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Affordable Care Act Q & A

Can I buy coverage outside the Marketplace open enrollment period?
Generally, there is only one open enrollment period. But states have some flexibility to set enrollment periods. Also, health insurance companies can choose to sell their plans at times other than the open enrollment period. But in most circumstances, you will only be able to buy health coverage during the annual open enrollment period.

In certain circumstances, you may qualify for a “special enrollment period,” which will allow you to enroll in a plan at a time that is not the official open enrollment period. This could apply, for example, when you’ve experienced a change in your life, such as a birth or adoption of a child, a relocation out of the area or state, or a loss of another type of health coverage.

Do I have to do anything to prove I have health insurance?
You should receive a notice from either your employer or health plan that will serve as proof of insurance coverage. This form will need to be submitted to the Internal Revenue Service as part of your regular tax return.

How can I compare health plans?
Plans are offered in four different tiers, sometimes called “metal levels,” so it’s easier to make “apples-to-apples” comparisons among plans. The tiers—bronze, silver, gold and platinum—are based on how generous the plan is for the benefits and services covered. Bronze plans will have the lowest premiums, but the individual’s share of costs such as deductibles and copayments will be higher. Platinum plans will have the highest premiums, but fewer additional costs for consumers. The actuarial value is based on what an average group of consumers might pay under the plan, but your own costs may vary depending on how much care you need.

Will I be able to buy my Medigap supplemental insurance in the marketplace?
The Health Insurance Marketplace is not for people who have Medicare and its supplemental Medigap coverage. Medigap is not sold through the Health Insurance Marketplace. So, you will continue to shop for Medigap supplemental coverage as you always have.

I have Medicare.  Do I have to buy coverage through the Marketplace?
If you are new to Medicare or if you have Medicare and want to make changes, you do not go through the Health Insurance Marketplace. As before, you will continue to have an annual Medicare open enrollment period from October 15 to December 7, when you can make changes to your Medicare Advantage or Medicare Part D coverage. Medicare also allows you to change your plan—from a Medicare Advantage plan to Original Medicare, including Part D coverage—between January 1 and February 14 each year. To make changes during open enrollment, visit 

I received financial help last year.  Will I still get help this year?
It is important to contact the marketplace where you originally enrolled to make sure you still qualify for financial help. Any life changes, particularly a change in income or in your family size, may affect the savings you are eligible for.

It is also a good time to review your plan to make sure it works for you and your family. You can review your options and make changes during the open enrollment period (November 15, 2014 through February 15, 2015).

I'm self-employed. Where can I buy health coverage?
Most states consider self-employed people as individuals. That means you can shop for private individual health insurance on your own, through a broker or through the Health Insurance Marketplace. But financial help is only available with plans bought through the Health Insurance Marketplace.

States set the rules for what size company is considered a small business when it comes to buying health insurance. Small businesses are defined as companies employing from two to 50 people. They can go to the Small Business Health Options Program (SHOP) to buy coverage. To find out more, visit your Health Insurance Marketplace.

I have a pre-existing condition. Can I be charged more?
The health care law makes sure health plans can’t deny you coverage because of health problems you had before your insurance started (known as pre-existing conditions). They also can’t charge you more for your premiums if you get very sick.

Does my health plan have to cover certain benefits?
As of 2014, all new plans sold to individuals and small employers must cover certain important health care services, known as essential health benefits (EHB). Each state has its own EHB, but all must cover the following:

  • Doctor’s office visits
  • Emergency room care
  • Hospital visits
  • Maternity and newborn care
  • Mental health and substance abuse treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care.

Is my employer required to provide me with health benefits?
In 2014, there was no requirement that employers provide health coverage for their workers. Beginning in 2015, large employers (those with 100 or more full-time equivalent employees) must provide affordable coverage, or pay a penalty. To be considered affordable, an employee’s share of the monthly payment (premium) can’t be more than 9.5 percent of their household income. While employers will be required to cover employees, they do not have to offer coverage for employees’ families.

Starting in 2016, large employers will have to offer coverage for employees’ children. However, there is no requirement that the employer pay a portion of the monthly payment (premium) and there is no requirement that they offer coverage to employees’ spouses. Mid-sized employers (those with 50-99 full-time equivalent employees) have until 2016 to comply with the law.

Can I get financial help with the costs of my health coverage?
Some low- and moderate-income families can qualify for financial help to pay for their monthly payments premiums for a health plan bought through the Health Insurance Marketplace (but not for plans bought on your own, outside the marketplace). That help is provided through a premium tax credit, which will lower the amount of the premium you must pay. You can use the premium tax credit in a few ways. You can use some or all of it right away as a discount on your premium, so you owe less when you make your monthly payment. You also can choose to get a partial or full refund when you file your taxes the following year. The premium tax credits are based on a sliding scale, so that the greatest help is available to people with the lowest income. Use this Calculator, by the Kaiser Family Foundation, to get an estimate of the financial help you may qualify for if you buy coverage through the Health Insurance Marketplace.

