Health Insurance Marketplaces (also known as Exchanges) are organizations set up to create more organized and competitive markets for buying health insurance. They offer a choice of different health plans, certify plans that participate, and provide information and in-person assistance to help consumers understand their options and apply for coverage. Through the Marketplace, individuals and families can shop for coverage if they need to buy health insurance on their own. Premium and cost sharing subsidies based on income are available through the Marketplace to make coverage affordable for individuals and families. People with very low incomes can also find out at the Marketplace if they are eligible for coverage through Medicaid and CHIP. Finally, small businesses can buy coverage for their employees through the Small Business Health Options Program (SHOP) Marketplace.
There is a health insurance Marketplace in every state for individuals and families and for small businesses. Some are operated by the State and have a special state name (such as CoveredCalifornia or The Maryland Health Benefit Exchange.) In other states where the federal government runs the Marketplace, it is called HealthCare.gov.
“What is the health insurance Marketplace?,” The Henry J. Kaiser Family Foundation, accessed 10/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-what-is-the-health-insurance-marketplace
Most people can shop for coverage in the Marketplace. To be eligible you must live in the state where your Marketplace is, you must be a citizen of the U.S. or be lawfully present in the U.S., and you must not currently be incarcerated.
Not everybody who is eligible to purchase coverage in the Marketplace will be eligible for subsidies, however. To qualify for subsidies (also called premium tax credits) people will have to meet additional requirements having to do with their income and their eligibility for other coverage.
“Who can buy coverage in the Marketplace?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-who-can-buy-coverage-in-the-marketplace
In general, you can only enroll in non-group health plan coverage during the Open Enrollment period.
For 2017 coverage, the Open Enrollment period begins November 1, 2016 and extends through January 31, 2017. Once the Open Enrollment period is over, individuals and families will not be able to enroll in Marketplace health plans until the next Open Enrollment period. However, if you experience certain changes in circumstances during the year, you will have a special 60-day opportunity to enroll in Marketplace health plans, outside of the Open Enrollment period.
For individuals and families buying non-group coverage on their own, outside of the Marketplace, you can only enroll in coverage during Open Enrollment periods and special enrollment opportunities, as well.
American Indians and Alaska Natives can enroll in coverage throughout the year, not just during Open Enrollment.
“When can I enroll in private health plan coverage through the Marketplace?,” The Henry J. Kaiser Family Foundation, accessed 10/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-when-can-i-enroll-in-private-health-plan-coverage-through-the-marketplace
In general, you can have a special enrollment opportunity to sign up for private, non-group coverage during the year, other than during Open Enrollment period, if you have a qualifying life event. Events that trigger a special enrollment opportunity are:
• Loss of eligibility for other coverage (for example if you quit your job or were laid off or if your hours were reduced, or if you lose student health coverage when you graduate) Note that loss of eligibility for other coverage because you didn’t pay premiums does not trigger a special enrollment opportunity
• Gaining a dependent (for example, if you get married or give birth to or adopt a child). Note that pregnancy does NOT trigger a special enrollment opportunity.
• Loss of coverage due to loss of dependent status (for example, because of divorce, legal separation, death, or “aging off” a parents’ plan when you turn 26)
• A permanent move to another state or within a state if you move outside of your health plan service area (starting July 11, 2016, if you move to or within a federal Marketplace state, you will only be eligible if you had previously been enrolled in other coverage, or meet other exceptions)
• Exhaustion of COBRA coverage
• Losing eligibility for Medicaid or the Children’s Health Insurance Program
• For people enrolled in a Marketplace plan, income increases or decreases enough to change your eligibility for subsidies
• Change in immigration status
• Enrollment or eligibility error made by the Marketplace or another government agency or somebody, such as an assister, acting on their behalf.
Note that some triggering events will only qualify you for a special enrollment opportunity in the health insurance Marketplace; they do not apply in the outside market. For example, if you gain citizenship or lawfully present status, the Marketplace must provide you with a special enrollment opportunity.
