If you have a disability, don’t qualify for disability benefits, and need health coverage, you have options in the Health Insurance Marketplace.
APPLYING FOR COVERAGE THROUGH THE MARKETPLACE
When you fill out a Marketplace health coverage application, you’ll find out if you qualify for a private health plan with premium tax credits and other savings based on your income. You’ll also find out if you qualify for Medicaid coverage.
When you fill out your application, you may be asked if you:
Have a physical disability or mental health condition that limits your ability to work, attend school, or take care of your daily needs
Get help with daily living activities through personal assistance, a medical facility, or nursing home
If you answer “yes” to any of these questions, the Marketplace may send your application to your state Medicaid office to see if you qualify for Medicaid based on a disability. Your state Medicaid office may contact you for more information about your disability.
Insurers offering coverage through the Marketplace can’t deny coverage or charge you more based on your answers to these disability questions. Private insurance plans in the Marketplace and all Medicaid programs cover all pre-existing health conditions from the first day your coverage takes effect.
IF YOU DO NOT QUALIFY FOR MEDICAID BASED ON YOUR DISABILITY
If you don’t qualify for Medicaid based on your disability, you have 2 more options for health coverage through the Marketplace:
You may qualify for Medicaid based only on your income. Some states have expanded their Medicaid programs to cover all adults who make less than a certain income level. Find out if your state is expanding Medicaid and what this means for you.
You may qualify to enroll in a health plan through the Health Insurance Marketplace with premium tax credits and other savings that make coverage more affordable. This will depend on your household size and income.
THE FEE FOR NOT HAVING COVERAGE
Under the health care law, most people must have health coverage, pay a fee, or get an exemption from the fee. This applies regardless of disability status.
If you don’t have coverage through Medicare, Medicaid, another public program, a job, the Marketplace, or another source, you may have to pay the fee.
Some people can get an exemption from the fee based on low income, hardship, or other factors.
If you are unemployed you may be able to get an affordable health insurance plan through the Marketplace, with savings based on your income and household size. You may also qualify for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP).
Your household size and income, not your employment status, determine what health coverage you are eligible for and how much help you will get paying for coverage.
YOUR OPTIONS DEPEND ON YOUR HOUSEHOLD INCOME
When you apply for Marketplace coverage you will estimate your income for the current calendar year.
MEDICAID, CHIP, AND INSURANCE PLANS THROUGH THE MARKETPLACE
When you fill out a Marketplace application, you will find out if you qualify for any of these types of coverage:
1. A Marketplace insurance plan. You may qualify for premium tax credits and savings on deductibles, copayments, and other out-of-pocket costs based on your household size and income. Some people with low incomes may wind up paying very small premiums. Learn about getting lower costs on a Marketplace insurance plan.
2. Medicaid. Medicaid provides coverage to millions of Americans with limited incomes or disabilities. Many states have expanded Medicaid to cover all people below certain income levels.
3. Children’s Health Insurance Program (CHIP). CHIP provides coverage for children, and in some states pregnant women, in families with incomes too high for Medicaid but too low to afford private insurance.
After you finish your Marketplace application, you will get an eligibility determination that tells you what kind of coverage you and others in your household qualify for.
COBRA COVERAGE AND THE MARKETPLACE
When you lose job-based insurance, you may be offered COBRA continuation coverage by your former employer.
1. If you’re losing job-based coverage and haven’t signed up for COBRA continuation coverage, learn about your rights and options under COBRA from the U.S. Department of Labor.
2. If you decide not to take COBRA coverage, you can enroll in a Marketplace plan instead. Losing job-based coverage qualifies you for a Special Enrollment Period. This means you have 60 days to enroll in a health plan, even if it’s outside the annual Open Enrollment Period.
Some states have expanded their Medicaid programs to cover all people with
household incomes below a certain level. Others have not. (FLORIDA HAS NOT
Whether you qualify for Medicaid coverage depends partly on whether your state has
expanded its program.
