Understanding the Affordable Care Act: Kaiser Family Foundation Q&A Clarifies ACA Details
By Space Coast Daily // January 7, 2016
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EDITOR’S NOTE: To assist you to better understand the Affordable Care Act and what it means to you and your family, Space Coast Daily is featuring a series of informational posts. If you need health coverage and want to avoid the fee for 2016, enroll in a plan by January 31. This informative series is sponsored by Health First Individual, which provides health insurance for individuals and families with access to more than 3,000 providers. CLICK HERE for information, get a free quote and apply online.
Kaiser Family Foundation Q&A
Q: I’m uninsured. Am I required to get health insurance?
A: 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.
Q: What’s the penalty if I don’t have coverage?
A: The penalty for not having minimum essential coverage is either a flat amount, or a percentage of household income, whichever is greater. The penalty has been phased in since 2014.
In 2015, the penalty is the greater of
• $325 for each adult and $162.50 for each child, up to $975 per family, or
• 2% of family income above the federal tax filing threshold, which is $10,300 for a single filer,
• $20,600 for people who file jointly
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
In later years, the flat penalty amounts for 2016 will be indexed based on the cost of living.
In all years, 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, short spells of uninsurance may not be subject to a penalty.
Q: When can I enroll in private health plan coverage through the Marketplace?
A: In general, you can only enroll in non-group health plan coverage during the Open Enrollment period.
For 2016 coverage, the Open Enrollment period begins November 1, 2015 and extends through January 31, 2016. Once 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, you will have a special 60-day opportunity to enroll in Marketplace health plans, outside of the Open Enrollment period.
For individuals and families buying non-group coverage on their own, outside of the Marketplace, you can only enroll in coverage during Open Enrollment periods and special enrollment opportunities, as well.
American Indians and Alaska Natives can enroll in coverage throughout the year, not just during Open Enrollment.
Q: Can I buy or change private health plan coverage outside of Open Enrollment?
A: In general, you can have a special enrollment opportunity to sign up for private, non-group coverage during the year, other than during Open Enrollment period, if you have a qualifying life event. Events that trigger a special enrollment opportunity are:
• Loss of eligibility for other coverage (for example if you quit your job or were laid off or if your hours were reduced, or if you lose student health coverage when you graduate) Note that loss of eligibility for other coverage because you didn’t pay premiums does not trigger a special enrollment opportunity
• Gaining a dependent (for example, if you get married or give birth to or adopt a child). Note that pregnancy does NOT trigger a special enrollment opportunity.
• Loss of coverage due to divorce or legal separation
• Loss of dependent status (for example, “aging off” a parent’s plan when you turn 26)
• Moving to another state or within a state if you move outside of your health plan service area
• Exhaustion of COBRA coverage
• Losing eligibility for Medicaid or the Children’s Health Insurance Program
• For people enrolled in a Marketplace plan, income increases or decreases enough to change your eligibility for subsidies
• Change in immigration status
• Enrollment or eligibility error made by the Marketplace or another government agency or somebody, such as an assister, acting on their behalf.
Note that some triggering events will only qualify you for a special enrollment opportunity in the health insurance Marketplace; they do not apply in the outside market. For example, if you gain citizenship or lawfully present status, the Marketplace must provide you with a special enrollment opportunity.
When you experience a qualifying event, your special enrollment opportunity will last 60 days from the date of that triggering event. If you can foresee a qualifying event (for example, you know the date when you will graduate and lose student health coverage) you can ask the Marketplace for a special enrollment opportunity up to 60 days in advance so new coverage will take effect right after your old coverage runs out.
States have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.
Q: I intended to shop for new coverage for next year but didn’t get around to it until January. Meanwhile, the Marketplace automatically renewed my current policy for another year. Can I still make a change?
A: Yes. If you pick a new plan by January 15, coverage under the new plan will take effect on February 1. If you pick a new plan between January 16 and January 31, coverage under the new plan will take effect March 1. In order to avoid a gap in coverage, you will have to pay the premium for your current policy until your new coverage takes effect.
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