if you don’t have coverage.
You may not have to pay a fee if:
- You cannot find insurance that costs less than about 8% of your household income after tax credits and any contributions by your employer are applied;
- You are a Native American, religious objector, or incarcerated;
- You are undocumented or a Deferred Action for Childhood Arrivals (DACA) recipient;
- You are a U.S. citizen living abroad;
- You are uninsured for 2 consecutive months or less in a year;
- Your household income is below the threshold for filing income taxes (about $10,000 for individuals and $20,000 for married couples); or
- You would have qualified for Medicaid if your state expanded Medicaid coverage, but your state has decided not to do so.
These exemptions from the fee are not automatic. You will have to apply on HealthCare.gov or when you file your taxes to be excused from the penalty. If none of these situations apply but you think you may still qualify for an exemption, find a local in-person assister who can help you understand your options at localhelp.healthcare.gov.
If you’re uninsured for 2 consecutive months or less in the year, you won’t have to pay a penalty. But if you have a gap in coverage of 3 months or more, you’ll have to pay a pro-rated penalty based on the numbers of months you went without insurance. Additionally, if you have 2 or more short gaps in coverage (2 months or less), you will have to pay a penalty for your second (and subsequent) coverage gap.
However, if you lose your insurance coverage during the year, you may qualify for a special enrollment period to sign up for a new plan and avoid a gap in coverage.
In most cases, you can apply for an exemption from the fee for going uninsured by filling out the appropriate form on HealthCare.gov: https://www.healthcare.gov/exemptions/. If you are undocumented, have Deferred Action for Childhood Arrivals (DACA) status, or were uninsured for 2 months or less in the year, you can apply for an exemption when you file you tax return.
Your options for health insurance coverage depend on several factors, including your age, state of residence, income level, employment status, and other personal circumstances. Your options could include:
- Staying on your parent’s plan until you are 26 years old;
- Medicaid coverage, depending on your income level and state;
- If you are a former foster youth, Medicaid coverage until you are 26 years old;
- Job-based insurance coverage, if your employer provides it to you;
- Student health insurance, depending on your school; and
- Purchasing your own plan. The best place to do this is on your state’s Health Insurance Marketplace website, where you can compare rates and find out if you are eligible for discounts based on your income. You can also use this Health Insurance Marketplace Calculator to see what discounts you may be eligible for!
If you don’t think you can afford coverage, go ahead and fill out an application on your state’s Health Insurance Marketplace website. You may be eligible for low-cost coverage through newly-expanded Medicaid programs or discounted coverage plans. By filling out an application, you can at least see your options or find out if you qualify for a “hardship exemption” so you won’t have to pay a penalty for going without insurance coverage.
If you can’t afford insurance after going through the marketplace, there may be clinics, community health centers, or hospitals in your area that provide free or low-cost care. These facilities can serve as a backstop until you can afford full coverage. If you’re a student, your school may also offer some basic services at no charge through the student health center. Download our HealthYI app to find local clinics, or check with your school’s student health department to see what they offer. You can also go to findahealthcenter.hrsa.gov to find a federally-qualified community health center near you.
You can now stay on a parent’s plan until you turn 26 years old. Your parent or guardian can add you to their existing health plan (if the plan offers dependent coverage), or buy a family plan on the new Health Insurance Marketplace. Either way, as long as you’re under 26, you can be added to your parent’s plan – even if you’re married, not living in the same state, and/or not financially dependent on your parent.
There are a few exceptions:
- Your parent’s plan must already offer coverage for dependent children.
- You may not be able to join if your parent has a “retiree-only” plan.
In addition, young adults who were in foster care can stay on Medicaid until age 26, regardless of income. If you were in foster care when you turned 18 or aged out and were enrolled in Medicaid while in foster care, you may be eligible for full Medicaid coverage.
Generally, no. If you are covered on your parent’s plan and you have or adopt a child, you can get a child-only plan for your child or switch to a family plan with them on the Health Insurance Marketplace. You will have 60 days after the birth/adoption of your child to do so.
However, if you are covered on your parent’s plan, that plan must cover recommended preventive services during your pregnancy at no cost, including preconception and prenatal care.
No! The Affordable Care Act requires insurance companies to cover young adults on their parent’s plan until age 26 if the plan offers dependent coverage, regardless of your tax status, student status, state of residence, or marital status.
