FAQ

Essential Health Benefits

All ACA-compliant health insurance plans in the individual and small group markets are required to cover 10 Essential Health Benefits (EHBs):

  1. Ambulatory Patient Services
    • Description: Outpatient care without hospital admission.
    • Examples: Doctor visits, outpatient surgeries, mental health services.
  2. Emergency Services
    • Description: Care for emergency medical conditions.
    • Examples: Emergency room visits for serious injuries or sudden illnesses.
  3. Hospitalization
    • Description: Inpatient care, surgeries, and overnight stays.
    • Examples: Surgery, overnight hospital stays, intensive care.
  4. Maternity and Newborn Care
    • Description: Prenatal, delivery, and postnatal services.
    • Examples: Check-ups during pregnancy, labor and delivery, newborn care.
  5. Mental Health and Substance Use Disorder Services
    • Description: Counseling and treatment for mental health conditions and substance abuse.
    • Examples: Therapy sessions, inpatient psychiatric care, substance abuse treatment programs.
  6. Prescription Drugs
    • Description: Medications prescribed by a health care provider.
    • Examples: Antibiotics, insulin, blood pressure medications.
  7. Rehabilitative and Habilitative Services and Devices
    • Description: Services and devices to help recover or improve skills.
    • Examples: Physical therapy after an injury, speech therapy, wheelchairs.
  8. Laboratory Services
    • Description: Tests to diagnose and manage conditions.
    • Examples: Blood tests, urine tests, pathology.
  9. Preventive and Wellness Services and Chronic Disease Management
    • Description: Screenings, immunizations, and management of chronic diseases.
    • Examples: Flu shots, cancer screenings, diabetes management programs.
  10. Pediatric Services
    • Description: Health care for children, including dental and vision care.
    • Examples: Well-child visits, immunizations, dental cleanings, eye exams.

Preventive Services at No Extra Cost

Under the ACA, many preventive services are covered without copayments or coinsurance, even if you haven’t met your deductible. This means you can receive preventive care at no additional cost.

  • Adult Services:
    • Blood pressure screening
    • Cholesterol screening
    • Colorectal cancer screening
    • Depression screening
    • Immunizations (e.g., flu shots, tetanus)
  • Women’s Services:
    • Mammograms
    • Cervical cancer screenings (Pap tests)
    • Contraception methods and counseling
    • Well-woman visits
  • Children’s Services:
    • Immunizations (e.g., measles, mumps, rubella)
    • Developmental screenings
    • Autism screenings
    • Vision screenings

Coverage for Pre-existing Conditions

  • Guaranteed Issue: Insurers cannot deny coverage or charge higher premiums based on pre-existing health conditions, such as diabetes, asthma, cancer, or pregnancy.
  • No Waiting Periods: Coverage for pre-existing conditions begins immediately upon the start of your plan.

Additional Protections

  • No Lifetime or Annual Limits: Plans cannot set a dollar limit on the amount they will spend on essential health benefits during the entire time you are enrolled in that plan.
  • Young Adult Coverage: Individuals can stay on their parent’s health insurance plan until age 26, even if they are married, not living with their parents, or financially independent.

General Eligibility

To enroll in health coverage through the ACA Marketplace, you must:

  • Be a U.S. Citizen or Lawfully Present Immigrant: This includes U.S. citizens, U.S. nationals, and individuals with eligible immigration status.
  • Live in the United States: You must reside in the state where you’re applying for coverage.
  • Not Be Incarcerated: Individuals currently incarcerated are not eligible to enroll in Marketplace coverage but can apply upon release.

Age Requirements

  • No Age Limit: Anyone can enroll in an ACA plan, regardless of age.
  • Young Adults: Can remain on a parent’s health plan until age 26.

Income Requirements

  • Marketplace Plans: Available to individuals and families who do not have access to affordable employer-sponsored insurance or other qualifying coverage.
  • Medicaid and CHIP: Low-income individuals and families may qualify based on income and household size.

Lawfully Present Immigrants

  • Eligible for Marketplace coverage and subsidies.
  • May qualify for premium tax credits and cost-sharing reductions.
  • Some may qualify for Medicaid and CHIP, depending on state policies.

