FAQ FOR INDIVIDUALS AND FAMILIES


FAQ FOR SMALL BUSINESSES



FAQ FOR INDIVIDUALS AND FAMILIES


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

The ACA, which is often called “Obamacare,” is the 2010 federal health reform law. It was created to:
  • Make it easier and more affordable for more Americans to get health insurance.
  • Improve the quality of health insurance and health care.
  • Increase focus on preventive care.
The law will require most Americans to have health insurance as of January 1, 2014. While some parts of the law have already started, major parts the law will begin in January 2014.



How is my health insurance changing in 2014?

This depends on where you get health insurance. If you get health insurance through your job, chances are you won’t see many changes – unless your employer changes your coverage options.

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. This 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.

There are also new health insurance rules that may improve the quality of the health insurance you already have or that you buy in the Marketplace. These include:
  • New protections – Health insurance companies can’t charge higher premiums because of gender or health status. They also can’t refuse or stop coverage if you get sick. Starting in 2014 most health plans can no longer set annual limits, and lifetime limits are not allowed on any health insurance plans.
  • New options – In the Missouri Health Insurance Marketplace, people can compare and buy health insurance plans. You can get help finding the right plan for you and your family through the marketplace website, in person, and by phone.
  • New benefits – New health insurance plans must cover recommended preventive care with no cost sharing. New health insurance plans for individuals and small businesses must cover essential health benefits. These are 10 categories of health services, usually included in the coverage provided by large employers.



What is the Missouri Health Insurance Marketplace?

The Missouri Health Insurance Marketplace is a website where you can compare and buy the health insurance plan that best fits your needs. You can get help understanding Marketplace health plans and applying for insurance online, in person, and by phone. Click here to find a location near you.

You can use the Missouri Marketplace if you:
  • Are an individual or family buying insurance on your own.
  • Don’t have access to affordable coverage through your job.
The Missouri Health Insurance Marketplace will open on October 1, 2013, with health insurance coverage starting January 1, 2014.



How do I use the Missouri Health Insurance Marketplace?

The Missouri Health Insurance Marketplace opens October 1, 2013. During the open enrollment period – October 1, 2013, through March 31, 2014 –– you can complete your marketplace application by:
  • Visiting the marketplace at www.healthcare.gov.
  • Calling 1-800-318-2596 (TTY: 1-855-889-4325).
  • Working with a navigator or certified application counselor in person. Click here to find a location near you.
To complete the application, you need to give information about you and your family, including:
  • Income.
  • Number of people in your family.
  • Any health insurance you currently have.
  • Information about your employer, if you or anyone in your household has a job.
Based on the information you give, the Missouri Health Insurance Marketplace will:
  • Let you know if you qualify for Medicaid, and ask if you want to apply for that coverage.
  • Let you know if you qualify for a premium tax credit, and ask if you’d like to use the credit right away to lower your health insurance premiums.
  • Let you know if you qualify for cost-sharing reductions. This option can only be used for a certain type of coverage.
The Missouri Health Insurance Marketplace lets you compare health plans offered by private health insurance companies and choose one that best meets your needs and your family’s needs.



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

You can start buying insurance through the Missouri Health Insurance Marketplace when it opens on October 1, 2013. The date your coverage starts depends on when you buy your health plan. This chart shows possible timing for when your coverage might start.
Plan Purchase DateCoverage Start Date
By December 23, 2013January 1, 2014
December 24, 2013 to January 15, 2014February 1, 2014
January 16,2014 to February 15, 2014March 1, 2014
February 16, 2014 to March 15, 2014April 1, 2014
March 16, 2014 to March 31, 2014May 1, 2014

In general, after December 23, 2013:
  • Coverage you buy after the 15th day of any month will start a month and a half later.
  • Coverage you buy before the 15th day of any month will start the first day of the next month.
Open enrollment on the Missouri Market place runs October 1, 2013, through March 31, 2014. 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.



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:

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

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 can’t get affordable coverage.



What are essential health benefits?

Essential health benefits are 10 categories of health services new health plans must cover. These categories are:
  • Ambulatory patient services, such as doctor office visits.
  • Emergency services.
  • Hospitalizations.
  • Maternity and newborn care.
  • Mental health and substance use disorder services.
  • Prescription drugs.
  • Rehabilitative and habilitative services and devices, like physical therapy and walkers.
  • Laboratory services, such as blood tests.
  • Preventive care and chronic disease management.
  • Pediatric services, including vision and dental care for kids.



I’m 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’ll find out if you can get a premium tax credit and cost-sharing reduction. Both of these options can reduce your health care costs. They are available to people with income at a certain level.

