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Frequently Asked Questions

The health care law—the Affordable Care Act (ACA)—gives you more control over your health care by offering ways to shop and pay for coverage with greater protections. It keeps in place today’s job-based insurance system and the Medicare health insurance program for people who are 65 and over and for some younger people with disabilities.

  • What is the Affordable Care Act (ACA) individual mandate and why do we have it?

    As of 2014, the ACA requires most Americans to have health insurance. The good news is that most people already have health coverage that meets the requirement, such as Medicare, Medicaid, TRICARE or veteran’s coverage, or a plan through an employer, or in some cases health coverage bought on one’s own. For those who need it, the health care law creates more ways to shop for coverage and more options to get financial help to pay for it. Under the law’s consumer protections, no one can be turned down for coverage because they have a pre-existing condition.

  • Test - The health care law—the Affordable Care Act (ACA)—gives you more control over your health care by offering ways to shop and pay for coverage with greater protections. It keeps in place today’s job-based insurance system and the Medicare health insurance program for people who are 65 and over and for some younger people with disabilities.

Understand Your Health Insurance Requirements

Understanding the Health Insurance Marketplace

  • What is the Health Insurance Marketplace?

    Through the Health Insurance Marketplace, you can shop online and get help by phone or in person to find the health plan that works for you and your family. The marketplace allows you to compare plans and costs on an “apples-to-apples” basis. You also can find out what kind of financial help you may be able to get to pay for premiums and copayments. For example, for coverage in 2019, an individual with a household income between about $12,140 and $48,560 or a family of four with a household income between about $25,100 and $100,400 would qualify for financial help. These are ballpark figures and will change every year. While people with very limited incomes will receive the greatest help, moderate-income families can often get help too. To learn more about the Health Insurance Marketplace, read The Health Care Law: More Choices, More Protections. To find the Health Insurance Marketplace in your state, visit www.HealthCare.gov or call 1-800-318-2596.

    See an estimate of the costs and financial help you may qualify for if you buy health coverage through the Marketplace – use this Health Insurance Marketplace Calculator.

  • If I need coverage, do I have to buy it through the Health Insurance Marketplace?

    The Health Insurance Marketplace is just for people who need to buy private individual health insurance. If you have insurance through Medicare or Medicaid, a military program or, in most cases, employer coverage, that coverage is separate from the marketplace. If you need to buy private individual health insurance, you can still get coverage outside of the Health Insurance Marketplace. But coverage may be different, and some consumer protections may not apply. Also, financial help is only available for plans offered through the marketplace for those who qualify. Be sure to read the plan details to make sure you are getting the coverage that meets the needs of you and your family. If you do need to buy coverage and want to find the Health Insurance Marketplace in your state, visit www.HealthCare.gov or call 1-800-318-2596.

  • I am not a U.S. citizen. Can I buy health coverage through the Health Insurance Marketplace?

    Only noncitizens living in the United States legally, officially referred to as lawfully present immigrants, can buy coverage through the Health Insurance Marketplace. Being “lawfully present” in the United States covers many kinds of entry permits and visas. It isn’t necessary to have a green card. Lawfully present immigrants might also be able to get a premium tax credit if they qualify based on their income. Undocumented immigrants are not able to buy coverage in the Health Insurance Marketplace. 

Choose a Health Insurance Plan from the Marketplace

  • How can I compare health plans offered in the Health Insurance Marketplace?

    Plans sold in the Health Insurance Marketplace are offered in four different tiers, sometimes called “metal levels,” so it’s easier to make “apples-to-apples” comparisons among plans. The tiers—bronze, silver, gold and platinum—are based on how generous the health plan is for the benefits and services covered. Bronze plans will have the lowest premiums, but the individual’s share of costs such as deductibles and copayments will be higher. Platinum plans will have the highest premiums, but fewer additional costs for consumers. The actuarial value is based on what an average group of consumers might pay under the plan, but your own costs may vary depending on how much care you need.

    Be sure to consider coverage and costs given your health care needs when comparing plans. See Choosing a Health Care Plan.

  • Health insurance plans seem confusing. Will they be explained better than before?

