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Health Insurance & Affordable Care Act

Readers Ask: Will Premium Subsidies Come In A Lump Sum And What Happens When You Don’t Pay Your Premium?

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A. Even if your employer offers health insurance, you can shop for coverage on the exchanges. However, since your income is more than 400 percent of the federal poverty level ($78,120 for a family of three in 2013), you won't be eligible for a premium tax credit if you buy a plan there. 

Don't dismiss plans sold outside the exchanges because you don't think they'll provide good coverage. Starting next year, individual and small group plans, whether they're sold through the online marketplaces or on the private market, all have to meet many of the same standards. 

"If you're not eligible for a tax credit, the coverage is going to look very similar inside and outside of the exchange," says Larry Levitt, senior vice president of the Kaiser Family Foundation. 

Plans can't turn people down or charge them more because they have pre-existing medical conditions, for one thing, and they must cover 10 comprehensive "essential health benefits." In addition, all plans must generally cap out-of-pocket spending at $6,350 for individuals and $12,700 for families, among other things. The only plans that are exempt from the new rules are those that are grandfathered under the law.

Q. What happens when people don't pay their premiums in a timely manner after they purchased insurance on the new exchange? If they are terminated from the policy, will they be able to re-instate? 

A. Consumers who are receiving premium tax credits for coverage on the exchange will get a 90-day grace period to catch up on late premiums, says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities. Other consumers not getting the subsidies may get more or less time, depending on the exchange rules or state law, says Park. 

Once the grace period has passed, consumers will generally have to wait until the next annual open enrollment period in the fall to re-enroll in coverage. If they're uninsured for more than three months, they could be assessed a penalty for not having insurance coverage of up to $95, or 1 percent of income in 2014, whichever is greater.

questions@kaiserhealthnews.org

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communications organization not affiliated with Kaiser Permanente.

Mon, Dec 19 2011

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