Frequently Asked Questions

 

What is the Affordable Care Act (ACA)? Is that the same thing as Obamacare?

The , which is often called “Obamacare,” is a law passed in 2010 that made many changes in how Americans get health insurance. It created a website, the Health Insurance Marketplace, as a way to buy health insurance.


How is my health insurance changing?

If you buy insurance for yourself or your family directly from a health insurance company, you have a choice to use the Missouri Health Insurance Marketplace. The Marketplace will allow you to compare health plans from different companies and select one that works best for you. Additionally, you may be able to get financial help to lower your health insurance premiums when you use the Missouri Health Insurance Marketplace. Click here to learn more about tax credits and subsidies.

There are also health insurance rules that may improve the quality of the health insurance you already have or that you buy in the Marketplace. Click here to learn more.


What is the Missouri Health Insurance Marketplace?

The Missouri Health Insurance Marketplace is an online marketplace where you can buy a Qualified Health Plan (, and in Missouri) or coverage from private insurance companies. You can use the Missouri Marketplace if you:

  • Are an individual or family buying insurance on your own.
  • Do not have access to coverage through your job.

The Open Enrollment Period for 2019 health coverage is Nov. 1 through Dec. 15, 2018. However, if you experience a major life change before or after open enrollment, you may qualify for a Special Enrollment Period to enroll in Marketplace coverage.


How do I use the Missouri Health Insurance Marketplace?

The Open Enrollment Period for 2019 health coverage is Nov. 1 through Dec. 15, 2018. However, if you experience a major life change before or after open enrollment, you may qualify for a Special Enrollment Period to enroll in Marketplace coverage. You can complete your marketplace application by:

  • Visiting the marketplace at www.healthcare.gov or by clicking here.
  • Calling 1-800-318-2596 (TTY: 1-855-889-4325).
  • Working with a or in person. Click here to find a location near you.

To complete the application, you need to give information about yourself and your family, including:

  • Household income.
  • Number of people in your family.
  • Any health insurance you currently have. (If you do not have any, that is OK).
  • Information about your employer, if you or anyone in your household has a job.

Based on the information you give, the Marketplace will let you know if you qualify for:

  • / and ask if you want to apply for that coverage.
  • A to lower health insurance premiums.
  • s to lower costs.

When can I use the Missouri Health Insurance Marketplace? Will my coverage start right away?

Open enrollment for 2019 health coverage is Nov. 1 through Dec. 15, 2018. However, if you experience a major life change before or after open enrollment, you may qualify for a Special Enrollment Period to enroll in Marketplace coverage.

In general:

  • Coverage you buy during the open enrollment period (Nov. 1 – Dec. 15, 2018) will begin January 1, 2019.
  • If you have a major life change, like getting married, having a baby, or losing a job, before or after the open enrollment period, you may still be able to buy a health plan in the Missouri Health Insurance Marketplace. This is called a Special Enrollment Period.

What if I miss open enrollment for the Missouri Health Insurance Marketplace? What is a Special Enrollment Period?

If you didn’t enroll in a health insurance plan by the open enrollment period deadline, you may qualify for a Special Enrollment Period to enroll in Marketplace coverage. If you have a major life change, like getting married, having a baby, or losing a job, after the open enrollment period ends, you may still be able to buy a health plan in the Missouri Health Insurance Marketplace within 60 days of the life event.


What kinds of health insurance plans will the Missouri Health Insurance Marketplace have?

Plans in the Missouri Health Insurance Marketplace are organized into four levels. The levels are based on how much the insurance company will pay for covered care and what your share of costs will be:

plan-graphic-for-website

All Missouri Marketplace health plans at all levels cover the same set of . Some plans may even cover additional .

The health plan level you choose will affect your monthly premiums and what you have to pay for covered health services, like doctor’s visits and prescription drugs.

The Missouri Marketplace also offers catastrophic coverage to young adults up to age 30 and other people who cannot get affordable coverage.


What are essential health benefits?

