FAQs

If you’re looking for health insurance, chances are you have a lot of questions. Take a look at some of the most common health insurance questions we receive.

 

  1. What is the health insurance Marketplace?

Health Insurance Marketplaces (also known as Exchanges) are new organizations that were set up to create more organized and competitive markets for buying health insurance. They offer a choice of different health plans and provide information to help consumers better understand their options. Through the Marketplace, individuals and families can shop for coverage if they need to buy health insurance on their own. Premium and cost sharing subsidies are available through the Marketplace to reduce the cost of coverage for individuals and families, based on their income and their eligibility for other coverage.

 

  1. 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.

 

  1. Who is eligible for Marketplace premium tax credits, also known as subsidies?

Premium tax credits will be 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.

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, whether it is their own or another family member’s. (There is an exception in cases when the employer plan is unaffordable because the employee only share of the premium exceeds 9.56% of the employee’s income in 2015. There is also an exception in cases where the employer plan doesn’t provide a minimum level of coverage.)

 

  1. When can I enroll in private health plan coverage through the Marketplace?

In general, you can only enroll in non-group health plan coverage during the Open Enrollment period.

The Open Enrollment period for 2016 has ended. The Open Enrollment period began November 1, 2015 and ended January 31, 2016. Now that the Open Enrollment period is over, individuals and families will not be able to enroll in Marketplace health plans until the next Open Enrollment period. However, if you experience certain changes in circumstances during the year, such as marriage or loss of health coverage from an employer, you will have a special 60-day opportunity to enroll in Marketplace health plans, outside of the Open Enrollment period.

American Indians and Alaska Natives can enroll in coverage throughout the year, not just during Open Enrollment.

 

  1. How can Synergy Benefit Advisors help me?

Synergy Benefit Advisors has licensed insurance agents all over the state that are able to provide unbiased guidance and give you the answers you need. Our licensed agents are trained and certified with the Health Insurance Marketplace and are appointed with all of the insurance companies offered on the Marketplace. Working with Synergy Benefit Advisors is free and does not change the cost of your insurance. If you need some guidance over the telephone or simply prefer to work face to face with a live person, you can call one of our licensed agents at 1-800-615-5980 for friendly advice and assistance.

 

  1. How long after I enroll in a plan will coverage take effect?

During Open Enrollment if you apply for coverage by December 15, and make your first premium payment by the due date specified by your plan, your new health coverage will begin January 1.

After that, if you enroll between the 1st and 15th day of the month and pay your premium by the due date, your coverage begins the first day of the next month. So if you enroll on January 10, 2016, your coverage begins February 1, 2016.

If you enroll between the 16th and the last day of the month and pay your premium by the due date, your effective date of coverage will be the first day of the second following month. So if you enroll on January 16, 2016, your coverage starts on March 1, 2016.

 

  1. I’m uninsured. Am I required to get health insurance?

Everyone is required to have health insurance coverage – or more precisely, “minimum essential coverage” – or else pay a tax penalty, unless they qualify for an exemption. This requirement is called the individual responsibility requirement, or sometimes called the individual mandate.

 

  1. What’s the penalty if I don’t have coverage?

The penalty for not having minimum essential coverage is either a flat amount, or a percentage of household income, whichever is greater. The penalty will be phased in.

In 2016, the penalty is the greater of

  • $695 for each adult and $347.50 for each child, up to $2,085 per family, or
  • 2.5% of family income above the federal tax filing threshold

The penalty is also capped at an amount equal to the national average premium for the median cost bronze health plan available through the Marketplace.

The penalty is assessed based on “coverage months.” This means that each month you are uninsured, you may owe 1/12th of the annual penalty. However, you can be uninsured for two months in a year and not be subject to a penalty.

 

  1. I notice Marketplace plans are labeled “Bronze,” “Silver,” “Gold,” and “Platinum.” What does that mean?

Plans in the Marketplace are separated into categories — Bronze, Silver, Gold, or Platinum — based on the amount of cost sharing they require. Cost sharing refers to health plan deductibles, co-pays and co-insurance. For most covered services, you will have to pay (or share) some of the cost, at least until you reach the annual out of pocket limit on cost sharing. The exception is for preventive health services, which health plans must cover entirely.

In the Marketplace, Bronze plans will have the highest deductibles and other cost sharing. Silver plans will require somewhat lower cost sharing. Gold plans will have even lower cost sharing. And Platinum plans will have the lowest deductibles, co-pays and other cost sharing. In general, plans with lower cost sharing will have higher premiums, and vice versa.

 

  1. I signed up for a Bronze plan with a high deductible during Open Enrollment. Now, six months later, I need surgery and would rather be in a different plan with a lower deductible. Can I change plans?

No, in general, once you sign up for a plan, you are locked into that coverage for the calendar year. A change in health status doesn’t make you eligible for a special enrollment opportunity.

 

  1. I’m leaving my job and will be eligible for COBRA. Can I shop for coverage and subsidies on the Marketplace instead?

Yes, leaving your job and losing eligibility for job-based health coverage will trigger a special enrollment opportunity that lasts for 60 days. You can apply for Marketplace health plans and (depending on your income) for premium tax credits and cost sharing reductions during that period. If you enroll in COBRA coverage through your former employer, however, you will need to wait to the next Marketplace Open Enrollment period if you want to switch to a Marketplace plan.

 

  1. I have COBRA and am finding it difficult to afford, but Open Enrollment is over. Can I drop my COBRA and apply for non-group coverage outside of Open Enrollment?

No, voluntarily dropping your COBRA coverage or ceasing to pay your COBRA premiums will not trigger a special enrollment opportunity. You will have to wait until you exhaust your COBRA coverage or until the next Open Enrollment (whichever comes first) to sign up for other non-group coverage.

 

  1. What happens if I’m late with a monthly health insurance premium payment?

The answer depends on whether you are receiving advanced premium tax credits. For people receiving advanced premium tax credits, if a payment due date is missed, insurers must provide a 90-day grace period during which consumers can bring their premium payments up to date and avoid having their coverage terminated. However, the grace period only applies if an individual has paid at least one month’s premium.

If, by the end of the 90-day grace period, the amount owed for all outstanding premium payments is not paid in full, the insurer can retroactively terminate coverage.

In addition, during the first 30 days of the grace period, the insurer must continue to pay claims. However, after the first 30 days of the grace period, the insurer can hold off paying any claims for care received during the grace period, which means you may be responsible to cover any health care services they receive during the second and third months if you fail to catch up on the amount owed before the end of the grace period. Insurers are supposed to inform health care providers when someone’s claims are being held. This could mean that providers will not provide care until the premiums are paid up so that they know they will be paid.

People not receiving advanced premium tax credits get a much shorter grace period; currently, the general practice is 30 days.

 

  1. 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 government?

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 will 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.