The exchange will offer a list of health plans and their premiums and out-of-pocket costs, including deductibles and copayments. If you decide to buy one of those plans, in most cases, you will be directed to the insurer’s website to make the payment. Some plans or insurance companies may require a phone call to set up payment. In some jurisdictions, consumers will make their first premium payment to the exchange and then further monthly payments to the insurer.
If your income makes you eligible for a tax credit subsidy, it will be applied upfront to the monthly premium payment. You won’t have to wait until you file your taxes in 2015 to get the credit.
You can also fill out paper applications or apply over the phone.
If my employer (or former employer, if I’m retired) offers me insurance, can I shop on the exchange to get a better deal?
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral (dental) and vision care
It’s important to keep in mind that insurers do have some discretion about which specific therapies they’ll cover within each category of benefit. So it’s very important to study a plan carefully to make sure it is offering any specific benefits you may need.
There’s a cap on how much you pay out of pocket for medical services each year. That cap is $6,350 for individual policies and $12,700 for family plans in 2014. Your regular monthly premiums do not count toward the cap.
My individual policy was canceled because it didn’t meet the requirements of the Affordable Care Act, according to a letter I got.from my insurer. What options do I have?
If you’ve been canceled and find that a new policy on the exchange is not affordable, you can purchase catastrophic coverage because you qualify for a hardship exemption. Catastrophic plans have low premiums, but very high deductibles and copayments.
No matter which plan you choose, the 10 essential benefits remain the same. There is also the option to purchase catastrophic insurance — low cost plans that cover minimal services but provide a safety net in the event of an accident or serious illness. But those plans do not come with subsidies.
People up to age 30 will have the option of buying a catastrophic plan that will cover only minimal services until they meet a deductible of roughly $6,400. The premium is usually much lower than the other plans. After the deductible is met, the plan covers the 10 essential health benefits — a kind of “safety net” coverage in case you have an accident or serious illness, according to the HealthCare.gov website. Catastrophic plans usually do not provide coverage for services like prescription drugs or shots. And there are other limits.
Whether your COBRA rate will go up depends entirely on what happens with your former employer’s health insurance plans. If its rates go up, so will yours. You’ll most likely see a higher increase than your former co-workers, however. That’s because their premiums may be subsidized by the employer, whereas yours are not.
Many people who might have used COBRA will find that buying insurance on the exchanges is cheaper. But pay close attention to when the enrollment period for the exchange is. People who enroll in COBRA and later decide they want to switch to an exchange plan generally won’t be allowed to do so until the exchange’s next annual open enrollment period. An exception would be if they exhaust their COBRA coverage.
According to HealthCare.gov:
In the Marketplace, catastrophic plans are available only to people under 30 and to some low-income people who are exempt from paying the fee because other insurance is considered unaffordable or because they have received “hardship exemptions”. Also, as of Dec. 19, people whose individual policies were canceled because they did not meet ACA standards can purchase a catastrophic plan. Marketplace catastrophic plans cover 3 annual primary care visits and preventive services at no cost.
There are caveats. One is that the cheaper plans come with big deductibles and lots of other out-of-pocket costs. Now, if you don’t think you’re going to have much in the way of medical expenses, that may be fine. But people should be aware that if they buy a plan that costs only $40 or $50 a month, they may have a $5,000 or $10,000 deductible before the plan starts paying benefits.
The other is that some of these less expensive plans come with very limited lists of doctors and hospitals. So if you have a particular doctor or hospital you know you want to use, you should check that before you sign up.
One subsidy is to help pay your monthly premiums. If you qualify for that subsidy (use our calculator), you can apply it toward the purchase of any plan — Bronze, Silver, Gold or Platinum. Where Silver plans come into play here is in calculating the amount of your subsidy: It’s based on the price of the second-lowest Silver plan in your area. If you choose a Gold or Platinum plan, you’ll still get the subsidy. But those plans have higher monthly premiums and you’ll have to make up the difference. Likewise, if you choose a Bronze plan, you’ll get the subsidy and your monthly premiums will be less.
There’s another subsidy to be had in the form of help with deductibles and copayments. To qualify for that subsidy, you do have to choose a Silver plan. Your income also has to fall below $28,725 for an individual or $58,875 for a family of four.
If you are disabled and have no income, you most likely won’t be shopping for insurance on the exchanges. Rather, you may qualify for Medicaid. In most states, if you qualify to collect Supplemental Security Income, or SSI, you also qualify for Medicaid. For more information on Medicaid eligibility and links to your state’s Medicaid office, click here.
