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 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 EXPANDED MEDICAID)
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.
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.