Health Care Reform FAQ: Getting Lower Costs on Coverage
How much will Marketplace health insurance cost?
Prices of Marketplace plans have not been set yet. Prices will be available Oct. 1, 2013, when open enrollment starts and you can begin shopping.
How will Marketplace health plans be priced?
All insurance plans available through the Marketplace will be offered by private insurance companies. The insurance companies will decide which plans to offer and how much each will cost.
All Marketplace plans must be approved by state insurance departments and certified by the Marketplace. Prices are approved by state insurance departments as required by state law.
Some Marketplace health plans will have lower monthly premiums and may charge you more out of pocket when you need care. Some will be higher-premium plans that cover more of your costs when you need care. Others will fall in between. All plans will cover the same list of essential health benefits.
Starting in October when you use the Marketplace to compare plans, you’ll see prices for all plans available to you. Prices will show any cost savings you may be eligible for based on your income.
How can I get lower costs on Marketplace coverage?
When you use the Marketplace, you may be able to get lower costs on monthly premiums or out-of-pocket costs, or get free or low-cost coverage.
You can save money in the Marketplace in three ways. All of them depend on your income and family size.
- You may be able to lower costs on your monthly premiums when you enroll in a private health insurance plan.
- You may qualify for lower out-of-pocket costs for copayments, coinsurance and deductibles.
- You or your child may get free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP).
Will I qualify for lower costs on monthly premiums?
It depends on the size of your household and the amount of income you earn every year. The lower your income, the higher your savings will be. In general, people at the following income levels will qualify to save in 2014. (The amounts below are based on 2013 numbers and are likely to be slightly higher in 2014.)
- Up to $45,960 for individuals
- Up to $62,040 for a family of two
- Up to $78,120 for a family of three
- Up to $94,200 for a family of four
- Up to $110,280 for a family of five
- Up to $126,360 for a family of six
- Up to $142,440 for a family of seven
- Up to $158,520 for a family of eight
If you fall within these thresholds, you’ll see the amount of savings you’re eligible for when you fill out your Marketplace application. Prices shown for insurance plans will reflect the lower costs.
These lower costs are handled with a tax credit called the Advance Premium Tax Credit. But these tax credits can be applied directly to your monthly premiums, so you get the lower costs immediately.
Will I qualify for lower out-of-pocket costs?
When you get coverage through the Marketplace, you may be able to get lower costs on deductibles, copayments and coinsurance.
As with the premium tax credits, whether you qualify depends on the size of your household and your annual income. For getting lower out-of-pocket costs, the threshold is lower.
Health insurance companies offering coverage through the Marketplace must lower the amount you pay out of pocket for essential health benefits if your household income is below the following amounts. (Incomes below are based on 2013 numbers. They are likely to be slightly higher in 2014.)
- Up to $28,725 for individuals
- Up to $38,775 for a family of two
- Up to $48,825 for a family of three
- Up to $58,875 for a family of four
- Up to $68,925 for a family of five
- Up to $78,975 for a family of six
- Up to $89,025 for a family of seven
- Up to $99,075 for a family of eight
Plans in the Marketplace are separated into four different categories: Bronze, Silver, Gold and Platinum. These categories are based on how much of your medical costs you pay and how much the plan pays when you get medical care. They are not based on plan quality. If you qualify for out-of-pocket savings, you must choose a Silver plan to get the savings.
Do I qualify for Medicaid?
That depends. You qualify for Medicaid based on income and family size. If you’re eligible, you get free or low-cost care and don’t need to buy a Marketplace plan.
Medicaid programs must follow federal guidelines, but they vary somewhat from state to state. Most states offer coverage for people below a certain income, including pregnant women, some seniors, people with disabilities and adults with children. Under the Affordable Care Act, Medicaid eligibility is expanding in most states.
If you didn’t qualify for Medicaid in the past, you may qualify under the new rules. To see if you qualify for Medicaid, visit your state’s Medicaid website. Check with your state’s program to find out what’s covered. If you’re still not eligible, check again in 2014, when new rules take effect in some states.
Are my children eligible for the Children’s Health Insurance Program (CHIP)?
It depends. Each state program has its own rules about who qualifies for CHIP. There are two ways to find out whether your children qualify:
- Visit www.insurekidsnow.gov, or call 1-877-543-7669.
- Fill out the Marketplace application when enrollment opens on Oct. 1, 2013. When you finish this application, the Marketplace or applicable entity will tell you which programs you and your family qualify for. If it looks like anyone in your family is eligible for CHIP, the Marketplace will notify the CHIP agency so that your coverage can start right away.
CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP covers parents and pregnant women. Every state offers CHIP coverage, and works closely with its state Medicaid program.
The benefits covered through CHIP are different in each state, but all states provide comprehensive coverage, including:
- Routine check-ups
- Doctor visits
- Dental and vision care
- Inpatient and outpatient hospital care
- Laboratory and X-ray services
- Emergency services
Can I buy a “catastrophic” plan?
People under age 30 and some people with limited incomes may buy what is called a “catastrophic” health plan. It protects you from very high medical costs. A catastrophic plan generally requires you to pay all of your medical costs up to a certain amount, usually several thousand dollars. Costs for essential health benefits over that are generally paid by the insurance company. These policies usually have lower premiums than a comprehensive plan, but cover you only if you need a lot of care. They basically protect you from worst-case scenarios.
In addition to people in their teens and twenties, people over 30 with low incomes for whom other insurance is not considered affordable or who have received a hardship exemption from the penalty may be able to buy these catastrophic plans in the Marketplace.
Where can I get free or low-cost care in my community?
If you can’t afford any health plan, you can get free or low-cost health and dental care at a nearby community health center.
How much you pay depends on your income. Community health centers are located in both urban and rural areas and provide the following services:
- Prenatal care
- Children’s immunizations
- Prescription drugs
- General primary care
- Specialized care for more serious conditions, including mental health, substance abuse and HIV/AIDS
What do American Indians and Alaska Natives need to know about the Marketplace?
If you’re a member of a federally recognized tribe and qualify for a health insurance plan in the Marketplace, you have certain protections, such as the following:
- Monthly special enrollment periods
- No copayments or other cost-sharing if your yearly income is below a certain level—around $70,650 for a family of 4 in 2013 ($88,320 for the same family in Alaska). When you fill out a Marketplace application, you’ll find out whether you qualify for these lower costs.
- If you qualify for Medicaid or CHIP and you’re eligible for or have gotten services from the Indian Health Service, tribal health programs or urban Indian health programs, you won’t have to pay Medicaid or CHIP premiums, enrollment fees or out-of-pocket costs. Indian trust income isn’t counted when determining Medicaid eligibility.
To get special Marketplace protections, you’ll need to provide a copy of a document issued by a federally recognized tribe that shows membership in that tribe.
If you’re applying for Marketplace coverage, in addition to basic information about household size and income, you’ll need to provide information about income from Indian trust land, natural resources, and items of cultural significance. This income won’t be counted for Medicaid or CHIP eligibility, but may be counted for Marketplace purposes.