1 Health Insurance Marketplace Frequently Asked Questions Q & A SPECIFIC TO THE HEALTH INSURANCE MARKETPLACE & ASSISTANCE Q1: Why is health insurance important? A: No one plans to get sick or hurt, but at some point, most people need treatment for an illness or injury. Health insurance helps pay these costs. Health insurance is a contract between you and an insurance company. You buy a plan or policy, and the company agrees to pay part of your medical expenses when you get sick or hurt. Did you know the average cost of a three-day hospital stay is $30,000? Or that fixing a broken leg can cost up to $7,500? Having health insurance can help protect you from unexpected costs like these. Q2: What is the Health Insurance Marketplace? A: The Health Insurance Marketplace - also known as the Health Insurance Exchange - is a one-stop shop where consumers can compare insurance plans, and apply for and enroll in health insurance coverage. Like you mentioned in your introduction, with one application you can find out if you qualify for health plans and other programs like Medicaid and the Children's Health Insurance Program (CHIP). You can also learn if you qualify for help paying for healthcare costs through tax credits and cost-sharing reductions. Q3: What types of health insurance plans are offered on the Marketplace? A: There are (4) categories of plans: bronze, silver, gold and platinum. This will make comparing prices and benefits of the plans very easy. You will get a clear picture of what the premiums will cost you and what the benefits and protections you would get before you enroll. The cost of health insurance through the Marketplace depends on the plan you choose, your age and your tobacco use. Q4: What do you pay for health insurance, in general? A: You will pay a premium, which is the amount of money charged for a certain amount of insurance coverage every month for health insurance. You may also have to meet a deductible. You must pay this amount out of your pocket before an insurer will pay any expenses. Let's say you have a $200 deductible. You go to the doctor and the total cost is $250. You pay the first $200 to cover the deductible, and then your insurance starts to pay its share. How much you pay for your premium and deductible depends on the type of insurance you have. Every plan has to pay 60% of your medical bills. But from there, you can decide, do you want to pay a higher premium and get more of your benefits paid - or do you want to pay a lower premium and run the risk that, if you get sick, you'll have to pay more out of your own pocket? So, a higher premium offers more coverage. A lower premium provides less coverage if you get sick. So if you think you are going to stay healthy, then you might want to pay a lower premium that would cover a smaller percentage of your bills.
2 Q5: So you still have to pay for the insurance, but tell me more about the help that's available to help pay for those premiums. A: When you apply on the Marketplace, you will enter information that may help you lower the cost of your health plan. The good thing is most people who apply will qualify for lower costs of some kind. Depending on income and family size, you can save money three ways: You may be able to lower your costs on your monthly premiums. You may qualify for lower out-of-pocket costs for co-pays, co-insurance and deductibles. You or your child may get free or low-cost coverage through Medicaid or the Children's Health Insurance Program. Here's an example of who may be eligible for lower costs: an individual with income between $11,490 and $45,960 a year a family of four with income between $23,550 and $94,200 a year Q & A SPECIFIC TO THE COVERAGE Q6: What types of health conditions will the insurance cover? A: It's important to know that all of the health insurance plans offered in the Marketplace will offer the same set of "essential health benefits." These are services all plans must cover and include: Preventive care and wellness services Doctor visits Prescription drugs Hospitalization and emergency department care Lab services Chronic disease management Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Rehabilitative services and devices Pediatric services, including oral and vision care For children, the health plans must cover a set of preventive health services at no cost when delivered by an in-network provider. Some of these preventive health services for children include: Autism screening Behavioral assessments Blood pressure screening Depression screening Developmental screening Hearing screening for all newborns Height, weight and BMI measurements Immunization vaccines through age 18 Obesity screening and counseling Sexually transmitted infection prevention and screening for adolescents at higher risk Vision screening The new health plans must cover certain preventive services without cost sharing. This means, when you have these services delivered by a network provider, you will not have to pay anything (no copayment, co-insurance, or deductible) to receive the recommended preventive health services. These preventive services include:
