The Affordable Care Act
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 (healthcare.gov), the Health Insurance Marketplace, as a way to buy health insurance.
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.
- Help more people get affordable health insurance.
- Hold insurance companies accountable for the premiums they collect.
Click here to learn more.
I have children. What does the Affordable Care Act mean for them?
There are rules for most health insurance plans that may improve coverage for your children. Health insurance plans must cover a set of essential health benefits. For children, 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 out-of-pocket cost to you. Preventive services for children include things like:
- Vaccines (shots) to prevent the flu or measles.
- Blood-pressure screenings.
- Vision and hearing screenings.
If your children are recently out of high school or college, you can keep them on your health insurance until they turn 26 years old.
Missouri Health Insurance Marketplace
What is the Missouri Health Insurance Marketplace?
The Missouri Health Insurance Marketplace is an online website where you can buy a Qualified Health Plan or catastrophic coverage from private insurance companies. You can use the Missouri Marketplace if you:
How do I use the Missouri Health Insurance Marketplace?
The Marketplace is similar to an online travel service, such as Expedia.com. It lets you:
- Shop for and compare health insurance plans.
- Estimate the cost of health insurance plans.
- See if you can get help paying for health insurance.
- Buy a health plan for you and your family.
You can apply online, by phone, or in person. You only need to fill out one application. To apply online, follow these steps:
- Visit healthcare.gov.
- Create an account, or login to an existing account.
a. Give your name, address, and other basic information.
- Fill out the application.
- Compare plans and choose the plan that best meets your needs.
- Pay your first monthly premium.
To apply by phone, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
To apply with in-person help, click here to find a location near you or call the Cover Missouri call center at 1-800-466-3213.
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’s okay).
- 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:
When can I use the Missouri Health Insurance Marketplace? Will my coverage start right away?
You need to enroll or re-enroll each year during open enrollment. Open enrollment is a time period when you can enroll in or change a health insurance plan. Find dates for open enrollment at healthcare.gov. Open enrollment usually happens from November 1 to December 15 of each year and plans start coverage on January 1.
However, if you experience a major life change outside of open enrollment, like getting married, having a baby, or losing a job, you may still be able to buy a health plan in the 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 deadline, you may qualify for a Special Enrollment Period to enroll in Marketplace coverage. A Special Enrollment Period is a period of time outside of open enrollment when some people can enroll in or change an insurance plan in the Marketplace. In general, you may get a Special Enrollment Period when you have a qualifying life event, which is 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 Marketplace within 60 days of your qualifying life event.
What kinds of health insurance plans will the Missouri Health Insurance Marketplace have?
Insurance plans fall into four categories based on how the costs of care are shared between you and the insurance company. All plans will cover the same 10 essential health benefits, including yearly doctor visits, trips to the emergency room, and prescription medicines. The four plan categories are:
Each health plan may have different costs, even if they are in the same category. When you shop for plans, you’ll see the available plans and costs in your area.
The Marketplace also offers catastrophic coverage to young adults up to age 30 and other people who cannot get affordable coverage.
What health care services does a Marketplace plan cover?
All Marketplace plans cover the 10 essential health benefits::
- Outpatient care: care you get when you don’t have to stay overnight in a hospital or other health care facility, such as doctor visits and same-day surgery, like getting your tonsils removed.
- Trips to the emergency room.
- Inpatient care: care you get when you stay overnight in a hospital or other health care facility, like if you have surgery or a serious medical condition.
- Care before and after your baby is born: care women get while they’re pregnant, during labor and delivery, and care for newborn babies.
- Care for mental health and substance: care you get to diagnose and treat mental health conditions, substance abuse or addictions, like treatment for depression or alcohol abuse.
- Prescription drugs: medicines your doctor prescribes or orders for you.
- Services and devices to help with daily living: services and devices that help you if you have a disability or long-term condition or need to recover from an injury, like physical therapy and walkers.
- Laboratory tests: tests that help doctors diagnose or treat an injury or health problem, like x-rays or blood tests.
- Free preventive care: routine health care you get to help prevent sickness, disease, or other health problems, like cancer screenings and wellness and well-woman checkups.
- Care for children up to age 19: care children get like health checkups, dental checkups, vision tests, and hearing tests.
What if I have a health problem or pre-existing condition?
Health insurance companies can’t refuse to cover you or charge you more just because you have a pre-existing condition (a health problem you had before your health insurance started). Health plans are also not allowed to charge higher premiums because of your medical history or current health.
I am self-employed. Can I get help paying for a Marketplace plan?
If you are self-employed – you run a business with no employees – you can use the 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 cannot afford health insurance? Can I get help paying for it?
There are several options if you can’t afford to buy health insurance. You can use the Marketplace to see if you can get financial help. This includes:
- Premium tax credits, which lowers how much you pay for monthly 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 do not qualify for a premium tax credit or cost-sharing reductions, you may qualify for Medicaid. Medicaid is a government program that provides public health coverage to children and adults who have low incomes or disabilities. When you fill out your Marketplace application, you will see if you qualify for Medicaid.
If you have trouble paying for health insurance and have children, your children may qualify for CHIP (Children’s Health Insurance Program), a program funded by the state and federal government to provide health coverage to children in families who earn too much money to qualify for Medicaid but can’t afford to buy health insurance. When you fill out your Marketplace application, you will see if you qualify for CHIP.
To learn more about financial help, click here.
What is the family glitch?
You may have heard about something called the “family glitch.” The Affordable Care Act requires employers to provide “affordable” insurance only for the workers themselves – not for their families. The family glitch is a regulation that keeps children and some adults from obtaining Marketplace coverage and tax credits if one parent has affordable employer coverage that is deemed “affordable,” even if family coverage is not affordable. To learn about coverage options for children who might be affected by the glitch, view this handout – “The Family Glitch: What Happens to Coverage for Kids?” – from Community Catalyst.
Medicare and Medicaid
Do I qualify for Medicaid
Medicaid is a government program that provides public health coverage to children and adults who have low incomes or disabilities. In Missouri, Medicaid is run by the Department of Social Services (DSS) and is called MO HealthNet.
Most Missourians who get MO HealthNet coverage are people with low incomes, 65 or older, blind or disabled, or children from families with low incomes. If you qualify depends on how much money you make and how many people are in your family. Children, their parents, people with disabilities, and people age 65 or older are covered by Medicaid at different income levels. When you fill out your Marketplace application, you will see if you qualify for Medicaid.
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.
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.
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.
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.
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.
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.