When you experience a qualifying event, your special enrollment opportunity will last 60 days from the date of that triggering event. If you can foresee a qualifying event (for example, you know the date when you will graduate and lose student health coverage) you can ask the Marketplace for a special enrollment opportunity up to 60 days in advance so new coverage will take effect right after your old coverage runs out. However, under new federal rules, Marketplaces are not required to offer advanced availability of special enrollment periods to people who anticipate a permanent move.
States have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.
“Can I buy or change private health plan coverage outside of Open Enrollment?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-can-i-buy-or-change-private-health-plan-coverage-outside-of-open-enrollment
During Open Enrollment, you can sign up for a Marketplace plan even if you already have COBRA. You will have to drop your COBRA coverage effective on the date your new Marketplace plan coverage begins. After Open Enrollment ends, however, if you voluntarily drop your COBRA coverage or stop paying premiums, you will not be eligible for a special enrollment opportunity and will have to wait until the next Open Enrollment period. Only exhaustion of your COBRA coverage triggers a special enrollment opportunity.
“I have COBRA and it’s too expensive. Can I drop it during Open Enrollment and enroll in a Marketplace plan instead?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-have-cobra-and-its-too-expensive-can-i-drop-it-during-open-enrollment-and-enroll-in-a-marketplace-plan-instead
No, voluntarily dropping your COBRA coverage or ceasing to pay your COBRA premiums will not trigger a special enrollment opportunity. You will have to wait until you exhaust your COBRA coverage or until the next Open Enrollment (whichever comes first) to sign up for other non-group coverage.
“I have COBRA and am finding it difficult to afford, but Open Enrollment is over. Can I drop my COBRA and apply for non-group coverage outside of Open Enrollment?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-have-cobra-and-am-finding-it-difficult-to-afford-but-open-enrollment-is-over-can-i-drop-my-cobra-and-apply-for-non-group-coverage-outside-of-open-enrollment
All health plans offered through the Marketplace must meet the requirements of “qualified health plans.” This means they will cover essential health benefits, limit the amount of cost sharing (such as deductibles and co-pays) for covered benefits, and satisfy all other consumer protections required under the Affordable Care Act.
Health plans may vary somewhat in the benefits they cover. Health plans also will vary based on the level of cost sharing required. Plans will be labeled Bronze, Silver, Gold, and Platinum to indicate the overall amount of cost sharing they require. Bronze plans will have the highest deductibles and other cost sharing, while Platinum plans will have the lowest. Health plans will also vary based on the networks of hospitals and other health care providers they offer. Some plans will require you to get all non-emergency care in-network, while others will provide some coverage when you receive out-of-network care.
“What health plans are offered through the Marketplace?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-what-health-plans-are-offered-through-the-marketplace
All qualified health plans offered in the Marketplace will cover essential health benefits. Categories of essential health benefits include:
• Ambulatory patient services (outpatient care you get without being admitted to a hospital)
• Emergency services
• Maternity and newborn care (care before and after your baby is born)
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including dental and vision care
The precise details of what is covered within these categories may vary somewhat from plan to plan.
“What health benefits are covered under Marketplace plans?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-what-health-benefits-are-covered-under-marketplace-plans
Not necessarily. All Marketplace health plans are required to cover the ten categories of essential health benefits. However, insurers in many states will have flexibility to modify coverage for some of the specific services within each category. Any modifications must be approved by the Marketplace before plans can be offered. All health plans must provide consumers with a Summary of Benefits and Coverage (SBC). This is a brief, understandable description of what a plan covers and how it works. The SBC will also be posted for each plan on the Marketplace web site. The SBC will make it easier for you to compare differences in health plan benefits and cost sharing.
Plans might differ in other ways, too. For example, the network of health providers might be different from plan to plan.
“Will covered benefits under all Marketplace plans be the same? How can I compare?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-will-covered-benefits-under-all-marketplace-plans-be-the-same-how-can-i-compare
Plans in the Marketplace are separated into categories — Bronze, Silver, Gold, or Platinum — based on the amount of cost sharing they require. Cost sharing refers to health plan deductibles, co-pays and co-insurance. For most covered services, you will have to pay (or share) some of the cost, at least until you reach the annual out of pocket limit on cost sharing. The exception is for preventive health services, which health plans must cover entirely.