Chart




What if I'm 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 and cost-sharing reduction that lower your health insurance costs.



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

Beginning in 2014 health insurance companies cannot deny you health insurance because of a pre-existing condition. New health plans are also not allowed to charge higher premiums because of your medical history or current health status.



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 PopulationsIncome Guidelines
Children (up to age 19)Up to 300% of the Federal Poverty Level (FPL)
ParentsUp to ~18% of FPL
Pregnant WomenUp to 185% of FPL
Disabled IndividualsUp to 85% of FPL
Missourians (age 65 and over)Up to 85% of FPL
Blind IndividualsUp to 100% of FPL
Qualified Medicare BeneficiariesUp to 100% of the FPL


2013 Federal Poverty Level (FPL)
Family SizeAnnual Income
~18% FPL85% FPL100% FPL185% FPL300% FPL
1n/a$9,767$11,490$21,257$34,479
2$2,808$13,184$15,510$28,694$46,530
3$3,504$16,601$19,530$36,131$58,590
4$4,104$20,018$23,550$43,568$70,650
Note: Income guidelines for parents are based on the July 1996 Aid for Families with Dependent Children (AFDC) payment standard, which is approximately 18 percent of FPL in 2013.



What is happening to Medicare?

Medicare is not really changing. There is a new benefit you can already use. Medicare now covers recommended preventive services, like wellness exams and mammograms, with no cost sharing.

Also, people on Medicare with prescription drug coverage who reach a gap in coverage – the “donut hole” – may see 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.



What happens if I don’t have health insurance?

Starting January 2014 most Americans will be required to have health insurance. If you don’t have insurance, you‘ll 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. You won’t have to show proof of insurance or that you are exempt from the requirement to have health insurance until you file your 2014 federal income taxes in 2015.

If you have to pay a penalty, the amount you owe may be subtracted from any tax refund you are due. The IRS cannot use liens or levies to collect any penalty payments you owe for not having health insurance.

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:

Year201420152016 and Beyond
Penalty is the larger amount of:1% of income2% of income2.5% of income
$95 per adult$325 per adult$695 per adult
$47.50 per child$162.50 per child$347.50 per child
(Up to $285 for a family)(Up to $975 for a family)(Up to $2,085 for a family)

If you don’t have insurance, you won’t have to pay a penalty if:
  • You’re part of a federally recognized religion that prevents you from accepting insurance benefits, such as Amish.
  • You’re a member of a recognized health care sharing ministry.
  • You’re a member of a recognized American Indian tribe.
  • You’re an undocumented immigrant.
  • You’re in jail or prison.
  • Your income is below the federal income tax filing threshold. In 2012 this was:
    • Annual income below $9,750 for an individual under age 65.
    • $19,500 for a married couple filing jointly with both people under age 65.
  • You don’t 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 $15,860 and a family of four with income below $32,500.



I heard there’s a requirement to have health insurance. How do I know if I’m following the law?

Starting January 1, 2014, most Americans will be required to have health insurance. If you are insured or receive health care through one or a combination of the following sources, you already meet the requirement:
  • A health insurance plan offered by your employer. This includes COBRA 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.



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.

You won’t be asked to show you have insurance or that you qualify for an exemption until you file your 2014 federal income taxes in 2015.



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

Beginning January 1, 2014, most Americans will be required to have health insurance.

If you don’t have insurance, you won’t have to pay a penalty if:
  • You’re part of a federally recognized religion that prevents you from accepting insurance benefits, such as Amish.
  • You’re a member of a recognized health care sharing ministry.
  • You’re a member of a recognized American Indian tribe.
  • You’re an undocumented immigrant.
  • You’re in jail or prison.
  • Your income is below the federal income tax filing threshold. In 2012 this was:
    • Annual income below $9,750 for an individual under age 65.
    • $19,500 for a married couple filing jointly with both people under age 65.
  • You don’t 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 $15,860 and a family of four with income below $32,500.



What if I can’t afford health insurance? Is there any help to pay for it?

There are several options if you can’t 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 can’t afford health insurance and don’t 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.

Some people may not be able to afford health insurance but find they don’t qualify for Medicaid or financial help through the Missouri Health Insurance Marketplace. If this applies to you or your family, you may not be required to buy health insurance. See exemptions for more information.

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. Also, most Americans will be required to have health insurance by January 2014 or pay a penalty. To learn more, click here.