    All plans purchased through the Health Insurance Marketplace and most employer plans have a Summary of Benefits and Coverage (SBC). This form includes important information about the coverage, such as the deductible, copayments, services not covered by the plan and whether people in the plan need a referral to see a specialist. It’s all presented in a way that makes it easier for consumers to make an “apples-to-apples” comparison of their coverage options.

    The SBC must also include examples of the typical costs for three common medical conditions (managing diabetes and having a baby, and a broken leg). Employers and insurers that use SBCs must make these summaries available when you shop for coverage, when you enroll in a plan or renew your coverage, or when there are significant changes to your benefits. You can also request a copy at any time. 

    Health plans bought outside the Health Insurance Marketplace may not offer the same benefits and protections, and may not provide an SBC, making it difficult to compare them. Be sure to check the details of the plans to make sure you are getting a plan that meets the needs of your family.

    Want to make sure you choose the right health insurance plan for you and your family? Find out what coverage, costs, and comparisons to consider.

  • Does my health insurance plan have to cover certain benefits?

    If you purchased a plan through the Health Insurance Marketplace, you can be sure your plan covers certain important health care services, known as essential health benefits (EHB). Each state has its own EHB, but all must cover the following:

    • Doctor’s office visits
    • Emergency room care
    • Hospital visits (such as for surgery)
    • Maternity and newborn care
    • Mental health and substance abuse treatment
    • Prescription drugs
    • Rehabilitative and habilitative services and devices
    • Laboratory services
    • Preventive and wellness services and chronic disease management
    • Pediatric services, including oral and vision care.

    Plans bought outside the Health Insurance Marketplace vary in the health care services they cover. Ask for and read the details of your plan to see what is covered.

Buy Health Insurance Through the Marketplace

  • How long do I have to sign up for a health plan through the Health Insurance Marketplace?

    If you need health insurance for 2019, the Health Insurance Marketplace is open for you to shop from November 1, 2018 through December 15, 2018. You must enroll by the December 15 deadline to ensure you will have coverage that starts January 1, 2019. Some states may allow for a longer period to enroll in coverage for 2019. Check with your marketplace.

  • If I buy or re-enroll in a health plan during the Health Insurance Marketplace open enrollment period, when will my coverage start?

    The Health Insurance Marketplace open enrollment period for 2019 health coverage is November 1, 2018 through December 15, 2018. If you are enrolled in a marketplace health insurance plan, your coverage ends December 31, 2018. To continue health coverage in 2019, you can renew or choose a new plan during the marketplace open enrollment period. You must enroll by the December 15 deadline to ensure you will have coverage that starts January 1, 2019.

    If someone is trying to sell you a plan outside these dates, it is likely the plan does not provide the same coverage for health care services. Learn more about what factors to consider when choosing a health plan.

  • Can I buy a health plan outside the Health Insurance Marketplace open enrollment period?

    Generally, there is only one Health Insurance Marketplace open enrollment period each year. But states have flexibility to extend enrollment periods for marketplace plans.

    In certain cases, you may qualify for a “special enrollment period,” which will allow you to enroll in a Health Insurance Marketplace plan at a time that is not the annual marketplace open enrollment period. This could apply, for example, when you’ve experienced a change in your life, such as a birth or adoption of a child, a relocation out of the area or state, or a loss of another type of health coverage.

    To find out if you qualify for a special enrollment period, or to report changed circumstances, contact the Health Insurance Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).

    If you don’t qualify for a special enrollment period and a broker or insurer is trying to sell you a plan outside these dates, it is likely the plan does not provide the same coverage for health care services as a marketplace plan. Learn more about what factors to consider when choosing a health plan.

  • After I sign up for a health plan in the Health Insurance Marketplace, can I change my mind and sign up for a different plan instead?

    Confused about how to choose a health insurance plan? Find out what coverage, costs, and comparisons to consider.

    If you decide you want to change health insurance plans after you’ve enrolled in one plan through the Health Insurance Marketplace, you can do so as long as it is still in the open enrollment period. Once your health coverage begins, you’ll have to wait for the next marketplace open enrollment period to change plans.

    In certain cases, you may be able to enroll in a plan at a time that is not the annual marketplace open enrollment period. This could apply, for example, when you’ve experienced a change in your life, such as the birth or adoption of a child, a relocation out of the area or state, or a loss of another type of health coverage.

