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Answers to Frequently Asked Questions

What is health insurance?
Health insurance is a service in which you and/or an employer on your behalf pay a monthly sum, known as a premium, to an organization in return for a promise of partial cost coverage of an agreed-upon set of medical services. Insurance companies offer different plans that cost different amounts and in return pay for different services. When you get sick or need medical attention, that organization will pay a share of any services that it has indicated will be covered under the plan you selected.

Why do I need health insurance?
Every citizen should have health insurance, for many reasons. If you get sick it will help pay for medical services that you may need to be healthy. Payments from insurance companies for medical costs will help make sure you do not go broke if you get sick or injured. If you have coverage you are more likely to seek preventive care, keeping you healthy and avoiding preventable hospitalizations. Medical costs for those without health insurance are paid by the rest of society.

Where do I get heath insurance?
Health insurance can be acquired in many ways. If you are age 65 or older, or are deemed to have a disability, you may be eligible for a federal government insurance program called Medicare. Details on this program can be found at www.medicare.gov.

If you are a low-income individual you may be eligible for a government insurance program called Medicaid. Details on this program can be found at www.medicaid.gov.

Some may receive coverage through the military, TRICARE or the Department of Veterans Affairs. Many receive health insurance through their employer, which often requires the individual to pay some or all of the monthly premium through paycheck withholding. Others still will purchase health insurance directly from a health insurance company that is active in their state. In 2014, a new method of obtaining health insurance will be available, through Health Insurance Marketplaces.

What are Health Insurance Marketplaces?
A Health Insurance Marketplace, otherwise known as a health insurance ‘Exchange’, is a website that acts as a virtual market for insurance where consumers can compare and contrast selected health insurance plans offered in their state. These virtual Marketplaces are comparable to websites consumers currently use to search for hotels and airline flights, such as Orbitz or Travelocity, in which an individual can compare and contrast different options at different costs. However, instead of airline flights, the products offered will be health insurance products called ‘Qualified Health Plans,’ or QHPs. These QHPs have been deemed qualified to be posted on each state’s website, because they meet the basic requirements for coverage indicated in the Affordable Care Act. Coverage under these insurance plans will be presented in plain language, so consumers can understand the difference between plans when it comes to costs, quality, and benefits covered.

Will these plans cover what I need?
Health insurance plans within these Marketplaces must offer a certain minimum level of coverage. This minimum level of coverage consists of benefits, termed the ‘Essential Health Benefits,’ that include services in the following ten coverage categories:

• Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive care, wellness services and chronic disease management • Pediatric services, including oral and vision care

Specific services offered within these ten categories will vary from plan to plan to offer flexibility and diversity that will suit the needs of different people.

How do I determine which plan is best for me?
The selection of the appropriate health insurance plan is an important task that requires some preparation on the part of the consumer. First, it will be important to evaluate your family health history and any potential health concerns you may need addressed. This will help you determine which services are important for you to have covered. Second, it will be important to look at your personal finances and establish a budget for health care related costs. Determine how much you are willing to pay each month, factoring in any eligible discounts or financial assistance (more on this later, see page 7). Also consider potential co-payments, deductibles and co-insurance you may incur when visiting physicians, hospitals and other medical facilities. Finally, examine the plans on the Marketplace website. Evaluate each plan against what you have determined are important medical services to be covered, and your budget. Note any special restrictions on coverage or exclusions that a plan may have and whether they may interfere with you or your family’s potential care. Research consumer and professional ratings of the insurance companies that offer your top few plans to get a better understanding of the quality of these companies. Also inquire if these plans cover services from providers close to you, and how many.

What insurance options will be available on the Marketplace?
All of the insurance products offered in a Marketplace will be categorized in four ‘tiers’ indicated by the metals ‘bronze,’ ‘silver,’ ‘gold,’ and ‘platinum.’ While the bronze plan will be the cheapest in terms of monthly payment or ‘premium’ required by the consumer, it will only cover 60 percent of the medical bills up to an established out-of-pocket maximum. The silver plan will cover 70 percent of medical bills, gold will cover 80 percent of the medical bills, and platinum will cover 90 percent and above of the medical bills up to an established out-of-pocket maximum, with higher monthly premiums for the patient to pay as the amount of coverage increases. After you reach your plan’s established out-of-pocket maximum, the plan will pay 100 percent of all covered medical care.