Talk to your parents, the insurance company, or plan administrator. If your parent has insurance through a job, the best person is usually in the Human Resources department.
Many plans have an “open-enrollment” period before the New Year, and start coverage on January 1st. If you don’t sign up then, you’ll normally have to wait until the next year, unless you have a “qualifying life event” that lets you enroll sooner.
For example, losing your student health plan or other insurance coverage is a qualifying event that could allow you to join your parent’s plan right away.
It depends on your school. Many colleges require you to have health insurance. More than half of colleges offer a Student Health Insurance Plan (SHIP). Many students purchase these plans, but there are other alternatives that may be available like:
1. Staying on your parent’s coverage,
2. Getting your own coverage (through an employer, or on the new Health Insurance Marketplace), or
3. Public programs like Medicaid.
Four-year schools are more likely to offer SHIPs than two-year schools. If you’re going to a community college, you may have to look outside of school for coverage.
If you’re going to school out of state, you can enroll in a plan through the Marketplace in the state where you’re attending school. Alternatively, you may also be able to get a plan through the Marketplace in the state(s) where your parent(s) lives.
Maybe. You will generally be able to apply for Medicaid in the state where you attend school if you meet that state’s residency requirements. In many states, you will qualify as a resident if you currently live in the state and intend to remain there for a period of time. Things like tax forms, utility bills, and receipts from rental payments can be used as evidence supporting your residency in a state. Check with the health agency in the state where you go to school for more information.
As a student, you may qualify for coverage under your school’s student health plan. Many schools require international students to have health insurance, and some schools may require international students to purchase the school health plan. If you are on a student visa (like an F visa), you can also buy a plan through your state’s Health Insurance Marketplace. If you buy a plan on the Marketplace, you may be eligible for discounts based on your income that will reduce your monthly costs. Check out the Health Insurance Marketplace Calculator to get an estimate.
Unfortunately, students with Deferred Action for Childhood Arrivals (DACA) status are generally not eligible to buy a plan through the Marketplace nor get a plan through Medicaid. However, you won’t have to pay a penalty for not having coverage. You can sign up for your school’s student health plan (if available) or shop for a plan outside the Marketplace. Note: Students with DACA status are eligible for free coverage through Medicaid in New York and California.
Whether or not you should enroll in a student plan depends on your personal circumstances. When thinking about whether to enroll in a student plan, keep the following things in mind:
- Compare the coverage and price to the coverage and price of other options.
- You may be able to get a discount on insurance if you buy a plan on the new Health Insurance Marketplace or qualify for free coverage through Medicaid in your state. Even if you have an offer of a SHIP, you may be able to get a less expensive plan through the marketplace or Medicaid.
- Check if your alternative options have in-network doctors in your school’s area. Often, only your SHIP is accepted at a campus health center.
- Consider your parent’s plan: would there be out-of-network charges to see doctors near school? Can you pay that? Do you go back home often, and have adequate access to your doctor in your home town?
- Review any health care that your school gives to all students, regardless of whether they buy the SHIP. Some schools automatically charge students a separate “student administrative health fee” to help cover the costs of providing services at a campus health center. You may be able to access basic services at the campus health center, and stay on a parent’s plan for larger issues.
- Ask yourself: which coverage option is the better bargain? Which has the most coverage? Which better fits your medical situation?
Note: Some schools may require you to actively opt-out (“waive out”) of a SHIP by filling out a form if you have insurance from another source, like your parents or a state program.
It depends on the plan, but almost all student plans, like other insurance plans, are now required to provide what’s called “Minimum Essential Coverage.” And now, student plans cannot discriminate against you or refuse to cover you if you have a pre-existing condition. They also must provide free preventive care, such as birth control, HIV and STD testing, and depression and domestic violence screenings.
There is a new tool for you to use to buy health insurance. Each state will have a new Health Insurance Marketplace (also called an Exchange) where you can see a variety of insurance options and compare plans.
You can use the Marketplace to:
- Compare health plans to pick the best one for you and your family.
- Find out if you qualify for new discounts that lower the cost of private health insurance—applying for a plan on the online marketplace is the only way you can qualify for and use these new discounts.