Re-Enroll in Health Insurance Through the Marketplace

  • How long do I have to sign up for a health plan through the Health Insurance Marketplace?

    If you need health insurance for 2019, the Health Insurance Marketplace is open for you to shop from November 1, 2018 through December 15, 2018. You must enroll by the December 15 deadline to ensure you will have coverage that starts January 1, 2019. Some states may allow for a longer period to enroll in coverage for 2019. Check with your marketplace.

  • If I buy or re-enroll in a health plan during the Health Insurance Marketplace open enrollment period, when will my coverage start?

    The Health Insurance Marketplace open enrollment period for 2019 health coverage is November 1, 2018 through December 15, 2018. If you are enrolled in a marketplace health insurance plan, your coverage ends December 31, 2018. To continue health coverage in 2019, you can renew or choose a new plan during the marketplace open enrollment period. You must enroll by the December 15 deadline to ensure you will have coverage that starts January 1, 2019.

    If someone is trying to sell you a plan outside these dates, it is likely the plan does not provide the same coverage for health care services. Learn more about what factors to consider when choosing a health plan.

  • Can I buy a health plan outside the Health Insurance Marketplace open enrollment period?

    Generally, there is only one Health Insurance Marketplace open enrollment period each year. But states have flexibility to extend enrollment periods for marketplace plans.

    In certain cases, you may qualify for a “special enrollment period,” which will allow you to enroll in a Health Insurance Marketplace plan at a time that is not the annual marketplace open enrollment period. This could apply, for example, when you’ve experienced a change in your life, such as a birth or adoption of a child, a relocation out of the area or state, or a loss of another type of health coverage.

    To find out if you qualify for a special enrollment period, or to report changed circumstances, contact the Health Insurance Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).

    If you don’t qualify for a special enrollment period and a broker or insurer is trying to sell you a plan outside these dates, it is likely the plan does not provide the same coverage for health care services as a marketplace plan. Learn more about what factors to consider when choosing a health plan.

  • Last year I bought health coverage through the Health Insurance Marketplace. Do I need to re-enroll in the plan for next year? Will I get the same financial help?

    People who signed up for coverage through the Health Insurance Marketplace should receive a notice from their health plan and another from the marketplace about renewing health coverage. The notices include information about coverage, including any changes to your plan, financial assistance for the following year, and the marketplace open enrollment period—November 1, 2018 through December 15, 2018.

    Some people will be automatically re-enrolled in the same or a similar health insurance plan for 2018. Others must contact the Health Insurance Marketplace directly to be re-enrolled. In general, if the marketplace doesn't have current income data for you, you may not get your financial help renewed. In either case, it is important that you check with your marketplace and review your health plan for 2018 to make sure it works for you and your family.

    Want to make sure you have the right health insurance plan for you and your family? Find out what coverage, costs, and comparisons to consider.

    You must report any changes in income or household size to the marketplace where you enrolled to be sure you are getting the right financial help for your family. Keep in mind most people will need to make changes to their plan and update their household information by December 15, 2018 to make sure coverage starts January 1, 2019. But your state may have a different deadline so be sure to check with the marketplace where you enrolled.

  • What do I do if the marketplace health insurance plan I had last year is no longer available?

    If your plan is no longer available, the insurer must offer you another plan that is similar. If your insurer is no longer offering any marketplace plans, it must notify you of that change 90 days before your coverage ends. In either case, it is a good idea to review your coverage every year to make sure what you are signing up for is something that meets the needs of you and your family. You can compare plans and shop for coverage through the Health Insurance Marketplace during the open enrollment period (November 1, 2018 through December 15, 2018). You also might find that your plan is still available outside the marketplace; however, you will not be eligible for financial help if you enroll in that plan. Financial help is only available for plans offered through the Health Insurance Marketplace. For more details, visit the marketplace where you enrolled for coverage last year.

    Use this Health Insurance Marketplace Calculator to get an estimate of the financial help you may qualify for and an estimate of your monthly payment (premium) for coverage you buy through the marketplace.

  • Do I need to report any changes in my household status, such as an increase in income, to the Health Insurance Marketplace?