• In all states: You can qualify for Medicaid based on income, household size,
disability, family status, and other factors. Eligibility rules differ between states.
• In states that have expanded Medicaid coverage: You can qualify based on
your income alone. If your household income is below 133% of the federal
poverty level, you qualify. (Because of the way this is calculated, it turns out to
be 138% of the federal poverty level. A few states use a different income limit.
IF YOUR INCOME IS LOW AND YOUR STATE HAS NOT EXPANDED MEDICAID
If your state has not expanded Medicaid and your income is below the federal poverty
level, and you do not qualify for Medicaid under your state's current rules, you will not
qualify for either health insurance savings program: Medicaid coverage or savings on a
private health plan bought through the Marketplace.
IF YOU DO NOT QUALIFY FOR EITHER MEDICAID OR MARKETPLACE SAVINGS
• You can get care at a nearby community health center. The health care law
has expanded funding to community health centers, which provide primary
care for millions of Americans. These centers provide services on a sliding
scale based on your income.
• If you don’t have any coverage, you don’t have to pay the fee. Under the law,
most people must have health coverage or pay a fee. But you won’t have to
pay this fee if you live in a state that hasn’t expanded Medicaid and you would
have qualified if it had. This is called having an exemption from the fee. You
can get an exemption when you apply for coverage in the Marketplace. Or you
can apply for the exemption without having to fill out a Marketplace application.
• If your expected yearly income increases so it’s between 100% and 400% of
the federal poverty level, you become eligible for a Marketplace plan with
advance payments of the premium tax credit. In this case, you may qualify for
a Special Enrollment Period (SEP) that allows you to enroll in a Marketplace
plan any time of year. You must contact the Marketplace Call Center within 60
days from the date your income changed to request this SEP. When you call,
you’ll need to attest that you:
– Weren’t eligible for Medicaid when you first applied because you live in
a state that hasn’t expanded Medicaid.
– Weren’t eligible for a Marketplace plan with tax credits when you first
applied because your income was too low.
– Had an increase in expected yearly income that now qualifies you for a
Marketplace plan with tax credits.
MARKETPLACE DECISIONS THAT EMPLOYERS CAN APPEAL
Under the health care law, certain employers with 50 or more full-time employees (or full time equivalents) must offer health insurance coverage to their full-time employees (and their dependents) that meets certain minimum standards or pay a fee called the Employer Shared Responsibility Payment.
Employers that get a notice from the Marketplace stating they may be subject to the fee can file an appeal if they believe they offered coverage to an employee that both:
1. Is affordable AND
2. Meets minimum value standards
This appeal may determine if an employee (and any household members) got help with costs through the Marketplace at the same time their employer offered them affordable health coverage that met the minimum value standard.
IMPORTANT: This appeal will not determine if an employer has to pay the fee. Only the Internal Revenue Service (IRS), not the Health Insurance Marketplace or the Marketplace Appeals Center, can determine which employers are subject to the fee. Learn more about the Employer Shared Responsibility Payment on IRS.gov.
HOW AN EMPLOYER CAN FILE AN APPEAL
Employers have 90 days from the date stated on the notice from the Marketplace to file an appeal. This appeal can be filed in two ways:
1. Fill out the Employer Appeal Request Form
2. Submit a letter with the following information:
-Employer ID Number (EIN)
-Employer’s primary contact name, phone number and address
-The reason for the appeal
Information from the Marketplace notice received, including date and employee information.
Mail your appeal requests form or letter and a copy of the Marketplace notice to this address:
Department of Health and Human Services
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061
AFTER AN APPEAL IS FILED
The employer will receive a letter saying the appeal was received. It will provide a description of the appeals process and instructions for submitting additional materials if needed.
IF YOUR EMPLOYER REQUESTS AN APPEAL
If your employer requests an appeal through the Marketplace Appeals Center, you will get a letter describing:
1. The appeals process
2. Your rights as an employee, as well as instructions for how to submit documents for consideration in the appeal
3. How your employer’s appeal may affect your eligibility for advance payments of the premium tax credit and cost-sharing reductions (if applicable) for the coverage year.
