Coverage Basics for Individuals & Families

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The Missouri Health Insurance Marketplace makes it easier and more for you and many other Missourians to get good quality . You can compare and buy a health insurance plan to fit your needs. You can use the Marketplace if you are uninsured or do not have access to affordable 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. To use the Marketplace, click here or call 1-800-318-2596 (TTY: 1-855-889-4325). If you prefer to talk to someone in person, click here to find a location.

PLAN CHOICES IN THE MARKETPLACE

Insurance plans in the Missouri Health Insurance Marketplace fall into four categories based on how the costs of care are shared between you and the insurance company. The four categories are , , , and Platinum. Platinum is not currently offered in Missouri. All health plans in the Marketplace cover the same set of .

The category you choose affects:

  • How much your premium is and what portion of the bill you will pay for covered like doctor visits or prescription medications.
  • Your total costs (the total amount you will spend for the year if you need a lot of care).

Each health plan may have different costs, even if they are in the same category. In general, the more you are willing or able to pay each time for health care service or a prescription, the lower your will be.

Costs by Plan Level

Click here to use the calculator to see if you can get financial help and how much you can save.

The Marketplace also offers “” plans to people under 30 years old and some people without other reasonably priced coverage options. This health plan protects you from very high medical costs only if you need a lot of care, like after a serious car accident. A catastrophic plan has a lower premium but generally requires that you pay all of your health care costs up to a certain amount – usually several thousand dollars. This health plan only pays for essential health benefits after you meet the . You can find out if you can get a catastrophic plan in the Missouri Health Insurance Marketplace.

REQUIREMENTS FOR INDIVIDUALS AND FAMILIES

Starting in 2019, it is not required to have health insurance. If you did not have insurance in 2018, you may pay a penalty – unless you meet certain conditions. For people without health insurance, the Missouri Health Insurance Marketplace is a website where you can compare and buy health plans.

If you are currently insured or receive health care through one or a combination of the following sources, you meet the requirement to have health insurance in 2018:

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

The Internal Revenue Service (IRS) will collect these penalties through your tax return, where you will be asked to show proof of health insurance.

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.

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.

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.

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.

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.

Premium

A premium is the cost of your health insurance. Premiums may be paid by you, your employer, or both. It is usually paid monthly or every three months. Or, it can be paid all at once for the whole year.

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.

Deductible

The amount you must pay for your covered health care services each year – for example, $1,000 – before your insurance plan will begin sharing the cost with you (see “coinsurance”).

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.

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).

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.