Frequently Asked Questions

Below are frequently asked questions about the new health care law. Become familiar with it and learn about your health insurance choices. Enrollment starts in October 2013 for coverage that becomes effective on January 1, 2014.
  • What is the new health care law?
Health care reform is an ongoing process to help our country's health care and insurance system work better. The reform effort you're hearing more about now is the Affordable Care Act, which became law in 2010. Some of its changes to health insurance are in place now and others are being phased in over time — many in 2014. One of the biggest changes of the new law is that many Americans who have been uninsured will now be able to get health insurance. In fact, most people will be required to get coverage or may have to pay a penalty.
  • What’s happening in 2014?
The new health care law expands health insurance to include more benefits for more people and is aimed at making coverage more affordable and available to uninsured people. The law is changing the way some Americans get health coverage. Some changes are happening now. The biggest change comes in 2014, when almost everyone in the U.S. will be required to have health insurance.
  • I have heard that October is important. What is so important about October?
The first open enrollment period for buying insurance on the new health insurance exchange begins October 1. At that time you will be able to go online or call, and shop for the different insurance plans available to you. The site will also offer a calculator to help you figure out what your monthly premium will be, and to see if you qualify for help with the cost of premiums in the form of a tax credit, depending on your situation. The first open enrollment will last through March of 2014. Coverage begins January 1, so the sooner you enroll, the sooner you'll be covered.
  • What is a health insurance “Exchange”?
The ACA requires states to establish a governmental agency or non-profit entity to make available qualified health plans. These will be known as “Exchanges” and are to be made available by 2014. All legal state residents who are not incarcerated could enroll in qualified health plans through the Exchange. Issuers could offer one or more of four types of health plans: bronze, silver, gold and platinum. The plans would provide increasing levels of services covered and limits on out-of-pocket spending. In addition, issuers could offer a catastrophic plan to those individuals under 30 years of age or those exempt from the individual mandate because no affordable health plan is available to them or exempt because of hardship. The catastrophic plan is available only in the individual market.
State Exchanges will be required to:
  • Operate a toll-free hotline and website;
  • Rate qualified health plans;
  • Inform individuals of Medicaid and CHIP eligibility;
  • Provide an electronic calculator to calculate plan costs;
  • Grant certifications of exemption from the individual responsibility requirement;
  • Allow regional or interstate exchanges if agreed to by the states and approved by the Secretary;
  • Include a Small Business Health Operating Program to help small businesses enroll their employees in qualified health plans; and,
  • Submit annual accounting reports to the Secretary.
  • How do the new health insurance exchanges work?
Beginning in October, you'll be able to go online to look at insurance plans available in your area, or get that information with a phone call. Most health insurance plans on the exchange will offer comprehensive coverage, from doctors to medications to hospital visits. You can compare all your insurance options based on price, benefits, quality and other features that may be important to you.
  • What coverage options will be available on the exchange?
All plans on the exchange will have similar types of benefits, and all will include essential health benefits. One of the biggest places they differ is on how the costs of the benefits are applied.
Exchange plans will be divided into four different levels — Bronze, Silver, Gold and Platinum.
Bronze Lower monthly payments
Higher cost when you receive medical care
Silver Higher monthly payment than a Bronze plan
Lower cost than a Bronze plan when you receive medical care
Gold Higher monthly payment than a Silver plan
Lower cost than a Silver plan when you receive medical care
Platinum Highest monthly payments
Lowest cost when you receive medical care
  • Am I buying insurance from the government?
The Affordable Care Act is based on more people buying health insurance from private insurance companies — not from the government. The government's role includes making sure these private plans meet standards for coverage and service, providing financial assistance for people who need it to buy insurance, broadening eligibility for public insurance programs in some states, and encouraging efforts to improve quality and control costs.
  • How does the new health care law help me today?
The Affordable Care Act adds benefits that help a lot of people with insurance. If you haven't been able to afford insurance in the past, it makes it possible for most people to find more affordable coverage. You also may get help paying for it through tax credits. If you haven't been able to qualify for insurance because of a health condition, it makes coverage available to you. And, if you've had insurance with restrictions that made it hard to cover all your health care needs, new rules remove some of the limits that may have been included in health coverage in the past.
  • My mom got turned down for insurance because of her diabetes. Will she be able to get covered under the new law?