The ACA provides financial assistance to make health insurance more affordable.

Premium Tax Credits

  • Purpose: Reduce the monthly cost of health insurance premiums.
  • Eligibility:
    • Household income between 100% and 400% of the Federal Poverty Level (FPL).
    • Not eligible for affordable employer-sponsored insurance that meets minimum value standards.
    • Must enroll in a plan through the Marketplace.
  • How It Works:
    • The credit amount is based on a sliding scale, with lower-income individuals receiving higher subsidies.
    • Can be applied in advance to lower your monthly premium (Advanced Premium Tax Credit).
    • Alternatively, you can claim the credit when you file your federal income tax return.

Cost-Sharing Reductions (CSRs)

  • Purpose: Lower out-of-pocket costs for deductibles, copayments, and coinsurance.
  • Eligibility:
    • Household income between 100% and 250% of the FPL.
    • Must enroll in a Silver plan through the Marketplace.
  • How It Works:
    • Reduces the amount you pay for covered services.
    • Lowers your out-of-pocket maximum.
  • Note: Even though insurers are no longer reimbursed by the federal government for CSRs, they are still required to provide these discounts to eligible consumers. Insurers have adjusted premiums to compensate, often increasing Silver plan premiums.

Medicaid and CHIP

  • Medicaid Expansion:
    • In states that expanded Medicaid, individuals with income up to 138% of the FPL may qualify.
    • Includes adults without dependent children.
  • Children’s Health Insurance Program (CHIP):
    • Provides coverage to uninsured children in families with incomes too high for Medicaid but too low to afford private insurance.
    • Eligibility varies by state, often covering children up to 200% or higher of the FPL.

Calculating Subsidies

  • Modified Adjusted Gross Income (MAGI): Your household income used to determine eligibility for financial assistance.
  • Household Size: Number of people in your tax household, including dependents.

Examples

  • Single Individual:
    • Income: $30,000/year
    • Percentage of FPL: Approximately 206% (based on 2023 FPL)
    • Eligible for Premium Tax Credits: Yes
    • Eligible for CSRs: Yes, if enrolled in a Silver plan
  • Family of Four:
    • Income: $70,000/year
    • Percentage of FPL: Approximately 233%
    • Eligible for Premium Tax Credits: Yes
    • Eligible for CSRs: Yes, if enrolled in a Silver plan

Open Enrollment Period

  • When: Typically runs from November 1 to January 15 each year (dates may vary by state).
  • Coverage Start Dates:
    • Enroll by December 15: Coverage begins on January 1.
    • Enroll between December 16 and January 15: Coverage begins on February 1.
  • Why Enroll During Open Enrollment:
    • Guaranteed coverage without denial for pre-existing conditions.
    • Access to a variety of plan options.
    • Ability to apply for financial assistance.

State-Specific Enrollment Periods

  • Some states with their own Marketplaces may have different enrollment dates.
    • California: Often extends Open Enrollment until January 31.
    • New York: May have extended enrollment periods.
    • Massachusetts: May set unique deadlines.
  • Action: Always check your state’s Marketplace for exact dates.

Special Enrollment Periods (SEPs)

  • Qualifying Life Events:
    • Loss of Health Coverage: Losing job-based coverage, aging out of a parent’s plan.
    • Changes in Household: Marriage, divorce, birth, or adoption of a child.
    • Changes in Residence: Moving to a new ZIP code or county, moving to the U.S. from a foreign country.
    • Other Situations: Changes in income, gaining citizenship, leaving incarceration.
  • Time Frame: Generally, you have 60 days before or after the event to enroll.

Medicaid and CHIP Enrollment

  • Year-Rround Enrollment: You can apply at any time if you qualify.

Employer-Sponsored Plans

  • Enrollment Periods:
    • Typically have their own Open Enrollment periods, often during the fall.
    • Check with your employer for specific dates.

