Who can buy coverage in the Marketplace?
Most people can shop for coverage in the Marketplace. To be eligible you must live in the state where your Marketplace is, you must be a citizen of the U.S. or be lawfully present in the U.S., and you must not currently be incarcerated.
Not everybody who is eligible to purchase coverage in the Marketplace will be eligible for subsidies, however. To qualify for subsidies (also called premium tax credits) people will have to meet additional requirements having to do with their income and their eligibility for other coverage.
How long after I enroll in a plan will coverage take effect?
In most states if you enroll in a private health insurance plan any time between November 1 and December 15 and make your first premium payment by the due date specified by your plan, your new health coverage starts January 1.
What health plans are offered through the Marketplace?
All health plans offered through the Marketplace must meet the requirements of “qualified health plans.” This means they will cover essential health benefits, limit the amount of cost sharing (such as deductibles and co-pays) for covered benefits, and satisfy all other consumer protections required under the Affordable Care Act.
Health plans may vary somewhat in the benefits they cover. Health plans also will vary based on the level of cost sharing required. Plans will be labeled Bronze, Silver, Gold, and Platinum to indicate the overall amount of cost sharing they require. Bronze plans will have the highest deductibles and other cost sharing, while Platinum plans will have the lowest. Health plans will also vary based on the networks of hospitals and other health care providers they offer. Some plans will require you to get all non-emergency care in-network, while others will provide some coverage when you receive out-of-network care.
Can I be charged more if I have a pre-existing condition?
No. Health plans are not allowed to charge you more based on your health status or pre-existing condition.
Can be charged more because of my age?
Yes, in most states you can, within limits. Federal rules allow insurers to charge older adults (e.g., in their sixties) up to three times the premium they would charge younger adults (e.g., in their early twenties). This limit on age rating applies to all non-group and small-group health insurance policies, whether sold in the Marketplace or outside of the Marketplace. Some states prohibit insurers from adjusting premiums for age, or limit the age adjustment to less than three-to-one.
My income is very low, so I’m only required to pay about $30/month for my health insurance premium. The tax credit picks up the rest, which is more than 90 percent of the total premium. I’ve missed 4 premium payments in a row. Can the insurance company cancel my coverage even though they got 90 percent of the payment on time from the IRS?
Yes. A person receiving an advanced premium tax credit has a 90-day grace period to pay all premiums that are owed. If the amount owed for all outstanding premium payments is not paid in full by the end of the grace period, the insurer can terminate coverage. The insurer would then have to return funds it received from the federal government for all but the first 30 days of the grace period.
I signed up for a health plan at the beginning of Open Enrollment, then changed my mind. Can I switch to a different plan as long as the Open Enrollment period hasn’t yet ended?
Yes. You can switch to a different plan at any time during Open Enrollment.
I received two notices in the mail in October about renewing coverage for next year—one from my health insurance company and one from the Marketplace. What is the difference?
Both notices are important and you should read them carefully. The notice from your health insurer should state whether your current plan is being offered again next year. If it is, the notice should describe any changes to that plan and the monthly premium for next year. The insurer notice will also advise you that, if you do nothing before December 15, you will automatically be re-enrolled in your current plan for another year.
If your current plan is not being offered again but your insurance company is offering similar plans next year, the notice from your health insurer will explain that your policy is not being continued. The notice will also describe another similar policy that will be offered next year and advise that if you do nothing before December 15, you will automatically be enrolled in that similar plan for next year. The insurer notice will also remind you that, whether or not your current plan will be offered next year, you are free to shop for new coverage and change plans during Open Enrollment.
The notice from your insurer should also describe the amount of APTC that you received this year and explain that, unless you update your application for financial assistance, in most cases you will continue to receive an adjusted amount of APTC for next year. The notice should also provide an estimate of the amount of your APTC for next year.
If your current plan is not being offered again and your insurance company will not offer any other plans next year, the notice from your health insurer will explain that your policy is not being continued. The notice will also advise that you cannot be automatically renewed into another policy. You will have to apply for a new plan during Open Enrollment.
The notice from the Marketplace will provide additional information about renewing your application for financial assistance. That notice will let you know whether you are eligible to have your financial assistance automatically adjusted and continued into next year without you having to take any action. That notice should also remind you to update your application for financial assistance to ensure that your eligibility determination reflects the most current information possible.
Who is eligible for Marketplace premium tax credits?
Premium tax credits are available to U.S. citizens and lawfully present immigrants who purchase coverage in the Marketplace and who have income between 100% and 400% of the federal poverty level. Premium tax credits are also available to lawfully residing immigrants with incomes below 100 percent of the poverty line who are not eligible for Medicaid because of their immigration status. (Generally, immigrants must lawfully reside in the U.S. for five years before they can become eligible for Medicaid.)
In addition, to be eligible for the premium tax credits, individuals must not be eligible for public coverage—including Medicaid, the Children’s Health Insurance Program, Medicare, or military coverage—and must not have access to health insurance through an employer. (There is an exception in cases when the employer plan is unaffordable because the employee share of the premium exceeds 9.56% of the employee’s income in 2018. There is also an exception in cases where the employer plan doesn’t provide a minimum level of coverage.)
How do the premium tax credits work?
Premium tax credits reduce your premium for most Marketplace policies. The amount of the tax credit you may receive depends on your income and the cost of Marketplace health plans in your area. The Marketplace will determine the expected contribution you are required to pay toward the premium for a mid-range (Silver) benchmark plan. The expected contribution will increase on a sliding scale based on your 2018 income. If your income is near the poverty level, the expected contribution you would be required to pay toward the benchmark plan is 2.01 percent of your income in 2018. As your income gets closer to 400% of the poverty level, the expected contribution you would be required to pay toward the benchmark plan is 9.56% of your income. The difference between the premium for the benchmark plan and your expected contribution equals the amount of your tax credit. (You do not have to pay more than the actual premium for the plan.) The Marketplace will tell you what that dollar amount is. You can use that amount to help pay the premium for any Bronze, Silver, Gold, or Platinum plan offered in the Marketplace. The credit cannot be used to pay for a Catastrophic plan.
Premium tax credits may be claimed at the end of the year, or you can apply for an advanced premium tax credit based on your estimated income for the upcoming year. If you elect to receive an advanced credit, the government will pay 1/12 of the credit directly to your insurance company each month and the insurer will bill you for the rest of the premium.
It’s important to keep in mind that when you apply for the premium tax credit during Open Enrollment, you won’t necessarily know for sure what your income for the coverage year will be, so you will apply based on your best estimate. Later, when you file your tax return, the IRS will compare your actual income to the amount of premium tax credit you claimed in advance. If you underestimated your income and claimed too much premium tax credit, you might have to pay back some or all of the difference. If you didn’t receive all of the premium tax credit you’re entitled to during the year, you can claim the difference when you file your tax return. You should report any changes in your income during the year to the Marketplace, so your credit can be adjusted and you can avoid any significant repayments at the end of the year.
Sourced by https://www.kff.org/health-reform/faq/health-reform-frequently-asked-questions/.