Some people also can get help with deductibles and copayments. To qualify, your income has to be less than 2.5 times the poverty level ($28,725 for an individual or $58,875 for a family of four). You also have to choose a so-called Silver plan. That’s the second lowest cost of the four levels of coverage that will be available — Bronze, Silver, Gold and Platinum.
Subsidy amounts are calculated based on your modified adjusted gross income, a figure you can find on your annual tax return by adding lines 8b and 37 on IRS Form 1040. That includes things like wages and interest, less deductions like tuition and alimony, and additional payroll taxes paid by the self-employed. It does not include assets such as the value of your house, stocks or retirement accounts. You’ll be asked to estimate what your income will be for next year; if you’re wrong, you’ll have to reconcile with the IRS come tax time the following year.
- You were homeless.
- You were evicted in the past 6 months or were facing eviction or foreclosure.
- You received a shut-off notice from a utility company.
- You recently experienced domestic violence.
- You recently experienced the death of a close family member.
- You experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your property.
- You filed for bankruptcy in the last 6 months.
- You had medical expenses you couldn’t pay in the last 24 months.
- You experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member.
- You expect to claim a child as a tax dependent who’s been denied coverage in Medicaid and CHIP, and another person is required by court order to give medical support to the child. In this case, you do not have the pay the penalty for the child.
- As a result of an eligibility appeals decision, you’re eligible for enrollment in a qualified health plan (QHP) through the Marketplace, lower costs on your monthly premiums, or cost-sharing reductions for a time period when you weren’t enrolled in a QHP through the Marketplace.
- You were determined ineligible for Medicaid because your state didn’t expand eligibility for Medicaid under the Affordable Care Act.
There are several other exemptions available as well.
I recently started working in July and now make $800 per week. When I’m listing my annual income, can I include the months that I wasn’t working? I’ll make about $20,000 this year.
My employer is not required to offer health insurance because we have less than 50 employees. I am shopping for insurance on the exchange but even with the subsidy I will have a difficult time affording the premium. My employer wants to contribute to help with the cost. How does he do this?
There are certain circumstances in which you’ll be allowed to change plans or add or drop someone from coverage outside of the regular annual enrollment period. This could happen if you lose your job; get married or divorced; give birth to or adopt a child; or move to a different state. Any such life events trigger a special 60-day enrollment period where you can change or buy health insurance on an exchange. Otherwise, you’ll have to wait until the next open enrollment.
The exchanges are designed for two major groups of people: those who don’t have insurance now, and those who currently purchase their own insurance, meaning they don’t get it through an employer.
If you have insurance at your job or through a public program like Medicare, Medicaid or the VA, you don’t need to pay attention to the exchanges unless you lose that coverage for some reason. If you have insurance through your employer, you can shop for and buy insurance on an exchange if you like, but you probably won’t qualify for a subsidy or tax credit. And you will lose the contribution your employer makes toward health insurance.
In states that decided not to participate in the Medicaid expansion, the rules are different, varying from state to state. About half of the states opted out of the Medicaid expansion, which is something that the U.S. Supreme Court gave them permission to do. In those states, the income cutoff to be eligible for Medicaid is generally much lower than what was set in the Affordable Care Act, so fewer people will qualify. And if you’re a childless adult, you’re most likely not eligible in states that rejected the Medicaid expansion. To find out the income cutoff in your state, check out the tables here.
Or, just try signing up for coverage at your health insurance exchange. The exchange will calculate whether you are eligible for Medicaid in your state, and, if you are, direct you to the proper state agency to get signed up. (Click here for our FAQ on how to navigate the exchanges.)
For older adults with a chronic health condition or regular prescription expenses, it may be best to consider a Gold or Platinum plan with a higher premium that gives you a policy with lower out-of-pocket expenses for doctor visits and hospital stays.
No, if you live abroad for at least 330 days within a 12-month period, you are not subject to the mandate to have health insurance. Insurance bought on the exchanges generally wouldn’t cover you while overseas anyway (neither does Medicare, by the way). Ex-pats need to find insurance that will cover them in the country where they live. The State Department keeps this list of companies that provide international coverage. For country-specific information, look here.
I’m currently employed part time, and I pay for my own health insurance (not through my employer). Will I be eligible to participate in the exchanges, or to take advantage of the tax credits?
If I’m retired and my former employer offers me insurance, can I shop on the exchange to get a better deal?
Other exempt groups include prisoners, Native Americans eligible for care through the Indian Health Service, immigrants who are in the country illegally, people whose religion objects to accepting insurance benefits, members of a health care sharing ministry and individuals who experience a short coverage gap of less than three consecutive months.
