Making the Complex Simple in 10 Easy Pieces

This is our ObamaCare top 10 list of the most important things to know about ObamaCare (the Affordable Care Act).

The law can be overwhelming, but understanding these ten “ObamaCare Facts” will be enough to help you get covered, avoid the fee, and participate in jovial water-cooler conversation.

Once you have memorized these facts, check out our ObamaCare Facts master list for every fact and statistic one could ever want to know about the law or check out our pros and cons list for more information on the political and economic side of things.

The ObamaCare Top 10 List

Understand these 10 ObamaCare bullet points, and you’ll be well on your way to becoming an Affordable Care Act expert. Please note that you can click on any of the links below to explore each topic in depth.

1. The Affordable Care Act (ObamaCare) requires you to get and keep major medical insurance (known as minimum essential coverage) throughout the year, pay a fee for each month you go without coverage, or get an exemption. The requirement to buy insurance is sometimes called the “individual mandate,” and the fee you have to pay is called the “individual shared responsibility payment.” There are over 20 exemptions from the fee, including a short coverage gap of fewer than 3 months everyone qualifies for and an exemption based on income. Some exemptions require you to apply for the marketplace in advance, all exemptions are claimed on form 8965.

In plain English: You need to Get Health Insurance if you can afford it, or you’ll have to pay a tax for every month you go without coverage or an exemption.

2. Minimum essential coverage includes all marketplace coverage, most major medical coverage sold outside of the marketplace, Medicare, Medicaid, employer-based coverage, and more. It does not include short-term health insurance.

In plain English: Ask the folks you Buy Insurance from if your policy counts as “minimum essential coverage.” If you are buying private insurance on your own outside of the Health Insurance Marketplace (HealthCare.Gov or your state marketplace), make sure you aren’t buying a short-term health policy.

3. Unless you qualify for Medicare, you can use HealthCare.gov or your state’s marketplace to sign up and enroll in a plan during each year’s open enrollment period. You can use the marketplace to compare plans, apply for cost assistance, and see if you qualify for Medicaid / CHIP. 24 / 7 assistance is offered on the phone, in-person, or via chat. If you don’t know what your state’s marketplace is, or are confused about how to shop for coverage, always start with HealthCare.gov.

In plain English: If you make your first stop HealthCare.gov, it will help you to avoid potential headaches. If your state has it’s own marketplace, HealthCare.gov will redirect you. Only plans purchased through HealthCare.gov or your state marketplace qualify for cost assistance to lower premiums and out-of-pocket costs.

4. You can ONLY purchase qualifying private medical insurance during open enrollment. This is true both inside and outside the marketplace. The only exception is if you’ve recently had a major life change like moving, getting married, or losing your job. A major life change may qualify you for a special enrollment period in the Health Insurance marketplace.

In plain English: Unless you recently had a major life change, you can’t Get Private Coverage outside of open enrollment. If you try to buy private insurance outside of open enrollment, chances are you’ll end up with a plan that doesn’t protect you from the fee. In most cases, you’ll just have to wait until next open enrollment unless, of course, you qualify for a special enrollment period.

5. By using the marketplace, you’ll find out if you qualify for cost assistance on your premium or out-of-pocket costs. Cost assistance is based on your income – which must be between 100% and 400% of the Federal Poverty Level (FPL) – and is only available through the marketplace. Out-of-pocket assistance is only offered on Silver plans. If you get cost assistance, you’ll need to file form 8962 at tax time. Those with affordable employer coverage can get coverage, but can’t get cost assistance. Those with Medicare can’t use the marketplace and must go with a Medicare plan. For those looking for the best value, we suggest people look into a Silver plan with a Health Savings Account (HSA) and be aware of where their income falls on the Federal Poverty Level. Keep in mind cost assistance is based on annual household income (head of household and spouse’s MAGI plus tax dependents AGI for the year you claim assistance), not monthly income.

In plain English: 6 in 10 uninsured Americans can get covered for $100 or less a month. There is a 6 in 10 chance this applies to you. Nearly 9 in 10 (87%) of those who enrolled in a marketplace account got assistance. Again, a 9 in 10 chance this applies to you. However, don’t forget that cost assistance is based on annual household income. If you make more income than you expected, you could end up repaying tax credits. See our page on comparing health plans for more tips and tricks on saving money on health plans.

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6. You can enroll in Medicaid and CHIP 365 days a year. Eligibility is based on income, which must be at or under 138% of the Federal Poverty Level (FPL) in states that expanded Medicaid. During open enrollment, you can find out if you qualify for Medicaid by going to HealthCare.gov. Outside of open enrollment, you’ll need to follow these steps to sign up for Medicaid.

In plain English: You can enroll in Medicaid and CHIP 365 days a year, but if your state rejected Medicaid expansion under the ACA, coverage options may be limited. Go here to see if you qualify.

