FAQs

Employer-Sponsored Health Coverage

Links to all state Marketplaces can be found at www.healthcare.gov

In the states that CLRA writes business, they are the following:

Virginia – healthcare.gov

Maryland – marylandhealthconnection.gov

District of Columbia – dchealthlink.gov

Starting in 2015, large employers must offer health insurance to their full time workers or pay a penalty.  These employers also must provide their employees with Form 1095-C to document that health coverage was offered.   Every employee of a large employer who was eligible for health coverage in 2015 should receive a form 1095-C in January of 2016.  Even if you declined to sign up for your health plan at work, you will still receive a form 1095-C.  Information on this form will also be reported to the IRS.

Form 1095-C will indicate your name and the name of your large employer, the months during 2015 when you were eligible for coverage, and the cost of the cheapest monthly premium you could have paid for coverage under your employer’s health plan. If you worked for a large employer that did not offer its full time employees health coverage, Form 1095-C will also indicate that.

Keep this form with your tax records.  You may need this form if you were offered health coverage by your employer and you did not sign up for it.  If you signed up for Marketplace coverage instead and received a premium tax credit, information on Form 1095-C will help you determine whether you were eligible for the tax credit (for example, if the cost of your employer health plan was more than 9.56% of your income.)  If you were uninsured in 2015 even though your employer offered you health coverage that year, you may be eligible for an exemption from the tax penalty if the cost of your employer health plan was more than 9.56 percent of your income.

https://www.irs.gov/pub/irs-prior/f1095c–2015.pdf

Yes, most group health plans offered by an employer are considered “minimum essential coverage.” Some limited benefit plans (for example, dental only plans) are not considered minimum essential coverage.  Your group health plan materials should indicate whether the plan is considered “minimum essential coverage.”

If it is and if you enroll in the plan, you will have met the requirement to have coverage and won’t owe a tax penalty.  However, the plan you described probably does not meet the standard for “minimum value.”  If this is the only plan your employer offers, you may be able to qualify for premium tax credits to help pay for Marketplace coverage.  The premium tax credits could help you afford coverage that would be more comprehensive.

You can apply for coverage in the Marketplace and you may qualify for premium tax credits if your employer plan doesn’t meet the Affordable Care Act’s standard for minimum value.

If your employer plan only covers preventive services and a few doctor visits, it probably doesn’t meet the minimum value standard, and so you could be eligible for premium tax credits to help buy a Marketplace plan.

However, if the mini-med plan is only one choice that your employer offers, and if another plan your employer offers would be affordable and meet the minimum value standard, then you will not qualify for premium tax credits in the Marketplace.

If you are considering applying for premium tax credits for coverage in the Marketplace, the test for whether your employer coverage is affordable is based on the cost of self-only coverage in the lowest cost plan your employer offers, compared to your household income (and not just your salary).

If you missed your opportunity to enroll in your employer plan during the company’s open enrollment season, you can still apply for coverage in the Marketplace during open enrollment, which runs from November 1, 2015 to January 31, 2016.

You can also apply for subsidies but you will have to provide information on the health coverage you are eligible for at work, even if you’re not enrolled in the plan. If the plan employer offered meets standards for affordability and minimum value, you will not be eligible for premium tax credits or cost-sharing reductions.

No, Just being eligible for COBRA doesn’t affect your eligibility for premium tax credits or cost-sharing assistance if you enroll in a Marketplace plan.

Yes, leaving your job and losing eligibility for job-based health coverage will trigger a special enrollment opportunity that lasts for 60 days. You can apply for Marketplace health plans during that period. If you enroll in COBRA coverage through your former employer, however, you will need to wait to the next Marketplace Open Enrollment period if you want to switch to a Marketplace plan.

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.

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.

Health Insurance and the 2015 Federal Income Tax Return

You should contact the Marketplace to call the mistake to their attention and request a corrected form 1095-A.  Information on 1095-A is also reported to the IRS, so it is important that you get a corrected form before you file your income tax return.

https://www.irs.gov/pub/irs-pdf/f1095a.pdf

Form 1095-A gives you information about the amount of advanced premium tax credit (APTC) that was paid during the year to your health plan in order to reduce your monthly premium.  This information was also reported to the IRS.  The APTC paid on your behalf during the year was based on the annual income you estimated you would earn when you signed up for Marketplace coverage.  Now you must file a federal income tax return to compute your actual income for that coverage year.  You will have to include Form 8962 with your return.  Instructions for this form will help you calculate how the APTC compares to the amount of premium tax credit you were eligible for.  If your actual income was lower than what you estimated, you are eligible for a larger premium tax credit and can claim the difference as a refund when you file your tax return.  If your income was higher than what you estimated, you are eligible for less premium tax credit and might have to pay back some or all of the difference when you file your return.

https://www.irs.gov/pub/irs-pdf/f1095a.pdf

Yes. Premium tax credits can be claimed in advance (during the year) or at year end when you file your taxes.  To claim the credit, you will need to file a federal income tax return and Form 8962.

Follow the instructions on Form 8962 to determine the amount of tax credit you should receive as a tax refund when you file your taxes.

https://www.irs.gov/pub/irs-pdf/f8962.pdf

No, there is a special rule to protect people in your circumstance.  If the Marketplace found you were eligible for premium tax credits at the time you enrolled (because your best estimate at that time was that your annual income would be between 100% and 400% of the federal poverty level), and if your income later fell below the poverty level, you are still eligible for the tax credits you received last year.  You will not be required to repay the premium tax credit when you file your tax return.

Yes.  You are required to file a federal income tax return for any year in which you received a premium tax credit.  When you file, you will have to calculate how much tax credit you were actually eligible for in that year.  The Marketplace determination you received last year was based on your good faith estimate of what your annual income would be.  When you file your tax return, you will report your actual income.

If your actual income turned out to be higher than you had estimated, you may have to repay some or all of the advanced premium tax credit (APTC) that was paid on your behalf during the year.  If your actual income turned out to be lower than you had estimated, you will be able to claim additional tax credit amounts as a tax refund.

To calculate this, you will need two special tax forms.   In January you will receive a form 1095-A in the mail from your health insurance Marketplace.  This form will indicate the amount of APTC that was paid to your health plan last year.  When you file your federal income tax return, you will also need to file Form 8962.  The instructions for Form 8962 will walk you through the steps to calculate the amount of tax credit that you were eligible for based on a final calculation of your actual income.  Once you’ve completed this form, you will know whether you are required to repay some of the APTC or whether you are owed additional premium tax credit.

https://www.irs.gov/pub/irs-pdf/f1095a.pdf

Possibly. You might still experience a life change (for example, due to a move or change in family status) that would qualify for a special enrollment opportunity.  If so, you would be able to sign up for coverage before the end of this year.

If you do have a qualifying event later this year, be sure to sign up for coverage as soon as possible so you won’t owe a penalty for being uninsured for the remaining months of the year.

Otherwise, be sure to apply for coverage during the next Open Enrollment period so you won’t also owe a tax penalty next year.

There are several options to consider.   Some people with very low incomes are automatically exempt from the individual responsibility requirement.  If your income was below the tax filing threshold ($10,300 in 2015 for single taxpayers, $20,600 for married taxpayers who file a joint return), you don’t need to file a tax return and you won’t be assessed a penalty for not having coverage during the year.

If you do intend to file a return anyway (for example, to get a refund of any income taxes that were withheld during the year), you will need to include Form 8965 with your tax return and check the box indicating that your income is below the filing threshold.

If your income is above the tax filing threshold, you will have to file a federal income tax return and claim an affordability exemption from the individual responsibility requirement. You can qualify for this exemption if the lowest cost plan that was available to you through the Marketplace in 2015 would have cost more than 8.05% of your household income, taking into account any premium tax credit that you were eligible for.  Or, if you were offered coverage by an employer in 2015, you would be eligible for the affordability exemption if your share of the premium for that plan would have cost more than 8.05% of your household income in that year.  You can apply for this exemption from the Marketplace in your state, before you file your 2015 federal income tax return, or you can apply for it directly on the tax return when you file.  Either way, you will need to file Form 8965 with your 2015 federal income tax return.