Essential health benefits are 10 categories of health services health plans must cover. These categories are:

  • Ambulatory patient (also called outpatient) services, such as doctor office visits.
  • Emergency services.
  • Hospitalizations.
  • Maternity and newborn care.
  • Mental health and substance use disorder services.
  • Prescription drugs.
  • Rehabilitative and services and devices, like physical therapy and walkers.
  • Laboratory services, such as blood tests.
  • Preventive care and disease management.
  • Pediatric services, including vision and dental care for kids.

I am worried about cost. How can I afford health insurance?

If you use the Missouri Health Insurance Marketplace to buy coverage, you may qualify for financial help. When you fill out your application, you will find out if you can get a premium tax credit or cost-sharing reductions. Both of these options can reduce your health care costs. They are available to people with income at a certain level.


What if I am self-employed?

If you are self-employed – you run a business with no employees – you can use the Missouri Health Insurance Marketplace to buy coverage. Depending on your income, you may also qualify for premium tax credit or cost-sharing reductions that lower your costs.


What if I have a health problem or pre-existing condition?

Health insurance companies cannot deny you health insurance because of a . Health plans are also not allowed to charge higher premiums because of your medical history or current health.


Do I qualify for Medicaid?

In general, Missouri’s Medicaid program, called MO HealthNet, covers people with very low incomes. Low-income children, their parents or guardians, disabled individuals, and older adults (age 65 or older) are covered by Medicaid at different income levels. Income is measured as a percentage of the federal poverty level and varies based on family size. You can use the Missouri Health Insurance Marketplace to see if you qualify for Medicaid.

Covered Populations Income Guidelines
Children (up to age 19) Up to 300% of the Federal Poverty Level () (meaning at or up to three times as much as the FPL).
Parents Up to about 18% of the FPL(meaning at or up to 0.18 times as much as the FPL).
Pregnant women Up to 185% of the FPL (meaning at or up to 1.85 times as much as the FPL).
Disabled individuals Up to 85% of the FPL (meaning at or up to 0.85 times as much as the FPL).
Missourians (age 65 and over) Up to 85% of the FPL (meaning at or up to 0.85 times as much as the FPL).
Blind individuals Up to 100% of the FPL (meaning up to as much as the FPL).
Qualified Medicare beneficiaries Up to 100% of the FPL (meaning up to as much as the FPL).

Note: Income guidelines for parents are based on the July 1996 Aid for Families with Dependent Children (AFDC) payment standard.

Family size 2018 federal poverty level

(100%-400%)                          (250%)

1 $12,140 – $48,560 $30,350 or less
2 $16,460 – $65,840 $41,150 or less
3 $20,780 – $83,120 $51,950 or less
4 $25,100 – $100,400 $62,750 or less

How does this impact Medicare?

Medicare was impacted in two ways:

  • covers recommended preventive services, like wellness exams and mammograms, with no .
  • People on Medicare with prescription drug coverage who reach a gap in coverage – the “donut hole” – may have seen their costs go down. This is because discounts on brand name and generic medications are being added to close the coverage gap. The donut hole should be closed by 2020.

I heard there is a requirement to have health insurance. How do I know if I am following the law?

Starting in 2019, it is not required to have health insurance. If you did not have insurance in 2018, you may have to pay a penalty. If you are insured or receive health care through one or a combination of the following sources, you meet the requirement for having health insurance in 2018:

  • A health insurance plan offered by your employer. This includes and retiree coverage.
  • Insurance bought on your own.
  • Medicare.
  • Missouri’s Medicaid program and Children’s Health Insurance Program (CHIP). Both of these programs are called MO HealthNet.
  • TRICARE. This is insurance for active duty service members, retirees, and their families.
  • Veterans Affairs (VA) health care.

What happens if I do not have health insurance?

Starting in 2019, it is not required to have health insurance. If you did not have insurance in 2018, you may pay a penalty. The Internal Revenue Service (IRS) will collect fines based on your tax return, where you will be asked to show proof of health insurance.

If you have to pay a penalty, the amount you owe may be subtracted from any tax refund you are due. The penalty will be the larger amount of either a flat rate or a percentage of income. The exact amount will depend on family size. Penalties are as follows:

  • 2.5% of income
  • $695 for each adult
  • $347.50 for each adult
  • (Up to $2,085 for a family)

If I have to buy health insurance, how do I prove I have it?