- Find out if you or your family members qualify for free or low-cost public programs, like Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).
Check out HealthCare.gov for more information!
Yes! Check out the Health Insurance Marketplace Calculator in our app to get an estimate of your savings and costs.
- Savings on your monthly payments: If you make less than 400% of the poverty level – roughly $47,100 a year as an individual or $97,000 a year as a family of four – you may be eligible for a discount on the amount you pay each month for insurance. This discount is called a Premium Tax Credit and it’s only available if you buy a plan through the Health Insurance Marketplace.
- Savings on your out-of-pocket costs: If you make less than 250% of the poverty level – about $29,400 a year as an individual or $60,600 a year as a family of four – you may also be eligible for discounts on your out-of-pocket costs when you get health care services. This discount is known as a cost-sharing subsidy and it’s only available if you buy a silver-level plan through the Marketplace.
- Free or low-cost coverage: If you make less than 138% of the poverty level or less– about $16,200 a year as an individual or $33,500 a year as a family of four, you may be eligible for free or low-cost health insurance through Medicaid or the Children’s Health Insurance Program (CHIP) in certain states.
There are four “metal levels” of plans sold on the Health Insurance Marketplace – Bronze, Silver, Gold, and Platinum. There is no difference in quality between different metals levels, but the metal levels do indicate the average amount the plan will pay for the health care you receive – and how much you will have to pay out-of-pocket. On average, Bronze plans pay 60% of your health care costs, Silver plans pay 70%, Gold plans pay 80%, and Platinum plans pay 90%.
Bronze plans tend to have lower monthly premiums (the amount you pay for coverage each month) but you have to pay more out-of-pocket when you receive services. In contrast, Platinum plans tend to cost more on a monthly basis but less when you use your insurance.
The next Marketplace Open Enrollment Period – when you can shop for and change health plans – runs from November 1, 2015–January 31, 2016. You will have to enroll in a plan by December 15, 2015 for your coverage to start on January 1, 2016. If you’re currently enrolled in a marketplace plan, you should also re-enroll by December 15th. After updating your information, you can choose to stay in your same plan or pick a new one that may provide better options or cost less.
If you experience certain life events, you may be able to sign up for or change health insurance plans outside of Open Enrollment through what’s called Special Enrollment. Examples of events that could qualify you for special enrollment include: getting married, having a baby, moving, losing other health coverage, gaining citizenship, and leaving incarceration. You will have 60 days after you experience a life event to sign up for coverage on the Marketplace.
American Indians and Alaska Natives can sign up for insurance coverage on the Marketplace year-round. Enrollment in Medicaid and CHIP – which provide low-cost coverage to qualified low-income individuals – is also year-round.
You’ll need the following information and documents for everyone in your household that is applying for coverage:
- Name and contact information;
- A form of identification such as a Social Security Number or document number listed on a Green Card or visa;
- Information on your household size and household income; and
- The policy numbers of any current health plans covering members of your household.
You will also need to complete the Employer Coverage Tool on HealthCare.gov, with information on every job-based plan you or someone in your tax household is eligible for (even plans you’re eligible for, but don’t enroll in). For more, see: https://marketplace.cms.gov/outreach-and-education/apply-for-or-renew-coverage.pdf.
You can also find in-person help in your area by visiting localhelp.healthcare.gov. You can also get help by phone 24 hours a day, 7 days a week by calling 1-800-318-2596.
Maybe! Generally, you can only sign up for health coverage during what’s known as Open Enrollment. The next open enrollment period runs from November 1, 2015–January 31, 2016.
However, you can sign up for coverage outside Open Enrollment if you:
- Qualify for Medicaid or CHIP, low-cost public health coverage programs;
- Are an American Indian or Alaska Native; or
- Experience certain life events – like getting married, moving, or having a child – that qualify you for what’s known as a Special Enrollment Period.
Go to HealthCare.gov to see all of the events that trigger special enrollment and see if you qualify. You will only have 60 days after the qualifying event to sign up for coverage on the Marketplace.
Maybe. If your plan offers family coverage, you can add a family member to your current plan during what’s known as Open Enrollment. Open Enrollment for the Health Insurance Marketplaces runs from November 1, 2015–January 31, 2016. If you or a family member experiences certain life events, you may be able to add a family member to your plan outside the Open Enrollment period. For example, if you get married, have or adopt a child, or a family member loses his or her job-based coverage, you can add them to your plan through a Special Enrollment Period. You will have 30 to 60 days from the qualifying event to update your plan (depending on the type of plan you have and where your live).