7. You can Buy Insurance outside of the marketplace. Many insurers work with HealthCare.gov and can help enroll you in a marketplace plan if you qualify for cost assistance during open enrollment. If you don’t qualify for cost assistance, then shopping outside the marketplace could even be your best option as, in many cases, you’ll have a wider selection of plans. Private insurance must be purchased during the annual open enrollment period as all insurers have adopted the marketplace’s open enrollment period.

In plain English: Want to get covered outside of the marketplace during open enrollment? Depending upon your region, if you make too much for cost assistance, this may be your best bet. Thanks in part to the Affordable Care Act, the cost and quality of major medical insurance is highly regulated, so how you shop is up to you. Make sure to compare quotes outside the Marketplace to quotes obtained on the Marketplace.

8. When you choose a health plan, in most cases you’ll have to keep that specific plan until the next open enrollment period. Make sure to choose a plan that meets all your needs. Things to keep in mind: PPOs tend to have wider networks than HMOs – you’ll want to make sure the drugs and services you need are covered under your plan. If you rarely use medical services, a high-deductible low premium plan could be your best option. If you use lots of services, you’ll probably want a low-deductible plan with high cost sharing. Consider getting an HSA-eligible plan to take advantage of the tax benefits of a Health Savings Account on higher-deductible plans. In general, higher-cost plans will save you more the more you use them. You can learn more about comparing plans here.

In plain English: Know what services you and your family will need, and then check the benefits sheet to make sure you are getting a plan that works for you. We suggest phoning an agent or meeting one in person for extra help. You can Change Your Plan at any time during open enrollment.

9. No matter what plan you get, most basics – like an annual checkup, immunizations, preventive tests, and more – will be covered with no out-of-pocket costs. Regardless of health status, any major medical plan that you want to pay for must be sold to you. You can’t be charged more based on gender or health status, and you can’t max out annual or lifetime dollar limits on essential care. Familiarize yourself with your new benefits, rights, and protections.

In plain English: All plans must offer basic care – make sure you take advantage of it.

10. As the law stands now, the “employer mandate” says that large employers with over 50 full-time equivalent employees have to cover their full-time workers starting in 2016.

In plain English: Your employer has to cover you if you work for a larger business. Some employers have stepped up to the plate early. Remember, if you have access to employer-based coverage, you can’t get cost assistance.

How to Sign Up For The Health Insurance Marketplace

If you are ready to sign up, you can use your State’s health insurance marketplace to enroll in private insurance, get access to subsidies, or apply for Medicaid or CHIP. Below are the ways to access the marketplace during open enrollment.

1) Find your State’s marketplace website.

2) Get in-person help. You can find in-person help by going to LocalHelp.Healthcare.gov.

3) Call the 24/7 marketplace helpline 1-800-318-2596.

4) Mail in a paper application. bit.ly/PaperApplication. (read these instructions first)

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How to Enroll in a Health Insurance Marketplace Plan

Below are the official directions for enrolling in a marketplace plan through healthcare.gov. Remember that signing up is only step one; to officially have coverage, you still need to choose a plan and make sure your first payment is made. The direction below are specifically for states running a federally based marketplace (i.e. State’s using healthcare.gov as their marketplace), but state-based marketplaces have very similar sign-up and enrollment processes. Don’t forget – you can only sign up and enroll during open enrollment.

  1. Set up an account. First, you’ll provide some basic information. Then choose a username, password, and security questions for added protection.
  2. Fill out the online application. You’ll provide information about you and your family, like income, household size, current health coverage information, and more. This will help the Marketplace find options that meet your needs. Important: If your household files more than one tax return, call the Marketplace Call Center at 1-800-318-2596 before you start an application.(TTY: 1-855-889-4325) This is a very important step. Please don’t skip it. Representatives can provide directions to make sure your application is processed correctly.
  3. Compare your options. You’ll be able to see all the options you qualify for, including private insurance plans and free and low-cost coverage through Medicaid and the Children’s Health Insurance Program (CHIP). The Marketplace will tell you if you qualify for lower costs on your monthly premiums and out-of-pocket costs on deductibles, copayments, and coinsurance. You’ll see details on costs and benefits to help you choose a plan that’s right for you.
  4. Enroll. After you choose a plan, you can enroll online and decide how you pay your premiums to your insurance company. If you or a member of your family qualify for Medicaid or CHIP, a representative will contact you to enroll. If you have any questions, there’s plenty of live and online help along the way.

For more details on signing up, you can check out our health insurance marketplace guide or find your State’s health insurance marketplace now to get started.

Shopping For Coverage Outside of Open Enrollment

If you missed open enrollment, you still have options for coverage including a special enrollment period and options for obtaining Medicaid, CHIP, or health coverage outside of the Marketplace. Check out our breakdown of what to do if you missed the ObamaCare deadline.

 

Ten Essential ObamaCare Facts
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