When you file your federal income taxes, there will be a place on your form to say if you have health insurance. If you get coverage through your job, your W-2 form may show the value of the health insurance you have through work and can be used as your proof of health insurance.


Is everyone required to have health insurance? Are there any exceptions?

Starting in 2019, it is not required to have health insurance. If you did not have insurance in 2018, you will not have to pay a penalty if:

  • You are part of a federally recognized religion that prevents you from accepting insurance benefits, such as Amish.
  • You are a member of a recognized health care sharing ministry.
  • You are a member of a recognized American Indian tribe.
  • You are an undocumented immigrant.
  • You are in jail or prison.
  • Your income is below the federal income tax filing threshold. In 2017 this was:
    • Annual income below $10,400 for an individual under age 65.
    • $20,800 for a married couple filing jointly with both people under age 65.
  • You do not have access to affordable health insurance. This means:
    • Health insurance would cost more than 8 percent of your income for individual coverage.
  • You would have qualified for Medicaid if Missouri had chosen to increase eligibility. The expansion would have covered individuals with income below $16,394 and a family of four with income below $33,534.

What if I cannot afford health insurance? Can I get help paying for it?

There are several options if you cannot afford to buy health insurance. You can use the Missouri Health Insurance Marketplace to see if you can get financial help. This includes:

  • Premium tax credits, which lowers how much you pay for health insurance premiums.
  • Cost-sharing reductions, which lowers how much money you have to spend out of your pocket for covered health services.

If you cannot afford health insurance and do not qualify for a premium tax credit or cost-sharing reductions, you may qualify for Medicaid. Medicaid is a public health insurance program for people with very low incomes.

If you have difficulty paying for health insurance and have children, your kids may qualify for the Children’s Health Insurance Program (CHIP), a public health insurance program for children with family income above Medicaid limits. You can see if you qualify for these programs by using Missouri’s Health Insurance Marketplace.

To learn more about financial help for individuals and families, click here.


Why do I need health insurance?

No one plans to get sick or hurt, but most people need medical care at some point. Health insurance helps pay for medical care and can protect you from having to pay high costs, for things like emergency room visits or hospitalizations after a car accident. These health care bills can add up quickly and often cause people to go into debt or even bankruptcy.

I heard there are consumer rights and protections. What does this mean?

The Affordable Care Act includes consumer protections that improve the quality of health coverage, increase access to affordable health insurance, and hold insurance companies accountable for the premiums they collect. Click here to learn more.

I have kids. Do any of these health insurance changes affect them?

There are rules for most health insurance plans that may improve coverage for your kids. Health insurance plans must cover a set of essential health benefits. For kids these benefits include dental and vision care, in addition to routine pediatric care like wellness visits.

Health insurance plans must also cover recommended preventive health services with no cost sharing. Preventive services for children include things like:

  • Vaccinations to prevent the flu or measles.
  • Blood-pressure screenings.
  • Developmental vision and hearing screenings.

If your kids are recently out of high school or college, you can keep them on your health insurance until they turn 26 years old.

Affordable Care Act (ACA), also known as Obamacare

A law passed in 2010 that made many changes in how Americans get health insurance. It created a website, the Health Insurance Marketplace, as a new way to buy health insurance.

Bronze health plan

A bronze health plan is one of four types of health plans you can buy in the Health Insurance Marketplace. Bronze plans usually have lower monthly costs, but higher out-of-pockets. They usually cover about 60 percent of your health plan costs. You would have to pay the other 40 percent.

Silver health plan

A silver health plan is one of the four types of health plans you can buy in the Health Insurance Marketplace. Silver plans usually have lower monthly costs, but higher out-of-pockets. They general cover 70 percent of your health plan costs. You would have to pay the other 30 percent.

Gold health plan

A gold health plan is one of four types of health plans you can buy in the Health Insurance Marketplace. Gold plans usually have higher monthly costs, but lower out-of-pockets. They usually cover about 80 percent of your health plan costs. You would have to pay the other 20 percent.

