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FAQs

Most commonly asked coverage questions

Individual

When the Affordable Care Act was written, lawmakers knew that it would be essential to get healthy people enrolled in coverage, since insurance only works if there are enough low-cost enrollees to balance out the sicker, higher-cost enrollees. So the law included an individual mandate, otherwise known as the shared responsibility provision.

This controversial provision stipulated that people who didn’t have minimum essential coverage would be subject to a tax penalty unless they were exempt from the shared responsibility provision.

But that tax penalty was eliminated after the end of 2018, under the terms of the Tax Cuts and Jobs Act of 2017. Technically, the individual mandate itself is still in effect, but there’s no longer a penalty to enforce it.

Pediatric dental is one of the ACA’s essential health benefits. But there’s no requirement that dental care for adults be covered.

And even though pediatric dental is considered an essential health benefit, it works differently from the other nine essential health benefits. In some states, pediatric dental benefits are embedded in health insurance plans, either because the state requires this or because the insurers choose to take this approach. But in most states, as long as there are stand-alone dental plans available for sale in the exchange, the health insurance plans in the exchange do not have to include pediatric dental coverage. Instead, applicants can be directed to purchase pediatric dental as a separate, stand-alone plan.

And dental coverage for adults is almost never included in marketplace plans. Adults can choose to purchase stand-alone coverage, but since this is not an essential health benefit, the plans virtually always include fairly low annual benefit caps (for pediatric dental coverage, insurers cannot impose a dollar limit on the benefits, since pediatric dental is considered an essential health benefit and those cannot have annual or lifetime caps on how much the insurer will pay for treatment).

The Open Enrollment Period begins November 1 and will run until December 15. If you sign up for health insurance coverage before December 15, your coverage starts on January 1. Outside of the Open Enrollment Period, you will need a qualifying event to sign up for health insurance coverage. These events are:

  • Loss of eligibility for other coverage (not including loss due to unpaid premiums)
  • Gaining a dependent (for example, if you get married or give birth to or adopt a child).
  • Divorce or legal separation
  • Loss of dependent status
  • Moving to another state or within a state if you move outside of your health plan service area
  • Exhaustion of COBRA coverage
  • Losing eligibility for Medicaid or the Children’s Health Insurance Program
  • For people enrolled in a Marketplace plan, income increases or decreases enough to change your eligibility for subsidies
  • Change in immigration status
  • Enrollment or eligibility error made by the Marketplace or another government agency or somebody, such as an assister, acting on their behalf

Your special enrollment opportunity will last 60 days from the date of that triggering event.

Medicare

If you’re eligible for Medicare when you turn 65, you can sign up during the 7-month period that:

  • Begins 3 months before the month you turn 65
  • Includes the month you turn 65
  • Ends 3 months after the month you turn 65

Individual Medicare supplement policies are designed to supplement the benefits available under the original Medicare program. Medicare supplement policies pay the 20% of Medicare-approved charges that Medicare does not pay. These plans typically do not restrict you to a network of doctors, but rather allow you to go to any doctor or facility that takes Medicare. Individual Medicare supplement policies include a basic core of benefits. In addition to the basic benefits, Medicare supplement insurers offer specified optional benefits. Each of the options that an insurance company offers must be priced and sold separately from the basic policy.

Medicare Advantage is a special arrangement between the federal Centers for Medicare & Medicaid Services (CMS) and certain insurance companies. Under this arrangement the federal government pays the insurance company a set amount for each Medicare beneficiary. The insurance company agrees to provide all Medicare benefits. The insurance company may provide some additional benefits, but it may also require payment of an additional premium. Beneficiaries under Medicare Advantage plans continue to pay the Part B Medicare premium to CMS. Your Medicare Advantage plan can terminate at the end of the contract year if either the plan or CMS decides to terminate their agreement.

Whether you are working or not when you turn age 65, you’ll still be eligible for Medicare coverage. It is not mandatory to sign up for Medicare. In fact, you may prefer the healthcare coverage offered by your employer. However, if you defer or decline Medicare coverage, you could pay some form of penalty.  In many cases, it’s best to apply for Medicare Part A when you become eligible, even if you’re covered by a group health plan. Delaying enrollment in Part A may lead to a penalty if you sign up later.

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