If you are seeking an exemption for incarceration, or membership in an Indian tribe or health care sharing ministry, you can apply through the health insurance exchanges or make a claim when you file taxes. If you are claiming economic hardship or a religious exemption, you must get an exemption certificate from the online insurance exchange. If you are claiming that coverage is unaffordable, that you are in the United States without proper documentation or that you have a coverage gap of less than three months, you can make the claim when you file your 2014 taxes in 2015.
Americans who live abroad for at least 330 days within a 12-month period also are not subject to the mandate. Insurance bought on the exchanges generally wouldn’t cover them while overseas anyway (neither does Medicare, by the way). Expats need to find insurance that covers them in the country where they live. The State Department keeps this list of companies that provide international coverage. For country-specific information, look here.
Most federal workers will continue to get their health coverage through the Federal Employees Health Benefits Program and will not be required to purchase coverage through the health law’s marketplaces. The only exceptions are for members of Congress and their personal staffs, who will be required to buy health insurance through the exchanges.
What if my parents don’t have insurance or buying subsidized coverage on the exchange is cheaper than staying on my parents’ insurance?
If your employer currently offers insurance, do you have to use that insurance, or do you have the option of selecting another plan?
You can enroll — and avoid paying any penalty — until March 31, 2014. If you sign up and pay your premium between Dec. 16 and Jan. 15, 2014, coverage starts on Feb. 1.
Jan. 16 - Feb. 15: Coverage begins March 1.
Feb. 16 - March 15: Coverage begins April 1
March 16 - 31: Coverage begins May 1.
For coverage starting in 2014, the open enrollment period is October 1, 2013–March 31, 2014.
For coverage starting in 2015, the open enrollment period is November 15, 2014–January 15, 2015.
Generally, people will be able to enroll in or change plans once a year during an annual open enrollment period. This first year, that period is unusually long. In subsequent years, the time period is supposed to be shorter, running from Oct. 15 to Dec. 7.
Update (Dec.18): Due to problems with the rollout of the law, insurance companies have voluntarily extended the payment deadline for coverage starting Jan. 1. Consumers will have until Jan. 10 to make the first payment - as long as they’ve signed up by the Dec. 23 deadline.
What happens if I sign up for a plan on the health exchange and get federal subsidies to help pay the premiums, but then don’t end up earning enough and should have been on Medicaid instead? Will I be expected to pay those subsidies?
The catch is that you have to estimate your income in advance. So you may overestimate your income, buy coverage and get subsidies, and then discover when tax time comes that you weren’t actually eligible, after all, because you earned too little. Experts assure us that this possibility has been taken into account, and you won’t be punished or thrown into jail or even asked to pay back the subsidies in those situations.
On the other hand, if you underestimate your income and get subsidies, then end up earning more, come tax time the following year you will be expected to pay back subsidies you weren’t eligible for.
Does the health law require higher-income Medicare beneficiaries to pay more for their Medicare prescription drug coverage?
It does. Currently, Medicare beneficiaries who earn more than $85,000 ($170,000 for a couple) pay more for their Medicare Part B premiums, which cover physician and outpatient services. The health law brought that same sliding-scale approach to beneficiaries’ prescription drug coverage in Medicare Part D, for those with incomes of more than $85,000 ($170,000 for a couple). Those income thresholds will be frozen through 2019.
Seniors will still get health coverage through Medicare’s traditional fee-for-service program or Medicare Advantage plans, private health insurance plans that are approved by Medicare. Those who are enrolled in Medicare Part A, which covers hospital care, or the Advantage plans will meet the health law’s mandate for individuals to have insurance.
If I choose to simply pay the tax and not purchase actual health insurance through the website or exchanges, am I covered for any health care expenses, such as private doctor visits or emergency room visits?
There is a separate federal law, called EMTALA, that requires hospitals to treat people who show up in emergency rooms. But those hospitals will send you a bill. In many cases people without insurance are also poor and can’t pay those bills, and hospitals end up eating the cost. But hospitals work hard to collect what they can, so they will come after people they think might be able to pay.
If you owe the penalty, it is assessed on your 2014 income tax form that’s due on April 15, 2015. And that’s how the government finds you — it asks on your income tax form if you had health insurance. People who have it will get some sort of certificate of coverage from their health insurers. If your income is so low that you do not file a tax return, you are exempt from paying the penalty.
How will the government know that someone does or doesn’t have health insurance if they don’t use the exchanges??
What type of penalties are involved if you start 2014 without insurance but get covered at some point in the year? Is the penalty pro-rated?
I know that the insurance companies will no longer be able to turn down people with pre-existing conditions. But can they ask about them? And if so, will such people have higher premiums than those without them?