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

The Affordable Care Act includes new 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. Some of these protections are already in place. The rest begin in 2014. Because of new rules, insurance companies can’t:
  • Refuse to cover you or your family because of a pre-existing health condition. This protection is already in place for children.
  • Cancel your health insurance policy because you get sick.
  • Charge higher rates because of gender, health status, or job.
  • Set limits on how much they will pay for covered essential health benefits in a single year or over your lifetime.
    • This means that you won’t run out of coverage if you develop a health problem that’s costly to treat. It’s important to know that the rules preventing annual limits are being phased in through 2014 and don’t apply to grandfathered health plans.
    • Also, annual and lifetime limits can still be applied to “nonessential benefits” – for example, your health plan can limit how much it will cover for dental care each year or over your lifetime, because dental care for adults is not an essential health benefit.
Additional protections and benefits from the health law include:
  • New health insurance plans must cover a set of essential health benefits.
  • New health insurance plans must cover recommended preventive health services with no cost sharing.
  • Young adults can stay on their parents’ health insurance until they turn 26 years old.
  • Health insurance companies must spend at least 80% of your premium on health services and activities that improve the quality of care. If they don’t meet this standard, your insurance company will owe you or your employer a rebate.
  • If a health insurance company raises premiums 10% or more, the federal government will review the increases to make sure they are justified.
  • There is a new review process if you appeal the insurance company’s denial to pay for your health care services. You will get a full and fair review of why your claim was denied. You’ll also have the option to have an independent review of your appeal.



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

There are new rules for most health insurance plans that may improve coverage for your kids. New 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.

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




FAQ FOR SMALL BUSINESSES


What is the Small Health Options Program (SHOP) Marketplace?

The SHOP Marketplace is a marketplace where small businesses owners can compare plans and buy coverage for their workers. The SHOP Marketplace opened on October 1, 2013, with health insurance coverage starting as early as January 1, 2014. For 2014, small businesses can use the SHOP Marketplace to compare plans and are encouraged to use an insurance agent, insurance broker, or Navigator to buy SHOP Marketplace plans.

Very small businesses with 25 or less employees, may qualify for a small business tax credit when they use the SHOP Marketplace.

You can use the SHOP Marketplace if you own a small business with 50 or fewer full-time equivalent employees for the first year. By 2016 businesses with up to 100 employees can use the SHOP Marketplace.

To learn more, click here.



What's considered a small business?

The answer depends on whether you’re talking about the Small Business Health Options Program (SHOP) Marketplace or the small business tax credit. The SHOP marketplace is open to businesses with 50 or fewer full-time equivalent employees in 2014. By 2016 the SHOP Marketplace will open to businesses with up to 100 full-time equivalent workers.

The small business tax credit is available to businesses with 25 or fewer full-time equivalent employees. To learn more about tax credits, click here.



How do I calculate the number of full-time equivalent employees I have?

To see if you can use the SHOP Marketplace or qualify for the small business tax credit, you’ll need to count your full-time employees and part-time workers. Full-time employees are individuals working an average of at least 30 hours a week. Part-time workers are counted as full-time equivalents. Generally, two part-time workers will count as one full-time equivalent. To calculate your FTE workers, click here.



Do I have to buy insurance for my employees? Are there penalties if I don’t?

No employer is required to offer health coverage. Some larger businesses will have to pay a penalty known as a shared responsibility payment if they don’t offer coverage that meets certain standards starting in 2015.

If your business has fewer than 50 full-time equivalent employees, you do not have to pay a penalty regardless of whether you offer your workers health insurance.

If your business has 50 or more full-time equivalent employees, you may pay a penalty if:
  • You don’t offer health insurance to your workers.
  • The coverage you offer isn’t considered affordable or have a minimum value.
Penalties for not providing coverage meeting these requirements are:
  • $2,000 per employee (not including the first 30 workers).
  • $3,000 per employee getting a premium tax credit.



What if I'm self-employed but don’t have any employees?

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 credits and cost-sharing reductions, which will lower your health insurance costs.



I’m worried about cost. How can I afford health insurance?

If your business has 25 or fewer employees, you may qualify for the small business tax credit. The tax credit gives businesses back a portion of what they pay for employees’ health insurance premiums. Small nonprofit organizations can use this tax credit too.

You’ll qualify for this tax credit if:
  • Your business has 25 or fewer full-time equivalent employees.
  • Your employees are paid on average of $50,000 or less each year.
  • You pay at least 50 percent of workers’ health insurance premium costs.
This tax credit is available now. Starting in 2014 the small business tax credit can only be used on coverage bought through the SHOP Marketplace.

To learn more about small business tax credit, click here.