Q & A

Q:        What is health care reform?

A:        The term “health care reform” refers to the federal Affordable Care Act (ACA), and any state laws passed to put it in place. It’s designed to help more people get affordable health care coverage and receive better medical care.

Q:        What are the Health Insurance Marketplaces?

A:        Marketplaces, sometimes called “Exchanges”, are state- or federally run places where people can buy health care coverage. They include websites, call centers, and physical locations, so you can get coverage online, over the phone, or in person. You can compare and choose health plans offered by private companies, get answers to questions, and find out if they are eligible for financial assistance or special programs.

Marketplaces will also operate a Small Business Health Options Program (SHOP). There, small-business employers can purchase coverage for their employees. SHOP Marketplaces will be open for enrollment in October 2013, and coverage purchased there will be effective January 1, 2014, or later, depending on the employer’s renewal date and application date. (Exception: Maryland SHOP opens April 1, 2014.)

Q:        Do I have to buy from the Marketplace?

A:        No. A Marketplace is just one of the ways people can shop for health coverage. However, you can only get financial help from the government if you buy coverage through a Marketplace. (Exception: Residents of Washington, D.C., purchasing health coverage on their own must buy coverage from the Marketplace.)

Q:        Who has to buy health insurance?

A:        Most people are required to have a basic level of health coverage as of January 1, 2014. Some people don’t have to buy insurance, based on their income or other status. Go to your Marketplace for details.

Q:        What if I can’t afford to buy health care coverage?

A:        You may get financial help to help pay for coverage, care, or both. The amount is based on your income, where you live, other coverage that may be available to you, and if you are a U.S. citizen or lawfully present in the U.S.

You can find out if you qualify for reduced premiums and reduced cost sharing through the Health Insurance Marketplaces. Here are some general income guidelines that might be used by the government to see if you qualify and how much help you would receive.

  • If you’re single, you could qualify if you make less than $45,960 (or if you live in Hawaii, less than $52,920).
  • For couples, you could qualify if you make less than $62,040 (or if you live in Hawaii, less than $71,400).
  • For a family of 4, you could qualify if you make less than $94,200 (or if you live in Hawaii, less than $108,360).

Q:        What if I don’t buy health care coverage in 2014?

A:        If you’re required to have coverage, you’ll be charged a tax penalty by the government if you go without insurance for 3 consecutive months or longer. You won’t be charged the tax penalty if you are uninsured for less than 3 consecutive months.

Q:        Can anyone get health care coverage?

A:        Insurance companies can no longer deny coverage because you have a medical condition, and you don’t have to pass a medical exam to qualify for coverage.

Q:        What services do new health plans cover?

A:        In general, for individual and small-group insured health plans, 10 broad categories of medically necessary services will be covered. This includes preventive care visits, immunizations, and screenings (such as mammograms and other cancer screenings). Maternity, newborn, and pediatric care will be covered, as well as emergency and hospital care. Laboratory services, prescriptions, and mental health (including substance abuse) services will also be covered. Some large-employer plans that were in effect before the Affordable Care Act was passed in March 2010 may not be required to cover all these services. Specific services and supplies, terms of coverage, and exclusions vary by state.

Q:        What does a “grandfathered” plan mean?

A:        A health plan that has been in existence since on or before March 23, 2010, and that meets certain requirements. Grandfathered plans are exempt from some of the changes required under the Affordable Care Act.