    Certain life changes, such as getting a raise, moving, or a death in the family, may change the type of coverage you qualify for or how much financial help you can receive. You’ll need to report life changes to the Health Insurance Marketplace where you enrolled for coverage. For example, if your income has increased, reporting that change will reduce the chance that you’ll have to pay back money at tax time. And if you haven't updated your income information in two years, you may lose your financial help.

    Examples of life changes that could change the coverage and financial help you may qualify for include:

    • Moving to a new area
    • Losing health coverage, such as job-based coverage
    • Change in citizenship or immigration status
    • Change in income, such as getting a raise or losing a job
    • Change in household status, such as getting married
    • Change in family size, such as a birth or death

    For more details about when and how to report any life changes go to www.healthcare.gov or call the Health Insurance Marketplace at 800-318-2596.

See If You Can Lower Your Health Insurance Costs

  • Do I need to report any changes in my household status, such as an increase in income, to the Health Insurance Marketplace?

    Certain life changes, such as getting a raise, moving, or a death in the family, may change the type of coverage you qualify for or how much financial help you can receive. You’ll need to report life changes to the Health Insurance Marketplace where you enrolled for coverage. For example, if your income has increased, reporting that change will reduce the chance that you’ll have to pay back money at tax time. And if you haven't updated your income information in two years, you may lose your financial help.

    Examples of life changes that could change the coverage and financial help you may qualify for include:

    • Moving to a new area
    • Losing health coverage, such as job-based coverage
    • Change in citizenship or immigration status
    • Change in income, such as getting a raise or losing a job
    • Change in household status, such as getting married
    • Change in family size, such as a birth or death

    For more details about when and how to report any life changes go to www.healthcare.gov or call the Health Insurance Marketplace at 800-318-2596.

  • Can I get financial help with the costs of my health insurance?

    Some low- and moderate-income families can qualify for financial help to pay for their monthly payments (premiums) for a health plan bought through the Health Insurance Marketplace (but not for plans bought on your own, outside the marketplace). That help is provided through a premium tax credit, which will lower the amount of the premium you must pay. You can use the premium tax credit in a few ways. You can use some or all of it right away as a discount on your premium, so you owe less when you make your monthly payment. You also can choose to get a partial or full refund when you file your taxes the following year. The premium tax credits are based on a sliding scale, so that the greatest help is available to people with the lowest income.
    Find out what coverage, costs, and comparisons to consider when shopping for health insurance.

    If your income changes in the middle of the year—whether your income goes up or down—be sure to let the Health Insurance Marketplace know, in case your premium tax credit must be adjusted. If your income goes up and you don’t notify the Health Insurance Marketplace, you may owe more in taxes for that year.

  • I received financial help through the Health Insurance Marketplace last year; will I still get it this year?

    It is important to contact the marketplace where you originally enrolled to make sure you still qualify for financial help. Any life changes, particularly a change in income or in your family size, may affect the savings you are eligible for. And if you haven’t updated your income information in two years, you may lose your financial help.

    Use this Health Insurance Marketplace Calculator to get an estimate of the financial help you may qualify for if you buy coverage through the Health Insurance Marketplace.

    It is also a good time to review your health insurance plan to make sure it works for you and your family. You can review your options and make changes during the marketplace open enrollment period (November 1, 2018 through December 15, 2018).

  • If I have health coverage through my job, can I get financial help with the costs of my health coverage?

    Most people who have health coverage through their employer are not eligible for premium tax credits in the Health Insurance Marketplace. In certain circumstances, you may be able to get a premium tax credit if your employer coverage is neither “affordable” nor “adequate,” as defined by the law, and you meet specific limited income levels. For example, for coverage in 2019, an individual with a household income between about $12,140 and $48,560 or a family of four with a household income between about $25,100 and $100,400 may be eligible for premium tax credits for coverage in the Health Insurance Marketplace. These are ballpark figures and will change each year. Check with your human resources department to learn more about your employer’s health plan or with your Health Insurance Marketplace to see if you quality for financial help. You can also use this Health Insurance Marketplace Calculator to get an estimate of the financial help you may qualify for if you buy coverage through the Health Insurance Marketplace.

