Even if your employer offers coverage, you can opt to buy a plan on the exchange. However, you may not be eligible for a subsidy unless you make less than 400 percent of the federal poverty level and your employer’s plan covers less than 60 percent of allowed medical expenses or costs more than 9.5 percent of your household income.
If I am buying coverage on my own, do I have to buy it on the exchange?
Consumers can shop for coverage on or off the exchange. However, subsidies are generally available only for plans sold on the exchange. Also, adults up to the age of 26 have another choice: They often can get coverage through their parents’ health plans.
What will the coverage sold on the exchanges look like?
Plans will have to offer a set of “essential benefits” that include in-patient hospital care, emergency, maternity and pediatric care as well as coverage for prescription drugs and lab services. Annual cost-sharing, or the amount consumers must pay for co-payments for medical services and deductibles, will be capped at $6,350 for individual policies and $12,700 for family plans in 2014.
What kinds of plans will be offered?
Insurers will offer four types of plans, based on the deductibles, co-payments and other costs the consumer will have to pick up. Insurers must present them in a standardized way so consumers can examine the benefits and cost and comparison-shop (not exactly as they might when booking a hotel or buying an airline flight, but almost).
What if I can’t afford the premiums?
The health law provides sliding-scale subsidies to help people with incomes up to 400 percent of the poverty level, as explained above. There’s additional help for co-payments and deductibles for people with incomes of up to 250 percent of the poverty level ($28,725 for an individual or $58,875 for a family of four). According to government estimates, subsidies will average $5,290 per person in 2014. People who get subsidies are required to pay 2 to 9.5 percent of their income toward premiums, based on how much money they make.
The health law also expands Medicaid. How will I know if I qualify?
The law sought to extend Medicaid to everyone who earns less than 138 percent of the federal poverty level — just under $16,000 for an individual and $32,500 for a family of four based on current guidelines. However, the Supreme Court ruled last year that states may opt out of that expansion. As of early this month, 22 states had chosen not to expand. While the District and Maryland are broadening their Medicaid programs, Virginia has not. People who would have qualified for Medicaid in states that don’t participate in the expansion can enroll in the exchanges, but they won’t qualify for subsidies if their income is below the federal poverty limit.
I am on Medicare. Do I need to use the exchange?
No. Medicare is not part of the health insurance exchanges. Medicare applicants can continue to go to Medicare.gov to sign up during their open enrollment period, which begins Oct. 15.
What about federal workers?
Most federal workers will continue to get coverage through the Federal Employees Health Benefits Program (FEHBP) and not be required to purchase coverage through the marketplaces. Members of Congress and their personal staffs, however, will be required to use the exchanges. The administration said the government would continue to pay up to 75 percent of the premium, as it does for federal workers enrolled in FEHBP, under a proposed rule by the Office of Personnel Management. Members of Congress and their personal staffs will not be eligible for the health law’s subsidies and will purchase coverage on the exchange in the state where they live, the agency said.
Where can I go for help?
You can start with Healthcare.gov. Beginning Oct. 1, the site will publish more information about the plans offered on the federally administered exchanges. If your state is running its own exchange, you’ll be directed there as well. The federal government has also set up call centers to answer questions from people in states with federal exchanges. That phone number is 800-318-2596. States running their own exchanges will also have individual call centers.
What happens if I don’t purchase insurance?
The penalty starts at $95 or 1 percent of income for the first year and rises to $695, or 2.5 percent of income for an individual in 2016.
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.