An insurance company that offers health coverage to heterosexual couples must do the same for same-sex spouses.
PROTECTIONS AGAINST DISCRIMINATION
As long as a couple is married in a jurisdiction with legal authority to authorize the marriage, an insurance company can’t discriminate against them when offering coverage. This means that it must offer to same-sex spouses the same coverage it offers to opposite-sex spouses.
This is true regardless of the state where:
– The couple lives
– The insurance company is located
– The plan is sold, issued, renewed, or in effect
MARRIED SAME-SEX COUPLES AND LOWER COSTS
– The Marketplace also treats married same-sex couples the same as married heterosexual couples when they apply for premium tax credits and lower out-of-pocket costs on private insurance plans. This is true in all states.
– In most cases, a married couple has to file a joint federal tax return to be eligible for premium tax credits and other savings on Marketplace plans.
– When you apply for coverage in the Marketplace, you will be asked if you are married. If you and your spouse plan to file a joint federal tax return for 2016, select “yes.” If you do not file a joint federal tax return, you are not eligible for the tax credit.
If you are under 30, you can get health coverage a few different ways, some designed specifically for you With a range of plan types and costs to choose from, it is not hard to find insurance that works for your life and your budget.
GETTING OR STAYING ON A PARENTS HEALTH INSURANCE PLAN
If are under 26 years old (25 or younger), you may be able to obtain coverage on your parent(s) health plan.
BUYING YOUR OWN INSURANCE PLAN
You may be able to buy your own plan through your local health insurance agency.
- Depending on your situation, you may be eligible for savings based on your income. If you are just starting your career and you are not making much money, you could get a very affordable plan – $75 or less per month, with good benefits.
- You can choose a: “Catastrophic” health plan – an affordable way to protect yourself from worse-case scenarios.
- Applying can be easy and fast. If you are single or you have a pretty straight- forward family situation; applying and finding out what savings you qualify for will not take much time at all.
- One catch: If someone other than yourself claims you as a tax dependent, you can buy a plan through the Marketplace but will not qualify for savings based on your income.
If you are in school, you may be able to enroll in a student health insurance plan – and meet the requirement for having coverage under the Affordable Care Act.
MEDICAID AND CHIP
If your income is low or you have certain life circumstances, you may qualify for free or low-cost coverage through Medicaid.
- If your state has expanded Medicaid coverage, you can qualify based on your income alone – in most states that have expanded, that is roughly $16,500 for a single person and about $22,000 for a married couple with no children,
- In all states, you can qualify based on factors including income, some family situations like pregnancy/having young children, and disability.
- If you have children, they might qualify for coverage under the Children’s Health Insurance Program (CHIP) – even if you do not qualify for Medicaid..
GET COVERED – OR PAY A FEE
Under the Affordable Care Act, you must have a plan that qualifies as minimum essential coverage or pay a fee on your next federal tax return.
The penalty in 2016 is 2.5% of household income or $695 per adult ($342,50 per child). The total fine amount will be calculated using the method that produces the higher dollar figure.
HOUSEHOLD EQUATION: TAX FILER + SPOUSE + TAX DEPENDENTS = HOUSEHOLD
Follow these basic rules when including members of your household:
1) Include your spouse if you are legally married.
2) If you plan to claim someone as a tax dependent for 2016, MAKE SURE TO include them on your application.
3) If you will not claim them as a tax dependent, do not include them.
4) Include your spouse and tax DEPENDENTS even if they do not live with you.
