Frequently Asked Questions
Click the topics below to reveal the frequently asked questions for each subject. If you need further clarification just give Insurance Benefits Team a call at: 817-367-7764 or use send a message through our Contact page. We’re here to help.
- Healthcare Marketplace Eligibility/Enrollment
- Help Paying Private Insurance Premiums
- Non-Traditional Households
- Job-Based Coverage
- Early Retirees/Medicare
- Variable Incomes
What is the health insurance Marketplace?
Can I buy or change private health plan coverage outside of Open Enrollment?
- Loss of eligibility for other coverage (for example if you quit your job or were laid off or if your hours were reduced, or if you lose student health coverage when you graduate) Note that loss of eligibility for other coverage because you didn’t pay premiums does not trigger a special enrollment opportunity
- Gaining a dependent (for example, if you get married or give birth to or adopt a child). Note that pregnancy does NOT trigger a special enrollment opportunity.
- Divorce or legal separation
- Loss of dependent status (for example, “aging off” a parents’ plan when you turn 26)
- Moving to another state or within a state if you move outside of your health plan service area
- Exhaustion of COBRA coverage
- Losing eligibility for Medicaid or the Children’s Health Insurance Program
- For people enrolled in a Marketplace plan, income increases or decreases enough to change your eligibility for subsidies
- Change in immigration status
- Enrollment or eligibility error made by the Marketplace or another government agency or somebody, such as an assister, acting on their behalf.
Note that some triggering events will only qualify you for a special enrollment opportunity in the health insurance Marketplace; they do not apply in the outside market. For example, if you gain citizenship or lawfully present status, the Marketplace must provide you with a special enrollment opportunity. When you experience a qualifying event, your special enrollment opportunity will last 60 days from the date of that triggering event. States have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.
What health benefits are covered under the new law?
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- 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.
What’s the penalty if I don’t have coverage?
- $95 for each adult and $47.50 for each child, up to $285 per family, or
- 1% of family income minus the federal tax filing threshold, which is $10,000 for a person who files singly, $20,000 for somebody who files jointly
In 2015, the penalty is the greater of:
- $325 for each adult and $162.50 for each child, up to $975 per family, or
- 2% of family income above the federal tax filing threshold
In 2016, the penalty is the greater of:
- $695 for each adult and $347.50 for each child, up to $2,085 per family, or
- 2.5% of family income above the federal tax filing threshold
In later years, the flat penalty amounts for 2016 will be indexed based on the cost of living. In all years, the penalty is also capped at an amount equal to the national average premium for the lowest cost bronze health plan available through the Marketplace. The penalty is assessed based on “coverage months.” This means that each month you are uninsured, you may owe 1/12th of the annual penalty. However, short spells of non insurance may not be subject to a penalty.
Are there exemptions to the penalty? What are they?
- Cannot afford coverage (defined as those who would pay more than 8 percent of their household income for the lowest cost bronze plan available to them through the Marketplace)
- Are not a U.S. citizen, a U.S. national, or a resident alien lawfully present in the U.S.
- Had a gap in coverage for less than 3 consecutive months during the year
- Won’t file a tax return because your income is below the tax filing threshold (In 2013, the tax filing threshold is $10,000 for individuals and $20,000 for a couple)
- Are unable to qualify for Medicaid because your state has chosen not to expand the program
- Participate in a health care sharing ministry or are a member of a recognized religious sect with objections to health insurance
- Are a member of a federally recognized Indian tribe
- Are incarcerated
Others who do not qualify through these categories but have experienced a hardship that makes it difficult to purchase insurance may apply through the health insurance marketplace for an exemption to the individual responsibility requirement.
What counts as Minimum Essential Coverage to satisfy the requirement to have health insurance?
- 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
- 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.
When can I apply for Marketplace premium tax credits when other coverage is available?
- Employer-sponsored coverage, unless the coverage is unaffordable (your required contribution to premium for self-only coverage costs more than 9.5% of household income) or does not meet minimum value (an actuarial value of less than 60%). Special rules apply when the affordability of family coverage is a concern.
- Government-sponsored coverage, including Medicare Part A coverage, Medicare Advantage plans, Medicaid coverage and the Children’s Health Insurance Program coverage, Veterans health coverage and TRICARE (coverage for members of the military)
- Coverage for Peace Corps volunteers
My family and I are offered health benefits through my job, but we can’t afford to enroll. My employer pays 100% of the premium for workers, but contributes nothing toward the cost of adding my wife and kids. Can we try to find a better deal in the Marketplace?
What income is counted in determining my eligibility for premium tax credits?
I understand eligibility for premium tax credits is based on our household income. Who counts as being in my household?
- U.S. citizen or resident of the U.S, Mexico or Canada
- Live with you for more than half the year
- Under age 19 at the end of the year (or under age 24 if a full-time student); a child is considered to live with the taxpayer while he or she is temporarily away from home due to education, illness, business, vacation or military service.
- Doesn’t provide more than 50% of his or her own support
Other individuals who can count as dependents include relatives, in-laws or full-time members of your household who are:
- U.S. citizen or resident of the U.S, Mexico or Canada
- Receive more than 50% of their support from you
- Are related to you or live in your home all year
- Make less than $3,900 (in 2013), generally excluding Social Security
A household can include individuals even if they are ineligible for tax credits (for example, individuals who are not lawfully present). Your household size can change during a year due to family changes, including the birth or adoption of a child, a child moving out of the house, and divorce or legal separation. When such changes take place you should report them to the Marketplace as they may affect your eligibility for subsidies. Family changes also can trigger a special enrollment opportunity when you can change health plans, even outside of the regular Open Enrollment period. Note that the definition of household for determining eligibility for premium tax credits sometimes differs from the definition of household for determining Medicaid eligibility. Ask your Marketplace for more information about who should be counted in your household. Keep in mind that if you estimate your income incorrectly and end up claiming more help than you are eligible for, you may have to pay back some or all of the premium tax credit you received. If you over-estimate your income and end up claiming less help than you are entitled to, the difference will be refunded to you when you file your income taxes the following year.
My partner and I live together but are unmarried. Is our combined household income what we should report?
I can’t afford to pay much for deductibles and co-pays. Is there help for me in the Marketplace for cost sharing?
How do I appeal a Marketplace decision?
- 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. The notice will explain the reasons for the decision and the process you should follow if you want to appeal. To request an appeal, you’ll have to provide your name and contact information and an explanation of what you are appealing and why. You can make your appeal online or in writing or over the phone by calling the Marketplace call center. 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 may want to ask a Navigator for help requesting an appeal.