If your income changes in the middle of the year—whether your income goes up or down—be sure to let your Health Insurance Marketplace know, in case your premium tax credit must be adjusted. If your income goes up and you don’t notify the Health Insurance Marketplace, you may owe more in taxes for that year.

What do I do if my health plan I purchased last year is no longer available?
If your plan is no longer available, your health plan must tell you about plans available to you, including one that will be similar to the one you have now. You can compare plans and shop for coverage through the Health Insurance Marketplace during the open enrollment period (November 15, 2014 through February 15, 2015). You also might find that your plan is still available outside the marketplace; however, you will not be eligible for financial help if you enroll in that plan. Financial help is only available for plans offered through the Health Insurance Marketplace. For more details, visit the marketplace where you enrolled for coverage last year.

When will my coverage start once I purchase in the Marketplace?
The open enrollment period for 2015 health coverage is November 15, 2014 through February 15, 2015. If you are enrolled in a marketplace plan, your coverage ends December 31, 2014. To continue health coverage in 2015, you can renew or choose a new plan during the open enrollment period.

If you want your coverage to start January 1, 2015, you’ll need to enroll or re-enroll by December 15, 2014. After this date, the day your coverage starts depends on when you enrolled or re-enrolled in coverage, as follows:

If you enroll or re-enroll between…

Your coverage will begin….

November 15, 2014 – December 15, 2014

January 1, 2015

December 16, 2014 – January 15, 2015

February 1, 2015

January 16, 2015 – February 15, 2015

March 1, 201

Do I need to re-enroll if I purchased coverage last year in the Marketplace?
People who signed up for coverage through the Health Insurance Marketplace should receive a notice from their health plan and another from the marketplace about renewing health coverage. The notices include information about coverage, including any changes to your plan, financial assistance for the following year, and the open enrollment period—November 15, 2014 through February 15, 2015.

Some people will be automatically re-enrolled in the same or a similar plan for 2015. Others must contact their marketplace directly to be re-enrolled. In either case, it is important that you review your health plan for 2015 to make sure it works for you and your family.

You must report any changes in income or household size to the marketplace where you enrolled to be sure you are getting the right financial help for your family. Keep in mind most people will need to make changes to their plan and update their household information by December 15, 2014 to make sure coverage starts January 1, 2015. But your state may have a different deadline so be sure to check with the marketplace where you enrolled. If you re-enroll after December 15, 2014, your new coverage will not start January 1, 2015. The day your coverage starts will depend on when you enroll or re-enroll in coverage.

Will I have to pay a penalty if I don’t have health coverage?
If you don’t have health coverage that meets the minimum requirements, you may have to pay a penalty. In 2015, for an individual, the penalty starts at $325 a year, or up to 2 percent of income, whichever is greater. The penalty will rise each year. The health care law says that certain people may not have to pay a penalty, including:

  • People for whom the regular payments (called premiums) are more than 8.5 percent of their income
  • People with income so low they don’t have to file taxes
  • People living in the United States illegally (undocumented immigrants)
  • People who have a gap in coverage of less than three months
  • People who are exempt because of their religious beliefs
  • American Indians and Alaska Natives
  • Americans living abroad for at least 1 year
  • People who have experienced a hardship (considered on a case-by-case basis)
  • People in prison

If you think you may be exempt from paying a penalty, you must apply for a waiver from your Health Insurance Marketplace.

Does everyone have to buy their health coverage in the Health Insurance Marketplace?
The Health Insurance Marketplace is just for people who need to buy private individual health insurance. If you have insurance through Medicare or Medicaid, a military program or, in most cases, employer coverage, that coverage is separate from the marketplaces. If you need to buy private individual health insurance, you can generally still get coverage outside of the Health Insurance Marketplace. But financial help is only available for plans offered through the Health Insurance Marketplace. If you do need to buy coverage and want to find the Health Insurance Marketplace in your state, visit or call 1-800-318-2596.

What is the Health Insurance Marketplace?
The Health Insurance Marketplace is a new way to shop for health coverage. Through the marketplace, you can shop online and get help by phone or in person to find the plan that works for you and your family. The marketplace allows you to compare plans and costs on an “apples-to-apples” basis. You also can find out what kind of financial help you may be able to get to pay for premiums and copayments. For example, for coverage in 2015, an individual with a household income between about $11,700 and $46,700 or a family of four with a household income between about $23,900 and $95,400 would qualify for financial help. These are ballpark figures and will change every year. While people with very limited incomes will receive the greatest help, moderate-income families can often get help too. To learn more about the Health Insurance Marketplace, read The Health Care Law: More Choices, More Protections. To find the Health Insurance Marketplace in your state, visit or call 1-800-318-2596.

What is the health care law?
The health care law—the Affordable Care Act—gives you more control over your health care by offering new ways to shop and pay for coverage with greater protections. It keeps in place today’s job-based insurance system and the Medicare health insurance program for people who are 65 and over and for some younger people with disabilities.


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