In the Marketplace, Bronze plans will have the highest deductibles and other cost sharing. Silver plans will require somewhat lower cost sharing. Gold plans will have even lower cost sharing. And Platinum plans will have the lowest deductibles, co-pays and other cost sharing. In general, plans with lower cost sharing will have higher premiums, and vice versa.
“I notice Marketplace plans are labeled “Bronze,” “Silver,” “Gold,” and “Platinum.” What does that mean?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-notice-marketplace-plans-are-labeled-bronze-silver-gold-and-platinum-what-does-that-mean
Insurers can also offer “Catastrophic” plans. Catastrophic plans have the highest cost sharing. In 2017, Catastrophic plans will have an annual deductible of $7,150 ($14,300 in family plans). You will have to pay the entire cost of covered services (other than preventive care) until you’ve spent $7,150 out of pocket; after that your plan will pay 100 percent of covered in-network services for the rest of the year. Not everybody will be allowed to buy Catastrophic plans. They are only for adults up to age 30, and for older people who can’t find any other Marketplace policy that costs less than 8.16 percent of their income.
“I also notice “Catastrophic Plans” that look even cheaper. What are those and can I buy one if I want?,” The Henry J. Kaiser Family Foundation, accessed 10/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-also-notice-catastrophic-plans-that-look-even-cheaper-what-are-those-and-can-i-buy-one-if-i-want
No. Health plans are not allowed to charge you more based on your health status or pre-existing condition.
“Can I be charged more if I have a pre-existing condition?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-can-i-be-charged-more-if-i-have-a-pre-existing-condition
All Marketplace health plans provide coverage based on a calendar year. Even if you signed up mid-year, coverage under your current plan continues through December. Open Enrollment is the time to renew coverage for next year. You can return to the Marketplace website or contact the Marketplace call center to renew coverage yourself so that it continues next year. In most states if you don’t act to renew your coverage by December 15, the Marketplace will automatically renew coverage for you in most cases. If your coverage is automatically renewed but you would still like to change plans, you can still do so until the last day of Open Enrollment, January 31, 2017.
“I signed up for a Marketplace health plan this year in the summer after I lost my job. Does my coverage get renewed in January or at the anniversary date next summer?,” The Henry J. Kaiser Family Foundation, accessed 10/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-signed-up-for-a-marketplace-health-plan-this-year-in-the-summer-after-i-lost-my-job-does-my-coverage-get-renewed-in-january-or-at-the-anniversary-date-next-summer
It depends. Insurers are allowed to make changes to policies each year. Most likely, the premium for your current policy will change next year. There may be other changes as well, for example, changes in the deductible or copays for some services. In some cases an insurer may stop offering a particular policy and offer you new choices, instead. Shortly before Open Enrollment begins, you should receive a notice from your insurance company describing any changes to your policy and the new monthly premium. If you want to continue the policy you can renew coverage for another year. If you prefer to shop for other coverage, you can do that during Open Enrollment.
“I like my Marketplace plan just the way it is. Will it stay the same in 2016?,” The Henry J. Kaiser Family Foundation, accessed 10/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-like-my-marketplace-plan-just-the-way-it-is-will-it-stay-the-same-next-year
Your coverage may automatically be renewed; even so, you may want to take steps to renew it yourself during Open Enrollment. If you are receiving a premium tax credit, it is wise to go through the process so that you can update your income and family information and see how much tax credit you may be eligible for based on the new premiums for the coming year. Open Enrollment for 2017 plans begins on November 1, 2016 and continues through January 31, 2017.
The process for renewing coverage may be a little different depending on where you live. In federal Marketplace states that use www.healthcare.gov, if you are currently enrolled in a Marketplace policy and you don’t take any action before December 15, in most cases the Marketplace will automatically renew your coverage under that policy for the coming year. Insurers may not offer all of the same plans next year that they offered this year. If your health plan will no longer be offered next year and you do nothing, your insurance company will automatically enroll you in another policy that is similar to the one you have currently.
