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Some common questions and topics asked about the Affordable Care Act (Obamacare).


Common questions

• Yes. If you qualify for a Special Enrollment Period (SEP), you can purchase health insurance either through the Marketplace or off-exchange. The Marketplace should be the first choice due to the possibility of receiving a Premium Tax Credit.

• If you qualify for Medicaid or Children's Health Insurance Program (CHIP), you can enroll any time.

• Yes If your wife is not yet old enough to qualify for Medicare and she does not have health insurance through an employer, she may apply through the Marketplace.

For the purpose of determining her subsidy (Premium Tax Credit) you will need to list your total household income not just income she may have.

• Unfortunately, the amount you pay for Medicare, Part D and supplemental insurance premiums cannot be deducted from your household income.

You also must remember to file a joint tax return.

• The HHS issued guidance on this subject in 2016. The HHS made it a little tougher for people to move for the purpose of gaming the system.

You are now required to have been enrolled in minimum essential health coverage for one or more days in the 60 days preceding the date of a permanent move.

People moving from a non-Medicaid expansion state get special scrutiny. If you weren't eligible for tax credits in you old state because your household income was below 100% of Federal Poverty Level (FPL), you could be ineligible for tax credits in the new state.

The key point is you must have had one day at least of coverage in a plan that met minimum essential health coverage, even if you did not get tax credits to pay for it.

For anyone who gains access to a new Qualified Health Plan (QHP) due to a permanent move, you have 60 days before or 60 days after the permanent move to enroll in a plan.

There is twist, states that run their own exchanges were given leeway to structure permanent moves. If you are moving to a state that runs their own exchange be sure to check with them.

Can I apply for coverage and subsidies from the Marketplace?

• Yes, you can purchase Marketplace coverage and based on your income you may be eligible to receive premium tax credits.

• No, you must contact both your Marketplace and your health plan and let them know you no longer need coverage.

You can keep your Marketplace plan, but you will lose any premium tax credits and cost-sharing benefits once Medicare Part A starts. This usually makes a Marketplace plan too expensive to keep.

• No. If you are not a U.S. citizen, U.S. national, or an alien lawfully present in the U.S., you are NOT eligible to buy a plan at the Marketplace.

However, you can shop for health insurance outside of the Marketplace. Insurers outside of the Marketplace are prohibited from turning you down based on your immigration status.

To obtain coverage, contact a state-licensed health insurance company or a licensed agent or broker.

• You can add your children to your Marketplace plan, but because they are eligible for your state's CHIP, they are NOT eligible for premium tax credits.

• The exception to that is if you live in a state that has a waiting period for enrolling in CHIP.

During the waiting period, your children are eligible for a premium tax credit; when the waiting period has ended, they can enroll in CHIP and will no longer be eligible for tax credits.

It is important that you contact both the Marketplace and your health plan and let them know you no longer need coverage.

If you use, you can log into your Marketplace account and select the “terminate coverage” option.

If you want to remove a family member from the policy but keep coverage for yourself, log in to your Marketplace account and select the “reporting a life change” option.

Don't hesitate to call the Marketplace for advise.

Making these changes online creates a written record that you ended coverage. Be sure to print a copy of all acknowledgements for your records.

After you make changes at the Marketplace be sure to call your insurance company and tell them when your changes are to take place.

Going through these steps will help protect you from getting premium bills for months you thought there was no coverage.

Do not stop paying the premium and expect all is finished.

• The Affordable Care Act requires all individual and small group plans to provide maternity coverage. The exception would be grandfathered small group plans. These are becoming fewer and fewer as the market changes and plans renew. Large-group plans have been required to provide maternity coverage since 1978.

• Obamacare does not provide dental or vision care for adults. Insurers may offer adult dental coverage but they are not required to do so.

♦ Remember, premium tax credits can only be used to pay for health coverage. Any dental or vision coverage offered at the Marketplace will need to be paid for without help from subsidies.

• Under the ACA, dental insurance is an essential health benefit for children. Dental coverage must be available for your child either as part of a health plan or a stand-alone plan. Dental insurance for children must be available to you but you are not required to buy it.