To apply for an affordability exemption from the Marketplace, in most states you would have to fill out a paper application, providing information about your expected income for the year in which you want the exemption, members of your household, and any employer-sponsored coverage that may have been offered to you.  If the Marketplace grants the exemption, you will receive an exemption certificate.  Include the exemption certificate number on Form 8965 and include that with your income tax return.

To apply for the affordability exemption directly on your tax return, the instructions for Form 8965 will explain the steps you must follow to determine whether you are eligible.  If so, you will enter that information on Form 8965 and include it when you file your income tax return.

There are several other exemptions from the individual responsibility penalty that you may qualify for.

https://www.irs.gov/pub/irs-pdf/f8965.pdf

When you file your return for this tax year (usually people do this next spring), there will be a space for you to indicate that you had health insurance coverage for the full year.

If you did not have health coverage for the entire year, there will be directions to help you calculate the tax penalty or to indicate that you owe no penalty if you qualify for an exemption.

Starting in 2015, large employers must offer health insurance to their full time workers or pay a penalty.  These employers also must provide their employees with Form 1095-C to document that health coverage was offered.   Every employee of a large employer who was eligible for health coverage in 2015 should receive a form 1095-C in January of 2016.  Even if you declined to sign up for your health plan at work, you will still receive a form 1095-C.  Information on this form will also be reported to the IRS.

Form 1095-C will indicate your name and the name of your large employer, the months during 2015 when you were eligible for coverage, and the cost to you of the cheapest monthly premium you could have enrolled in under your employer’s health plan. If you worked for a large employer that did not offer its full time employees health coverage, Form 1095-C will also indicate that..

Keep this form with your tax records.  You may need this form if you were offered health coverage by your employer and you did not sign up for it.  If you signed up for Marketplace coverage instead and received a premium tax credit, information on Form 1095-C will help you determine whether you were eligible for the tax credit (for example, if the cost of your employer health plan was more than 9.56% of your income.)  If you signed up for Marketplace coverage and received a premium tax credit, and if your employer offered you coverage that is determined to be affordable, you may have to repay some or all of the tax credit you received.  If you were uninsured in 2015 even though your employer offered you health coverage that year, you may be eligible for an exemption from the tax penalty if the cost of your employer health plan was more than 9.56 percent of your income.

https://www.irs.gov/pub/irs-prior/f1095c–2015.pdf

Help Paying Private Health Insurance Premiums

Yes.  If you are married but unable to file a joint return because of domestic abuse, you can file as married-filing-separately and claim the premium tax credit.  Similarly, if you cannot file a join return because you are unable to locate your spouse due to spousal abandonment, you can file as married-filing-separately and claim the premium tax credit.

In either instance, you will need to check the “Relief” box in the top right-hand corner of Form 8962 and file that with your tax return.  You are not required to submit documentation of the abuse or abandonment with your tax return, but should keep any documentation for your records.

Special rules apply for women in this situation, depending on where they live. In general, Medicaid is considered to be “minimum essential coverage,” and you are not eligible for premium tax credits when you are eligible for other minimum essential coverage. However, States have the option of limiting Medicaid covered benefits just to pregnancy-related services for women who are eligible for Medicaid because they are pregnant. In states that elect to limit coverage in this way, Medicaid coverage for pregnant women is not considered “minimum essential coverage.”

If you are pregnant and eligible for limited Medicaid coverage, you don’t have to drop your Marketplace coverage. You remain eligible for Marketplace coverage and subsidies and if you stay enrolled, you would not have to pay back the advance payments you receive while you are pregnant.

If you do decide to enroll in limited Medicaid coverage for pregnant women, at least in 2015, you will not be subject to a penalty for not having coverage even though the pregnant women coverage is not considered minimum essential coverage.

Finally, you may be able to enroll in both programs. The right choice for a woman who becomes pregnant while enrolled in a Marketplace plan will depend on a number of factors: whether her health care providers participate in both Medicaid and Marketplace coverage, the relative costs of Marketplace and Medicaid coverage, which will depend at least in part whether other members of her family are enrolled, and whether she wants her baby to be automatically enrolled in Medicaid at birth. (When a pregnant woman covered by Medicaid gives birth, her baby is automatically eligible for Medicaid for one year, until his/her first birthday.)

You can all enroll in the same family plan, and your daughter can apply her premium tax credit to reduce her share of the premium for that family plan, but your daughter would lose her eligibility for cost-sharing reductions.

If two individuals (or two separate households) qualify for different levels of cost-sharing assistance, or if one qualifies and the other doesn’t, and if they want to be covered under the same plan, they must select a plan that provides the level of cost-sharing reduction that they all would qualify for.

In this case, since you do not qualify for any help with cost sharing, the three of you could only enroll together in a plan without cost sharing subsidies.

Yes. The Marketplace will allocate the monthly advance payment across the two plans. In most cases the Marketplace will allocate the monthly advance payment in proportion to the premiums for the two plans.

Yes. Although the general rule is that people are not eligible for Marketplace subsidies when they are also eligible for affordable job-based health coverage, there is a special rule for young adults. As long as a young adult is not claimed as a tax dependent by her parents, the availability of dependent coverage under her parents’ health plan does not affect her eligibility for premium tax credits in the Marketplace.

Because you are not married, you will be considered two separate households for the purposes of determining eligibility for premium tax credits and Medicaid.

Assuming that neither of you are claiming any dependents on your tax returns, you will each be considered as a household of one and your own income will be used to determine eligibility for premium tax credits and Medicaid as well as the amount of any premium tax credit and cost-sharing reduction you may qualify for.

If you are eligible for premium tax credits, you will each receive a separate determination of the amount of your credit and whether you are eligible for a cost-sharing reduction. Whether you can use your credits to buy a family policy rather than two individual policies will depend on the offerings in your state Marketplace.

If an applicant did not file taxes in a prior year, income will be verified by the Marketplace through use of electronic wage data. If the information cannot be verified electronically, the applicant may be asked to submit additional paper documentation within 90 days, such as pay stubs, a work contract or other verification of income.

One challenge a young adult may face in her first year of independent tax filing is verifying income, since one of the prime sources of income data is a prior year tax return. However, other methods of verification are available; for instance, the Marketplace will have access to monthly wage data that can verify current income.

In the case of someone who is self-employed or who has fluctuating income, additional documentation of income may be accepted.

The fact that a young adult has not filed in the past will not prevent her from receiving premium tax credits.  When she applies, if the Marketplace cannot verify her income right away, she will receive a provisional (temporary) eligibility determination based on the income information she puts in her application.

The Marketplace will then give her a period of time (usually 90 days) to provide additional documentation of income.  Current pay stubs, bank deposit records, or other documentation may be appropriate, depending on her situation.

You should file your federal income tax return for 2014 as soon as possible.  Then log into your Marketplace account, update your application information, and tell the Marketplace that you have filed your taxes by attesting to that question on the application.

Immigrants

Hospitals are required to provide emergency care and treatment to all individuals regardless of immigration or insurance status, though afterwards they can bill for their services. In addition, individuals may get low-cost care at community health centers.

Individuals may purchase health coverage through an employer or a spouse’s employer or the individual insurance market outside of the Marketplace. Some states and counties also offer health programs for immigrants.

Some undocumented youth have been given temporary permission to stay in the United States under a program called Deferred Action for Childhood Arrivals. These individuals are lawfully present in the United States and can be granted work authorization and Social Security numbers. However, they are not eligible for Medicaid, CHIP, or the Marketplaces.