I have insurance through my spouse’s employer, but I might be able to get a better deal on the exchanges. Will I be able to buy health insurance through the health insurance exchanges?
Arizona, Arkansas, California, Colorado, Connecticut, Delaware, D.C., Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Rhode Island, Vermont, Washington, West Virginia
Indiana and Pennsylvania have decided to move forward with expansion after 2014. The following states have said no to the Medicaid expansion or have not yet decided:
Alabama, Alaska, Florida, Georgia, Idaho, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wyoming
Wisconsin is “not moving forward at this time.” This list is current as of Dec. 11, 2013. Check here for updates.
If you make too much to qualify for Medicaid but too little to qualify for subsidies on the exchange, then you are exempted from the new mandate to carry health insurance. (See our FAQ on the individual mandate here.)
If that’s your situation — you’re poor and still have no health insurance — you can still seek health care with other safety net providers, such as federal community health centers and free clinics run by local nonprofits.
If you can’t afford the insurance your school offers or your school doesn’t offer coverage, you might fall into one of a few categories.
First, if you’re a full-time student and you’re not working, or if you’re working just part-time, you probably don’t earn enough to trigger the requirement to have health insurance. It applies only to people who earn enough to have to file income taxes; that’s just under $10,000 this year for a single person under age 65.
But what if you want insurance? Well, if you’re under 26 and your parents are insured, you’re in luck. One popular part of the law lets young adults stay on their parents’ health insurance plans until they turn 26. In states that opt to expand Medicaid, that will also become an option for many college and graduate students. It’s for people who earn up to 133 percent of poverty, or about $15,000 a year for an individual. But only about half the states are planning to expand Medicaid.
I’m a veteran who participates in my regional healthcare plan through the military TRICARE system. Will the ACA affect my health care?
In addition, if you plan to become pregnant while on your parents’ plan, you should check to make sure maternity benefits are covered. Although by law most group plans must provide maternity coverage for employees and their spouses, children aren’t protected by the law, and employers don’t always provide coverage.
Starting in 2015, employers with 50 or more workers have a responsibility — but no mandate — to offer employees health coverage. If they don’t, they may face fines, but only if their workers go to health insurance exchanges and have earnings low enough to qualify for federal subsidies. Stores and restaurants — less likely to offer health insurance in the past — may be most affected. The coverage rule doesn’t affect workers who put in less than 30 hours a week.
There are no responsibilities for small employers with fewer than 50 workers. If they want to buy coverage for their employees, the insurance exchanges represent a new option for them in terms of where to shop. Certain employers with fewer than 25 workers are eligible for federal tax credits. To qualify, the company has to cover at least half of the premium for all of its employees, and also have average wages of less than $50,000. For details on these tax credits, see this answer sheet from the IRS.
I would like to know if it is true that some people, for so-called religious reasons, will be getting a free ride. If this is true, then who are these people, how many are there and who will pay for their coverage?
I’m restricted to doctors in my state, and they are more expensive than if I were to buy a plan in a neighboring state. Is it possible for me to buy an out-of-state plan?
What if I don’t qualify for assistance by the government’s definition, but I still can’t afford insurance on my own?
If you are self-employed, is there a cap to how much you can make to use the Affordable Care Act insurance?
Is it true that subsidies apply only to Silver-level plans, and that if a person decides to purchase a lower-cost Bronze plan, the subsidy cannot be applied?
Some employers that have offered part-time workers minimal coverage, such as Trader Joe’s and Home Depot, have dropped it on the grounds that those workers can now find coverage through the insurance exchanges. Most workers in this situation will be pleased with the outcome. They’ll most likely find better coverage than what they had for less money. Although depending on the situation, some people may see their premiums go up.
However, employers increasingly offer incentives to get spouses off their plans. They may charge workers extra if a covered spouse has access to other insurance, or they may pay bonuses when spouses are not on the company policy.
The health law does require employers who offer coverage to employees to also offer coverage to dependent children, or pay a penalty.
There are two themes to what they are doing. In trying to control their own spending, employers are often shifting health costs to employees. So the average annual deductible for an individual — what consumers pay before insurance kicks in — nearly doubled in the past seven years, from $584 in 2006 to $1,135 this year, according to the Kaiser Family Foundation.
But employers aren’t just making workers pay more. They’re also trying to make them think more about health-related expenses and behavior.
Companies such as grocer Kroger Co. pay only a fixed amount for particular drugs or procedures, giving patients incentive to shop around for the best price. IBM started giving rebates to workers who adopt healthful lifestyles. Penalizing smokers with surcharges is one of the few discriminatory measures the health act allows.
Insurers are required to provide dental coverage for children 18 and under, but not for adults.