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 receive better medical care.

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Q:

What are the Health Insurance Marketplaces?

A:

Marketplaces, sometimes called “Exchanges”, are state- or federally run places where people can buy health care coverage. They include websites, call centers, and physical locations, so 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 are eligible for financial assistance or special programs.

Marketplaces also operate a Small Business Health Options Program (SHOP). There, small-business employers of 50 or fewer employees can buy coverage for their employees. In California and Colorado, starting in 2016, the SHOP will become available to employers with 51 to 100 employees.

Employers of up to 50 may qualify but the way the tax credit works, only those employers with 24 or fewer employees will qualify. Employers of 24 or fewer employees will qualify for a tax credit for coverage purchased through the SHOP.

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Q:

Do I have to buy health insurance from the Marketplace?

A:

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

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Q:

Who has to buy health insurance?

A:

Most people are required to have a basic level of health coverage. You are allowed to have one break in the year. If you have a break for one month, then you will have to pay a penalty for the next break in coverage even if it lasts less than one month.

You can only have one break in coverage and it can last no more than 3 months. If you go without it for more than 3 months in a row, you may have to pay a tax penalty. Some people, however, don’t have to buy insurance, based on their income or other status. For more details, go to your state’s Health Insurance Marketplace.

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

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Q:

When can I buy health coverage?

A:

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

If you don’t have health coverage, you can buy individual or family health coverage directly from us (Exception: Residents of Washington, D.C., purchasing health coverage on their own must buy coverage from the Marketplace.)or through the Health Insurance Marketplace during the open enrollment period for 2016, which runs from November 1, 2015, through January 31, 2016. This means that January 31, 2016, is the deadline to enroll for 2016 coverage.

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Q:

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

A:

You may get federal financial assistance to help pay for coverage, care, or both. The amount of help is based on the size of your family, your income and, the cost of coverage in the Marketplace.

You can find out if you qualify for reduced premiums and reduced cost sharing through the Health Insurance Marketplaces. Here are
some general income guidelines that might be used by the government to see if you qualify and how much help you would receive.


  • If you’re single, you could qualify if you make less than $47,080 (or if you live in Hawaii, less than $54,200).
  • For couples, you could qualify if you make less than $63,720 (or if you live in Hawaii, less than $73,320).
  • For a family of 4, you could qualify if you make less than $97,000 (or if you live in Hawaii, less than $111,560).

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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 by the government (with some exceptions) if you go without insurance for 3 months in a row or longer. You are allowed to have one break in the year. If you have a break for one month, then you will have to pay a penalty for the next break in coverage even if it lasts less than one month. 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 are uninsured for less 3 months. If you go without it for more than 3 months in a row, you may have to pay a tax penalty.

When you file your taxes for 2015, you’ll have to show you have coverage.

For more details, go to your state’s Health Insurance Marketplace.

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Q:

Can anyone get health care coverage?

A:

Yes. 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 new health plans cover?

A:

The Affordable Care Act requires most new 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.

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 grandfather plans— are not required to cover all these services. See “What is a grandfathered plan?” for description.

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Q:

What is a “grandfathered” plan?

A:

A health plan that has been in existence since on or before March 23, 2010, and that meets certain requirements. Grandfathered plans are not legally obligated to comply with some of the changes required under the Affordable Care Act.

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