3 Blood pressure, diabetes, and cholesterol tests Many cancer screenings, including mammograms and colonoscopies Counseling on such topics as quitting smoking, losing weight, eating healthy, treating depression, and reducing alcohol use Regular well-baby and well-child visits, from birth to age 21 Routine vaccinations against diseases such as measles, polio, or meningitis Counseling, screening, and vaccines to ensure healthy pregnancies Flu and pneumonia shots In total, there are 15 covered preventive services for adults, 22 covered preventive services for women, including pregnant women, and 26 covered preventive services for children. Q7: In the past, a health insurance company wouldn't cover you if you had a pre-existing condition, such as a cancer diagnosis. A: That's the great thing about the Marketplace. No insurance plan can turn you away or charge you more because you have an illness or medical condition, now or in the past. They must cover treatments for these conditions. Also, the plans can't charge women more than men for the same plan. APPLYING & ENROLLING FOR COVERAGE Q8: When can consumers enroll for health insurance on the Marketplace? A: Starting November 15, 2014, you can fill out an application in three ways: 1. Online at 2. If you don't have access to a computer, you can also call a toll-free number, , and talk to a trained customer service representative. 3. If completing the application seems intimidating, there are Navigators or Certified Assisters throughout our community. In fact, we can help you complete the enrollment form. Our representatives can also accommodate Spanish-speaking residents. The initial open enrollment period ends January 31, Outside of open enrollment, you cannot enroll in Marketplace coverage unless you have a "qualifying life event." That means you have moved to a new state, had certain changes in your income or changes in your family size - such as marriage, divorce, or a newborn. Q9: After someone enrolls, how soon will coverage begin? A: The coverage start date depends on when you select your plan and pay the premium: If you pay the premium between Nov Dec. 15, 2015, coverage begins Jan. 1, If you pay the premium between Dec. 16, Jan. 15, 2016, coverage begins Feb. 1, If you pay the premium between Jan. 16, 2015 Jan. 31, 2015, coverage begins March 1, Q10: So how does the Marketplace actually work? A: When you apply online, you will set up an account with some basic information, such as your name, address and . For the application portion, you will provide information about you and your family - such as your household income, household size, current health coverage information (if any), and some other questions. Once your information is entered, you will view all the options you qualify for, including private insurance plans and free and low-cost coverage through Medicaid and the Children's Health Insurance
4 Program (CHIP). The Marketplace will also tell you whether you qualify for lower costs on your monthly premiums and out-of-pocket costs on deductibles, copayments, and coinsurance. You will see details on costs and benefits before you choose a plan. Q11: Who is eligible to buy health insurance in the Marketplace? A: To be eligible: You must live in the U.S. You must be a U.S. citizen And you can't be currently incarcerated U.S. citizens living in a foreign country are not required to get health insurance coverage under the Affordable Care Act. Q12: What if a person already has health coverage through their employer? A: Individuals who can get insurance through their employers can buy insurance through the Marketplace if their premiums are not affordable. This means their portion of the cost is 9.5% of their total household income - or if the plan pays less than 60% of the cost of covered benefits. This rule only applies to the Individual Insurance Plan offered in the workplace, not added members. Q13: What about coverage for individuals who are self-employed? A: If you're self-employed with no employees, you can use the Marketplace to find health coverage that meets your needs. Q14: What is the penalty if a person does not have health insurance coverage by January 1st? A: If you have access to affordable coverage, such as through your employer, but remain uninsured, you may have to pay a penalty when filing your 2016 income taxes. This penalty is $695 per adult, $ per child - up to $2,085 per family or 2.5% of family income, whichever is higher. And without insurance, you'll be responsible for all of your medical costs. Examples: Family of 4 with a household income of $42,000, 2.5% of income = $1,050. The penalty would be $2,085. Family of 4 with a household income of $125,000, 2.5% of income = $3,125. The penalty would be $3,125. Q15: Does everyone have to have insurance? Are there any exemptions? A: Exemptions from having health insurance will be only be granted under certain circumstances. Uninsured people will not have to pay a fee if they: are uninsured for less than (3) months of the year are determined to have very low income and coverage is considered unaffordable are not required to file a tax return because their income is too low would qualify under the new income limits for Medicaid, but that heir state has chosen not to expand Medicaid eligibility are a member of a federally-recognized Indian tribe participate in a healthcare-sharing ministry are a member of a recognized religious sect with religious objections to health insurance If you don't qualify for any of these situations, you can apply for an exemption in the Marketplace asking not to pay a fee.