Catastrophic coverage or plan

An insurance plan in the Health Insurance Marketplace that offers limited coverage for health care services. This plan is only available to adults under age 30 or adults who get a hardship waiver. Rules for qualifying for Catastrophic coverage are shown at www.healthcare.gov.

Affordable and minimum value coverage

Employers who offer insurance may be subject to penalties if the coverage they offer is not considered affordable or does not provide a minimum level of coverage. To be considered affordable coverage, a worker’s share of premiums should be less than 9.5% of their pay. For example, if a worker is paid $35,000 a year, his or her share of premiums for individual coverage should be less than $3,325 for the year.

For coverage to meet the minimum value requirement, it should have an actuarial value of 60%. For example, if a covered health service costs $100, the health plan would pay $60 and the worker would be responsible for paying $40.

Navigator

People in communities throughout Missouri who are certified to provide free help to consumers enrolling in the Health Insurance Marketplace.

Certified application counselor (CAC)

People who provide free help to consumers enrolling in the Health Insurance Marketplace. CACs work at local community organizations, hospitals or health centers.

Medicaid

A government health insurance program for Americans who have low incomes or disabilities. In Missouri, this program is called “MO HealthNet” for adults, and “MO HealthNet for Kids” for children up to age 19.

Children’s Health Insurance Program

The Children’s Health Insurance Program (CHIP) is public health insurance for children. CHIP covers children in families who may not have access to other health insurance coverage and have family income above the Medicaid eligibility level. In Missouri, this program is called MO HealthNet.

Premium tax credit

Money the government pays to help cover monthly premium payments for people who qualify. People who qualify, in general, are those who enroll in a Marketplace plan and have a yearly income that is between 100 percent and 400 percent of the Federal Poverty Level (FPL). Other rules for qualifying for tax credits are shown at www.healthcare.gov. To see how much you could save, use the calculator.

Cost-sharing reduction

Money the government pays to help cover out-of-pocket health care costs for people who qualify. People who qualify, in general, are those who enroll in a Marketplace Silver plan and have a yearly income that is from 100 percent to 250 percent of the Federal Poverty Level (FPL). Other rules for qualifying for cost-sharing reductions are shown at www.healthcare.gov.

Out-of-pocket

Money that you pay for health care services yourself, out of your own pocket. These costs include deductibles, copayments and coinsurance. They do not include monthly premiums.

Essential Health Benefits

The 10 kinds of health care services most insurance plans must now cover, including care to help prevent disease, care for children, emergency care, prescription drugs, and more. Learn more about essential benefits here.

Benefits

Benefits are the health care services and items covered under a health insurance plan. Benefits vary based on your specific health insurance plan. Under the health law, essential health benefits are a set of benefits new health plans sold to individuals and families must cover.

Habilitative/habilitation services

Services that help you keep, learn, or improve skills and functioning for daily living. For example, these services might include therapy for a child not walking or talking at the expected age.

Chronic (disease)

A chronic disease is an illness that lasts a long time. Doctors can treat chronic diseases but cannot cure them.

Health insurance

Health insurance is coverage through a contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium. A health insurer can be a health insurance company, an employer, or a union. Public health insurance programs like Medicare and Medicaid are similar, where the federal or state government pays some or all of your health care costs.

Pre-existing condition

Any health problem you have before a new health insurance plan begins is considered a pre-existing condition. Some common examples are asthma, diabetes, and heart disease.

Federal poverty level (FPL)

A measurement of how much a person or family needs to earn so they can pay for food, clothing, housing and other necessary things. The government decides what the FPL is for each year.

For example, in 2016 the FPL was set at $11,880 for one person and $24,300 for a family of 4 people.

Medicare

A government health insurance program for Americans who are age 65 or older, certain younger people with disabilities, and people who have end-stage renal disease (kidney failure).

Cost sharing

Cost sharing is what you pay for health services out of your own pocket. Most health insurance plans have some type of cost sharing. Deductibles, coinsurance and co-pays are all types of cost sharing. Health insurance premiums are generally not considered part of cost sharing.

COBRA coverage

If you lose your job, you can temporarily keep your employee health insurance – but you must pay all of the monthly premiums yourself, including the share the employer used to pay.