Frequently Asked Questions - Health Insurance Marketplace
Gundersen answers your questions about the Health Insurance Marketplace.
What is the Health Insurance Marketplace?
The Marketplace is an online portal where you can shop for health insurance plans that fit you or your family's needs. You can compare plans based on price, benefits, quality, and other features important to you before you decide which plan to purchase.
What is the Marketplace in my state?
Is there a phone number I can call?
Who qualifies for the Marketplace?
Most people will be eligible for health coverage through the Health Insurance Marketplace. To be eligible for health coverage through the Marketplace, you:
- Must live in the United States
- Must be a U.S. citizen or national (or be lawfully present)
- Can't be currently incarcerated
What if someone doesn't have health coverage?
If someone who can afford health insurance doesn't have coverage, they may have to pay a fee. They also have to pay for all of their healthcare. The fee increases every year. It's important to remember that someone who pays the fee will not have any health insurance coverage. They still will be responsible for 100% of the cost of their medical care. You cannot sign up for health coverage through the Marketplace outside of an open enrollment period, unless you have a qualifying life event (marry, divorce, have a baby, move to a new coverage area).
When can I sign up?
The next open enrollment period begins November 1 and runs through December 15.
Why should I have health insurance?
Having health coverage can help protect you from potentially high costs associated with health care. Insurance coverage protects you from high medical costs two ways:
- Out-of-pocket maximum: This is the total amount you'll have to pay if you get sick. For example, if your plan has a $3000 out-of-pocket maximum, once you pay $3000 in deductibles, coinsurance, and co-payments the plan will pay for any covered care above that amount for the rest of the year.
- No yearly or lifetime limits: Health plans in the Marketplace can't put dollar limits on how much they will spend each year or over your lifetime to cover essential health benefits. After you've reached your out-of-pocket maximum, your insurance company must pay for all of your covered medical care with no limit.
What's the difference between Marketplace health plans and other private plans?
No matter how you buy your health insurance—through the Marketplace, directly from an insurance company, or with the help of an agent or broker--all plans for individuals and small groups must cover the same set of essential health benefits. These benefits include certain doctor's visits, hospital stays, preventive services, prescription drugs, mental health, and other categories of coverage.
Plans will not be able to charge you more or refuse to cover you if you have a pre-existing condition. Most plans also must offer the consumer rights and protections provided under the health care law. When you apply for Marketplace coverage, you'll find out whether you qualify for lower costs on your premiums or out-of-pocket costs. These savings are based on your household income and size.
Will I qualify for lower out-of-pocket costs?
The Marketplace cost-sharing reduction lowers the amount you have to pay for out-of-pocket costs like deductibles, coinsurance, and co-payments. These are costs you have to pay when you get care. This savings is based on your income and family size.
What if I have a pre-existing health condition?
Being sick won't keep you from getting health coverage. An insurance company can't turn you down or charge you more because of your condition. Once you have insurance, it can't refuse to cover treatment for pre-existing conditions. Coverage for your pre-existing conditions begins immediately. This is true even if you have been turned down or refused coverage due to a pre-existing condition in the past. The only exception is for grandfathered individual health insurance plans--the kind you buy yourself, not through an employer. They do not have to cover pre-existing conditions.
If you have one of these plans you can switch to a Marketplace plan during open enrollment and immediately get coverage for your pre-existing conditions.
What are my health coverage options if I'm unemployed?
If you're unemployed you may qualify for Medicaid, the Children's Health Insurance Program, or lower costs on Marketplace insurance based on your income. Your household size and income, not your employment status, will determine what health coverage options you're eligible for and how much help you get paying for coverage. When you apply for Marketplace coverage you will report your current income and estimate your income for the next year.
Can I keep my own doctor?
Most health insurance plans offered in the Marketplace have networks of hospitals, doctors, specialists, pharmacies, and other health care providers. Networks include health care providers that the plan contracts with to take care of the plan's members. Depending on the type of policy you buy, care may be covered only when you get it from a network provider. When comparing plans in the Marketplace, you will see a link to a list of providers in each plan's network. If staying with your current doctors is important to you, check to see if they are included before choosing a plan.
What do I need to do before I sign up on the Marketplace?
Learn about different types of health coverage. Through the Marketplace, you'll be able to choose a health plan that gives you the right balance of costs and coverage. You can be better prepared if you understand the types of coverage you'll choose from.
- Make a list of questions you have before it's time to choose your health plan.
- Make sure you understand how coverage works, including things like premiums, deductibles, out-of-pocket maximums, co-payments, and coinsurance. You'll want to consider these details while you're looking for health insurance.
- Gather basic information about your household income. Most people using the Marketplace will qualify for lower costs on monthly premiums or out-of-pocket costs. To find out how much savings you're eligible for, you'll need income information, like the kind you get on your W-2, current pay stubs, or your tax return.
- Set your budget. There will be different types of health plans to meet a variety of needs and budgets. You'll need to figure out how much you want to spend on premiums each month.
- Find out if your employer plans to offer health insurance. If not, you may need to get insurance through the Marketplace or from other sources. If you don't have coverage, you may have to pay a fee.
- Explore current options. You may be able to get help with getting coverage now through existing programs. Learn more about health insurance for adults up to age 26, and programs for people and children in families with limited incomes including Medicaid and the Children's Health Insurance Program (CHIP). Medicare covers people who are 65 and older or who have certain disabilities.
- Find out which Marketplace will serve you. If your state runs the Marketplace, you'll use its website to compare your options and enroll in coverage instead of this one. If your state doesn't run the Marketplace, you'll use this website, HealthCare.gov.
If I receive my coverage from my spouse's employer, will I have minimum essential coverage?
Yes. Employer-sponsored coverage is generally minimum essential coverage. If an employee enrolls in employer-sponsored coverage for himself and his family, the employee and all of the covered family members have minimum essential coverage.
Do my spouse and dependent children have to be covered under the same policy or plan that covers me?
No. You, your spouse and your dependent children do not have to be covered under the same policy or plan. However, you, your spouse and each dependent child for whom you may claim a personal exemption on your federal income tax return must have minimum essential coverage or qualify for an exemption, or you will owe a payment when you file.
My employer tells me that our company's health plan is "grandfathered." Does my employer's plan provide minimum essential coverage?
Yes. Grandfathered group health plans provide minimum essential coverage.
I am a retiree, and I am too young to be eligible for Medicare. I receive my health coverage through a retiree plan made available by my former employer. Is the retiree plan minimum essential coverage?
Yes. Retiree health plans are generally minimum essential coverage.
I work for a local government that provides me with health coverage. Is my coverage minimum essential coverage?
Yes. Employer-sponsored coverage is minimum essential coverage regardless of whether the employer is a governmental, nonprofit or for-profit entity.
Do I have to be covered for an entire calendar month in order to get credit for having minimum essential coverage for that month?
No. You will be treated as having minimum essential coverage for a month as long as you have coverage for at least one day during that month.
If I change health coverage during the year and end up with a gap when I am not covered, will I owe a payment?
Individuals are treated as having minimum essential coverage for a calendar month if you have coverage for at least one day during that month. Additionally, as long as the gap in coverage is less than three months, you may qualify for an exemption and not owe a payment.