In the past, insurance companies were able to decline or offer adjusted rates to individuals based on certain medical conditions. Beginning in January 2014, anyone who buys a new plan or renews their current plan will be guaranteed issue. This means that they'll be able to get insurance that includes coverage for their medical conditions. (If a plan is purchased or renewed before January, 2014 they will not be guaranteed issue.)
  • My 22-year old son just graduated from college, but doesn’t have a job. Will the new health care law give him coverage?
Under the new health care law, you are already able to cover your adult children on your plan up to the age of 26. Most limits to keeping your young adult son or daughter on your coverage have been removed, meaning they don't have to be a full-time student, live with you, have a disability or be a tax dependent.
  • I am retired but not yet eligible for Medicare. Can I get a policy on the exchange?
In general, most U.S. citizens and legal residents will be required to have coverage beginning January 1, 2014, or may face a penalty. If you are retired but not yet eligible for Medicare, you will still be required to have coverage. One of your options would be to purchase health insurance on the exchange.
  • Under the new law, will I be able to pick my own doctors and hospitals?
Yes, if you do not have a grandfathered health plan You can choose your primary care physician or your child's pediatrician from your health plan's network of doctors. You also will not need a referral to visit an OB-GYN.
In addition, your health plan cannot require you to get prior approval before visiting an emergency room. The new law also prevents plans from charging higher copayments or coinsurance for out-of-network emergency room visits.
  • Will my rates be adjusted if I smoke?
Tobacco use is a reason why health insurance providers can adjust your rates. Other reasons include: where you live, the size of your family and your age. This applies only to individual plans and small groups plans unless large group coverage is offered through the health insurance exchange.
  • How will the Affordable Care Act affect COBRA?
The Affordable Care Act did not eliminate the Consolidated Omnibus Budget Reconciliation Act (COBRA) or change the COBRA rules.
  • What if I can’t afford health insurance?
You can expect to see more choices in health plans in 2014 that may allow you to find coverage that meets your needs and stays within your budget. You also may be able to get a new kind of tax credit that lowers your monthly premium. Depending on your situation, you may even be eligible for a $0 premium plan. You'll be able to see what your premium, deductibles and out-of-pocket costs will be before you make a decision to enroll. In some states, if you cannot afford health insurance and you meet certain requirements, you will not be required to pay a penalty.
  • What is this penalty I keep hearing about if I don’t sign up for health insurance by 2014?
If you don't have health insurance in 2014, you may have to pay a penalty on your federal income tax. In 2014, the penalty for individuals is the higher of two amounts — $95 or 1% of income. These penalties increase each year. Learn more about the health care penalty and who is exempt.
  • If I am unemployed and don’t have coverage for a few months during a year, will I have to pay this penalty?
No. According to a proposed rule from the U.S. Department of Health & Human Services (HHS), short gaps in coverage won't trigger the coverage requirement. In other words, if you are temporarily unemployed, you won't be fined for losing your health coverage between jobs.
For more information, view this fact sheet on the proposed rule from HHS and the Internal Revenue Service.
  • Do people have to change the plans they are in now?
The ACA includes a “grandfathering” provision that will allow people to keep the plans they had on the date of enactment, subject to some changes, as discussed below. This means that an individual does not have to terminate coverage they had as of the Act’s enactment date. Additionally, existing group health plans may allow new employees and dependents to join the “grandfathered” plans, and new dependents can be added to “grandfathered” plans.
Existing group grandfathered health plans will have to be amended to:
  • Reduce the waiting period such that it is no longer than 90 days;
  • Remove lifetime benefit limits;
  • Comply with the limitation on annual limits;
  • Allow the extension to age 26 but limited to an adult child who is not eligible for enrollment in an employer-sponsored plan until 2014;
  • Provide the uniform coverage documents; and,
  • Apply the standard definitions.
  • What is the individual mandate?
Beginning in 2014, most individuals will be required to maintain minimum essential health coverage or pay a penalty. For those under 18, the penalty will be one-half the amount for adults. Exceptions to this requirement will be made for religious objectors, those who cannot afford coverage, taxpayers with incomes less than 100% of the federal poverty level (FPL), Indian tribe members, those who receive a hardship waiver, individuals not lawfully present, incarcerated individuals and those without coverage for less than 3 months during the previous year.
  • What is the definition of “dependent” as it applies to the ACA?
ACA regulations provide that a health plan may base eligibility for dependent child coverage only in terms of the relationship between a child and participant, and may not deny or restrict coverage based on factors such as: financial dependency, residency, student status, employment or marital status.