You should report changes in your income to the Marketplace. A change in income may change the type of coverage or discounts you qualify for. For example, if your income decreases, you may be eligible for a new or larger tax credit. If your income increases, you should report your change in income to avoid having to pay money back at tax time. For guidance on reporting changes, visit: https://www.healthcare.gov/reporting-changes/why-report-changes/.
If you’re on a Marketplace plan and become eligible for full Medicaid (as a result of a decrease in your household income and/or increase in your family size), you have the option of remaining on your original insurance plan or switching to Medicaid. However, you will no longer qualify for premium tax credits on the Marketplace. Note: Women who become eligible for pregnancy-related Medicaid may be able to enroll in both Medicaid and a Marketplace plan, and won’t lose eligibility for federal tax credits.
If you are enrolled in Medicaid and your income rises above the Medicaid cutoff for your state, you will lose coverage under Medicaid. But remember that a change in income (either up or down) could qualify you for a special enrollment period of 60 days. During this period, you can enroll in a Marketplace plan and may be eligible for tax credits to lower the cost of coverage.
Q. I wasn’t eligible for Medicaid or Marketplace tax credits, because my income was below the poverty level and my state did not expand Medicaid. What happens if my income increases above the poverty line – will I be eligible for coverage now?
Yes. If you were not eligible for affordable health coverage because your state did not expand Medicaid eligibility and you did not make enough money to qualify for tax credits through the marketplace, and your income increases, you may be eligible to enroll in a marketplace plan with tax credits. To find out if you qualify to enroll in health coverage due to an increase in income, call the Marketplace Call Center at 1-800-318-2596.
You can cancel your Marketplace coverage at any time by logging into your Marketplace account and selecting the red “End (terminate) all coverage” button. Check with your insurance company afterward to confirm your plan was cancelled. If you got a plan outside the Marketplace, contact your insurance company to cancel your coverage. Note: if you cancel your coverage without replacing it, you may have to pay a fine for the months you’re not covered.
WHAT ARE MY HEALTH INSURANCE OPTIONS IF…
If you have health insurance through your school, you’ll need to get new insurance after you graduate. Your options may include: getting added to a parent’s plan if you’re under age 26; applying for your own plan through the new Health Insurance Marketplaces; or getting insurance through a new job. You’ll have a limited period of time after your student plan ends (30-60 days) to sign up, so act fast. Check out younginvincibles.org/special-enrollment/#graduating for more.
If you’re on your parent’s health insurance plan, you may need to get a new plan when you turn 26. Your options may include: applying for a plan through the new Health Insurance Marketplaces; getting insurance through your employer; or extending your current insurance with COBRA. Check with your parent’s insurer to find out when your coverage will end – you’ll only have 30-60 days after that to sign up. See http://younginvincibles.org/special-enrollment/#26yrs for more.
If you have health insurance through your employer and lose that coverage do to a job loss or reduction in hours, you may qualify for a Special Enrollment Period to sign up for a new plan. Depending on your income and where you live, you may be eligible for free or discounted coverage through the Health Insurance Marketplace or Medicaid. You may also have the option of extending your current coverage through COBRA. Check out http://younginvincibles.org/special-enrollment/#losejob for more. Note: you may only have 30-60 days to sign up, so don’t delay. Check out http://younginvincibles.org/special-enrollment/#losejob for more. Note: you may only have 30-60 days to sign up, so don’t delay.
Check with your new employer to find out if they offer health insurance. Don’t delay – you may only have 30-60 days from your start date to sign up for the insurance. Check out http://younginvincibles.org/special-enrollment/#losejob for more.
If you move permanently, you may be able to sign up for or change your health insurance plan. Even if you’re already covered, if you’re moving to a different state, your old plan may not cover you in your new state, so you may need to switch plans. See http://younginvincibles.org/special-enrollment/#moving for more. Note: you may only have 30-60 days to sign up, so act fast.
