What are the minimum requirements to obtain coverage through the Health Insurance Marketplace?

The Marketplace was created to be very accessible to millions of people who might not have had easy access to health insurance coverage in the past. However, there are certain requirements to be met in order to purchase a plan.

1. You must be a U.S. citizen or “lawfully present” immigrant.
2. You must live in the United States.
3. And you can’t be currently incarcerated serving time in a jail or prison.

What is Minimum Essential Coverage?

To avoid being charged the individual mandate (also referred to as fee, fine, penalty, or responsibility payment), employees are obligated to obtain an insurance plan that meets the requirements of “minimum essential coverage” which include the new benefits, rights, and protections laid out in the legislation, and must remain covered throughout the year, or procure an exemption.

How are my premium costs calculated?

Insurance companies are prohibited to discriminate when offering health coverage, and there have been new restrictive measures put in place to prevent this. However, there are 5 factors that may be considered when figuring out premium costs:

1. Individual vs. Family – A plan covering an individual will generally cost less than a plan covering a family. Size of the family may also factor into the cost.
2. Location – Where you reside may affect your coverage cost as an insurance company will consider factors such as competition, local regulations, price of living, etc.
3. Tobacco users vs. non-users – There are many health risks associated with tobacco use, and health insurance companies will definitely factor this into their calculations. Tobacco users will generally expect to pay a higher premium.
4. Age – Due to health complications of aging, a younger enrollee will typically pay less than an older enrollee.
5. Plan Category – The four metal categories in a Marketplace plan are Bronze, Silver, Gold, and Platinum. Although they offer similar coverage, they differ in premiums and deductible costs depending on the plan you go with.

What is the penalty if I do not carry health insurance?

The fee for not having health coverage is calculated in one of two ways, whichever amount is higher. You may be charged a flat fee or a percentage fee which will be applied to your federal income tax returns for the years that you were not insured.

Below are the 2016 fee calculations:

1. Flat Fee – You will be charged $695.00 per adult and $347.50 per dependent (under 18) to reach no more than $2,085.00 per family
2. Percentage Fee – In this calculation you will be charged 2.5% of the annual household income above the tax filing threshold, not to exceed the national average for bronze plan premiums.

If you did not have health insurance coverage in 2015, the fees were applied as such:

1. Flat Fee – You will be charged $325.00 per adult and $162.50 per dependent (under 18) to reach no more than $975.00 per family
2. Percentage Fee – In this calculation you will be charged 2% of the annual household income above the tax filing threshold, not to exceed the national average for bronze plan premiums.

How would I qualify for an exemption?

If you qualify for an exemption, you will not be subject to the penalty for being uninsured. Below are some examples of exemptions that may apply to you or your family’s situation:

• You were uninsured for under 3 months of the year
• You don’t meet the income tax filing threshold and so are not required to file
• You are not lawfully present in the U.S.
• The lowest-priced plan option provided exceeds 8% of your household income
• You are a member of tribe recognized by the federal government
• You are a member of a federally recognized organization with religious objections to insurance, Medicare, Social Security, etc.
• You are currently incarcerated and serving a term in jail or prison
• You qualify for hardship exemption

You can visit online to see more examples that might qualify you for an exemption from being assessed the fee for non-coverage.

What is a Life Changing Event, and how does that will that affect how my health insurance works for me?

A life changing event would generally involve major changes in your life that would directly affect your household income, or the gaining or losing of a family member. These events must be reported, as they could directly affect how your plan is supposed to function and could result in back pay when you file your taxes, if you fail to do so.