“I signed up for Marketplace coverage last year and I want to continue in this plan for another year. Do I have to do anything during Open Enrollment?,” The Henry J. Kaiser Family Foundation, accessed 10/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-signed-up-for-marketplace-coverage-last-year-and-i-want-to-continue-in-this-plan-for-another-year-do-i-have-to-do-anything-during-open-enrollment
You should return to the Marketplace to update your application for financial assistance. You can do this on your own, either by logging in to your account on the web site or by calling the Marketplace call center. Or you can visit a Navigator or other in-person assister in your community. Your Marketplace web site and call center will have contact information for in-person assisters near you.
If you don’t update your application by December 15, in most cases and in most states, the Marketplace will automatically adjust the amount of your premium tax credit for next year. The automatic adjustment will be based on a rough inflation adjustment to your most recently reported income and on changes in the cost of the benchmark silver plan in the Marketplace next year.
Updating your application is a good idea because, chances are, the amount of premium tax credit you will be eligible for next year will be at least somewhat different from the current amount and automatic adjustments made by the Marketplace may not fully reflect your situation. It is important to report any changes in your household income and your family status so your eligibility determination will be up to date and so the amount of financial assistance you receive next year will be as accurate as possible.
“I received financial assistance this year – a premium tax credit reduced my monthly health insurance premium. I want to continue financial assistance next year. What should I do?,” The Henry J. Kaiser Family Foundation, accessed 10/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-received-financial-assistance-this-year-a-premium-tax-credit-reduced-my-monthly-health-insurance-premium-i-want-to-continue-financial-assistance-next-year-what-should-i-do
Everyone is required to have health insurance coverage – or more precisely, “minimum essential coverage” – or else pay a tax penalty, unless they qualify for an exemption. This requirement is called the individual responsibility requirement, or sometimes called the individual mandate.
“I’m uninsured. Am I required to get health insurance?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-im-uninsured-am-i-required-to-get-health-insurance
The penalty for not having minimum essential coverage is either a flat amount, or a percentage of household income, whichever is greater. The penalty has been phased in and will be adjusted each year for inflation.
For 2016, the penalty is the greater of
• $695 for each adult and $347.50 for each child, up to $2,085 per family, or
• 2.5% of family income above the federal tax filing threshold, which is $10,350 for a single filer, $20,700 for people who file jointly in 2016
For 2017, the penalty is the greater of
• The 2016 flat amounts, indexed for inflation, or
• 2.5% of family income above the federal tax filing threshold
In later years, the flat penalty amounts for 2016 will be indexed based on the cost of living.
In all years, the penalty is also capped at an amount equal to the national average premium for the median cost bronze health plan available through the Marketplace.
The penalty is assessed based on “coverage months.” This means that each month you are uninsured, you may owe 1/12th of the annual penalty. However, short spells of uninsurance may not be subject to a penalty.
For more information about the penalty, also called the individual responsibility payment, see the IRS web site.
“What’s the penalty if I don’t have coverage?,” The Henry J. Kaiser Family Foundation, accessed 10/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-whats-the-penalty-if-i-dont-have-coverage
Premium tax credits reduce your premium for most Marketplace policies. The amount of the tax credit you may receive depends on your income and the cost of Marketplace health plans in your area. The Marketplace will determine the expected contribution you are required to pay toward the premium for a mid-range (Silver) benchmark plan. The expected contribution will increase on a sliding scale based on your 2017 income. If your income is near the poverty level, the expected contribution you would be required to pay toward the benchmark plan is 2.04 percent of your income in 2017. As your income gets closer to 400% of the poverty level, the expected contribution you would be required to pay toward the benchmark plan is 9.69% of your income. The difference between the premium for the benchmark plan and your expected contribution equals the amount of your tax credit. (You do not have to pay more than the actual premium for the plan.) The Marketplace will tell you what that dollar amount is. You can use that amount to help pay the premium for any Bronze, Silver, Gold, or Platinum plan offered in the Marketplace. The credit cannot be used to pay for a Catastrophic plan.