CHART: Who to include in your household
|RELATIONSHIP||INCLUDE IN YOURHOUSEHOLD?||Notes|
|Dependent children, including adopted and foster children||Yes||Include any child you will claim as a tax dependent, regardless of age.|
|Children, shared custody||Sometimes||Include children as household members only during years you claim them as tax dependents.|
|Non-dependent child under 26||Sometimes||Include them only if you want to cover them on your Marketplace plan.|
|Children under 21 that you take care of||Yes||Include any child under 21 that you take care of and who lives with you, even if the child is not technically your dependent. (If a child under 21 has relied on you financially: you claim said child as a household member|
|Unborn children||No||Do not include a baby until it is born. You have up to 60 days after the birth to enroll your baby into health coverage.|
|Dependent parents||Yes||Include parents only if you will claim them as tax dependents.|
|Dependent sibling and other relatives||Yes||Include them only if you will claim them as tax dependents.|
|Spouse||Yes||Include your legally married spouse, whether opposite sex or same sex. In most cases, married couples must file taxes jointly to qualify for savings.|
|Legally separated spouse||No||Do not include a legally separated spouse, even if you live together.|
|Divorced spouse||No||Do not include a former spouse, even if you live together.|
|Spouse, living apart||Yes||Include your spouse unless you are legally separated or divorced|
|Spouse, if you are a victim of domestic abuse, domestic violence, or spousal abandonment||NOT REQUIRED||In these cases, you do not have to include your spouse.|
|Unmarried domestic partner||SOMETIMES||Include an unmarried domestic partner only if you have a child together or you will claim your partner as a tax dependent.|
|Roommate||No||Do not include people you live with unless they are a spouse,tax dependent, or covered by another exception in this chart.|
Do you want a health insurance plan that fits your personal medical needs and budget? You want a plan that you’ll still be happy with six months from now!
A licensed health insurance agent wants those same things for you.
When it’s time to shop for a new health plan for yourself or your family, working with a licensed agent can make a big difference. Why struggle on your own or with the limited assistance that most government-exchange “navigators” can offer when there are licensed agents ready to help?
What’s the value of shopping for health insurance through a licensed agent?
Here are three simple reasons:
1) You can use an agent’s services for free. Agents are paid by the insurance companies and the premiums are the same, no matter where you buy it or whether an agent was involved. A plan never costs more because you choose to buy with an agent. When you understand the benefits of shopping through a licensed agent – and the fact that you don’t have to pay more for using an agent – it’s easy to see why shopping with an agent is the smart way to go. And contrary to misinformation, health insurance agents do not attempt to convince you to buy now.
2) Agents make it easy to understand your options. Unless you have a real passion for fine print and health insurance terminology, it’s not always easy to understand what you’re seeing when comparing health insurance options. Licensed health insurance agents are specially trained to help you understand how plans differ from one another and how your coverage will actually work in the real world.
3) Agents are your advocates even after you enroll. Your agent is there for you even after you buy a new health insurance plan. Your agent can help you re-shop each year during the Obamacare open enrollment period, or whenever qualifying life changes happen and you need to update your coverage. What’s more, your agent can serve as your advocate with the insurance company when you have questions about benefits or about how a medical claim was processed.
How do licensed agents and government-exchange navigators differ?
1) Will you pay more to work with them? No, and this is true of both licensed agents and government-exchange navigators. The plan you choose will cost the same regulated price no matter where you buy it. Why limit yourself to shopping only what’s available at the government exchange.
2) Can they help you apply for subsidies? You can apply for health insurance subsidies through government exchanges OR through the licensed agents authorized to process subsidy applications. Depending on your income, these subsidies can significantly lower your out of pocket expenses toward your monthly premiums.
3) Can they help you enroll in subsidy-eligible plans? You may be able to enroll in subsidy-eligible plans through both licensed agents and government exchange navigators. In most states, licensed agents can provide you with access to the very same subsidy-eligible health insurance plans that are available through the government exchange in your state.
4) Can they show you plans available outside of government exchanges? Navigators can’t help you here. Government exchanges only show you some of the plans available. If you are not using a subsidy, licensed agents can also show you other Obamacare-compliant plans that will save you from a tax penalty but which are only available outside of government exchanges.
The following information applies only to persons having insurance policies written through the Marketplace (Exchange).
If anyone in your household had a Marketplace plan in 2015, you should have received Form1095-A Health Insurance Marketplace Statement.