  • I have retiree coverage from my former employer but it’s expensive. I’m not eligible for Medicare yet; will I be able to buy coverage in the Health Insurance Marketplace until then?

    If you have retiree health coverage, it is important to know that you are not eligible for financial help through the Health Insurance Marketplace. If you are considering dropping your retiree coverage, you can shop for a new plan through the Health Insurance Marketplace and you may be able to get financial help based on your household size and income. However, you won’t be able to enroll until the next marketplace open enrollment period. You also may not be able to return to the retiree plan if you drop it. Be sure to compare costs and benefits and talk with your former employer about your coverage options before you make any changes.

    Once you become eligible for Medicare, you will not use the Health Insurance Marketplace and won’t be eligible for financial help through the marketplace.

Know Your Health Insurance Protections

  • I have a pre-existing health condition. Can I be charged more for my health insurance?

    The ACA makes sure health plans sold through the Health Insurance Marketplace can’t deny you coverage because of health problems you had before your insurance started (known as pre-existing conditions). They also can’t charge you more for your premiums if you get very sick.

    If you choose to buy a health plan outside of the Health Insurance Marketplace, it may not offer the same benefits and may charge more for a pre-existing condition. Check with your plan to see what is covered.

  • How long can my child remain on my family health insurance plan?

    For most plans, you can keep your children on your family health plan until they turn age 26, even if they don’t live at home, are married or attend school. If your health plan charges more for each child you cover, you may have to pay an additional amount to add your older child to your plan. It is important to know that not all employers have to offer a family plan. Check with your employer for the details about adding your adult child to your family plan. Also, plans bought outside the Health Insurance Marketplace may not have to cover your children up to age 26. Check the details of your plan.

  • Is there a limit on how much I have to pay out-of-pocket for my health care?

    For employer plans and those bought through the Health Insurance Marketplace, the ACA sets a limit on how much of a share of the costs you will have to pay for health care in the form of deductibles, copayments and coinsurance. The most you can pay out-of-pocket in 2019 is $7,900 for an individual plan and $15,800 for a family plan (the amount will rise slowly, year to year, with inflation). This does not include your monthly premiums. And, this limit only applies to costs you pay for care you receive from an in-network provider and for essential health benefits, which will probably be most health services covered in your plan, but not necessarily all of them. Check your plan details to see what the limit is for your plan.

  • Can my health plan limit how much they will pay toward my covered services?

    For employer plans and those bought through the Health Insurance Marketplace, health plans cannot put a dollar limit on how much they will pay for covered services you receive in a year (annual dollar limit) or over the total time you are enrolled in the plan (lifetime dollar limit). Previously, plans could limit the amount they would pay for covered services, for example, $100,000 in a year or $500,000 over the life of the policy. It’s important to know that health plans can still include other limits not tied to the cost of benefits. For example, your health plan may set a limit on the number of physical therapy visits it will cover. Check your plan details to see what the limit is for your plan.

  • Is my employer required to provide me with health benefits?

    Employers with 50 or more employees must provide affordable health coverage for their workers, or pay a penalty. To be considered affordable, an employee’s share of the monthly payment (premium) can’t be more than about 9-10 percent of their household income. Check with your marketplace for the exact amount.

    Employers must also offer coverage for employees’ children. However, there is no requirement that the employer pay a portion of the monthly payment (premium) for children to enroll and there is no requirement that they offer coverage to employees’ spouses.

  • What can I do if my health insurance plan denies my claim for health benefits that I thought would be covered by the plan?

    For employer plans and those bought through the Health Insurance Marketplace, the ACA strengthens your right to file an appeal if your health plan will not pay for a medical service you received or won’t give you prior approval for a medical service you need. Before the health care law, your right to appeal your health plan’s decision, known as an internal appeal, varied greatly, depending on the state in which you lived. Also, most people in employer health plans didn’t have the right to request an outside review of their internal appeal. The law now offers you the opportunity to request a review of an internal appeal by an independent outside organization, known as a third party. This is called an external review. If your plan denies your claim for health benefits, they must provide you with information on the steps you can take to appeal that decision and how to get help doing it. Check your plan details about the process for filing a claim for denied coverage.