• All plans at the Marketplace include vision coverage for children. Not all plans include vision coverage for adults.

Vision screening for children falls under preventive care, which means it's covered at no charge. But vision screening is not the same as an eye exam.
The screening may not diagnose your child's condition. It may be necessary to have an eye exam.

An eye exam may be free, subject to a copay or applied to your plan's deductible. It all depends upon your insurance company and the plan you choose.

Be sure to read the plan's Summary of Benefits (SB) before deciding. In many cases, plans can be found off-exchange which provide better benefits at a similar price.

• The ACA does not require an insurer to cover chiropractic services but many plans do include some coverage. All plans must include coverage for physical therapy.

• Yes. Insurers are permitted to charge older adults more than they would charge younger adults. It is a sliding scale which gets worse as you get older. Premiums for a 64-year old cannot be more than three times the premium of a 21-year old.

• No. The subsidies are not considered income and are not taxed. But you will need to report them when you file taxes.

• Yes. You must make the change while Open Enrollment is still open.

If Open Enrollment has ended, you will need to wait until next year's Open Enrollment. The exception would be if you had a life event that qualifies you for a Special Enrollment Period (SEP).

• Maybe not. If your insurer continues to offer your plan then they will automatically consider you want to continue. However, if your insurer drops your plan they may just put you into a "similar" plan.  You may not like that similar plan.

Insurers always make changes to their policies each year. You should review the changes for next year.

• Premiums usually go up while benefits go down. It is best to consider other plans. You may find a better one for your family.

You can make changes during Open Enrollment.

♦ If you decide to make no changes, you should still update your income estimates for next year.  If you obtained your health insurance through, log in to your account and update your income.  This will help you to receive the correct amount of premium tax credits.

Estimated income wrong

• If you live in a state that did not expand Medicaid and your estimate put you over the federal poverty level but now your actual income would put you below 100% of the federal poverty level … you will not be required to repay the premium tax credit. There is a special rule in the Affordable Care Act that applies in this situation.

• It is a confusing rule. But as long as the Marketplace estimated at the time of enrollment that your income would be between 100 and 400 percent of the federal poverty level for your household and you were determined eligible at the time or your application, you won’t have to pay back the advance premium tax credits received during the year.

I would have qualify for Medicaid instead of premium tax credits. Do I need to pay back premium tax credits I received?

• No. You do not need to pay back any tax credits. You would still be considered eligible for premium tax credits because the Marketplace found you were not eligible for Medicaid at the time of your application.

• In most cases, yes. When you file your income taxes you will reconcile your tax credits and if you were over paid you will need to pay them back. Usually, this amounts to a reduction in your tax refund.

However, if you do not have a refund coming there is no mechanism for the government to actually collect this overpayment.

No. Unlike premium tax credits, which are reconciled each year based on the income you actually earned, cost-sharing reductions are not reconciled.

What happens?

How does this affect tax credits?

• If your income turns out to be higher than you estimated, you will need to return some tax credits. If you your income turns out to be lower than you estimated, you will receive more tax credits.

At tax filing time, your refund will be adjusted. Your refund will be reduced to pay back credits or increased to make up for the credits you did not receive.

How does this affect cost-sharing reductions ?

• Cost-sharing reductions are not like premium tax credits, there is no “reconciliation” of cost-sharing reductions based on actual income for the year.

This means there is no obligation to repay any cost-sharing reductions received if your income is above the amount that was estimated.

Similarly, there will be no refund of cost-sharing paid if income ends up below the estimate.

• Yes. Premium tax credits can be claimed in advance (during the year) or at year end when you file your taxes.

To claim the credit, you will need to file a federal income tax return and Form 8962.

Changes in income

• Yes. You should report any change in income to the Marketplace right away.

The Marketplace will recalculate any premium tax credit based upon your new estimate of annual income.

By reporting promptly and recalculating your premium tax credit you are avoiding having to repay significant overpayments when you file taxes.

• Yes

Unemployment insurance is general included in your gross income.

• The stimulus payment as a result of the COVID-19 emergency is not taxed so it does not count.

• No, there is a special rule to protect people in your situation.