  • According to the ACA, which types of health plans need to cover adult children until age 26?
The ACA applies to all health plans that offer dependent coverage.
  • Do grandfathered health plans have to cover a child up to age 26?
Yes, but they are not required to offer coverage to a child that is eligible for other employer-sponsored coverage. After 2014, they have to offer coverage to a child up to age 26, without restriction.
  • Since married dependents are covered, does that mean the spouse of the dependent or the children of the dependent would be covered?
No. The ACA does not require that the spouse of the dependent be covered, nor does it require that the dependent of a dependent be covered (which is a grandchild).
  • On the date of the employer group health plan’s next renewal and open enrollment, can dependent children of covered employees under age 26 be added back to the employee’s group health plan?
Yes, the ACA’s regulations state that any covered child under age 26, whose coverage ended, or who was denied coverage (or were not eligible for coverage) because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll under a 30-day transition period. The 30-day period may or may not coincide with the employer group health plan’s open enrollment.
  • If an employer’s group health plan does not have an annual open enrollment, does the employer’s group health plan still have to offer a 30-day transition period?
Yes, the ACA’s regulations state that any covered child under age 26, whose coverage ended, or who was denied coverage (or was not eligible for coverage), because the health plan did not previously cover dependent children to age 26, is eligible to enroll. They will have a right to enroll under a special 30-day transition period beginning on the health plan’s renewal year. Employees who wish to add dependents may do so whether they need to change their enrollment status from single or employee/spouse to a status that allows dependents, or if they were not previously enrolled in a health plan but wish to do so and add a dependent.
  • Are health plans required to verify student status for this new class of eligible dependents (adult children)?
No, student status can no longer be used to determine dependent status after the effective date of the ACA.
  • If a dependent loses a job that provides coverage, is that a qualifying event to move to the parent’s coverage?
The ACA’s regulations do not address this specific scenario. However, it is believed that the health plan would be required to cover the dependent.
  • If a dependent who is 26 or younger loses his/her employer health plan, do they have to exhaust COBRA first, or can they go immediately on to their parent’s health plan?
Neither the ACA nor the regulations address this. However, normally when a dependent loses coverage through their own employer, that dependent may enroll as a dependent on their parent’s health plan because it is considered a special enrollment event under HIPAA (e.g., loss of other coverage); and the dependent does not have to enroll in COBRA or exhaust their COBRA coverage.
  • If a dependent is already on COBRA and is under the age of 26, can the dependent enroll onto the parent’s health plan at renewal?
  • If COBRA ends, is that a qualifying event to move to the parent’s health plan?
Yes, assuming the adult child is under age 26.
  • Is the applicable age of dependent coverage up to 26 or through the age of 26 (does it end on a birthday)?
Coverage must be allowed to continue until the child reaches the age of 26. Sponsors of group health plans will be required to make dependent coverage available to children up until that day. Plan sponsors are free to elect more generous benefit designs, if available to them, such as covering dependents until the end of the month or even the year in which the child attained the age of 26.
  • Is the parent’s employer allowed to alter the contribution requirement for overage dependents?
No. Dependents up to age 26 are not considered overage dependents. For dependents under the age of 26, the health plan must treat dependents uniformly and may not charge more or have a different benefit structure for dependents based on age.

  • What is the effective date of the lifetime limit mandate?
No health plan may impose lifetime limits on the Essential Health Benefits of a health plan after the ACA effective date.
  • Does the restriction apply to all benefits that may be offered under a group heath plan?
No. The restriction on lifetime limits only applies to Essential Health Benefits as defined under the ACA. Health plans may enforce lifetime limits on specific covered benefits that are non-Essential Health Benefits.
  • While the provisions prohibit lifetime dollar limits, are health plans still allowed to have frequency limits - such as annual visit or other treatment limits?
The ACA and the interim final rule prohibit the use of lifetime limits on the dollar amount of benefits for an individual. Nothing in the rule would appear to prohibit the use of lifetime visit limits or other treatment limits.
  • What happens to enrollees that have already reached their lifetime benefit limit (maximum) under the health plan before the effective date of this provision? Would they be eligible for additional benefits under the health plan?
Once the lifetime limits provision becomes applicable to a health plan, the health plan must give the individual a written notice that the lifetime limit no longer applies and that the individual, if covered, is eligible for benefits.