Skip to content

AARP Members Enjoy Exclusive Discounts on Travel, Dining and More. Join Today

 

Affordable Care Act Q & A

The AARP Daily News Alert will feature answers to a health care law “question of the day” throughout the month of December. Be sure to tune in throughout the month for more answers to frequently asked questions about the health care law.

If I buy or re-enroll in a health plan during the Health Insurance Marketplace open enrollment period, when will my coverage start?

The Health Insurance Marketplace open enrollment period for 2016 health coverage is November 1, 2015 through January 31, 2016. If you are enrolled in a marketplace health insurance plan, your coverage ends December 31, 2015. To continue health coverage in 2016, you can renew or choose a new plan during the marketplace open enrollment period.

If you want your health insurance coverage to start January 1, 2016, you’ll need to sign up or renew your health plan by December 15, 2015. After this date, the day your coverage starts depends on when you enrolled or re-enrolled in coverage, as follows:

If you sign-up or re-enroll between...         Your coverage will begin...

November 1, 2015 – December 15, 2015         January 1, 2016
December 16, 2015 – January 15, 2016         February 1, 2016
January 16, 2016 – January 31, 2016         March 1, 2016

After I sign up for a health plan in the Health Insurance Marketplace, can I change my mind and sign up for a different plan instead?

If you decide you want to change health insurance plans after you’ve enrolled in one plan through the Health Insurance Marketplace, you can do so as long as it is still in the open enrollment period and the coverage hasn’t started (known as the “effective date”). Once your health coverage begins, you’ll have to wait for the next marketplace open enrollment period to change plans.

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

What is the Health Insurance Marketplace?


Through the Health Insurance Marketplace, you can shop online and get help by phone or in person to find the health 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 2016, an individual with a household income between about $11,800 and $47,100 or a family of four with a household income between about $24,300 and $97,000 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 www.HealthCare.gov or call 1-800-318-2596.

Do I need to report any changes in my household status, such as an increase in income, to the Health Insurance Marketplace?

Certain life changes, such as getting a raise, moving, or a death in the family, may change the type of coverage you qualify for or how much financial help you can receive. You’ll need to report life changes to the Health Insurance Marketplace where you enrolled for coverage. For example, if your income has increased, reporting that change will reduce the chance that you’ll have to pay back money at tax time.

Examples of life changes that could change the coverage and financial help you may qualify for include:

  • Moving to a new area
  • Losing health coverage, such as job-based coverage
  • Change in citizenship or immigration stats
  • Change in income, such as getting a raise or losing a job
  • Change in household status, such as getting married
  • Change in family size, such as a birth or death

For more details about when and how to report any life changes go to www.healthcare.gov or call the Health Insurance Marketplace at 800-318-2596.

How long can my child remain on my family health insurance plan?

You can keep your children on your family health plan until they turn age 26, even if they don’t live at home, are married or attend school. If your health plan charges more for each child you cover, you may have to pay an additional amount to add your older child to your plan. It is important to know that not all employers have to offer a family plan. Check with your employer for the details about adding your adult child to your family plan.

How can I make sure the health coverage I bought through the Health Insurance Marketplace continues into the new year and that I’m getting any financial help I qualify for in 2016?

The Health Insurance Marketplace open enrollment (November 1, 2015 through January 31, 2016) is the time when you can apply for a new health plan, keep your current plan, or pick a new one. The deadline to enroll is December 15, 2015, if you want coverage to begin on January 1, 2016. Keep in mind that states may have different deadlines for picking a plan and reporting changes (such as income or household size) to make sure you don’t have a gap in coverage and are getting the right financial help. It is very important to visit the marketplace in your state to learn about specific deadlines.

What do I do if the marketplace health insurance plan I had last year is no longer available?

If the plan you purchased through the Health Insurance Marketplace is no longer available, your health insurer 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 1, 2015 through January 31, 2016). 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.

Last year I bought health coverage through the Health Insurance Marketplace. Do I need to re-enroll in the plan for next year?

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 marketplace open enrollment period—November 1, 2015 through January 31, 2016. 