What if I still cannot decide on the best plan for me?
Recognizing that selecting a health insurance plan can be overwhelming, the Affordable Care Act called for the creation of the ‘navigator program,’ in which individuals or organizations (Navigators) are trained to help you search for the health plan that is best for you. These Navigators will inform you of coverage options (but not select one for you), help facilitate enrollment in a plan, and help you understand your rights and responsibilities. They will also assist with troubleshooting, highlight financial assistance opportunities, make sure you are put in touch with someone that can accommodate your cultural and language needs, and help direct you to the appropriate office to express a complaint.

When and how do I enroll?
There will be a period of time each year, termed an ‘annual open enrollment period’ in which you can enroll in a health plan for the first time or change health plans through a Marketplace. In October 2013, consumers will be able to view information about the different plans available through the Marketplace in their state. The initial open enrollment period will last from the beginning of October 2013 through March 2014. Starting in the fall of 2014 and for all subsequent years, open enrollment will last from October 15 until December 7.

Enrollment can be performed through a single streamlined application that will determine eligibility not only for QHPs, but state Medicaid and Children’s Health Insurance Programs (CHIP), financial assistance with cost-sharing and a premium tax credit as well. All of this information will be available on your state’s Marketplace website, which you will find listed in the back of this publication. In addition to being able to access this information and apply directly through the Marketplace website, there is also a national toll-free hotline available for enrollment and questions at (800) 318-2596.

What if I need help with the application process?
If you need assistance with the application process, you may use a Navigator, as outlined above. In addition, Marketplaces may have ‘certified application counselors’ that can provide you with direct assistance online, by phone or in person. These counselors will be trained to help you in your application process and maintain confidentiality.

Who runs these Marketplaces and does it matter?
The Affordable Care Act gave each state the option of setting up a Marketplace itself, allowing the Federal Government to set up a Marketplace in the state, or partnering with the Federal government (partnership exchange). For 2014, 16 states and the District of Columbia plan to run state-based exchanges, 8 states plan to run a partnership exchange, and the remaining 26 states will allow the Federal government to run their exchange. Each Marketplace will have a wide variety of insurance options available regardless of who is running it.

What’s the difference between a plan on the Marketplace and other commercial plans?
Starting in 2014, no matter how you buy your health insurance - through the Marketplace in your state or directly from an insurance company with the help - all plans sold in the individual and small group markets must offer the consumer rights and protections provided under the healthcare law. In addition, all plans sold in the individual and small group markets (except for certain grandfathered plans) may not charge or refuse to cover you if you have a pre-existing condition, and must cover Essential Health Benefits.

However, the only way you may receive federal assistance such as tax credits or subsidies to get lower costs for your premium based on income is by purchasing your insurance through the Marketplace. Premium Insurance Tax Credits (PITC) are available to individuals between 100-400 percent of the Federal Poverty Level. PITC is based on your household income and size. Your eligibility for and assistance from Premium Insurance Tax Credits is determined during the enrollment process within the Marketplace.

Can I keep my current doctor?
Most health insurance plans have a network that includes a specific set of hospitals, doctors, specialists, pharmacies, and other health care providers that they contract with to provide services to patients enrolled in their plans. You will need to research the network that is outlined within the plan options during your selection process to ensure that you choose a plan that covers your current doctor.

When comparing plans in the Marketplace, you will have the opportunity to view a list of providers in each plan’s network. You may also work with a Navigator or certified application counselor to make sure your doctor is covered in the network of the plans you are considering. If staying with your current doctors is important to you, you should check to see if they are included before you choose a plan.

Can I get dental coverage?
In the Health Insurance Marketplace, you may get dental coverage as part of a health plan or by itself through a separate, stand-alone dental plan. Under the Affordable Care Act, dental insurance is treated differently for adults and children 18 and under. Dental coverage for children is an Essential Health Benefit, and thus must be made available in either stand-alone plans or included within plans that cover children. However, dental coverage is not considered an Essential Health Benefit for adults, and thus is an optional benefit that adults may select if they desire. Insurance companies do not have to offer adult dental coverage, however you are likely to see plans in your Marketplace that do offer dental plans for adults either included or as stand-alone policies. Included dental benefits, if any, will be identified in the coverage summary for each plan.

What about vision coverage?
At this time, any separate vision plans available on the Marketplace would be at the discretion of the insurance company offering coverage. If you are seeking additional coverage related to your eye health (commonly including eye exams, contacts, eyeglasses, etc), we encourage you to look specifically at the Marketplace within your state to find out what is available, or ask your current eye care provider for information on the vision networks in your area. As with dental coverage, the Affordable Care Act treats vision coverage differently for adults and children 18 and under. Vision coverage for children is an Essential Health Benefit, so it must be made available in either stand-alone plans or included within plans that cover children.