Lawfully present immigrants generally include:

  • lawful permanent residents (or “green card holders”);
  • persons fleeing persecution, including refugees and asylees;
  • other humanitarian immigrants, including those granted temporary protected status;
  • Cuban/Haitian entrants; and survivors of domestic violence, trafficking, and other serious crimes.

Most immigrants who are residents lawfully present in the U.S., including “green card holders,” must have health insurance coverage or they will pay a tax penalty unless they qualify for an exemption. 

Check with your Marketplace for more information about how the requirement applies to you, or if you want to apply for an exemption.

Immigrants who are not lawfully present in the U.S. will not pay a tax penalty if they do not have health insurance.

Medicaid, CHIP, and the Marketplaces must protect individuals’ information and keep it private. Information can be used only for eligibility and enrollment purposes.

In general, getting health insurance through Medicaid, CHIP, or the Marketplaces will not prevent an individual from obtaining lawful permanent resident status (get a green card) or citizenship.

Only those individuals in a family who are applying for health insurance are required to provide citizenship and immigration status. Applicants also must provide a Social Security Number if they have one.

Citizenship and immigration status for those applying for health insurance will be checked electronically with several systems, including the Social Security Administration, the Department of Homeland Security, and SAVE (Systematic Alien Verification for Entitlements).

If an individual’s status cannot be checked through an electronic match, the individual can give other documentation of his or her status.

Citizen and lawfully present family members can get health insurance coverage through Medicaid, CHIP, and Marketplaces even if other family members are not lawfully present.

Family members who are not lawfully present, including undocumented immigrants, may apply for health insurance for citizen and lawfully present family members. For example, an undocumented immigrant parent may apply for health insurance for a citizen child.

When a family with mixed immigration status applies for health insurance, it only has to give citizenship and immigration status for those family members applying for coverage.

Non-applicants, such as a parent applying for a child, do not have to provide citizenship or immigration status. Non-applicants will be asked to provide a Social Security Number, but do not have to provide one unless the family is applying for help with costs for Marketplace coverage and the individual is the tax-filer for the household, and the individual has a SSN.

Lawfully present immigrants can get tax credits to help pay premiums and cost-sharing for health insurance through the Marketplaces.

Like citizens, they can get tax credits to help pay premiums if they make between 100% and 400% of the federal poverty level.

Lawfully-present immigrants who make less than 100% of the federal poverty level also can get help paying premiums and cost sharing if they cannot enroll in Medicaid. Many lawfully-present immigrants cannot enroll in Medicaid until they have been in the United States for five or more years.

Undocumented immigrants cannot receive help paying for premiums or cost sharing for Marketplace coverage and may not buy health insurance through the Marketplaces even at full cost.

Individual Mandate

No. A special exemption for low income individuals who reside in states that did not expand Medicaid can now be claimed directly on the federal income tax return.  You are eligible to claim this hardship exemption for the calendar year if, at any time during that year, you resided in a state that did not expand Medicaid coverage and if your income for that year was below 138 percent of the federal poverty level.

You can also apply separately to the Marketplace for an exemption certificate to qualify for this hardship exemption, though claiming the exemption directly on your tax return may be simpler.

No, you can apply to the Marketplace for a hardship exemption at any time during the year.  Most hardship exemptions will be granted for the month before the hardship, the months of the hardship, and the month after the hardship. You will need to document the timing of the hardship in your application.

For people ineligible for Medicaid only because their state hasn’t expanded Medicaid eligibility, the hardship exemption will be granted for the entire calendar year.  You can claim this exemption directly on your tax return; you are not required to apply for the exemption from the Marketplace.

However, if you do apply for this type of hardship exemption from the Marketplace, you will also have to apply for Medicaid coverage and be denied, then submit the Medicaid denial to the Marketplace with your hardship exemption application.

For some types of exemptions, you must apply through the health insurance Marketplace; for other types, you must apply when you file your taxes; some types of exemptions can be claimed either way

If you did not maintain minimum essential coverage every month of this year and you don’t qualify for an exemption you will need to pay a “shared responsibility payment” to the IRS on your federal income tax return. If you are like most people, you will need to file your tax return by April 15 next year.

Starting in 2015, health insurance companies, employer-sponsored health plans, and public health programs such as Medicaid are required to provide you with documentation of coverage.

In 2016, you should receive a form 1095-B from your health plan or insurance company indicating the months in 2015 when you were covered under the plan.  If you were enrolled in family coverage, Form 1095-B will indicate the names of all family members who were covered with you under the plan. (If you worked for a large employer, with more than 50 employees, you might receive a Form 1095-C instead of or in addition to the Form 1095-B.) A copy of this form will also be reported to the Internal Revenue Service.

If you were covered by more than one plan during the year, you should receive a Form 1095-B (or 1095-C) from each plan.  When you file your tax return for this calendar year (most people will do this by April 15 next year) you will have to enter information about your coverage (or your exemption) on the return.

If you are a resident of a foreign country for the full calendar year, you will not have to pay a tax penalty, even if you don’t have minimum essential coverage.

No, if you are covered even one day during a month, you are considered to be insured for that month.

Similarly, a person who is considered exempt from the individual responsibility requirement for even one day during a month is considered exempt for that month.

The rule for short coverage gaps is that only the first short coverage gap in a year will be recognized. You wouldn’t be penalized for lacking coverage in March, but you may owe a penalty for your second gap in coverage in August if you don’t otherwise qualify for an exemption during that period.

People may apply for a hardship exemption if they have experienced difficult financial or domestic circumstances that prevent them from obtaining coverage – such as homelessness, death of a close family member, bankruptcy, substantial recent medical debt, or disasters that substantially damage a person’s property.

In addition, a hardship exemption may be granted to people who were determined ineligible for Medicaid only because their state hasn’t expanded Medicaid coverage to residents with income up to 138% of the federal poverty level.

(Note, most hardship exemptions must be obtained by applying directly to the Marketplace.  However, the exemption for low income persons living in states that have not expanded Medicaid can also be claimed directly on the tax return.)

Marketplace Eligibility, Enrollment Periods, Plans and Premiums

Each health insurance Marketplace can decide whether to require all insurers to cover pediatric dental benefits or whether to allow the sale of stand-alone dental policies. When stand-alone dental policies are allowed, health insurers in the Marketplace might not be required to cover pediatric dental benefits.

If your health plan covers dental benefits, you will pay one premium for everything. If you get dental benefits through a stand-alone plan, you will have to pay a separate premium for the dental benefits.

Under the health care law, dental insurance is treated differently for adults and children 18 and under.

Dental coverage for children is an essential health benefit. This means it must be available to you, either as a covered benefit under your health plan or as a free-standing plan. This is not the case for adults. Insurers don’t have to offer adult dental coverage.

Health plans in the Marketplace must include a link to their prescription drug “formulary” with other on-line information about the plan. The “formulary” is a list of prescription drugs the plan will cover.

If you don’t find your drug on the formulary but your doctor says it’s medically necessary for you to take that specific drug, you can appeal for an exception to the plan formulary.

Plans are not required to cover any care received from a non-network provider, though many plans today do, at least to some extent. If you do receive care out of network, it could be costly to you.

It is very important to understand the difference between network provider benefits versus non-network provider benefits, which will be explained in the “Summary of Benefits Coverage.”

When you get care out of network, the benefits may be applied to a separate deductible and a separate out-of-pocket maximum.

Each plan sold in the Marketplace must provide a link on the Marketplace web site to its health provider directory so consumers can find out if their health providers are included.

The provider network information that insurance companies provide may or may not tell you whether a provider is accepting new patients, or whether a provider speaks your language.

Please double-check with your Doctor to see if they accept Marketplace Health Plans as we have been hearing stories of Doctor’s turning down their patients who have gotten Marketplace Health Plans.

Catastrophic plans are only for adults up to age 30, and for older people who can’t find any other Marketplace policy that costs less than 8.13 percent of their income.

