Health Reform and Your Insurance Options

The familiar world of health insurance is going through a lot of changes. If you're trying to get your bearings, take a look at what's different since the health reform bill became law.

The highlights:

  • No one can be denied coverage because of health problems they had in the past. This is known as a "preexisting condition." In addition, health insurance companies cannot charge you more if you have a preexisting condition.
  • If you have children who are 19 to 26, they can stay on your insurance plan.
  • Insurance plans, with some exceptions, now cover some preventive medical services. You won't need to pay a co-payment or reach the deductible first. These preventive services include certain vaccinations and screenings.

Health insurance Marketplaces are set up in each state. Marketplaces, also known as Exchanges, are websites where you can shop for coverage, enroll in a health plan, and find out if you qualify for a government subsidy to help pay your premium.

What You'll Find in the Health Insurance Marketplace

What is it? The health insurance Marketplace is a new way to find health coverage. It lets you compare the costs and benefits of different plans.

Each state has a Marketplace. The federal government oversees the Marketplaces in some states, while other states run their own.

All plans sold on the Marketplace must include 10 essential health benefits:

  1. Outpatient care
  2. Emergency care
  3. Hospitalization
  4. Pregnancy, maternity, and newborn care
  5. Mental health and substance use treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative care
  8. Laboratory services
  9. Preventive and wellness services
  10. Pediatric care, including vision and dental

In addition to offering standardized benefits, Marketplace plans must fit into one of four “tiers” based on how much of your medical expenses are covered:

  • Platinum - on average covers 90% of your medical expenses
  • Gold - on average covers 80%
  • Silver - on average covers 70%
  • Bronze - on average covers 60%

Plans can't turn you down because you have a health problem or you've had one in the past.

Who can use it? To get health insurance from an exchange, you must:

  • Be a U.S. citizen or legal immigrant
  • Not be in prison
  • Lack access to affordable coverage through an employer

Continued

Because of that, the Marketplaces are primarily for people who are buying insurance on their own, as well as small businesses.

How does the Marketplace help me find a plan? Your Marketplace has tools and information to help you select between options, such as:

  • Websites for comparing available plans
  • Information in simple language about how each plan works
  • A toll-free phone number you can call for help
  • Calculator that shows you how much your options cost
  • Help with enrolling in government programs such as Medicaid if you're eligible

When can I enroll? Marketplaces have an open enrollment period (usually November through January) when you can shop for coverage and enroll in a plan. You must enroll in a plan during that timeframe, or you will have to wait until the next open enrollment period, unless you have special circumstances. You may be eligible for a special enrollment period if you had a qualifying event such as losing your job or other insurance coverage. If you are eligible for Medicaid, you can enroll at any time during the year.

Can I get help paying for coverage?Many people will be able to get tax credits to lower the cost of their coverage. In 2016, you can get tax credits if you have a yearly income between:

  • $11,770 and $47,080 for a single person
  • $24,250 and $97,000 for a family of four

What if I don't want insurance?The law requires that you have it. If you don't have it through your job or a government program like Medicaid, you have to buy insurance. If you don't, you pay a penalty. The penalty would be the larger amount of the following:

  • $695 for each adult and $347.50 for each child, up to $2,085 per family
  • Or 2.5% of your family's income, up to a maximum of the average annual premium for a bronze level plan

However, you won't have to pay the fine for going without insurance if:

  • You belong to a religion that has religious objections to insurance.
  • Insurance would cost more than 8.05% of your income, even with help from an employer or the tax credits.
  • Your income is so low that you aren't required to file a tax return ($10,000 for an individual; $20,000 for a family).
  • You would have been eligible for Medicaid, but you live in a state that did not expand its program.

WebMD Medical Reference Reviewed by Sarah Goodell on February 11, 2016

Sources

SOURCES:

Henry J. Kaiser Family Foundation: "The affordable care act three years post-enactment," "Preventive services covered by private health plans under the affordable care act," "Explaining health care reform: Questions About Health Insurance Exchanges," "Establishing health insurance exchanges: an overview of state efforts, " "Frequently asked questions," "The Requirement to Buy Coverage Under the Affordable Care Act."

American College of Physicians: "Health Insurance Tax Credits for Individuals and Families."

HealthCare.gov: "What's changing and when," "About the Health Insurance Marketplace," "Checklist for individuals and families."

© 2016 WebMD, LLC. All rights reserved.

Pagination