Am I buying government health insurance through the Marketplace?
Every health insurance plan purchased through a Marketplace is provided by a private insurance company - not the government. The premiums will be paid directly to the insurance company that issues the plan. If you are eligible, the federal government may provide you with financial assistance to pay these premiums, in the form of Premium Insurance Tax Credits for people who qualify based on their household income and size.

How will Health Insurance Marketplaces help me save money?
The theory behind Health Insurance Marketplaces is that presenting the coverage available from each health insurance plan through an easy-to-understand summary of costs and benefits in a centralized location will allow for consumer comparison. This simplified comparison will encourage increased competition between insurance companies, resulting in better benefits and lower costs to attract consumers to their plans. That is, health insurance companies will be competing over you.

What if I cannot afford coverage?
Navigators will be able to inform you of any financial assistance available to help reduce your medical costs. One example of such financial assistance will be the Premium Insurance Tax Credits (PITC), available to individuals between 100-400 percent of the Federal Poverty Level. In addition cost-sharing assistance may be available to individuals with annual incomes at or below 250 percent of the Federal Poverty Level.

Your eligibility for financial assistance is determined when you fill out your application during enrollment and is based on both income and the size of your family. Once you complete your application, you should be informed about the amount you would be able to receive in assistance immediately.

What if I am unemployed?
You can still enroll in a Qualified Health Plan through a Marketplace. In addition, you may also qualify for Medicaid, the Children’s Health Insurance Program, the Premium Insurance Tax Credit and/or lower cost sharing related to a Qualified Health Plan purchased through a Marketplace based on your household income and size. Your eligibility for these programs will be determined during the enrollment process.

What are catastrophic plans? Do I qualify?
Catastrophic plans are Qualified Health Plans (QHPs) sold through the Marketplace that are similar to High Deductible Health Plans. Catastrophic plans do not cover any benefits other than 3 primary care visits per year before you meet the plan’s deductible. The premium amount you pay each month for health care is generally lower than for other QHPs, but the initial out-of-pocket costs are generally higher. To qualify for a catastrophic plan, you must be under 30 years old or obtain a "hardship exemption" because the Marketplace determined that you are unable to afford other health coverage. If you enroll in a catastrophic plan, you will not be eligible for Premium Insurance Tax Credits or cost-sharing assistance regardless of your household income.

What are the special situations that allow enrollment into a Marketplace plan outside of the open enrollment periods?
Most people will need to complete the enrollment process during annual enrollment periods each fall. However, in certain circumstances you may be eligible to enroll at other times throughout the year. The situations that allow consumers to be eligible for special enrollment are:

• Immediately following a marriage, birth or adoption • When you gain citizenship or qualifying immigration status • If you loss minimum essential coverage, such as through loss of employer-based coverage • If you gain or lose eligibility for Premium Insurance Tax Credits or assistance with cost-sharing • If you move your permanent residence to a new state • Consumers who are currently enrolled in non-qualifying employer-based coverage • Consumers who are recognized as a member of a federally recognized tribe, including American Indian or Alaska Native Tribes • If your enrollment/non-enrollment in a QHP is the result of an error or inaction by the Marketplace • If you demonstrate that the QHP in which you are enrolled violated its contract with you • If your insurance policy is removed from the Marketplace for not adhering to legal standards • Exceptional circumstances, in accordance with guidelines issued by the Department of Health and Human Services (HHS) and as accepted by the Marketplace

Note: The initial open enrollment ends on March 31, 2014. Outside of open enrollment, you cannot enroll in a QHP through a Marketplace unless you meet one of these situations and must seek other coverage or pay the penalty. In order to qualify under any of these scenarios, you may need to provide documentation to show that you meet the above listed exceptions for special enrollment.

What happens if I miss my enrollment period?
The initial enrollment period is from October 1, 2013 through March 2014. After that, enrollment periods will occur each fall. If you miss the initial enrollment period and are not able to enroll through one of the exceptions listed above, you will have to wait until the next enrollment period in the fall.

There will not be automatic re-enrollment in your plan each year, so you will need to be sure to renew your coverage each year. If you miss the open enrollment period and are not covered under another health insurance plan, you may need to pay a penalty for not being covered.

What happens if I move to another state?
If you move to another state permanently you will need to change insurance to a plan in your new state. Moving to a new state meets one of the enrollment exceptions listed above, so you will not have to wait for the new open enrollment period, and can enroll in a plan in your new state right away.

