10 Most-asked questions

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 was designed to help more people get affordable health care coverage and better medical care.

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Q:

What are the health insurance marketplaces?

A:

Marketplaces, sometimes called “exchanges”, are federally or state-run places where people can buy health care coverage. You can reach the marketplaces through their websites, call centers, and physical locations. This means 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 you're eligible for financial assistance or special programs.

Marketplaces also operate a Small Business Health Options Program (SHOP) or, in the state of California, Covered California for Small Business. Small business employers of with 1 to 50 (1 to 100 in California and Colorado) full-time-equivalent employees can buy coverage for their employees.

Employers with 25 or fewer full-time-equivalent employees may qualify for a tax credit, which is only good for 2 years, for coverage purchased through the SHOP or Covered California for Small Business.

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Q:

Do I have to buy health care coverage from the marketplaces?

A:

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

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Q:

Who has to buy health care coverage?

A:

Most people are required to have a basic level of health care coverage. You’re allowed to have 1 break in the year.

You can only have 1 break in coverage, and it can last no more than 3 months. If you go without coverage for more than 3 months in a row, you may have to pay a tax penalty. Some people, however, don’t have to buy coverage, based on their income or other status. For info about getting a waiver, go to your state’s marketplace.

State or jurisdiction URL
California coveredca.com
Colorado connectforhealthco.com
District of Columbia dchealthlink.com
Georgia healthcare.gov
Hawaii healthcare.gov
Maryland marylandhealthconnection.gov
Oregon healthcare.gov
Virginia healthcare.gov
Washington state wahealthplanfinder.org

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Q:

When can I buy health care coverage?

A:

If you have health care coverage through your employer, you should get more details about your next enrollment period from your employer.

If you don’t have health care coverage, you can buy individual or family health care coverage directly from us or through the marketplaces during the open enrollment period for 2018. Check with your marketplace for open enrollment dates. (Exception: Residents of the District of Columbia, purchasing health care coverage on their own must buy coverage from their marketplace.)

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Q:

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

A:

To help you pay for coverage and/or care, you may get federal financial assistance if you're a U.S. citizen or legal resident. The amount of help is based on the size of your family, your income, and the cost of coverage in the marketplaces.

For general income guidelines and to see if you qualify for federal financial help, visit buykp.org. Here you can also compare plans, calculate your rate, or apply online.

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Q:

What if I don’t buy health care coverage?

A:

If you’re required to have coverage, you’ll be charged a tax penalty (with some exceptions) if you go without coverage for 3 months in a row or longer.

The tax penalty will be based on the number of months you go without coverage. You won’t be charged the tax penalty if you don’t have health care coverage for less than 3 months. You’re allowed 1 break in coverage per year.

When you file your taxes, you’ll have to show you have coverage. For more details, go to your state's or jurisdiction’s marketplace.

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Q:

Can anyone get health care coverage?

A:

Only a U.S. citizen or legal resident can purchase coverage through the marketplaces. If you’re a non-US citizen other coverage may be available to you outside of the marketplaces. Health plan issuers 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.

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Q:

What services do the metal health plans cover?

A:

The Affordable Care Act (ACA) requires the metal health plans to cover what are called “essential health benefits”. These benefits fall within 10 broad categories of health care services.

Specific services and supplies, terms of coverage, and exclusions vary by state or jurisdiction.

Covered services include preventive care visits, immunizations, and screenings (such as mammograms and other cancer screenings). Maternity, newborn, and pediatric care are also covered, as are emergency and hospital care. Laboratory services, prescriptions, and mental health (including substance abuse) services are covered as well.

Some plans — known as grandfathered plans — aren’t required to cover all these services. See “What is a grandfathered plan?” for a description of this type of coverage.

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Q:

What is a “grandfathered” plan?

A:

Health care coverage that was in existence on or before March 23, 2010, and that meets certain requirements. Grandfathered plans aren’t legally obligated to comply with some of the requirements under the Affordable Care Act (ACA).

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