Understand Medicare As a Result of the Affordable Care Act

  • Will I be able to buy my Medigap supplemental insurance in the Health Insurance Marketplace?

    The Health Insurance Marketplace is not for people who have Medicare and its supplemental Medigap coverage. Medigap is not sold through the Health Insurance Marketplace. So, you will continue to shop for Medigap supplemental coverage as you always have. 

  • Will I have to go through the Health Insurance Marketplace if I want to get Medicare or if I want to make changes to my Medicare plan?

    If you are new to Medicare or if you have Medicare and want to make changes, you do not go through the Health Insurance Marketplace. As before, you will continue to have an annual Medicare open enrollment period from October 15 to December 7, when you can make changes to your Medicare health or prescription drug plans. For more information about enrolling or changing your Medicare plan, visit www.Medicare.gov.

  • What is the Medicare doughnut hole?

    Most Medicare Part D prescription drug plans have a coverage gap, also known as a doughnut hole. Before the health care law was passed, once your total spending on prescriptions reached a certain limit, you had to pay for all of your prescription drug costs on your own. After paying a certain amount on your own, your prescription drug plan would help pay for prescriptions again. Now, because of the health care law, the coverage gap is slowly closing. The gap will disappear in 2020. View our Health Care Law Timeline to see how much the doughnut hole closes each year. 

Understand Taxes and Marketplace Health Insurance

  • What is a Cadillac plan?

    Cadillac plans are expensive health insurance plans offered by employers. These plans generally have high monthly payments (premiums) and low deductibles, and often cover even the most expensive treatments. Under current law, health insurance plans and employers are scheduled to pay a 40-percent tax on these expensive plans beginning in 2022.

  • Why does my W-2 from my employer include the cost of my health benefits?

    The health care law requires employers to report the total cost of employer-sponsored health coverage on the W-2 forms they send to their employees each January. The amount is not taxable as income — that hasn’t changed. Rather, the goal of the reporting is to make employees aware of the total cost of the health benefits they get on the job; it is purely informational.

  • Is there a tax on real estate sales because of the health care law?

    There has always been a Medicare tax on wages, split between the employer and the employee, but before now, income earned through investments rather than work was not taxed. Within the health care law, there is a rule that calls for high-income households to be subject to a 3.8 percent tax on investment income starting in 2013. The tax will only apply to individuals with adjusted gross income of $200,000 per year, or $250,000 for couples. However, this tax does not amount to a 3.8 percent sales tax on all real estate transactions. The bottom line is that the tax is on investment income for people with high incomes. It will not affect the majority of people. 

Learn How the Affordable Care Act Keeps Health Insurance Costs Low

  • What is a medical loss ratio (MLR)?

    The medical loss ratio (MLR) helps to make sure your monthly health insurance payments (premiums) go further in covering your health care. The MLR shows how much of a plan’s premium is spent on health care and quality improvement compared with the amount that is spent on administrative expenses, like marketing and profits. In general, health plans sold to individuals and small business employers must spend at least 80 cents of each premium dollar on health care and just 20 cents on administrative costs. Insurance sold to large employers (generally more than 50 employees) must spend at least 85 cents of every premium dollar on health care and just 15 cents on administrative costs. The MLR applies to all plans available through the Health Insurance Marketplace; however, it may not apply to plans purchased outside the marketplace and some small employer plans.

  • How can I tell if my plan meets the medical loss ratio (MLR)?

    If your health insurer must meet the MLR, it must submit a report each year to the U.S. Department of Health and Human Services showing how much they spend on health care and other activities that improve care. You can find these reports at www.HealthCare.gov.

  • What happens if my insurer doesn’t meet the medical loss ratio (MLR)?

    For plans bought through the Health Insurance Marketplace and many employer plans, if a health insurer does not meet the medical loss ratio (MLR), they must give their consumers a rebate for the amount of premiums that were above the threshold. For example, if a plan was supposed to spend no more than 20 cents on the dollar for administrative costs, but actually spent 24 cents on the dollar, they would owe their consumers 4 cents on every premium dollar paid.

    If you bought the coverage on your own, the health insurer owes you a rebate. If you have your coverage through your employer, the employer will get the rebate. In both cases, the rebate can be returned as a credit on your next year’s premium.