Health Reform and Your Insurance Options

The world of health insurance is going through a lot of changes. If you're trying to get your bearings, take a look at what's different since the health reform bill became law.

The highlights:

  • No one can be denied coverage because of health problems they had in the past.* This is known as a "preexisting condition." In addition, health insurance companies cannot charge you more if you have a preexisting condition.
  • If you have children who are 19 to 26, they can stay on your insurance plan.
  • Insurance plans, with some exceptions, now cover some preventive medical services. You won't need to pay a co-payment or reach the deductible first. These preventive services include certain vaccinations and screenings.

Health insurance Marketplaces are set up in each state or by the federal government. Marketplaces, also known as Exchanges, are websites where you can shop for coverage, enroll in a health plan, and find out if you qualify for a government subsidy to help pay your premium.

What You'll Find in the Health Insurance Marketplace

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What is it? The health insurance Marketplace is a way to shop for and buy health coverage. It lets you compare the costs and benefits of different plans.

Each state has a Marketplace. The federal government oversees the Marketplaces in some states, while other states run their own.

All plans sold on the Marketplace must include 10 essential health benefits*:

  1. Outpatient care
  2. Emergency care
  3. Hospitalization
  4. Pregnancy, maternity, and newborn care
  5. Mental health and substance use treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative care
  8. Laboratory services
  9. Preventive and wellness services
  10. Pediatric care, including vision and dental

In addition to offering standardized benefits, Marketplace plans must fit into one of four “tiers” based on how much of your medical expenses are covered:

  • Platinum - on average covers 90% of your medical expenses
  • Gold - on average covers 80%
  • Silver - on average covers 70%
  • Bronze - on average covers 60%

Plans can't turn you down because you have a health problem or you've had one in the past.*

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Who can use it? To get health insurance from an exchange, you must:

  • Be a U.S. citizen or legal immigrant
  • Not be in prison
  • Lack access to affordable coverage through an employer

Because of that, the Marketplaces are primarily for people who are buying insurance on their own, as well as small businesses.

How does the Marketplace help me find a plan? Your Marketplace has tools and information to help you select between options, such as:

  • Comparing the benefits and costs of available plans
  • Information in simple language about how each plan works
  • A toll-free phone number you can call for help
  • Calculator that shows you how much your options cost
  • Help with enrolling in government programs such as Medicaid if you're eligible

When can I enroll? Marketplaces have an open enrollment period (usually in the fall) when you can shop for coverage and enroll in a plan. You must enroll in a plan during that timeframe, or you will have to wait until the next open enrollment period, unless you have special circumstances. You may be eligible for a special enrollment period if you had a qualifying event such as losing your job or other insurance coverage. If you are eligible for Medicaid, you can enroll at any time during the year.

Can I get help paying for coverage? Many people will be able to get tax credits to lower the cost of their coverage. In 2020, you can get tax credits if you have a yearly income between:

  • $12,490 and $49,960 for a single person
  • $25,750 and $100,300 for a family of four

Am I required to have health insurance? The tax reform bill Congress passed in 2017 eliminated the penalty for people who do not have health insurance beginning in 2019.

*Insurance companies can sell short-term health plans (those that offer coverage for less than 12 months) that do not include the 10 essential health benefits and deny coverage for pre-existing conditions.

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