5 WHAT IFS Q16: What if a company will no longer provide health insurance in 2016? A: If you lose your job or your employer no longer offers health insurance, you may buy an individual plan through the Marketplace. You may also have the option of keeping your health insurance for a limited time (usually 18 months) through a program called COBRA continuation coverage. Q17: If a person currently has a doctor, can they keep their doctor if they get health insurance through the Marketplace? A: Depending on the plan chosen, a person can keep their current doctor. When comparing plans in the Marketplace, you will see a link to a list of doctors in each plan's network. If staying with your current doctors is important to you, be sure to check to see if they are included before choosing a plan. Q18: What if a person is pregnant and wants to buy a Marketplace plan? A: As mentioned, an insurance company can't deny you coverage because you are pregnant when you join a health insurance plan. However, insurance companies can still impose waiting periods for certain benefits. Fortunately, the healthcare reform law now puts a limit on these waiting periods. A waiting period for maternity care benefits can be no longer than 90 days. So if you are pregnant when you join a healthcare plan, the longest you have to wait before your insurance company will pay for your maternity care, labor and delivery costs is 90 days, or (3) months. Q19: What if I work part-time and want to buy a Marketplace plan? A: If you work part-time, you can purchase a plan through the Marketplace. However, if you're eligible for your employer's group health plan even though you work part-time, you aren't eligible for any cost savings previously mentioned, unless the coverage your employer is offering is not considered "affordable." If you have to contribute more than 9.5% of your income toward your employer's plan, it's not considered "affordable." Q20: What if I lose my group insurance through my job? A: If you lose your group health insurance because you quit, are fired or are laid off, you have the option of continuing your plan through COBRA for 18 months or purchasing an individual plan through the Health Insurance Marketplace. You do not need to wait until an open enrollment period to sign up for a Marketplace plan if you lost your group insurance. Q21: What do American Indians and Alaska Natives need to know about the Marketplace? A: Members of a federally recognized tribe have certain protections in the Marketplace. They do not have to pay a fee if they do not have health coverage. They more easily qualify for lower out-of-pocket costs for deductibles, copayments, and coinsurance. They get monthly special enrollment periods allowing them to get insurance outside the yearly open enrollment period. They also have special cost and eligibility rules for Medicaid and the Children's Health Insurance Program (CHIP). For more information, visit healthcare.gov/tribal.
6 Q22: Why is it that the adult children of retired members of the military cannot stay on their parents' insurance? A: The Affordable Care Act allows adult children to stay on their parents' health plan until they reach age 26 in most cases. However, Tricare, the health plan for military service members, is governed by a different set of statutes, and the ACA's provisions that expand young adult coverage do not apply to it. Tricare allows dependent children to remain on their parents' plan until age 21, or until they turn 23 if they're full-time students supported financially by their parents. Once adult children are no longer eligible for regular Tricare, they can enroll in the Tricare Young Adult Program, which provides coverage for children up to age 26 who are unmarried and don't have employer coverage available to them. Unlike regular Tricare, however, the young adult program is a premium-based plan that costs up to $180 per month. Q23: What about a divorced dad who is responsible for maintaining his child's health insurance; if he's retired and in the Medicare program, what options are available to him? A: He can buy insurance on the health insurance Marketplaces, which offers child-only policies for children up to age 21. Q24: So a child can stay on his or her parent's employer-based insurance plan until age 26. However, if it is cheaper for the child to get subsidized coverage through the health insurance marketplace, can he or she do so? A: It depends. Almost anyone can shop for coverage on the Marketplace. But that child will only be eligible for subsidies to reduce the cost of coverage under certain circumstances. If the parents do not claim him as a dependent on their tax return and his own income is between % of the federal poverty level ($11,670 to $46,680 in 2014 in states that do not expand Medicaid), or % of the federal poverty level ($15,521 to $46,680 in 2014 in states that expanded Medicaid), he could be eligible for premium tax credits on the Marketplace. However, if the parents do claim him as a dependent, his eligibility will be based on the family's income, not just his own. It's also worth looking into Medicaid eligibility for that. Roughly, half the states have decided to expand Medicaid coverage to adults with incomes up to 138% of the federal poverty level as provided for under the Affordable Care Act. Medicaid would be even less expensive than a private plan on a Marketplace. However, if the parents claim their son or daughter as a dependent on their tax return, the family's income would have to be no more than 138% of poverty in order for him to qualify. Q25: I chose a plan in the Marketplace last year, can I choose a different one this year? A: Yes. If you chose a plan last year through the Marketplace, you can go through the Marketplace again this open enrollment and look over your options. If you do not take any action during open enrollment, you will be auto-enrolled in the plan you currently have. Be sure to check and see if your plan has changed in any way, call or go onto your insurance provider's website.
7 Q & A REGARDING HOSPITAL SIGN-UP ASSISTANCE Q26: What information do I need to bring with me to my appointment to help with enrollment? A: Residents will need to bring the following information for each covered family member: the Social Security number or document number for legal immigrants employer and income information; for example, wage and tax statements from pay stubs or W-2 forms. any current health insurance policy number if eligible for any employer health insurance (i.e. through a spouse or parent) information about that employer's plan