1) Don’t file your taxes until you have an accurate 1095-A form.
2) It includes information about Marketplace plans for everyone in your household having a Marketplace plan in 2015.
3) It is issued by the Marketplace, not the IRS.
4) You should have received it by mail or in your online Marketplace account.
5) Keep your 1095-A forms with your important tax information, like W-2 forms and other records.
6) The 1095-A provides the details to complete form 8962 that is filed with your tax return if you are receiving a tax credit with your health insurance.
HOW TO FIND YOUR 1095-A ONLINE
- Log in to your Marketplace account.
- Select your 2015 application – not your 2016 application.
- Select “Tax forms” from the menu on the left.
- Download your Form 1095-A. You may have more than one form for your household. If so, download each of them.
- If you can’t find it in your Marketplace account, contact the Marketplace Call Center at 1-800-318-2596.
WHAT’S ON FORM 1095-A AND WHY YOU NEED IT
- Your 1095-A contains information about Marketplace plans any member of your household had in 2015, including:
1) Premiums paid
2) Premium tax credits used
3) A figure called “second lowest cost Silver plan (SLCSP)”
-You will use information from your 1095-A to fill out Form 8962, Premium Tax Credit (PDF) and
1095-A instructions (PDF). This is how you will “reconcile” – determine if there is any difference
between the premium tax credit you received and the amount for which you qualified.
HOW TO KNOW IF YOUR SLCSP INFORMATION IS CORRECT
Look at Part III, column B of your 1095-A, titled “Monthly second lowest cost silver plan (SLCSP) premium.” It should show figures for each month any household member had the Marketplace plan.
The SLCSP premium is incorrect if:
– Part III, Column B has a “0” or is blank for any month someone in your household had
the Marketplace plan
– You did not tell the Marketplace about changes to your household – such as an increase or decrease to your income, having a baby, moving, getting married or divorced, or losing a dependent.
If either applies to you, you will use the “tax tool” to get the premium for your second lowest cost silver plan. You do not need to request a new form if your SLCSP is the only thing wrong with your 1095-A. Just print out a copy of your tax tool results. You will use it and the rest of the information from your 1095-A when you file.
NOTE: If you receive a 1095-A for your policy written off the Marketplace (direct with the insurance company), you do not file it with your income tax forms. You should retain it with your tax records.
If you are self-employed and not otherwise eligible for employer’s group health coverage you may enroll in flexible, high-quality, qualified health insurance coverage that works well for people who run their own businesses. You may enroll in a qualified health insurance plan if you are a freelancer, consultant, independent contractor, or other self-employed worker.
You are considered self-employed if you own a business that reports income to the IRS.
COVERAGE OPTIONS FOR THE SELF-EMPLOYED
It is recommended that you contact your local insurance agency and schedule an appointment to determine if you qualify for a premium tax credit subsidy and other savings on a qualified health insurance plan. Tax credit (subsidy) is based on your income and household size. To receive the tax credit, your household income must fall between 100%-400% of the federal poverty level.
You will also learn if you qualify for free or low-cost coverage through Medicaid or CHIP programs in your state. This will depend on your income, household sizes, and other factors. In order to qualify for Medicaid your household income must be below the federal poverty level.
You may choose from several categories of health insurance plans. The lower cost plans that mainly protect you in worst-case scenarios; to plans with higher monthly premiums but less out-of-pocket costs when you receive health care services.
SELF-EMPLOYMENT INCOME AND MARKETPLACE SAVINGS
As you apply for coverage; you will have to estimate your modified adjusted gross income and also your household income. The premium tax credit savings is based on your estimated modified adjusted gross income for the year you’re applying for coverage, not last year’s income.
Estimating your income for the upcoming year may seem like a difficult task… Contacting your local health insurance agency and finding an insurance agent to guide you through this process is highly recommended, and the insurance agent’s services come at NO COST TO YOU.
Most Americans under the age of 65 are required to have minimum essential health coverage or pay a penalty that is increasing each year. This is true no matter what your job status is.