North Carolina Health Insurance Marketplace

Who is the Marketplace for?

The North Carolina Health Insurance Marketplace is where eligible residents can shop for and buy insurance in person, online, or by phone. In North Carolina, the Marketplace is run by the federal government. The Marketplace, also called an Exchange, is mainly for people who:

  • Don’t have insurance
  • Aren’t insured by their employer
  • Don’t have Medicare
  • Aren’t included in their spouse’s employer insurance
  • Have pre-existing conditions and may have had trouble getting insurance before
  • Have private insurance but want to look at other options
  • Own a small business

The Affordable Care Act requires most Americans to sign up for health insurance or pay a penalty at income tax time. Generally, you don't need to buy insurance through the Marketplace if you are covered by Medicaid, Medicare, TRICARE, or an employer-sponsored plan.

When You Can Enroll: The next open enrollment period is Nov. 1, 2016, to Jan. 31, 2017. Enroll online at HealthCare.gov or call 800-318-2596. You can also download an enrollment application at HealthCare.gov, or get help in person through a Navigator or insurance broker.

If you have a life-changing event -- such as the birth of a child, losing your job, or moving to a new state -- you don't have to wait for the next enrollment period. You can sign up or change coverage within 60 days of the event. You can also sign up for Medicaid at any time, if you are eligible.

Plans and Costs

Getting Started: You’ll need to provide information about you and your family members when you apply. Here’s a checklist of what you’ll need:

  • Social Security number (or document number if you are a legal immigrant)
  • W-2 forms: Wage and tax statements or pay stubs for all employed members of the household. For people who are self-employed or do not have a regular salary, include an estimate of household income.
  • Policy numbers of health insurance plans covering any members of the household
  • Immigration/citizenship status
  • Tobacco use

 

Types of Plans: All insurance plans on the Marketplace are sold by private companies or co-ops. They can offer four types of coverage: bronze, silver, gold, and platinum. These “metal level” plans all cover the same kinds of benefits. The difference is how much they pay on average toward the costs of health care services. Another type of plan is called catastrophic. These have less expensive monthly fees called premiums, but they also offer less coverage. Catastrophic plans are mainly for healthy people under 30.

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Go to HealthCare.gov to compare plan costs.

  • Bronze Plan: You pay 40% and the plan pays 60%.
  • Silver Plan: You pay 30% and the plan pays 70%.
  • Gold Plan: You pay 20% and the plan pays 80%.
  • Platinum Plan: You pay 10% and the plan pays 90%.
  • Catastrophic Plan: You pay 100% of a set amount of money called the deductible before the plan's coverage kicks in. Three primary care visits per year and preventive services are covered for free before you meet the deductible.

Within the metal levels are different types of plans, including:

HMO (health maintenance organization): You can only get treated by doctors in the plan's network (except in a medical emergency). You pay the full cost of care if you use a health care provider outside the network. You also need a referral from your primary care doctor before seeing a specialist.

PPO (preferred provider organization): You can see doctors and go to a hospital outside of your plan’s network for an additional cost. You generally do not need a referral before seeing a specialist.

POS (point of service): You can see doctors and go to a hospital outside of your plan’s network at an additional cost. You also need a referral from your primary care doctor to see a specialist.

EPO (exclusive provider organization): You are limited to doctors and hospitals that are part of your plan’s network (except in a medical emergency), but you generally do not need a referral before going to a specialist.

Costs: Costs of plans on the Marketplace vary based on your age, the number of people in your family, where you live, and your tobacco use. They cannot charge you more because of your sex or a pre-existing health condition.

What to Know When Choosing a Plan

Co-pay, Coinsurance, Deductibles, and Premiums: In addition to your monthly premium, here are other insurance costs to consider as you choose a plan:

  • Co-pay: A set amount you’ll pay for a health care service, such as a doctor visit
  • Deductible: The amount you need to pay before your coverage kicks in
  • Coinsurance: The percentage of costs you’ll pay for a health care service, such as a doctor’s visit

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Your Choice of Health Care Provider: If you would like to keep your current doctor, check to make sure she's in the network you choose. You will pay either all or some of the cost of your health care if you choose a doctor outside the network.