Premium tax credits may be claimed at the end of the year, or you can apply for an advanced premium tax credit based on your estimated income for the up-coming year. If you elect to receive an advanced credit, the government will pay 1/12 of the credit directly to your insurance company each month and the insurer will bill you for the rest of the premium.
It’s important to keep in mind that when you apply for the premium tax credit during Open Enrollment, you won’t necessarily know for sure what your income for the coverage year will be, so you will apply based on your best estimate. Later, when you file your tax return, the IRS will compare your actual income to the amount of premium tax credit you claimed in advance. If you underestimated your income and claimed too much premium tax credit, you might have to pay back some or all of the difference. If you didn’t receive all of the premium tax credit you’re entitled to during the year, you can claim the difference when you file your tax return. You should report any changes in your income during the year to the Marketplace, so your credit can be adjusted and you can avoid any significant repayments at the end of the year.
“How do the premium tax credits work?,” The Henry J. Kaiser Family Foundation, accessed 10/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-how-do-the-premium-tax-credits-work
You can apply the premium tax credit to any Bronze, Silver, Gold, or Platinum plan offered through the Marketplace. Premium tax credits cannot be applied to Catastrophic plans or to stand-alone dental plans. If you are also eligible for cost sharing reductions, be aware that these can only be obtained through Silver plans offered in the Marketplace.
“Can I use the premium tax credit to reduce the cost of any Marketplace health plan?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-can-i-use-the-premium-tax-credit-to-reduce-the-cost-of-any-marketplace-health-plan
Yes. If your income is between 100% and 250% of the federal poverty level, you can also qualify for cost sharing reductions. These will reduce the deductibles, copays, and other cost sharing that would otherwise apply to covered services.
The cost sharing reductions will be available through modified versions of Silver plans that are offered on the Marketplace. These plans will have lower deductibles, copays, coinsurance and out-of-pocket limits compared to regular Silver plans. Once the Marketplace determines you are eligible for cost sharing reductions, you will be able to select one of these modified Silver plans, based on your income level.
“I can’t afford to pay much for deductibles and co-pays. Is there help for me in the Marketplace for cost sharing?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-cant-afford-to-pay-much-for-deductibles-and-co-pays-is-there-help-for-me-in-the-marketplace-for-cost-sharing
Yes, you can keep your Medicare and you do not need to make any changes to your coverage because of Obamacare. You may have heard about the requirement that all adults need to have health insurance coverage (known as the “individual mandate”) or have to pay a penalty if they go without health insurance, but your Medicare coverage satisfies this requirement. If you have Medicare Part A, or Part A and Part B, this penalty won’t apply to you. Having Part B only doesn’t satisfy this requirement.
“I am covered by Medicare. Can I keep my Medicare coverage even though these Marketplace plans are available, or do I need to make a change?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-am-covered-by-medicare-can-i-keep-my-medicare-coverage-even-though-these-marketplace-plans-are-available-or-do-i-need-to-make-a-change
If you have Medicare, you should keep it. In fact, companies that sell Marketplace plans are prohibited from selling these plans to you if they know you are covered by Medicare. If you do drop Medicare, and choose to re-enroll later, you can only re-enroll during the Medicare general enrollment period (from January 1 to March 31), and your coverage would not begin until July of that year. You also may face a penalty for late enrollment. If you don't sign up for Part B when you're first eligible or if you drop Part B and then sign up again later, your monthly Part B premium may go up 10% for each year that you could have had Part B, but didn't. You may also owe a late enrollment penalty for Part D drug coverage, which is equal to 1% of the national average premium amount for every month you didn't have coverage as good as the standard Part D benefit.
“I am over age 65 and covered by Medicare, but I’m wondering if I can purchase one of the health plans offered through the Marketplace and drop my Medicare coverage? Is that an option for me or should I keep my Medicare?,” The Henry J. Kaiser Family Foundation, accessed 9/13/2016, http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-am-over-age-65-and-covered-by-medicare-but-im-wondering-if-i-can-purchase-one-of-the-health-plans-offered-through-the-marketplace-and-drop-my-medicare-coverage-is-that-an-option-for-me-or
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