The plans will have an annual deductible of $6,850 ($13,700 in family plans). You will have to pay the entire cost of covered services (other than preventive care) until you’ve spent $6,850 out of pocket; after that your plan will pay 100 percent of covered services for the rest of the year.

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.

  • 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
  • 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.

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.  You can compare the different plans offered on the Marketplace by going to the designated Marketplace of your state.

These essential health benefits include at least the following items and services:

  1. Outpatient care—the kind you get without being admitted to a hospital
  2. Trips to the emergency room
  3. Treatment in the hospital for inpatient care
  4. Care before and after your baby is born
  5. Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy
  6. Your prescription drugs
  7. Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
  8. Your lab tests
  9. Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease.
  10. Pediatric services: This includes dental care and vision care for kids

 

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
  • Hospitalization
  • 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.

Marketplace Verification and Appeals

That’s not advisable. The Marketplace will check the information you provide against a number of databases (including IRS data, Social Security data, wage databases, and others).

If the information you provide is very different from what’s in these databases, you may be asked to provide additional documentation. In addition, at the end of the Application for Health Coverage and Help Paying Costs, you will have to sign that you have provided true answers to all questions to the best of your ability. Knowingly providing untrue information is against the law and could even result in civil money fines.

The required documentation will depend on the type of hardship you experienced.

For example, if you seek a hardship exemption because you are ineligible for Medicaid due solely to your state’s decision to not expand Medicaid eligibility, you will need to apply for Medicaid coverage and be turned down, and then include that Medicaid denial with your exemption application.

If your hardship involves being unable to afford other medical bills during the past two years, the Marketplace will ask to see copies of those bills. If your hardship involves the death of a family member, the Marketplace will ask to see a copy of the death certificate or newspaper death notice. When you request an exemption from the Marketplace, the application will describe the type of documentation you should provide.

You may be asked for additional information about your projected income. The Marketplace will compare your estimated income to other available data on your most recent income (for example, with tax return data.)

If you estimate your annual income will be substantially less than you earned in previous years the Marketplace will ask you to provide documentation to support your estimate. This may include a letter from your employer, a pay stub from your new job or other documents. In some cases, just explaining your changed circumstances may be enough.

Your employer is not required to fill out the form that asks about affordability of your job-based health plan. If for any reason you cannot obtain this information from your employer, you should report to the Marketplace what you know, yourself, about your eligibility for employer sponsored coverage, the cost of that coverage, and whether it meets minimum value.

The Marketplace may try to follow up with your employer and collect or verify this information. The Marketplace will determine your eligibility for subsidies based on the information you provided or based on any information the Marketplace was able to obtain on its own through other follow up with your employer.

Although employers aren’t required to provide you this information up front, most are expected to do so.  And starting in 2015, all employers will be required to provide you with this information at year end.  In 2016, your employer will be required to provide you with a Form 1095-C that indicates whether health benefits they offered to you in 2015 meet the requirements for affordability and minimum value.

https://www.irs.gov/pub/irs-prior/f1095c–2015.pdf

This will depend on the reason for your appeal and the documentation needed to decide your appeal.

Contact the Marketplace for more information about your appeal.

You can request an appeal of any Marketplace decision, including decisions about

  • Your eligibility to buy coverage in the Marketplace
  • Your eligibility for, or the amount of, premium tax credits or cost sharing reductions
  • Your eligibility for an exemption from the penalty for not having health insurance
  • Untimely (late) notice from the Marketplace about a decision

To make your appeal, start by reviewing the Marketplace’s decision. You will have received the decision (called a determination notice) online if you initially applied online, or in the mail if you submitted a paper application. So far, in the federal Marketplace, the notice will not provide much detail to explain the reasons for the decision, but it will describe the process you should follow if you want to appeal. To request an appeal in federal Marketplace states, you’ll have to submit the appeal in writing.  You can write a letter or use appeal forms available on healthcare.gov.  Your written appeal should provide your name and contact information and an explanation of what you are appealing and why.

You can submit documents to the Marketplace that support your case. You can submit documents along with your initial appeal request or at any time during the appeal process, up until a hearing.

The Marketplace may offer you the option of receiving temporary benefits while your appeal is pending. You can accept the temporary benefits or waive them. If you accept temporary benefits during the appeals process and then lose your appeal, you might have to pay back the benefits you weren’t eligible for.

The Marketplace will review your completed appeal once it is submitted. Then the Marketplace will let you know its decision.  If you still disagree with the decision, you can request a hearing. While you are waiting for the hearing to take place, the Marketplace may contact you to try to resolve the dispute informally.

You can appeal the Marketplace’s decision to reduce your tax credit.  Information on how to appeal will be included on the final determination notice.  If your appeal is successful, your tax credit will be restored retroactively.

Generally, if the Marketplace hasn’t received the requested information within 90 days and you didn’t already ask for an extension, the Marketplace can cancel your premium tax credits.

If the Marketplace requires you to provide information, we highly suggest supplying the documentation to them to continue your premium tax credits.

Medicare

Yes, if you are not covered by Medicare, an insurer can sell you a Marketplace plan. But because you are eligible for premium-free Medicare Part A, you are not eligible to receive the premium tax credit to help reduce the cost of a Marketplace policy, even if you would qualify based on your income.

To learn more about your coverage options under Medicare, including the Medicare Advantage plans, Part D prescription drug plans, and Medigap supplemental policies available in your area, and how to enroll, you can go to the Medicare Plan Finder on www.Medicare.gov or call 1-800-MEDICARE.  You can also contact the State Health Insurance Assistance Program in your state or the Social Security Administration.  Medicare provides links and phone numbers for these and other organizations at the following website: http://www.medicare.gov/contacts/.  Information about Medicare Advantage plans, Part D drug plans, and Medigap policies is not available through the federal or state Marketplaces.

No, companies that sell Marketplace plans are prohibited from selling these plans to you if they know you are covered by Medicare.  If you do not live in a state that requires insurance companies to sell Medigap policies to people under age 65, some insurance companies still may voluntarily sell Medigap policies to people under 65, although they will probably cost you more than Medigap policies sold to people over 65,  If you want prescription drug coverage to supplement your Medicare Part A and Part B benefits, you can purchase a Part D prescription drug plan.  You can also look into receiving your Medicare-covered benefits through a Medicare Advantage private plan, such as an HMO or PPO.  Medicare Advantage plans are not allowed to turn down people with Medicare based on your health status or having a pre-existing condition, but access to providers is generally more limited than in traditional Medicare.
Keep in mind that when you turn 65 and are enrolled in Part B, you will get a six-month opportunity to enroll in any Medigap policy you want.

Possibly, depending on the type of doctor you see and the type of care you receive.  The law increased by 10% the payments that Medicare gives to primary care providers, including primary care doctors, nurse practitioners, and physician assistants, for all primary care services that they provide to people with Medicare.  For example, if you go to see your primary care doctor for an office visit because you have a cold, your doctor will get paid 10% more for that office visit.  The law also increased by 10% the payments that Medicare gives to general surgeons who practice in areas that are underserved, such as rural and low-income communities, for major surgical procedures that they perform on people with Medicare.  These additional payments from Medicare started in 2011 and are scheduled to end in 2015, although Congress could decide to continue them beyond 2015.

Until recently, there was a formula that determined how Medicare paid doctors overall.  Obamacare did not make any changes to that formula, but it was replaced by a 2015 law (the Medicare Access and CHIP Reauthorization Act) with a new method for determining how Medicare pays physicians; this new method will be used in the coming years.

Yes, the law did make some changes to the Medicare Advantage program.  This program is an alternative to traditional Medicare, where people on Medicare can choose to enroll in a private plan, such as an HMO or PPO, to receive your Medicare-covered benefits.  The law reduced payments to these plans to bring them closer to the average costs of traditional Medicare.  The law also provided additional payments to plans that earn high quality ratings.  Whether the plan that you are enrolled in will respond to these payment changes will depend on several factors, but rest assured that your plan is still required to provide all benefits that are covered by traditional Medicare.  But your plan might charge higher premiums, increase the cost-sharing amounts that you pay for services, reduce the number of providers in the plan’s network, or reduce additional benefits that the plan might cover, such as dental exams or eyeglasses.

