Q: What is the Utah health insurance marketplace?
A: The Utah health insurance marketplace or also known as the obamacare or healthcare marketplace, is an online health insurance marketplace where consumers can shop for and buy health insurance during open enrollment periods (the current open enrollment runs from Nov 15, 2014 through Feb 15th, 2015). The idea is to be able to compare health plan choices, determine if you are eligible for a tax credit (called a subsidy) to help pay for your plan, and find out if you qualify for Medicaid, the federal insurance program for the poor.
Q: What’s a subsidy?
A: Subsidies are calculated on a sliding scale based upon annual income. For a quick reference guide to see how much you qualify for visit Utahhealth.com to get a rough estimate on health insurance prices and estimated subsidies.
If you are between 100 percent and 400 percent of the Federal Poverty Level (about $46,000 for individuals and $94,200 for families of four in 2013), you will be eligible for tax credits to help you pay for health insurance. This money is called a “subsidy” and it can be used to help you pay for monthly premiums. If you are at or below 250 percent of the poverty level, you will be eligible to receive help with out-of-pocket medical expenses. Beware, though, that if your income level goes up during the year, you may have to pay back some of this financial aid. For More Information: This is all subject to change.
Q: When can I sign up for health insurance in Utah?
The 2016 Open Enrollment period for the Affordable Care Act (Obamacare) is November 1, 2015 to January 31, 2016. Key deadlines are:
- November 1, 2015: Open Enrollment starts. Enroll or change your coverage here.
- December 15, 2015: Deadline to have coverage that begins on January 1, 2016 (if you apply on December 16 you’re coverage will most likely not start until February 1).
- December 31, 2015: Coverage ends for 2015 plans. You will be auto-renewed if you don’t change your plan.
- January 31, 2016: This is the last day you can apply for 2016 coverage before the end of Open Enrollment.
If you miss this window you cannot enroll until the Marketplace re-opens in November 2016 unless you have a special “life event” such as having a baby or losing your job. You’ll also be just to a fine of 2.5% of your income or $695 per adult, whichever is greater.
Q: Do I have to buy health insurance?
If you miss this window you cannot enroll until the Marketplace re-opens in November 2016 unless you have a special “life event” such as having a baby or losing your job. You’ll also be just to a fine of 2.5% of your income or $695 per adult, whichever is greater, so if you don’t buy health insurance in most cases you will get a penalized unless you qualify for a hardship exemption.
Q: Will I have to pay the penalty if I lose my job?
A: No. You may spend three months uninsured without a penalty if you lose your job.
Q: If I am buying my own insurance, do I have to buy an exchange plan?
A: No. You can purchase insurance on the exchange or in the private market. However, subsidies will not be available to those who purchase privates plans sold off the exchange.
Q: Does every state have an exchange?
A: Yes. Sixteen states and the District of Columbia are running their own exchanges, 27 states have federally operated exchanges, and 7 states have partnerships with the federal government to run the exchanges. To see what’s available in your state, visit U.S. News & World Report’s guide to health insurance plans.
Q: If I can get insurance through work, can I still buy a plan on the health exchange?
A: Yes. However, you may not qualify for subsidies on the exchange unless your employer’s health insurance plan costs more than 9.5 percent of your annual income, among other restrictions.
ple will file this return in 2015. For years beyone this please refer to the healthcare gov or the internal revenue service.
- Premium A premium is a fixed amount you pay to your insurance plan, usually every month. You pay this even if you don’t use medical care that month.
- Deductible If you need medical care, a deductible is the amount you pay for care before the insurance company starts to pay its share. Once you meet your deductible, your insurance company begins to cover some costs of your care. Some plans have lower deductibles, like $250. Some have higher deductibles, like $2000. Many plans provide preventative services and sometimes other health care, before you’ve met your deductible.
- Copayment A copayment is a fixed amount you’ll pay for a medical service after you’ve met your deductible. For example, after meeting your deductible you may pay $35 for a visit to the doctor’s office that would cost $125 if you didn’t have coverage. The health plan pays the rest.
- Coinsurance Coinsurance is similar to copayment, except it’s a percentage of costs you pay. For instance, you may pay 30% of the cost of a $100 medical bill. So you would pay $30 and the health plan would pay the rest.
- Out-of-pocket maximum This is the total amount you’ll have to pay if you get sick. For example, if your plan has a $3000 Out of pocket maximum, once you pay $3000 in deductibles, coinsurance, and copayments the plan will pay for any covered care above that amount for the rest of the year.
- No yearly or lifetime limits Health plans in the HealthCare Marketplace can’t put dollar limits on how much they’ll spend each year or over your lifetime to cover essential health benefits. After you’ve reached your out-of-pocket maximum, your insurance company must pay for all of your covered medical care with no limit according to the affordable care act ACA or the marketplace.
- How much is the premium per month with and with out subsidy?
- Is your current doctor or hospital part of the plan’s provider network?
- Is there a deductible on this plan?
- Is there coinsurance
- Will you have copayments?
- How does the plan handle visits to the emergency room? Does a copay exist?
- Are hospitalization and major medical expenses covered? If so What percentage.
- What is the policy’s annual individual (or family) out-of-pocket expense limit? What costs are included vs. excluded in the out-of-pocket expense limit?
- Is there a waiting period before you’re fully covered? Should be not waiting period but ask the agent anyway
- Do you offer all the metal plans including Bronze, silver, gold and platinum.
- Do you need additional coverage, such as dental, vision or prescription drug coverage?
- Are you planning any major medical expenses for the following year (for example, having elective surgery)?
- What is the average rate increase per year with the company
- How long has the company been in business for?
- Are my prescriptions covered on this plan. Not all companies treat prescription cost the same. Make sure you have the agent look your RX prescription and see if it comes in a tier rating or just percentage.
- Does the plan offer an HSA
- What is the out of pocket maximum? Find out your worst case scenario.
- Am I eligible for obamacare?
- How does my income year to year effect my subsidy with the affordable care act?
What types of individual plans does the marketplace offer?
Individual HMO Health Insurance Plans
HMOs, or Health Maintenance Organizations, offer health care from a network of health care providers. HMOs tend to have lower premiums and deductibles, but offer limited flexibility for choosing doctors and hospitals. Under an HMO plan, you need a referral from your primary care physician to see a specialist and you may have to pay 100% of cost if you see a doctor out-of-network.
Individual PPO Healthcare Plans
PPOs, or called Preferred Provider Organizations, also have affordable premiums and deductibles – however, they offer more flexibility to see any doctor you want and don’t require a referral from your primary care physician to see a specialist (as is required from an HMO). Under a PPO, out-of-network costs are covered, but at a lower rate than in-network costs. These plans sometimes tend to be higher in cost.
Individual High Deductible Healthcare Plans
High Deductible Health Plans, tend to have lower premiums than both HMOs and PPOs, but much higher deductibles. Deductibles are the out-of-pocket expenses you have to pay before insurance starts to cover you. You can use an HSA to lessen the financial burden of covering the high deductibles. These plans generally have similar flexibility to PPO plans.
Individual Health Savings Account
HSAs, or Health Savings Accounts, are growing in popularity for a variety of reasons. Though they may not be for everyone, if you can afford to put up the money up front, you can benefit from tax savings, and people typically save a decent chunk of money when all is said and done because they don’t have to pay the expensive premiums.
Essential Health Benefits for Individuals
Every single health insurance marketplace and private health insurance plan sold must cover the following essential health benefits:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (such as surgery)
- Maternity and newborn care (care before and after your baby is born)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services