Enrollment Methods

  1. Online
    • Healthsherpa.com: For states using the federal Marketplace.
    • State-Based Marketplaces: If your state operates its own Marketplace (e.g., Covered California, New York State of Health).
  2. By Phone

Steps to Enroll

  1. Complete the Application
    • Personal Information: Names, dates of birth, Social Security numbers.
    • Household Information: Tax filing status, dependents.
    • Income Details: Estimated income for the coverage year, sources of income.
    • Current Coverage: Any existing health insurance information.
  2. Review Eligibility Results
    • After submission, you’ll receive an eligibility determination notice.
  3. Compare Plans
    • Considerations:
      • Monthly premiums
      • Deductibles, copayments, and coinsurance
      • Out-of-pocket maximums
      • Provider networks
      • Prescription drug coverage
  4. Select a Plan
    • Choose the plan that best meets your needs.
  5. Enroll and Pay
    • Enroll in the plan.
    • Pay the first month’s premium to activate coverage.

Required Documents

  • Identification: Social Security numbers or document numbers for immigrants.
  • Income Verification: W-2 forms, pay stubs, tax returns.
  • Immigration Documents: For non-citizens (e.g., Green Card, work authorization).

Tips for Enrollment

  • Estimate Income Accurately: To ensure correct subsidy amounts.
  • Check Provider Networks: Ensure your doctors are in-network.
  • Review Plan Details: Understand covered benefits and costs.
  • Seek Assistance: If needed, get help from navigators or brokers.

Special Enrollment Periods (SEPs)

  • Qualifying Life Events:
    • As mentioned earlier, certain events allow you to enroll outside Open Enrollment.
  • Documentation:
    • You may need to provide proof of the qualifying event.

Medicaid and CHIP

  • Year-Round Enrollment:
    • If you qualify based on income and other criteria, you can enroll anytime.

Alternative Options

  • Short-Term Health Plans:
    • Caution: These plans are not required to cover essential health benefits or pre-existing conditions.
    • May have significant limitations.
  • Health Care Sharing Ministries:
    • Organizations where members share medical expenses.
    • Not insurance and not regulated in the same way.
  • Limited Benefit Plans:
    • Provide minimal coverage.
    • Not ACA-compliant.

Risks of Being Uninsured

  • Medical Costs:
    • Without insurance, you may face high medical bills in case of illness or injury.
  • State Penalties:
    • Some states impose penalties for not having health insurance.
  • Yes: Under the ACA, insurers cannot deny you coverage or charge you more due to pre-existing health conditions.

Protections for Individuals with Pre-existing Conditions

  • Guaranteed Issue: You have the right to purchase any plan during Open Enrollment.
  • Community Rating: Premiums cannot vary based on health status.
  • No Waiting Periods: Coverage for pre-existing conditions begins immediately.

Examples of Pre-existing Conditions

  • Chronic Diseases: Diabetes, heart disease, asthma.
  • Mental Health Conditions: Depression, anxiety disorders.
  • Past Illnesses: Cancer survivors, individuals with past surgeries.

Individual Mandate Overview

  • Original Requirement: The ACA included an individual mandate requiring most Americans to have health insurance or pay a tax penalty.

Current Status

  • Federal Penalty:
    • As of 2019, the federal tax penalty for not having health insurance has been reduced to $0.
  • State Mandates:
    • Some states have their own individual mandates with penalties for being uninsured:
      • California: Penalty enforced; minimum penalty is $750 per adult and $375 per dependent child.
      • Massachusetts: Penalty varies based on income and can be up to $1,704 per year.
      • New Jersey: Penalty is calculated based on income and family size.
      • Rhode Island: Similar to the federal penalty prior to 2019.
      • District of Columbia: Penalty applies; calculated similar to federal mandate.

What This Means for You

  • No Federal Penalty: You won’t owe a penalty on your federal tax return for being uninsured.
  • Check State Laws: If you live in a state with its own mandate, you may face a penalty for not having coverage.
  • Importance of Coverage:
    • Even without a federal penalty, having health insurance is crucial for financial protection and access to health care.

Overview

  • Medicaid Expansion: A provision in the ACA allowing states to expand Medicaid eligibility to more low-income individuals.

Eligibility Under Expansion

  • Income Threshold:
    • Up to 138% of the Federal Poverty Level (FPL).
    • Calculation: Includes a 5% income disregard, effectively making the limit 138%.
  • Who Qualifies:
    • Adults aged 19-64 without dependent children.
    • Parents and caretakers with incomes below the threshold.