What if I have a pre-existing medical condition?
Starting in 2014, health insurance plans cannot refuse to cover you or charge you more just because you have a pre-existing health condition. Additionally, a plan cannot impose any waiting periods before they cover treatment for a pre-existing condition. This is true even if you have been turned down or refused coverage due to a pre-existing condition in the past.

Can I add a family member to my policy after enrollment?
There are no family policies sold through the Marketplace. Everyone will receive insurance coverage as an individual and will have their own policy. The only exception is for newborn care, which will be covered temporarily under the mother’s policy for a grace period.

What are my options as a non-citizen lawful permanent resident?
You are eligible to participate in the Marketplace, as well as receive Premium Insurance Tax Credit assistance.

Is there an age limit for those who can purchase insurance in the Marketplaces?
No. Insurance products will be available on Marketplaces for people of all ages.

What if I currently have COBRA insurance?
If you currently have, or are eligible for COBRA continuation health coverage, you can choose to keep it if you prefer. Beginning in October 2013, you will have the option to switch to a health plan in the Marketplace for coverage beginning on January 1, 2014.

If you lose your COBRA coverage, you will qualify for a special enrollment period in which you can enroll in a plan through a Marketplace outside of the open enrollment period. This is true whether the coverage runs out or you choose to end it.

I am self-employed. Can I enroll in a plan through a Marketplace?
Yes, if you are self-employed and have no employees, you may buy insurance through the Marketplace.

I’m currently enrolled in a plan from my employer, but it is not meeting my needs. Can I enroll in a plan from the Marketplace?
Yes, you may purchase health insurance through a Marketplace instead of through your employer. However, you will no longer receive employer contributions toward your health insurance premiums and you will not be eligible for the Premium Insurance Tax Credit or for assistance with your cost-sharing obligations, regardless of your household income and/or size, if the health insurance offered through your employer is deemed ‘affordable’ (less than 9.5 percent of your annual household income for 2014) and provides a minimum value. For more information on this, visit www.healthcare.gov or request assistance through one of the resources provided at the end of this publication.

What if I choose not to purchase insurance?
If you do not purchase insurance, you may be required to pay an annual penalty if you are uninsured for 3 months or more in a given year. In 2014, the total amount of the penalty is $95 per adult and $47.50 per child, with a maximum penalty of $285 per family, OR one percent of family income, whichever is greater.

In 2015, the penalty is $325 per adult and $162.50 per child, with a maximum penalty of $975 per family, OR two percent of family income, whichever is greater. In 2016 and beyond, the penalty is $695 per adult and $347.50 per child, with a maximum penalty of $2,085 per family, OR 2.5 percent of family income, whichever is greater.

You are not required to pay the penalty even if you are uninsured if:

• you are not required to file a tax return because your income is too low ($10,00 for an individual, $20,000 for a family in 2013); • you have to pay more than 8 percent of your annual income to obtain health insurance, after taking in account any employer contributions or tax credits; • you would qualify under the new income limits for Medicaid, but your state has chosen not to expand Medicaid eligibility; • you are a member of a federally recognized Indian tribe; • you are a member of a recognized religious sect with religious objections to health insurance; or • you are incarcerated.

What is not considered minimum essential coverage?
“Minimum essential coverage” is defined to include coverage under a government-sponsored plan (including Medicare, Medicaid, CHIP, TRICARE or Veterans health care programs), health plans sold through Marketplaces, employer plans and health plans purchased on the individual market.

What resources are available for Spanish-speakers?/¿Cuáles son los recursos para los hispano hablantes?
Spanish-speaking consumers who have questions about the Marketplaces should visit www.cuidadodesalud.gov, which is an informational website presented entirely in Spanish. In addition, representatives are available to answer questions in Spanish and other languages through a toll free hotline, at (800) 318-2596.

InsureUStoday also has bilingual representatives to help Spanish-speakers answer any questions they have on Marketplaces. They can be reached at (866) 207-8023.

¿Cuáles son los recursos para los hispano hablantes?

El sitio de web www.cuidadodesalud.gov está completamente disponible en español para ayudar a los consumidores con las cuestiones sobre el Mercado de Seguros Médicos. Adicionalmente, los representantes pueden plantear preguntas en español y otros idiomas por medio de una línea de traducción, al llamar a (800) 318-2596.

InsureUStoday.org también utiliza representantes bilingües para ayudarles a los hispano hablantes a contestar sus preguntas sobre el Mercado de Seguros Médicos al comunicarse a (866) 207-8023.