Can I be charged more for health insurance if I have a pre-existing condition?
No, assuming that you sign up for a plan on a health insurance exchange created by the Affordable Care Act. You also cannot be forced to pay more for coverage if you develop a health condition after signing up for coverage. However, if you sign up for a plan outside the exchange, you may be charged more if you have a pre-existing condition, and your costs may go up if you develop a health condition after signing up for the plan.
Is my employer required to provide health insurance?
Your employer must provide affordable health insurance if it has 50 or more employees. The coverage must include children, but it does not need to include spouses.
Do I need to pay a penalty if I do not have health insurance?
Generally not, unless you live in a state that specifically provides for a penalty, such as New Jersey or Massachusetts. The Affordable Care Act initially imposed penalties on individuals who did not obtain health insurance, but Congress essentially nullified the individual mandate by reducing the penalty to zero as of 2019. Most states have not passed individual mandates.
What is a health insurance exchange?
Also known as a health insurance marketplace, a health insurance exchange is a website that allows consumers to compare various health insurance options by cost and coverage. Many states have set up their own health insurance exchanges, while people in other states will need to use the federal health insurance exchange. You only need to purchase coverage through an exchange if you are not already covered through your employer or another program, such as veterans benefits. Consumers still can purchase coverage outside the exchange, but they will not have access to the same protections and benefits.
Which benefits does a health insurance plan need to cover?
If you purchase a plan on the health insurance exchange, you should review the list of essential health benefits that it covers. While these will vary somewhat depending on the state, federal law requires essential health benefits to include emergency care, hospital stays, visits to doctor’s offices, prescription drugs, lab costs, maternity care, services for newborns and children, rehabilitative therapy and devices, services for chronic diseases, and services for people dealing with mental health conditions or substance abuse. If you do not purchase a plan on the health insurance exchange, however, it does not need to provide these benefits.
What are the tiers of plans in the health insurance exchange?
There are four main tiers of plans in the health insurance exchange: bronze, silver, gold, and platinum. A consumer pays the least up front in premiums for bronze plans, but they pay greater amounts in deductibles and copayments when medical needs actually arise. At the opposite end of the spectrum, a platinum plan requires a consumer to pay a fairly substantial premium, but they will pay much less in deductibles and copayments.
Is there a limit on how much I need to pay out of pocket for medical costs?
Yes, if you get insurance through your employer or a health insurance exchange. Annual limits are set for individual plans and family plans. The limit applies only to services from a provider in the appropriate network and to essential health benefits. It does not apply to premiums.
Is there a limit on how much my plan will pay for covered services?
No, as long as you get your coverage through your employer or a health insurance exchange. A plan still may impose limits of other types, however, such as the number of covered visits to a certain type of specialist.
When can I sign up for health insurance?
The open enrollment period usually lasts between November 1 and December 15 each year for coverage that starts on January 1 of the following year. Some states provide a longer open enrollment period. In unusual situations, a consumer may be able to enroll in a plan outside the open enrollment period. This might arise when they have a child, they move to a new state, or they lose access to another form of health insurance.
Can I change my plan if I am not satisfied with it?
You can make a change to your plan as long as the open enrollment period lasts. After it ends, you likely will need to wait until the start of the next open enrollment period to make a change.
Do I need to re-enroll in my plan each year?
Some plans automatically re-enroll participants, while others require a participant to re-enroll through the health insurance exchange. You will get a notice from your plan and a notice from your exchange that tells you the steps for renewing your coverage, as well as any changes to the plan.
What happens if my plan is no longer offered?
The insurer must offer you another plan that provides similar coverage. If the same plan is still offered outside the health insurance exchange, you can think about whether you would want to sign up for the plan again while giving up the benefits provided by the exchange. If the insurer completely stops offering plans through the exchange, it must provide you with 90 days of notice before the end of your coverage.
Can I get financial help with paying for my health insurance?
Yes, the federal government provides a premium tax credit on a sliding scale to individuals and families with low incomes. This reduces the amount of your premium, as long as you buy your plan through a health insurance exchange. You can use the tax credit as a discount on your premiums, or you can use it to get a refund when you file your taxes in the next year. If your income or family size changes, you may no longer be eligible for a tax credit, or you may be eligible for a tax credit if you were not previously eligible. You should make sure to consistently review and update this information.
How long can my children stay on my plan?
If you sign up for coverage through the exchange, your children can stay on your plan until they turn 26. This is true even if they do not live with you or if they get married. Plans offered outside the exchange are not required to provide this length of coverage for children. If you get health insurance through your employer, it will not necessarily cover your children unless your employer has at least 50 employees.
Can I get coverage through a health insurance exchange if I am not a U.S. citizen?
You can get coverage through a health insurance exchange as long as you have legal status in the U.S. This does not necessarily mean that you have a green card. Non-citizens who do not have permanent resident status can get health insurance. Only undocumented immigrants (foreign nationals who do not have legal status in the U.S.) are excluded.
Can I get coverage through a health insurance exchange if I have retiree coverage?
No, you cannot get coverage through the exchange if you have retiree coverage through your employer. You would need to drop your retiree coverage before signing up for a plan on the exchange. Before dropping retiree coverage, you should be aware that you cannot sign up for a plan on the exchange until the next open enrollment period. Also, you might not be able to resume retiree coverage if you change your mind.
How does the Affordable Care Act affect Medicare and Medigap coverage?
It does not affect them. You must sign up for Medicare and Medigap supplemental coverage separately from a health insurance exchange, using the traditional process.
Can I appeal a denial of a claim for benefits?
Yes, you will receive information on the steps required for an appeal when you receive the denial notice from the insurer. You may be able to seek not only an internal review of the decision but also an external review by an independent third party.