If the Marketplace found you were eligible for premium tax credits based on your best estimate at the time you enrolled, and if your income later fell below the poverty level, you are still eligible for tax credits you received last year.

• You will not be required to repay premium tax credits when you file your return.

• Yes

This is a change in your household size and it will affect your premium tax credit.

If you do not report this to the Marketplace right away, you will have to report this change when you file taxes.

• Reporting earlier helps you to avoid the pain of having to repay overpayments when you file taxes.

Will I need to change plans ?

• If your income increased and you are no longer eligible for cost-sharing reductions, you are eligible for a Special Enrollment Period (SEP). You can change to a plan that does not have cost-sharing reduction.

• If you fail to make the change during this special enrollment period, then the insurer of your current plan can move you to another silver plan which does not have cost-sharing reductions.

Can I change plans ?

• If your income decreased you need to report this to the Marketplace.

If the Marketplace determines you are now eligible for cost-sharing reductions you are eligible for a Special Enrollment Period (SEP) and may choose a new plan with cost-sharing reduction. It must be a silver plan.

• If you fail to make the change during this special enrollment period, then your current insurer will move you to a new plan.

It is better to make this selection on your own. You may find a different insurance company’s plan is better.

What happens?

• You may be eligible for a Special Enrollment Period (SEP) if your income change makes you eligible for a different cost sharing level.

You could change plans or you could stay on your current plan but with lower cost sharing (deductible, copay and coinsurance).

• If you have already paid some cost sharing charges under your current plan they will carry over as long as you do not change the plan. This will help you toward reaching your out-of-pocket maximum.

• If you choose a new plan any cost sharing charges you have already paid will not carry over to the new plan.

What happens?

Can I now get premium tax credits ?

• If you were previously ineligible for premium tax credits because your income was below 100% of the federal poverty level and you also could not get Medicaid because your state did not expand their Medicaid program, a rise in income above the 100% level would trigger a Special Enrollment Period (SEP) for you.

You may qualify for premium tax credits through the Marketplace.

Employer coverage

Can I buy through the Marketplace ?

• If the coverage offered to you by your employer was affordable but you forgot to enroll or chose not to enroll you will not be able to receive premium tax credits at the Marketplace.

You can apply for health insurance at the Marketplace or off-exchange, but you will not receive any assistance with paying for premiums.

• If you missed the open enrollment period for the Marketplace, you will need to wait until the next open enrollment period. Choosing to not to enroll in your employer’s health insurance does not qualify for a Special Enrollment Period (SEP).

Can I buy a Marketplace plan instead? And would I be able to get premium tax credits ?

• Yes, you can buy a plan. But receiving tax credits is unlikely.

The Affordable Care Acts specifies that you may be eligible to receive premium tax credits if your employer’s health plan DOES NOT meet the minimum value standard or is considered not affordable. Additional reading: Minimum Value and Affordable.

Can I look for better coverage and subsidies in the Marketplace?

• Yes, as long as you do so during the Open Enrollment period.

A sticky point would be if you signed up for a Health Reimbursement Account (HRA). In that case, you may not be eligible for premium tax credits.

Remember that outside of Open Enrollment, you cannot voluntarily drop your retiree coverage and replace it with other Marketplace coverage.

Do I have to enroll in COBRA or can I enroll in a Marketplace plan?

• You can choose to do either. Just because you are eligible for COBRA does not prevent you from being eligible for premium tax credits.

Loss of employer-sponsored health insurance qualifies for a special enrollment period for the Marketplace.

• During open enrollment period you can drop COBRA and enroll in a Marketplace plan.

• Outside of open enrollment, you must have a special situation to qualify for a special enrollment period.

It could be COBRA benefits are exhausted or a life changing event like marriage or the birth of a child.

Choosing to not pay COBRA premiums is not a special situation.

Young adult coverage

• Yes, you would be eligible to buy insurance for yourself at the Marketplace and depending upon your income you may be eligible for premium tax credits.

You cannot be claimed as a dependent by your parent, if you are then you would not qualify for tax credits.

Can I change to a Marketplace plan ?

• You need to wait until open enrollment in order to apply for coverage. At that time, you could drop your student health coverage.

• Outside of open enrollment, if you were to drop your student health plan you would not qualify for a Special Enrollment Period (SEP).