The law also included protections for people enrolled in Medicare Advantage plans.  Plans are limited in how much cost sharing they can charge enrollees for certain services, and there are limits on how much plans can spend on administrative expenses and profits.

To learn more about how your Medicare Advantage plan’s coverage might be changing, as well as your other coverage options under Medicare, including all of the Medicare Advantage plans, Part D drug plans, and Medigap supplemental policies available in your area, you can go to the Medicare Plan Finder on www.Medicare.gov or call 1-800-MEDICARE.

Yes, the law included changes that could save you money if you have very high prescription drug costs.  If you are enrolled in a Medicare Part D plan and you have very high drug costs, the law is helping to reduce the costs you pay when you reach a gap in coverage that is sometimes referred to as the “doughnut hole.”  This gap in coverage is being phased out between now and 2020.  If your total drug costs are more than $3,310 in 2016, after that point you will pay 45% of the cost of your brand-name drugs and 58% of the cost of your generic drugs.  These amounts are gradually being lowered to 25% for both brand-name and generic drugs by 2020.

The law also included a new requirement that people on Medicare with higher incomes pay a higher premium for Part D coverage.  These higher premiums are paid by single beneficiaries enrolled in Part D plans with incomes greater than $85,000 and married couples with incomes greater than $170,000.

When you turn 65, you should sign up for Medicare and notify your Marketplace plan that you now qualify for Medicare coverage.  Your Marketplace coverage will not be cancelled automatically by your plan when you turn 65 and sign up for Medicare, but if you receive premium tax credits to help you pay for your Marketplace plan premium, your eligibility for these tax credits will end when your Medicare Part A coverage starts (people with Medicare are not eligible for these tax credits, and the premium tax credit can only be used for the purchase of Marketplace coverage, not Medicare).  If you choose to keep both Medicare and Marketplace coverage, you will have to pay the full price for your Marketplace plan, and Medicare will be the primary payer.

If you decide to drop your Marketplace coverage when you become eligible for Medicare, make sure your Medicare coverage has started before you cancel your Marketplace plan so that you avoid any gaps in coverage.  You can start signing up for Medicare three months before your 65th birthday.

Yes, in general, people age 65 or older who are not entitled to premium-free Medicare can purchase health insurance coverage in the Marketplace (except undocumented immigrants).  If you sign up for a Marketplace plan, you will be eligible for premium tax credits to make the coverage in the Marketplace more affordable if your income is between 100% and 400% of the federal poverty level (about $11,800 to $47,000 for an individual in 2016).

Keep in mind that if you are able to continue working, you may be able to earn enough work history to qualify for premium-free Medicare in the future.  So another option for you to consider would be to sign up for Part A and Part B coverage when you turn 65 (you will have to pay a premium for both Part A and for Part B), and when you become eligible for premium-free Part A through your work history, you will then only have to pay a premium for Part B.

It doesn’t.  You can keep your employer-sponsored health insurance coverage as long as that is an option for you.  Since you are already eligible for Medicare because you are over age 65, you should sign up for Medicare when you stop working or if you lose your employer coverage before then.  Once you decide when you want to stop working, you should contact the Social Security Administration about how and when to enroll in Medicare to be sure you don’t have a gap in coverage.

No.  Medicare doesn’t offer spouse or dependent coverage.  Although your husband now qualifies for Medicare, you do not qualify yet because you are younger than age 65.  If you do not have health insurance now, you can consider signing up for health insurance coverage through a Marketplace plan.

If your household income is less than 400% of the federal poverty level, you may qualify for premium tax credits to reduce your cost of a Marketplace policy.  If your household income is at or below 138% of poverty (about $16,200 for an individual in 2016), you might be eligible for Medicaid if you live in a state that has expanded its Medicaid program.

Minimum Essential Coverage

As the name implies, a short-term health insurance policy offers coverage for a period of less than 12 months (e.g., many offer coverage for just 6 months) and are renewable at the option of the insurance company.

Though you may be given an opportunity to request to renew the policy, if you’ve made claims since you bought it, the insurer can refuse to renew it. This is also called a non-guaranteed-renewable policy.

Short-term policies are not considered minimum essential coverage. Insurance companies that sell such policies are required to notify you that they do not constitute minimum essential coverage.

Grandfathered plans are those that were in existence on March 23, 2010 and have stayed basically the same. If you buy coverage on your own and you first purchased your policy prior to March 23, 2010, it may be a grandfathered plan.

A grandfathered group plan also must have been first established prior to March 23, 2010. To retain grandfather status, the group plan cannot be significantly changed (that is, the employer can’t significantly change covered benefits or cost sharing or the share of the plan premium that you are required to contribute.) Because employer plans tend to change from year to year, most have already lost grandfather status or will lose it over time.

Employers with grandfathered group health plans are allowed to enroll new employees in the grandfathered plan. So even if you first joined a group health plan after March 23, 2010, you should ask about its grandfathered status. Your employer or your insurer must let you know if your health plan is grandfathered.

No. Some types of coverage do not qualify as minimum essential coverage. These include hospital indemnity policies (that pay a fixed dollar amount per day when you are hospitalized), discount plans, short-term nonrenewable policies, or plans that provide coverage only for a specific disease (i.e., cancer-only policies).

Companies that sell these products, also called “excepted benefits,” are required to notify you if they don’t qualify as minimum essential coverage.

If you receive such a notice, and don’t obtain other coverage that is minimum essential coverage, you may have to pay a tax penalty.

All health insurers and employer-sponsored group health plans must provide people with a Summary of Benefits and Coverage, which uses a standard format to outline the benefits, cost-sharing and coverage limits of plans.

The Summary of Benefits and Coverage must also say whether the plan meets minimum value and counts as minimum essential coverage.

Most people with health coverage today have a plan that will count as minimum essential coverage. The following types of health coverage count as minimum essential coverage:

  • Employer-sponsored group health plans
  • Union plans
  • COBRA coverage
  • Retiree health plans
  • Non-group health insurance that you buy on your own, for example, through the health insurance Marketplace
  • Student health insurance plans
  • Grandfathered health plans
  • Medicare
  • Medicaid
  • The Children’s Health Insurance Program (CHIP)
  • TRICARE (military health coverage)
  • Veterans’ health care programs
  • Peace Corps Volunteer plans

Be aware that outside of the Marketplace, other policies be for sale that may look like health insurance (such as short term individual policies, or policies that only cover cancer.) These kinds of products are sometimes referred to as “excepted benefits.” They do not count as Minimum Essential Coverage.

Non-traditional Households

The Affordable Care Act (ACA) and other new federal policies put in place important new protections for LGBT individuals and their families.

Health insurance Marketplaces, which are organizations set up in every state to create more organized and competitive markets for buying coverage, are prohibited from discriminating on the basis of sexual orientation and gender identity. You cannot be turned away or charged more for being lesbian, gay, bisexual, or transgendered. You also can’t be denied coverage or charged more because of any pre-existing health condition, such as your HIV status.  Insurers can’t limit how much they’ll spend on your medical care – over a year or over a lifetime.

Under the ACA, these protections extend to the health benefits provided in the Marketplace plans, which cannot discriminate based on sexual orientation, gender identity, or health status in how they design their essential health benefits.

In addition to these Marketplace protections, the ACA prohibits discrimination based on gender identity in all health programs that receive federal funding, such as Medicaid and Medicare, among other programs.

There are also other new federal policies designed to protect you and your family.  Hospitals must now allow visitation by a same-sex partner (whether or not you are married) and same-sex partners must be afforded the same treatment as other spouses for long-term care, such as nursing home care under Medicaid.  In addition, same-sex couples (whether or not you are married) now have the same rights as others to name a representative to make medical decisions on a patient’s behalf.