Congratulations! When you get married, you may qualify for a Special Enrollment Period to sign up for or change your health insurance. You may only have 30-60 days from the date of your marriage to sign up, so don’t delay. If you already have a plan through the Health Insurance Marketplace, be sure to update your family size and income to get all the tax credits you deserve and to avoid owing money at tax time. Check out http://younginvincibles.org/special-enrollment/#married for more.
Note: Insurance companies must now offer legally married same-sex spouses the same coverage that they offer opposite-sex spouses, regardless of the state you live in.
If you get a divorce, you may qualify for a Special Enrollment Period to sign up for new health insurance coverage. Depending on your income, you may be eligible for free or low-cost coverage through the Health Insurance Marketplace or Medicaid. To see if you qualify, visit: healthcare.gov/screener/.
If you are low- or middle-income, you may be eligible for Medicaid coverage while you’re pregnant. Medicaid for pregnant women includes health care through pregnancy and for 60 days after the birth of your child. Go to Healthcare.gov to find out if you qualify. Note: Becoming pregnant does not qualify you for a Special Enrollment Period in the Health Insurance Marketplace. However, giving birth does trigger a Marketplace Special Enrollment Period when you and your newborn can sign up for a marketplace plan.
Most health insurance plans must now cover maternity care and childbirth as part of the 10 Essential Health Benefits. For more on health coverage while you’re pregnant, visit: healthcare.gov/what-if-im-pregnant-or-plan-to-get-pregnant/.
Congratulations! When you have or adopt a child, you may qualify for a Special Enrollment Period to sign up for or change your health insurance. Depending on your income, you may be eligible for free or low-cost coverage through the Health Insurance Marketplace or Medicaid. Check out http://younginvincibles.org/special-enrollment/#baby for more.
Note: If you’re on your parent’s plan, you won’t be able to add your child to that plan. But, you may be able to get a child-only policy or switch to a family plan on the Marketplace.
Members of federally-recognized tribes can enroll in health insurance through the Marketplace year-round. For more information on how the health care reform law affects American Indians and Alaskan Natives, visit http://www.ihs.gov/aca/faq/.
Although you can apply for and enroll in a plan through your state’s Health Insurance Marketplace, you should pay your premium directly to your insurance company. Each insurer handles payments differently, so follow the instructions from your insurer to determine what forms of payment are accepted and the due date of your first payment. Insurance companies usually require you (or your employer) to pay premiums monthly, quarterly, or yearly. Your insurance won’t go into effect until your first payment has been made.
Many insurance providers allow enrollees to print off a temporary insurance ID card from their website. Call your insurer or visit their website to check the status of your card and see if you can get a temporary card in the meantime.
Check with your insurance plan or Medicaid program for a list of doctors in your plan’s “network.” Your insurance company will often charge you more for visiting doctors who are out of your plan’s network – so visit an in-network doctor if you can. Download our HealthYI app to find doctors near you.
Some types of insurance plans, like Health Maintenance Organizations (HMOs), require you to get a referral from your primary care doctor before you can see a medical specialist, like an allergist or cardiologist. Check your insurance plan to see if you need a referral before you can see certain types of doctors.
Primary care doctors should be your first stop for non-emergency medical situations such as yearly physicals, immunizations, colds, and minor injuries. You should only use the emergency room for life-threatening situations. Primary care doctors are ideal for routine medical visits because you will generally have a minimal wait time and develop a relationship with a doctor who knows you and has access to your medical records. On the other hand, if you visit the emergency room for non-emergency conditions, you could face extensive wait times and much higher costs.
Bring your insurance card with you and be prepared to answer brief questions about your family health history and any medicines you take. It’s also a good idea to bring a list of questions and issues to discuss with your doctor. For more information, visit: http://marketplace.cms.gov/technical-assistance-resources/c2c-roadmap-to-health-poster.pdf.
If your insurer doesn’t pay for a specific doctor visit or service, you have the right to appeal the decision. Whenever your insurance company refuses to pay for a service, the insurer must explain in writing why they denied the service and let you know how you can appeal the decision. You can contact your state’s department or division of insurance to get help with an appeal or file a complaint against your insurer. Visit www.naic.org/state_web_map.htm to contact your state insurance department.
