Navigator Guide FAQ of the Week: Am I Required to Get Coverage?

Open Enrollment for marketplace coverage under the Affordable Care Act (ACA) begins today and goes through December 15. To help assisters and consumers navigate this enrollment season, CHIR has updated its Navigator Resource Guide, with thanks to support from the Robert Wood Johnson Foundation. The Guide is a practical, hands-on resource with over 300 searchable frequently asked questions (FAQs) on topics such marketplace eligibility, premium and cost-sharing assistance, the individual mandate, and post-enrollment issues for individuals.

Throughout Open Enrollment, we will highlight FAQs that are likely to be top of mind for consumers as they apply for and enroll in health coverage. This week, we are focusing on whether health insurance is still mandatory, and why it is important to have.

I heard that the mandate to have health insurance no longer applies. Is that correct?

The individual responsibility requirement, also known as the individual mandate, is a provision of the Affordable Care Act requiring that all citizens obtain a minimum standard of health insurance coverage.

As of January 1, 2019, there is still a requirement to maintain coverage, although you will not be charged a tax penalty unless you live in California, District of Columbia, Massachusetts, New Jersey, or Rhode Island. Still, maintaining “Minimum Essential Coverage” is required by federal law, and obtaining such coverage determines your eligibility for premium tax credits and most special enrollment periods. Also, health insurance coverage provides important financial protection in case you need health services such as when you are sick or have an injury.

If there’s no longer a penalty, why should I get coverage?

You are still required by law to have Minimum Essential Coverage, but will not be charged a tax penalty for failing to have coverage in 2019 or 2020 unless you live in a state with an individual mandate (California, District of Columbia, Massachusetts, New Jersey, or Rhode Island).

Beyond these legal requirements, insurance coverage is an important protection against unexpected, high medical costs. The cost of paying for medical care out of pocket is prohibitively expensive for most people, and while insurance coverage can also present a financial burden, it is far less than the cost of paying for an emergency situation or treatment for an unforeseen diagnosis without coverage.

To ensure that an insurance product provides comprehensive coverage and adequate financial protection, and to see if you qualify for premium tax credits, visit HealthCare.gov.

Where should I buy coverage?

First, you should visit HealthCare.gov to see if you qualify for premium tax credits based on your income, which can significantly lower the cost of coverage. Plans available through HealthCare.gov are also guaranteed to provide the Affordable Care Act’s protections, including a comprehensive set of benefits and limits on cost-sharing that can save you money when you access health services.

If you do not qualify for premium tax credits to purchase plans on HealthCare.gov, you can still purchase coverage there, or you can try to shop for similar coverage that still provides the Affordable Care Act’s protections outside of the marketplace. To access these plans, contact your state’s Department of Insurance for a list of reputable brokers that can help you shop for Minimum Essential Coverage.

There may be other coverage options available outside of the marketplace that do not provide the Affordable Care Act’s protections. These include plans that are not traditional health insurance products, including short-term, limited duration insurance, association health plans, health care sharing ministries, and Farm Bureau plans. If an insurer or entity cannot provide a Summary of Benefits and Coverage that indicates coverage is Minimum Essential Coverage, be aware that the plan may have coverage limitations, particularly for pre-existing health conditions or for basic medical care. Always insist on getting plan documents to review prior to buying a plan.

What should I keep in mind as I think about health insurance?

Most people are eligible for financial assistance through the Marketplace. If you are in a household whose total income is between 100 and 400 percent of the Federal Poverty Level, you are likely eligible for help lowering your premiums, and in some cases, your deductibles, co-payments, and out-of-pocket maximums.

Additionally, you may want to seek in-person assistance from a certified Navigator in your community. You can find Navigators by contacting your state’s Department of Insurance, or by using the “Find Local Help” tool on HealthCare.gov.

Stay tuned for more FAQs of the Week blogs, watch out for daily FAQs, and keep the conversation going by following us on Twitter @GtownCHIR.

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