Recent Supreme Court Rulings and What They Mean for Your Insurance Options if you are Legally Married to a Same-Sex Partner:

Beyond the new protections under the ACA, the Supreme Court’s June 2013 ruling (overturning part of the Defense of Marriage Act (DOMA) in United States v. Windsor) and subsequent June 2015 ruling (in Obergefell v. Hodges that same-sex couples have the right to marry in the United States) mean that same-sex marriages are now recognized under federal and state law.  This has implications for the new health care Marketplaces as well as for Medicaid and CHIP, Medicare, and coverage through your employer:

Health Care Marketplace: Because of the DOMA decision, legally married same-sex couples can apply jointly for tax credits in the Marketplace.  These tax credits help you pay the costs of your health plan.  Tax credits are calculated based on your federal income tax filing, so marketplaces must recognize same-sex marriages and base eligibility on a married couple’s income.  In fact, legally married couples, including same-sex couples, must file a joint tax return to gain access to these tax credits. If you are not legally married – if you are in a domestic partnership, a civil union, or another relationship –you’ll may still be able to get these credits but will need to apply for them as two individuals instead of as a couple; depending on your state Marketplace, you may be able to use your individual credits to buy a family policy rather than two individual policies.

 Medicaid and CHIP: Because of the Obergefell decision, all states now must recognize same-sex marriages when determining whether or not you meet your state’s income eligibility requirement for Medicaid and CHIP.

 Medicare: If you are legally married to your same-sex partner, you may now qualify for Medicare coverage depending on your spouse’s work history.

Health coverage through an employer: Because of the Windsor and Obergefell decisions, all federal employees, federal contractors, members of the military, veterans, and state employees who are legally married to a same-sex partner may now obtain spousal health benefits for their partner. In addition, all health insurance issuers who offer coverage to opposite-sex spouses must also offer coverage to same-sex spouses.  However, there remains some question about whether private employers can legally limit spousal coverage to opposite-sex spouses only, many experts believe that an employer who does so would likely found to be in violation of federal Civil Rights law.

Department of Veterans Affairs:  The VA now recognizes all same-sex marriages and will extend benefits to all same-sex spouses of Veterans, including CHAMPVA health coverage, survivor compensation, and burial benefits

The rules for premium tax credit eligibility will be the same in all states; however the type of policy you can buy will depend on where you live.

Because you are not married, you will be considered two separate households for the purposes of determining eligibility for premium tax credits and Medicaid. Assuming that neither of you are claiming any dependents on your tax returns, you will each be considered as a household of one and your own income will be used to determine eligibility for premium tax credits and Medicaid as well as the amount of any premium tax credit and cost-sharing reduction you may qualify for.

If you are eligible for premium tax credits, you will each receive a separate determination of the amount of your credit and whether you are eligible for a cost-sharing reduction. Whether you can use your credits to buy a family policy rather than two individual policies will depend on the offerings in your state Marketplace.

Assuming you are eligible for premium tax credits, the amount of your credit will be calculated based on how you file your taxes. If for example, you each claim one of your children, you each will be considered as a household of two. The income of each household would be evaluated separately to calculate eligibility for and the amount of premium tax credits and cost-sharing reductions.  

Using a different example, if you claim both children as dependents on your tax return, then you and your children will be considered a household of 3, your income will be the basis for determining subsidy eligibility for the 3 of you. Your partner will be a household of one and his/her eligibility for premium tax credits will be determined separately.

As for the type of coverage your family can purchase, that may vary based on the Marketplace rules where you live. For example, some insurers may offer family coverage only to married couples. If you buy one policy for the entire family, all the tax credits you are eligible for can be used to reduce the premium for that policy. If you buy separate policies, you can allocate the premium tax credits across two plans.

Renewing Marketplace Coverage for 2016

No.  When you go back to the Marketplace you will need to do both.  In federal Marketplace states, healthcare.gov will show you the information you entered last year when you applied for financial assistance. 

If nothing has changed, you will be able to indicate that on the website.  The Marketplace will then provide you with an updated eligibility decision, and then you can continue to select a new plan for next year.

No. When you re-apply for financial assistance, the Marketplace will determine the new amount of your financial assistance, and then you will need to re-select your current plan in order for the updated premium tax credit amount to be applied to your premium next year.

If you want the new premium tax credit to take effect on January 1, you will have to update your application for financial assistance on or before December 15.

Both notices should indicate the plan you are currently enrolled in and the names of any family members who are enrolled in your plan.  If the notices don’t match, that suggests there is a discrepancy in the enrollment information that the Marketplace and your health plan have.  You should contact the Marketplace and your health plan as soon as possible to verify your correct and up-to-date enrollment information.

If you received APTC in 2014, you must have filed a 2014 income tax return and reconciled your tax credit amount this year in order to continue receiving APTC next year.  Remember, the advanced premium tax credit you received in 2014 was based on your estimated income for that year.  The law requires you to file a tax return at year end and reconcile your estimated income with your actual income.

If you had under-estimated your 2014 income, you might have repay some of the 2014 APTC that you received.  If you had over-estimated your 2014 income, you could claim additional tax credit when you filed your return.  Either way, the IRS requires this annual reconciliation and people who fail to reconcile the APTC they received last year will not be allowed to continue receiving advanced premium tax credits next year.

To continue receiving APTC in 2016, if you haven’t yet filed a 2014 return with a completed Form 8962, you should do so as soon as possible.  To do this, you will also need Form 1095-A, which should have been sent to you by the Marketplace in January with information about your 2014 APTC.  If you don’t have form 1095-A, you should call your Marketplace Call Center to obtain a copy; or if you live in a federal Marketplace state, you can log into your account on HealthCare.gov and find it there.

As soon as you file your 2014 tax return and completed Form 8962, contact the Marketplace to update your account to reflect this change.  If you are in a federal Marketplace state, starting on November 1, 2015, you can log into your Marketplace account on HealthCare.gov and update your application.  Be sure to check the box telling the Marketplace you reconciled your premium tax credits.

Both notices are important and you should read them carefully.  The notice from your health insurer should state whether your current plan is being offered again next year.  If it is, the notice should describe any changes to that plan and the monthly premium for next year. The insurer notice will also advise you that, if you do nothing before December 15, you will automatically be re-enrolled in your current plan for another year.

If your current plan is not being offered again but your insurance company is offering similar plans next year, the notice from your health insurer will explain that your policy is not being continued.  The notice will also describe another similar policy that will be offered next year and advise that if you do nothing before December 15, you will automatically be enrolled in that similar plan for next year.

The notice from the Marketplace will provide additional information about renewing your application for financial assistance.  That notice will let you know whether you are eligible to have your financial assistance automatically adjusted and continued into next year without you having to take any action.  That notice should also remind you to update your application for financial assistance to ensure that your eligibility determination reflects the most current information possible.

It depends on where you live.  In federally run marketplace states, HealthCare.gov will make some automatic adjustments to your financial assistance for next year, but these adjustments will only be approximate.   That’s why it is a good idea for you to update your application for financial assistance.   By applying for an updated eligible determination, you can enter the most up to date information you have about your projected income and family status for the next plan year.

The process may be somewhat different in state-run Marketplaces. You should receive a notice from your state-run Marketplace explaining the process.  Even so, you may want to consider updating your application yourself to be sure your eligibility determination is based on the most current information you can provide.

Yes, in fact there are several reasons.  First, in the federal marketplace, when you first applied for coverage, you had the opportunity to authorize the Marketplace to check online income data about you, including from your tax returns, for another 1 to 5 years.  If you did not authorize this (note that most people did give authorization), your financial assistance will NOT be automatically continued for 2016.  You must re-apply for financial assistance if you want the APTC for 2016.

Second, if you did authorize the Marketplace to check income information about you, it will check the most recently available information, which for most people will be your 2014 federal income tax return.