Start by making sure that your prescription is covered by your insurance plan. You can find this information by visiting your insurer’s website, looking at your Summary of Benefits and Coverage, or calling your insurer directly. If your plan doesn’t cover your prescription, ask your insurance company if you can get a one-time refill of your prescription. And check with your doctor to see if there’s a similar medication that you can switch to that’s covered by your plan.
If you can’t get a one-time refill, you have the right to begin your company’s drug exceptions process. This process allows you to get a prescribed drug that isn’t usually covered by your health plan. For more information on the drug exceptions process, visit: www.healthcare.gov/using-your-new-marketplace-coverage/prescription-medications/.
Most insurance plans must cover FDA-approved contraceptive methods at no additional cost to you. The law requires insurance plans to cover one type of each birth control method (ex. implant, intrauterine device (IUD), or hormonal birth control). However, insurers are not required to cover every product within each category. For example, a plan may cover a generic version of birth control pills for free, but require a co-pay for the brand name version of the product. If you need help or additional information, call the National Women’s Law Center’s CoverHer hotline at 1-866-745-5487 where you can get personalized help understanding and accessing your benefits.
Check your insurance policy to find out when your current plan ends, and make sure you renew your plan or shop for a new one before your coverage ends. If you bought a plan through the Health Insurance Marketplaces in 2015, your current plan will end on December 31, 2015. This fall, you should receive notices from your insurer and the Marketplace detailing how to renew your current plan and tax credits (if applicable) for 2016. Make sure to update your information – including income, household size, and place of residence – with the Marketplace, to make sure you’re getting the right plan and discounts. You’ll also have the chance to shop around or switch to a new plan during the Open Enrollment period from November 1, 2015 – January 31, 2015. But make sure you renew or change your plan by December 31, 2015 to avoid a gap in coverage. For more information, visit: www.healthcare.gov/blog/we-are-making-it-easy-for-you-to-keep-your-marketplace-coverage-next-year/.
The Health Insurance Marketplace created a set of resources called From Coverage to Care to help people understand and use their health coverage. Visit marketplace.cms.gov/technical-assistance-resources/c2c.html for resources in English and Spanish.
Medicaid is joint program between state and federal governments that provides free or low-cost health coverage to low-income children, parents, pregnant women, and people with disabilities. The Affordable Care Act (ACA, also known as Obamacare) initially made all adults and children making less than 138% of the poverty level or less – about $16,200 a year for an individual or $33,500 a year for a family of four – eligible for health insurance coverage under Medicaid.
Due to a 2012 Supreme Court ruling on the law, each state can now choose whether or not to expand Medicaid eligibility to cover their low-income residents. So far, 29 states and the District of Columbia have chosen do so. Whether or not you are eligible for Medicaid depends on your income level and in which state you live. To find out if you are eligible for Medicaid, fill out an application for insurance on your state’s Marketplace website.
Some states have expanded eligibility for Medicaid coverage to all individuals making less than about $16,200 or less a year (or about $33,500 or less a year for a family of four). If you live in one of the 29 states or the District of Columbia that expanded Medicaid, you may be eligible for free or low-cost coverage. The best way to determine if you are eligible for Medicaid is to fill out an application for insurance on your state’s Health Insurance Marketplace (or “Exchange”). Even if you aren’t eligible for Medicaid, the Marketplace application process will let you know if you are eligible for a new kind of tax credit to make insurance coverage more affordable.
If your state hasn’t expanded Medicaid and your income is between 100% and 400% of the poverty level – roughly $11,800 and $47,000 a year for an individual, or $24,300 and $97,000 a year for a family of four – you may be eligible for discounts on coverage through the Health Insurance Marketplace. Check out the Health Insurance Marketplace Calculator in our app to get an estimate of your savings and costs.
If your state has not expanded Medicaid and your income is below the poverty level – about $11,800 a year for individuals or $24,300 a year for a family of four – you are unfortunately in what’s known as the “coverage gap.” You will not be eligible for discounts to buy a plan on the Marketplace and you may not be eligible for coverage through Medicaid. However, you may be able to receive care through Community Health Centers for little to no cost.
If your income is below the poverty level and your state has not expanded Medicaid, you will not have to pay the fee for not having health insurance, because your state has not made affordable coverage available to you. You should apply for an exemption from the fee by going to HealthCare.gov.