State Participation

  • As of 2023, 38 states and D.C. have adopted Medicaid expansion.
  • Non-Expansion States:
    • 12 states have not expanded Medicaid (exact number may vary; check current data).
    • Individuals in these states may fall into a coverage gap, earning too much to qualify for Medicaid but too little for Marketplace subsidies.

Benefits of Expansion

  • Increased Coverage: Millions more people gain access to health care.
  • Improved Health Outcomes: Early detection and management of conditions.
  • Economic Benefits: Reduced uncompensated care costs for hospitals.

How to Apply

  • Through the Marketplace: When you apply for coverage, the system will determine Medicaid eligibility.
  • State Medicaid Agencies: You can apply directly through your state’s Medicaid office.

Financial Assistance Options

  1. Premium Tax Credits:
    • Lower your monthly premium costs.
    • Available for incomes between 100% and 400% of the FPL.
  2. Cost-Sharing Reductions:
    • Reduce out-of-pocket costs.
    • Available for incomes between 100% and 250% of the FPL on Silver plans.
  3. Medicaid and CHIP:
    • Free or low-cost coverage for eligible individuals and families.
    • Income thresholds vary by state.

Community Resources

  • Community Health Centers:
    • Provide services on a sliding fee scale.
    • Offer primary care, dental, mental health services.
  • Prescription Assistance Programs:
    • Help with the cost of medications.
  • Local Programs:
    • Some states and localities offer additional health care assistance programs.

Negotiating Medical Bills

  • Payment Plans:
    • Many providers offer payment plans for medical bills.
  • Financial Assistance:
    • Hospitals often have charity care or financial assistance policies.
  • Non-Profit Hospitals:
    • Required to have financial assistance policies and provide community benefits.

Avoiding Insurance Scams

  • Beware of Non-ACA-Compliant Plans:
    • Some plans may be marketed as cheap alternatives but lack essential coverage.
  • Verify Legitimacy:
    • Ensure plans are sold through the official Marketplace or reputable insurers.

Small Business Health Options Program (SHOP)

  • Purpose: Allows small businesses to offer health and dental coverage to employees.
  • Eligibility:
    • Employers with 1-50 full-time equivalent (FTE) employees.
    • Must offer coverage to all full-time employees (those working 30+ hours/week).
  • Benefits:
    • Choice of Plans: Access to high-quality plans.
    • Potential Tax Credits:
      • Small Business Health Care Tax Credit:
        • Up to 50% of premium costs for qualifying businesses.
        • For businesses with fewer than 25 FTE employees with average wages below $56,000.

Employer Responsibilities

  • Under 50 FTE Employees:
    • Not Required to offer health insurance.
    • Reporting Requirements: May have to report coverage information to employees and the IRS.
  • 50 or More FTE Employees:
    • Employer Mandate:
      • Must offer affordable health insurance that provides minimum value.
      • Penalties: May face penalties if not compliant.

Employee Options

  • Employees offered employer-sponsored insurance that meets affordability and minimum value standards are not eligible for premium tax credits through the Marketplace.

How to Enroll in SHOP

  • Online: Through Healthcare.gov or a state’s SHOP Marketplace.
  • Through an Agent or Broker: Can assist with plan selection and enrollment.

Detailed Overview

  • Cost-Sharing Reductions lower the amount you pay for out-of-pocket costs when you receive health care services.

Eligibility Criteria

  • Income Level:
    • Household income between 100% and 250% of the FPL.
  • Enrollment Requirement:
    • Must enroll in a Silver plan through the Marketplace.

Benefits

  • Lower Deductibles: You pay less before insurance starts covering costs.
  • Reduced Copayments: Lower fixed amounts for services like doctor’s visits.
  • Lower Coinsurance: Pay a smaller percentage of the cost of services.
  • Reduced Out-of-Pocket Maximum: The total amount you pay in a year is capped at a lower amount.

Levels of Cost-Sharing Reductions

  • Income Between 100% – 150% FPL:
    • Highest level of assistance.
    • Silver plan’s actuarial value increases to 94%.
  • Income Between 150% – 200% FPL:
    • Moderate assistance.
    • Actuarial value increases to 87%.
  • Income Between 200% – 250% FPL:
    • Lower level of assistance.
    • Actuarial value increases to 73%.