You would need to have a situation that caused you to lose coverage like graduating or leaving school to qualify for a Special Enrollment Period (SEP).

We have a Marketplace plan. Can we cover him on our policy?

• Yes, you can. However, you need to make sure he can access in-network services while he is away at school.

Some insurers sell plans in many states and offer regional or national provider networks.

If your plan doesn't offer network providers in your son's state, you should consider buying a separate plan for your son.

• Yes. Age is the key factor if your parents receive coverage through an employer.

• If your parents purchase health insurance through the Marketplace then they will claim you as a dependent and your income will be included as part of the household income. Depending upon your income tax credits could be affected.

• You can remain covered as a dependent on your parent’s policy until you turn 26. When you turn 26, you will qualify for a Special Enrollment Period (SEP). You will be able to apply for insurance through the Marketplace and you may be able to receive premium tax credits.

• Alternatively, if your parent's insurance is obtained through an employer with 20 or more employees, you may be able to continue under COBRA. COBRA is usually more expensive than a Marketplace plan, especially for younger people.

Dependents for premium tax credits

• The number of dependents claimed on your tax return will be taken into consideration when premium tax credits are calculated.

A dependent generally, would include children, siblings, parents, grandchildren, other family members and even people who are unrelated to the taxpayer if they meet IRS rules.

♦ The Affordable Care Act limits premium tax credits to U.S. citizens and lawful residents only.

The IRS on the other hand does permit the claiming of a child as a dependent if the child is a citizen or resident of the U.S., Canada or Mexico.

The application process at the Marketplace will ask the immigration status of all family members.

• An adult child can be claimed as a dependent if he meets IRS rules covering dependency.

The child must be under the age of 19 or, if a full time student younger than 24 as of the end of the calendar year.

There's no age limit if your child is "permanently and totally disabled."

The adult child must have lived with you all year as a member of your household.

• Your child can work and earn money but you still must provide more than half that person’s total support for the year.

• Yes and no.

If the adult child is claimed as a dependent on his parents taxes, then it is his parents who will receive any possible premium tax credit.

• Dependents can qualify for premium tax credits in a sense but it based on the household income. The premium tax credits would then be used to help purchase coverage for the household, which includes the dependent.

Am I still responsible for the dependents insurance coverage ?

• You are not required to claim someone as a dependent on your tax return.

♦ Not claiming an eligible dependent does not release you from your obligation to provide the dependent with health insurance.

You can still be held responsible for your dependent’s Shared Responsibility Payment (penalty) for not having coverage.

♦ January 01, 2019 — The federal mandate is no longer in effect so the penalty is gone.

Medicaid and premium tax credits

• No

If your income is between 100 and 138 percent of the federal poverty level and you are determined eligible for Medicaid, you would not be eligible for premium tax credits.

♦ However, if you are not eligible for Medicaid because your state did not expand Medicaid or for another reason, you may qualify for premium tax credits.

• Usually, no.

Most pregnancy-related Medicaid is considered Minimum Essential Coverage (MEC). If a woman enrolls in pregnancy-related Medicaid, she will be ineligible for premium tax credits.

♦ However, Arkansas, Idaho and South Dakota have pregnancy-related Medicaid that is not considered to be Minimum Essential Coverage. In this case, the woman would be eligible for premium tax credits.

Special enrollment periods

♦ Marriage, divorce or legal separation, job loss, when one member of the family loses minimum coverage and the birth of a baby triggers open enrollment for the entire family.

♦ Moving to a new location may qualify for special enrollment if the plans available in the new location are different than the ones you have now. If they are not different then you may not qualify for special enrollment.

♦ A rise in income could trigger a Special Enrollment Period (SEP) under some circumstance. If you your income was below 100% of the federal poverty level and you also could not get Medicaid. A rise in income above the 100% level would trigger a Special Enrollment Period (SEP).

♦ Additional changes that may qualify for a Special Enrollment Period (SEP) can be found in more detail at Special Enrollment Period.

Yes, in most states. You may be able to select a health plan, but the effective date of coverage will be delayed while the Marketplace verifies your eligibility for the SEP.

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