If the income you reported on your 2014 tax return was more than 500% of the federal poverty level ($58,350 for a single person, $117,750 for a family of 4), your financial assistance will not automatically be continued for 2016.  Instead, to continue receiving an APTC in 2016, you will have to re-apply for financial assistance and provide information about your expected 2016 income.

Third, if you received a premium tax credit in 2014 but then, in 2015, you did not file a 2014 federal income tax return including Form 8962, your financial assistance will NOT be continued for 2016.  You will need to file a 2014 tax return as soon as possible, including a completed IRA Form 8962.  Once you have filed, if you live in a federal Marketplace state, log into your account on HealthCare.gov, update your application, and be sure to check the box telling the Marketplace that you filed a 2014 tax return and reconciled your premium tax credits.

Note that the process for renewing financial assistance may vary in other states.  All state Marketplaces will send consumers notices prior to the start of Open Enrollment explaining the process for continuing or re-applying for financial assistance in 2016.

If you live in a federal Marketplace state and you don’t update your application, in most cases, healthcare.gov will automatically adjust the amount of your 2015 premium tax credit for 2016. 

If that turns out to be less than the amount you’re actually eligible for in 2016, you will have to pay more premium each month than you otherwise would have had to, although you can receive a refund for the rest when you file your 2016 tax return. 

If the automatically adjusted 2015 premium tax credit amount turns out to be more than you are actually eligible for in 2016, you will have to repay all or part of the difference when you file your 2016 tax return.

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 CLRA Group as one of our agents will help 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 2015 premium tax credit for 2016.  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 in 2016.

Updating your application is a good idea because, chances are, the amount of premium tax credit you will be eligible for in 2016 will be at least somewhat different from what you were eligible for last year 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 in 2016 will be as accurate as possible.

Yes.  If you pick a new plan by January 15, coverage under the new plan will take effect on February 1.  If you pick a new plan between January 16 and January 31, coverage under the new plan will take effect March 1.

In order to avoid a gap in coverage, you will have to pay the premium for your current policy until your new coverage takes effect.

Tobacco Surcharge for Premiums

Yes, assuming your coverage is purchased in a state that allows the tobacco surcharge. An insurer can adjust the premiums of health plans sold to small businesses based on the number of workers who use tobacco.

The insurer is not required to lower your premium until you renew your policy the following year.

You would be subject to the tobacco surcharge when you renew your plan the following year.

If you report inaccurate or false information about your tobacco use on an application, an insurer is allowed to retroactively impose the tobacco surcharge to the beginning of the plan year. However, the insurer is not allowed to cancel your coverage because of the false or incorrect information.

No. If the cost of health insurance, taking into account both your premium tax credit and the tobacco surcharge, exceeds 8 percent of your income, you are not subject to the penalty for failure to obtain insurance.

“Tobacco use” means a person has used a tobacco product an average or four or more times per week for the past six months.

The surcharge on tobacco users can only be applied to an individual who can legally purchase a tobacco product in the state. Thus, the surcharge does not generally apply to a person under age 18.

In most states, yes. Generally, an insurer can charge as much as 50% more for a person who uses tobacco products.

States can prohibit insurers from applying a tobacco surcharge or further limit the tobacco penalty and some have done so. (For example, California, Massachusetts, Rhode Island, Vermont and the District of Columbia prohibit tobacco rating for their Marketplace plans.]

If you qualify for premium tax credits to reduce the cost of Marketplace coverage, this tax credit amount will be based on the premium before the tobacco surcharge is applied, which means that a smoker must pay the full cost of the surcharge.

Uneven Incomes

First, you should report your income change to the Marketplace. The Marketplace will determine your new eligibility for premium tax credits, based on your higher income, and adjust the level of subsidy going forward. If you make this adjustment promptly, it’s likely you won’t receive any more advanced premium tax credit during the entire year than you’re eligible for based on your annual income.

As for the new “affordability” of your job-based coverage option, that won’t be taken into account when you file your taxes. As long as the Marketplace determined you were not eligible for affordable job-based coverage when you initially applied for Marketplace coverage and subsidies, that determination will hold for the remainder of the year. The IRS refers to this as a “safe harbor,” and won’t require you to go back and re-compute the affordability of your job-based coverage at year end when you file your taxes.

Yes, even if you don’t earn enough to owe taxes, you must file a tax return in order to receive a premium tax credit.

There is no limit to the number of times a person may report income, family or insurance-eligibility changes to the Marketplace. Changes that are reported by enrollees will be verified by the Marketplace. Then the Marketplace will send you a notice (called a redetermination notice) showing your revised eligibility for premium tax credits and cost-sharing reductions.

People can always ask the Marketplace to provide them with a monthly advance premium credit below the amount the Marketplace determines based on the household’s income if they want to minimize the chance of needing to owe money at the end of the year.

The adjustment will take effect by the first day of the month following the date of the redetermination notice. For example, if an enrollee reports a change in income on June 25 and the Marketplace verifies the change and sends a redetermination notice to the enrollee on July 3, the change will be implemented on August 1.

The adjustment will take effect by the first day of the month following the date of the redetermination notice.

For example, if an enrollee reports a change in income on June 25 and the Marketplace verifies the change and sends a redetermination notice to the enrollee on July 3, the change will be implemented on August 1.

Yes, you can make adjustments during the year whenever you need to. There is no limit to the number of times a person may report income, family or insurance-eligibility changes to the Marketplace.

Changes that are reported by enrollees will be verified by the Marketplace. Then the Marketplace will send you a notice (called a redetermination notice) showing your revised eligibility for premium tax credits and cost-sharing reductions.

People can always ask the Marketplace to provide them with a monthly advance premium credit below the amount the Marketplace determines based on the household’s income if they want to minimize the chance of owing money at the end of the year.

It’s common for income to fluctuate, particularly if you are self-employed, perform seasonal work or have multiple jobs. To achieve the most accurate premium tax credit amount, you should report income changes to the health insurance Marketplace during the year, as they happen.

If you claim a premium tax credit during the year and your actual income for the entire year edges over 400% FPL, you will need to pay back the full credit amount. To avoid this result, if you estimate your annual income will be close to 400% FPL, you could also consider waiting until you file your taxes to take all or a portion of the premium tax credit on your tax return instead of receiving advance payments.

Unfortunately, in most states so far, the data match inconsistency notices are not very specific in describing the additional documentation that is required.  Instead, notices list generic types of types of income documentation without specifying the documentation appropriate for you.

If you are self-employed and estimate your income next year will be significantly less than what you reported on your most recent tax return, you should provide copies of any documents that support your estimate.  Make sure to provide copies and not original documents.  If you don’t have documents, a signed statement explaining your estimate may be accepted.  Be sure to include your name and ID number, a description of the income you expect to earn next year, a description of how you arrived at your estimated income amount, and an explanation of why other documentation is not available.

In reviewing your application, the Marketplace will compare the amount of income you estimate for next year to the most recent information about your income that is available (usually, that will be the tax return you filed this year reporting last year’s income.)

If that amount is more than 10% different from the amount you put on your application, you might receive a data match inconsistency notice from the Marketplace and you’ll need to provide more documentation.

In cases of an income data match inconsistency, the Marketplace will ask you to provide documentation within 90 days.  During that period, you can get premium tax credits based on the income you attested to in your application.

However, if you have not resolved the data match inconsistency within 90 days, the Marketplace will adjust or end your advance premium tax credit based on the most recent income information it can find.

Women's Health

In general, Medicaid coverage for abortion is very limited. In most states, Medicaid covers abortions only when the pregnancy is the result of rape or incest or if the woman’s life is endangered because federal law limits the use of federal funds to these circumstances.

However,  17 states do go beyond this limit and use state funds to cover other abortions.

It depends on where you live and the specific plan you choose. Some states allow plans in the Marketplace to cover all abortions and some states prohibit or limit plans’ coverage of abortion to certain cases.