How to Access CSRs

  • Automatic Application:
    • When you apply for coverage, the Marketplace determines your eligibility.
    • The Silver plans you see will already reflect the reduced cost-sharing amounts.

Important Notes

  • Even if You Choose a Different Metal Tier:
    • CSRs are only available with Silver plans.
    • If you choose a Bronze or Gold plan, you won’t receive CSRs, even if you qualify.
  • Impact of Federal Policy Changes:
    • Despite changes in federal reimbursement to insurers, CSRs are still provided to eligible consumers.
    • Insurers may have adjusted premiums to compensate, often leading to higher Silver plan premiums.
  • Silver Loading:
    • The practice of increasing Silver plan premiums to account for CSR costs.
    • May result in higher premium tax credits, benefiting consumers who choose non-Silver plans.

During Open Enrollment

  • Yes: You can change plans any time before the Open Enrollment deadline.

After Open Enrollment

  • Special Enrollment Period:
    • You can change plans if you experience a Qualifying Life Event.
  • Within the Same Insurer:
    • Some insurers may allow plan changes within their offerings.
    • Check with your insurer for policies and any restrictions.

Medicaid and CHIP

  • Changes Allowed:
    • You can change plans or coverage if your eligibility changes.

Employer-Sponsored Plans

  • Mid-Year Changes:
    • Generally, changes are limited to Open Enrollment unless you have a Qualifying Life Event.

Tips

  • Review Plan Options Carefully:
    • Understand that changing plans may affect your provider network and covered medications.
  • Impact on Subsidies:
    • Changing plans may affect your premium tax credits and cost-sharing reductions.

Coverage Requirements

  • Essential Health Benefit:
    • All Marketplace plans must cover prescription drugs.
  • Formulary (Drug List):
    • Each plan has a list of covered medications.
    • Drugs are placed into tiers affecting cost-sharing amounts.

Understanding Drug Tiers

  • Tier 1: Generic Drugs
    • Lowest copayments.
    • FDA-approved equivalents of brand-name drugs.
  • Tier 2: Preferred Brand Drugs
    • Moderate copayments.
    • Brand-name drugs without generic equivalents.
  • Tier 3: Non-Preferred Brand Drugs
    • Higher copayments.
    • Brand-name drugs with lower-cost alternatives.
  • Tier 4: Specialty Drugs
    • Highest copayments or coinsurance.
    • High-cost medications for complex conditions.

Cost Considerations

  • Deductibles:
    • Some plans have separate deductibles for prescriptions.
  • Copayments and Coinsurance:
    • Vary based on the drug tier.
  • Out-of-Pocket Maximums:
    • Includes spending on prescriptions.

Tips for Managing Prescription Costs

  1. Check the Formulary:
    • Ensure your medications are covered.
    • Look for plans where your medications are in a lower tier.
  2. Generic Medications:
    • Ask your doctor if generics are available.
  3. Mail-Order Pharmacies:
    • May offer cost savings for maintenance medications.
  4. Assistance Programs:
    • Pharmaceutical companies may offer patient assistance programs.
  5. Appeals Process:
    • If a needed drug is not covered, you can request an exception.

Available Resources

  1. Navigators and Certified Application Counselors
    • Provide free, unbiased assistance.
    • Help with understanding options and completing applications.
    • Can be found at community organizations, hospitals, and clinics.
  2. Insurance Agents and Brokers
    • Licensed professionals who can recommend plans.
    • May receive commissions from insurers.
  3. Marketplace Call Center
    • Phone: 1-800-318-2596 (Available 24/7)
    • Assistance in multiple languages.
  4. Online Tools
    • Plan Finder: Compare plans based on costs and benefits.
    • Subsidy Calculator: Estimate your eligibility for financial assistance.
  5. State Departments of Insurance
    • Can provide information on insurance regulations and consumer protections.

Tips for Seeking Help

  • Prepare Questions:
    • Write down any concerns or questions before seeking assistance.
  • Have Documents Ready:
    • Personal information, income details, and current coverage information.
  • Verify Credentials:
    • Ensure that the individual assisting you is certified or licensed.