Some people will be automatically re-enrolled in the same or a similar health insurance plan for 2016. Others must contact the Health Insurance Marketplace directly to be re-enrolled. In either case, it is important that you check with your marketplace and review your health plan for 2016 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, 2015 to make sure coverage starts January 1, 2016. But your state may have a different deadline so be sure to check with the marketplace where you enrolled. If you re-enroll in your health insurance plan after December 15, 2015, your new coverage will not start January 1, 2016. The day your coverage starts will depend on when you enroll or re-enroll in coverage.

I’m self-employed and want to buy health insurance. Where should I go to buy my plan?

If you are self-employed with no employees you can shop for private individual health insurance for yourself and your family 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. 

If you are a small business, you can go to the Small Business Health Options Program (SHOP) to buy coverage. Small businesses are defined as 2 – 50 or 2 – 100 employees depending on your state. To find out more, visit the Health Insurance Marketplace.

Does my health insurance plan have to cover certain benefits?

As of 2014, all new health insurance 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 (such as for surgery) 
  • 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.

I have a pre-existing health condition. Can I be charged more for my health insurance?

The ACA 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.

Can my health plan limit how much they will pay toward my covered services?

No, health plans cannot put a dollar limit on how much they will pay for covered services you receive in a year (annual dollar limit) or over the total time you are enrolled in the plan (lifetime dollar limit). Previously, plans could limit the amount they would pay for covered services, for example, $100,000 in a year or $500,000 over the life of the policy. It’s important to know that health plans can still include other limits not tied to the cost of benefits. For example, your health plan may set a limit on the number of physical therapy visits it will cover.

What can I do if my health insurance plan denies my claim for health benefits that I thought would be covered by the plan?

The ACA strengthens your right to file an appeal if your health plan will not pay for a medical service you received or won’t give you prior approval for a medical service you need. Before the health care law, your right to appeal your health plan’s decision, known as an internal appeal, varied greatly, depending on the state in which you lived. Also, most people in employer health plans didn’t have the right to request an outside review of their internal appeal. The law now offers you the opportunity to request a review of an internal appeal by an independent outside organization, known as a third party. This is called an external review. If your plan denies your claim for health benefits, they must provide you with information on the steps you can take to appeal that decision and how to get help doing it.

Is there a limit on how much I have to pay out-of-pocket for my health care?

The ACA sets a limit on how much of a share of the costs you will have to pay for health care in the form of deductibles, copayments and coinsurance. The most you can pay out-of-pocket in 2016 is $6,850 for an individual plan and $13,700 for a family plan (the amount will rise slowly, year to year, with inflation). This does not include your monthly premiums. And, this limit only applies to costs you pay for care you receive from an in-network provider and for essential health benefits, which will probably be most health services covered in your plan, but not necessarily all of them.

How can I compare health plans offered in the Health Insurance Marketplace?


Plans sold in the Health Insurance Marketplace 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 health 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. 

All health plans sold to individuals and small businesses will fit into one of these levels of coverage. This will make it easier to compare plans to find one that works for you and your family.

Is my employer required to provide me with health benefits?

As of 2016, employers with 50 or more employees must provide affordable health coverage for their workers, or pay a penalty. To be considered affordable, an employee’s share of the monthly payment (premium) can’t be more than about 9-10 percent of their household income. 

Employers must also offer coverage for employees’ children. However, there is no requirement that the employer pay a portion of the monthly payment (premium) for children to enroll and there is no requirement that they offer coverage to employees’ spouses.

Can I buy a health plan outside the Health Insurance Marketplace open enrollment period?

Generally, there is only one Health Insurance Marketplace 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 marketplace open enrollment period. But in most cases, you will only be able to buy health insurance coverage during the annual marketplace open enrollment period. In certain cases, 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 marketplace 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. To find out if you qualify for a special enrollment period, or to report changed circumstances, contact the Health Insurance Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).

After I sign up for a health plan in the Health Insurance Marketplace, can I change my mind and sign up for a different plan instead? Once I buy one plan can I change my mind and switch?

If you decide you want to change health insurance plans after you’ve enrolled in one plan through the Health Insurance Marketplace, you can do so as long as it is still in the open enrollment period and the coverage hasn’t started (known as the “effective date”). Once your health coverage begins, you’ll have to wait for the next marketplace open enrollment period to change plans.

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



(Video) Jean Chatzky on ACA: AARP’s Financial Ambassador talks about the benefits and protections of the health care law.

Join the Discussion

0 | Add Yours

Please leave your comment below.

You must be logged in to leave a comment.

Next Article

Read This