Catastrophic plans are a new type of plan for individuals under the age of 30, or those who qualify for a “hardship exemption” because they cannot afford other coverage. Catastrophic plans have cheaper monthly costs (your premium) and will cover three primary care visits and preventive services at no cost.
Catastrophic plans have VERY high deductibles, sometimes more than $6,000. These deductibles work much like deductibles for car insurance, meaning you have to spend a certain amount of money before the insurance company covers the rest. In other words, the plans help to provide basic routine care and protect against major medical catastrophes, but may still require significant out-of-pocket spending.
Note: You will NOT be able to use tax credits to purchase a catastrophic plan like you would to purchase traditional plans on your state’s Health Insurance Marketplace.
A pre-existing condition could be any health issue you had before your insurance coverage began. It could be something as common as allergies to a very serious health problem, such as cancer. In the past, even being a victim of domestic violence has been classified as a “pre-existing condition.” Before the new health care law, insurance companies could refuse to cover any costs associated with a pre-existing condition, charge you more, or refuse to sell you a policy altogether. Now, all insurance companies are required to cover you even if you have a pre-existing condition, and cannot charge you more because of the condition.
Yes. As of 2014, your health insurance:
- Must cover you even if you have a pre-existing condition;
- Cannot charge you more because of a pre-existing condition;
- Cannot put dollar limits on how much care is covered under your plan each year, and
- Cannot put dollar limits on how much care is covered over the life of your plan.
In general, mental health services are covered by health insurance. The following are important changes to mental health coverage as a result of the new health care law:
- Restrictions on coverage cannot be any stricter for mental health coverage than they are for physical health coverage.
- Insurance companies can’t require you to pay more out-of-pocket (have greater co-pays, co-insurance, or deductibles) for mental health services than they do for other medical services.
- Plans can still impose non-monetary restrictions, such as caps on the number of mental health visits.
Check with your insurance plan to find out what specific services are covered.
Yes. With a few exceptions, insurers must now cover FDA-approved contraceptive methods and counseling for all women at no additional cost. This includes birth control pills, patches, shots, implants, intrauterine devices (IUDs), and emergency contraceptives (like Plan B). The law does not require insurance plans to cover drugs that induce abortion.
If you work for a religious employer such as house of worship, your employer is not required to provide an insurance plan that offers contraception coverage. Check your plan to find out if these services are covered. If you work for a religiously-affiliated nonprofit organization such as a religious hospital, university, or charity, you will get contraception coverage directly from your insurer at no additional cost. You may receive a separate policy or paperwork from your insurer for this contraception coverage.
If you’re looking for a doctor nearby who can provide STD testing, or information about STDs generally, go to: http://www.cdc.gov/std/prevention/default.htm.
Most plans are required to offer some STD screenings for free, as well as STD prevention counseling for those at a high risk. Plans are also required to offer at no cost to you certain vaccines for infections that may be transmitted through sexual activity, such as HPV and hepatitis A and B. Ask your doctor about these vaccines and other vaccines you may need.
There are several changes to what insurance companies must cover for new and expectant mothers. Starting in 2014, insurance companies can’t refuse to cover costs associated with your pregnancy or charge you more because you’re pregnant. Certain services are offered at no additional cost to you, including anemia and gestational diabetes screening, breastfeeding support, and well-baby visits.
Depending on your state and income level, your family may be eligible for Medicaid coverage during your pregnancy. Visit HealthCare.gov to see if you’re eligible.
- HealthCare.Gov- Great resource for all health care questions.
- White House—Fact Sheet on Young Adults and PPACA
- Department of Health and Human Services—Fact Sheet on Dependent Coverage Regulations
- Health and Human Services—Q&A on Dependent Coverage
- IRS– Notice on Tax-Free Dependent Coverage
- Kaiser Family Foundation—To get information on dependent coverage laws in your state
- State Health Access Reform Evaluation (SHARE)- To get information on dependent coverage laws in your state.
- Patient Protection & Affordable Care Act: Signed by President Obama, 3/23/2010
- HR 4872, and Minor Amendments: Reconciliation Bill signed by President Obama on 3/30/2010.
- National Conference of State Legislatures: To get state-based information regarding dependent coverage.
- If you have other questions about dependent coverage or the information on this page, contact:Questions@YoungInvincibles.org.