Under the Patient Protection and Affordable Care Act (PPACA), who will have access to affordable health insurance options?
All U.S. citizens, nationals and noncitizens who are lawfully present (in the U.S.
with a work or study visa) may enroll.
What’s an exchange?
An exchange is a program, established in each state, as a way for individuals and
small groups to purchase affordable health insurance. The exchanges will be run
by state, federal or combined governments and will make it easier for people to
compare health insurance options. The exchanges will oversee the insurance options
available and will provide resources such as plan summaries.
What happens if my state decides not to set up an exchange or isn’t ready by January 2014?
If a state decides not to set up an exchange, the federal government, through the
Department of Health and Human Services will perform the services on behalf of the
What is the Health Insurance Marketplace?
In a general sense, the Health Insurance Exchange and the Health Insurance Marketplace
are one in the same. While each state may have a different name for their state-based
Marketplace or Exchange, the federally run program is called the Health Insurance
Marketplace. This program has been established to provide organized and competitive
markets for buying health insurance with a choice of different health plans, each
including the same set of essential health benefits.
Can coverage be purchased outside an exchange?
In most states individual and group coverage will be available outside the exchange.
These policies will have to comply with the same rules on essential health benefits,
coverage levels and cost-sharing as those policies sold through the exchange.
What are the essential health benefits that are included in the new health insurance plans?
Starting in 2014 all plans for individuals and small groups must cover the same
set of essential health benefits which includes:
- Doctor’s visits Hospital stays
- Preventive services
- Prescription drugs
- Mental health
- Emergency services
- Ambulatory patient services
- Maternity and newborn care
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and Wellness Services
- Pediatric Services
What are the coverage or metal levels?
There will be four levels of benefits available through the exchanges:
- PLATINUM – designed to pay 90 percent of covered claims costs
- GOLD – designed to pay 80 percent of covered claims costs
- SILVER – designed to pay 70 percent of covered claims costs
- BRONZE – designed to pay 60 percent of covered claims costs
What if I have a pre-existing health condition?
Beginning January 1, 2014, all health insurers will have to sell coverage to everyone
who applies, regardless of their medical history or health status. In addition,
insurers will not be allowed to charge more to individuals with pre-existing conditions,
nor will they be able to exclude coverage for those conditions from the insurance
plans they sell.
How will I know if I qualify for government subsidies to make health insurance more affordable?
Beginning in 2014, tax credits will be available to U.S. citizens and legal immigrants
who purchase coverage in the new health insurance exchanges and who have income
up to 400% of the federal poverty level ($43,320 for an individual or $88, 200 for
a family of four.)
To be eligible for the premium tax credits, individuals must not be eligible for
public coverage such as Medicaid, the Children’s Health Insurance Program, Medicare,
or military coverage, and must not have access to health insurance through an employer.
Kaiser has a calculator that can give you an idea of your eligibility.
If I have insurance from my employer, can I go to the exchange for coverage?
You can, but you probably won’t want to. Your employer’s plan is usually a better
deal. Many employers subsidize your premiums and you can pay for your coverage using
pretax dollars. If your employer offers you coverage, you probably won’t qualify
for a tax credit unless your share of the premium is more than 9.5 percent of your
modified adjusted gross income.
How can I find out if my doctor accepts exchange-based insurance?
Many of the insurance providers’ networks of doctors and hospitals will be narrower
than are typically found in commercial insurance. So just because your doctor accepts
Blue Cross plans doesn’t necessarily mean the doctor will take the same carrier’s
plan offered on the exchange. Each plan will be required to provide a directory
that lists their network’s providers.
What is the penalty if I don’t obtain health insurance?
The penalty for people who forego insurance is the greater of $695 per year (up
to $2,085 per for a family) or 2.5% of income. The penalties will be phased in over
time at $95 in 2014, $325 in 2015, and $695 in 2016.
What if I’m self-employed?
If you run an income-generating business with no employees, then you’re considered
self -employed (not an employer) and can get coverage through the Marketplace. You
are not considered an employer even if you hire independent contractors to do some
Can I get dental coverage in the marketplace?
Under the health care law, dental insurance is treated differently for adults and
children 18 and under. Dental coverage for children is an essential health benefit
and must be made available either as part of a health plan or as a free-standing
plan. This is not the case for adults. Insurers don’t have to offer adult dental