In about half the states, Marketplace plans are prohibited from offering coverage that includes abortions, or are restricted to covering abortions in very limited circumstances.

You should check the plan details to find out whether your plan covers abortion services.

During Open Enrollment, you and your spouse will apply as a household of two. When the baby is born, you can update your family information with the Marketplace to reflect that you have become a household of three. At that point, you may qualify for a larger premium tax credit.

For example, if you and your spouse together earned an income that is twice the federal poverty level for a household of two ($31,860), you would be required to contribute about 6.41% of your household income toward the premium for the benchmark plan in the Marketplace.

Once the baby is born and you are a household of three, that income would constitute just 159% of the federal poverty level for a family of three and you would only be required to contribute about 4.07% of your income.

When you report your new family status to the Marketplace you will also have a 60-day special enrollment opportunity to add the baby to your plan, and you will be able to change health plans during that period if you want to do that.

This will vary by state. Some states have requirements that plans cover some infertility services, but there is no national requirement for coverage of infertility services.

If you need these services and are shopping for coverage, check the plan details about coverage and out of pocket charges for infertility care.

The ACA requires that all new private plans, including those in the employer market, individual market, and health insurance Marketplaces, cover lactation counseling and breast pump rental without any charge.

Check your plan details to find out the specific number of counseling sessions and type of breast pump that it covers, or if your plan covers purchase of a breast pump.

If you are nursing and work for a large employer (50 or more employees), your employer must provide access to a private room (that is not a bathroom) and break time for you to express milk.

Yes.  However, you may only enroll during Open Enrollment period (November 1, 2015 – January 31, 2016).  Once enrolled, your plan will be required to cover maternity services.

You may also qualify for a premium subsidy, depending on your family income and your eligibility for employer coverage.  Once born, you can add the baby to the plan.  You will also be allowed to change plans at that time.  Birth of a child is a qualifying event that allows you to enroll in or change your coverage, no matter when during the year the baby is born.

Your special enrollment period will last for 60 days from the date of birth.  Adding the baby will change the plan premium and also your subsidy, assuming you qualify for premium tax credits. Depending on your income and the state you reside in, you might also qualify for Medicaid and there is not a limited open enrollment period for Medicaid.

The rules are somewhat different depending on the plan your parents have.

If your parents are covered under a small employer plan (less than 50 workers) provided by an insurance company through the Marketplace or outside of the Marketplace, or if your parents are covered under a nongroup policy they bought themselves, then your parent’s plan is required to cover your prenatal care and delivery.

However, if your parents are covered under a group health plan offered by a large employer (50 or more workers), then your parent’s plan is only required to cover your prenatal care, but is not required to cover the delivery.

Medicaid covers prenatal and delivery services in all states. You could see if you can qualify for Medicaid on your own.

Although most employer plans were already required to cover maternity care prior to enactment of the ACA, most individual plans did not cover maternity care.

Starting in 2014, new individual insurance plans, including those available through the Marketplaces, are required to cover maternity services including child birth and newborn care.

All new private plans, including employer sponsored plans, must cover prenatal visits and screenings, folic acid supplements, tobacco cessation counseling and interventions, and breastfeeding services without any co-pay because they are considered preventive services.

All state Medicaid programs cover maternity care without cost-sharing to low-income women who qualify for coverage.

If you are enrolled in a non-grandfathered plan, then you must be allowed to see your OBGYN without a referral. Women in grandfathered plans and Medicaid may be able to schedule a visit with an OBGYN without a referral. Check with your plan.

The federal government has now requires that plans must cover at least one form of contraception in each the 18 methods for women identified by the FDA. A plan may use reasonable medical management techniques such as prior authorization or step-therapy, and require cost-sharing to encourage an individual to use specific services or items within a chosen FDA approved contraceptive method.

The plan must have a process in place to ensure that your particular contraceptive service or product is covered without cost sharing when your provider recommends it based on medical necessity.

Since the federal government issued rules that made the contraceptive coverage requirements clear in May 2015, insurers who were previously not covering at least one version of each method without cost sharing must adjust their coverage for plans starting on or after July 12, 2015. For example, if your employer plan begins in January, your plan must update their contraceptive coverage by January 2016.

Young Adults and Students

No. Catastrophic health plans are not eligible for premium tax credits or cost sharing reductions.

In general, only young adults under the age of 30 are eligible to buy a catastrophic plan. However, older adults can buy a catastrophic plan if no other qualified health plan offered through the Marketplace in 2016 would cost less than 8.1% of income.

A “Catastrophic plan” is a qualified health plan offered through the Marketplace that covers essential health benefits and requires the highest level of cost sharing allowable for essential health benefits. In 2016, under a “catastrophic policy,” the annual deductible for covered services is $6,850 for an individual (twice that amount for a family policy.)

After you have satisfied the deductible, the plan will pay 100% for covered essential health benefit services for the remainder of the year. “Catastrophic policies” may also be sold by insurers outside of the health insurance Marketplace.

Yes, you can be covered as a dependent up to age 26 on your parent’s Marketplace policy. If your parents don’t claim you as a tax dependent (and you file independently), then your eligibility for premium tax credits will be based on your income alone. With your income at 255% FPL, you will qualify for a premium tax credit. Once you know the amount, you can decide to sign up for a Marketplace policy on your own, or be covered as a dependent on your parent’s policy until you are 26.

If you enroll in your parents’ plan, you can elect to have your premium tax credit paid directly to your parents’ insurer each month, or you can claim it on your tax return later when you file.

You can remain covered as a dependent on your parent’s policy until you turn 26. Once you lose eligibility as a dependent, you will qualify for a special enrollment opportunity. At that point, you will also be able to apply for health coverage and assistance through the Marketplace, even though it won’t be during a regular Open Enrollment period.

In addition, if your parent’s policy is a group plan offered by an employer with at least 20 workers, you would also be able to continue coverage under the policy through COBRA for up to 3 years.  However, the employer contribution to the premium would end and Marketplace subsidies cannot be applied to the COBRA coverage.

The rules are somewhat different depending on the plan your parents have.

If your parents are covered under a small employer plan (less than 50 workers) provided by an insurance company through the Marketplace or outside of the Marketplace, or if your parents are covered under a non-group policy they bought themselves, then your parent’s plan is required to cover your prenatal care and delivery.

However, if your parents are covered under a group health plan offered by a large employer (50 or more workers), then your parent’s plan is only required to cover your prenatal care, but is not required to cover the delivery. Medicaid covers prenatal and delivery services in all states. You could see if you can qualify for Medicaid on your own.

Your parent’s plan, regardless of the source, generally won’t be required to cover your child as a dependent. You will be responsible for obtaining coverage for your baby. Depending on your income, your child may be eligible for coverage under the Medicaid/CHIP program in your state. Or, you can buy a family policy through the Marketplace and, depending on your income, you may be eligible for a premium tax credit to reduce your cost of that coverage.

Yes, as long as you are younger than 26. Being married does not affect your eligibility to be covered as a dependent under your parent’s plan.

No. You and your spouse will be counted as a household of two and the income you and he report on your joint tax return will be counted for purposes of determining your eligibility. Your son will be counted separately as a household of one, and his income will be counted separately to determine his eligibility.

After the Marketplace decides the amount of premium tax credit each of your “households” are eligible for, the three of you can apply for a family policy offered on the Marketplace and you can apply your combined premium tax credits to reduce what your family has to pay for that policy.

Yes, you are eligible to be covered as a dependent up to age 26 regardless of where you actually live.

However, your parent’s health plan probably has a network of participating providers and it may be difficult for you to find in-network care when you are living in another state. If you find that your parent’s plan doesn’t cover health providers in the state where you live, you can also explore the option of signing up for coverage on your own.

Moving will qualify you for a special enrollment opportunity to enroll in other coverage.

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