Prescription Drug Coverage : If you take drugs for an ongoing condition, check the plan’s coinsurance and copayment requirements. Also, check whether the drug is on the plan’s list of covered medications, called the formulary.

Your age: If you are under 30 and are in good health, you may want to consider a plan with a lower premium, such as a catastrophic plan.

Pre-existing conditions: If you need regular care, consider how many doctor and specialist visits and tests you may need.

Benefits

What’s Covered: All approved plans in the state must cover the same package of benefits, called essential health benefits. They include:

  1. Outpatient services, such as doctor visits or tests done outside a hospital
  2. Emergency services
  3. Hospital stays
  4. Pregnancy and baby care
  5. Mental health and substance abuse services, including behavioral health treatment
  6. Prescription drugs, including generic and certain brand-name drugs
  7. Lab tests
  8. Rehabilitative services, such as those that help people recover from an accident or injury, and habilitative services, which help people with developmental issues.
  9. Preventive and wellness services, along with those that help people manage chronic conditions; these are covered at no additional cost.
  10. Services for children, including dental and eye care

 

Financial Aid and Medicaid

You may be eligible for financial aid to help pay for insurance or for government sponsored insurance, such as Medicaid or CHIP. Here’s what’s available:

Premium Subsidies (also known as Tax Credits): You may qualify for a federal subsidy to help lower your monthly premium. The subsidy is available only if you buy your insurance in the Marketplace. In general, you'll be eligible if you're single and make between $11,880 and $47,520 a year, or if you have a family of four and make between $24,300 and $97,200 a year. Subsidies are based on your estimated household income and the cost of the health plans in your area. The lower your income the more assistance you will receive. You can use your previous year's tax return to estimate your current income. When you file taxes, the IRS will adjust your subsidy based on your actual income.

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You also may be eligible for cost-sharing subsidies if your income is below $29,700 for an individual or $60,750 for a family of four. Cost-sharing subsidies lower your out-of-pocket costs when you get medical care. Cost-sharing subsidies are available only if you buy a silver-level plan.

Medicaid Expansion : Some states expanded Medicaid so more people can get health insurance coverage. Although North Carolina did not, you may still qualify for some type of assistance even if your income is too low to qualify for a premium subsidy. You will not have to pay a fine for not having insurance if your state did not expand Medicaid and your income is too low to qualify for a premium subsidy.

CHIP: The Children's Health Insurance Program, called Health Choice for Children in North Carolina, provides coverage for children of some families who have a low income but are not eligible for Medicaid. For information, go to ncdhhs.gov.

Check with HealthCare.gov to see if you are eligible for these programs.

Available Resources

In addition to Healthcare.gov, there are several ways you can get help with your insurance decisions:

  • Call Center: You can call the federal government's help line, 800-318-2596, 24 hours a day, 7 days a week, for information, help, and to buy insurance.
  • Navigators and Assisters: They can teach you about the Marketplace and guide you through your insurance decisions. Here are the organizations approved to operateNavigator programs.
  • Local, State, and Federal Organizations: Many health and community organizations, public libraries, and hospitals are offering help. Find a list at LocalHelp.HealthCare.gov.
  • Insurance Brokers and Agents: People in the insurance business who are specially trained also can help you buy insurance through the Marketplace, and they may have policies that are not offered on the Marketplace. You can only get tax credits or subsidies if you buy through the Marketplace, though.

 

WebMD Medical Reference Reviewed by Sarah Goodell on October 04, 2016

Sources

SOURCES:

Healthcare.gov.

Federal Register.

IRS.gov.

HHS.gov.

Kaiser Family Foundation web site.

Healthinsurance.org.

MDC (http://www.mdcinc.org/projects/health-care-navigators).

Mountain Projects of North Carolina.

NC Health Assistance.

 

 

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