Frequently Asked Questions

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Frequently Asked Questions About ObamaCare

Beginning in 2014, the Affordable Care Act includes a mandate for most individuals to have health insurance or potentially pay a penalty for noncompliance. Individuals will be required to maintain minimum essential coverage for themselves and their dependents. Some individuals will be exempt from the mandate or the penalty, while others may be given financial assistance to help them pay for the cost of health insurance.

ACA/ObamaCare Mandated Health Insurance

What is the penalty for not having the mandated health insurance?
Is anyone exempt from purchasing the mandated health insurance?
Are there exceptions to the penalty for not having health insurance?
Am I buying government health insurance on the online marketplace?

Choice of Provider / Ob-Gyn Direct Access

Can any participating primary care provider be chosen as a primary care provider?
Can a plan require members to obtain a referral or prior authorization before seeking care from a participating ob/gyn provider?

Clinical Trials

What are the new coverage requirements?
What is a “qualified individual”?
What is an “approved clinical trial”?
What are “routine patient costs”?
May a plan require a qualified individual to participate in a trial through a participating provider?

Dependent Coverage

Does this provision impact current plans or just new plans? Does the dependent coverage requirement apply to all markets?
Does the dependent mandate apply to married children?
Does it apply to grandfathered plans?
When will dependents who would meet the new provision of the federal law be allowed to enroll for coverage? How do I get my 21 year old onto my insurance plan?
Exactly when does coverage cease per dependents?
If a dependent is covered by a parent’s plan and a spouse’s plan, which plan pays first?
Can I get coverage even though I recently graduated from college and am no longer on my parents plan?
Does the young adult provision apply to plans or issuers that do not provide dependent coverage?

Existing Insurance Coverage

I’m covered by a Medicare HMO which served my health very well. Will I be able to maintain the same coverage I have now that health insurance reform is implemented?

Health Insurance Marketplace / Exchange

What Does Actuarial Value mean?
What do they mean by Metallic Plans?
What’s a Health Insurance Marketplace? What’s a Health Insurance Exchange?
What’s an Open Enrollment Period?
Who can Qualify for a Premium Tax Credit (Subsidy)?
How do I apply for a Premium Tax Credit (Government Discount)?

Health Reform Information

What is the Affordable Care Act/ObamaCare?
What is the Federal Poverty Level?
What is Medicaid?
How does Medicaid relate to exchange subsidies?
What is The Children’s Health Insurance Program?
What is Medicare?
What is a full-time employee?

Insurance Premiums

How do premiums vary by location?
How do premiums vary by age?

Lifetime and Annual Limits

Lifetime Limits

When does the prohibition on lifetime maximums go into effect? Do lifetime maximums apply to grandfathered plans or only to new plans?
What happens to people who have reached a lifetime limit?
Annual Limits

When does the prohibition on annual limits go into effect?
It is important to note that most plans do not have system capability to support these restricted annual limits for essential benefits, and we will not be offering this option.
Can a plan accumulate all benefits (essential and nonessential) toward the restricted annual limit?
Are internal limits permitted, if in the aggregate they add up to the minimum restricted annual limit?
Are lifetime and annual limits on out-of-network services permitted in plans that offer coverage for in-network and out-of-network services?

Minimum Essential Coverage and Essential Health Benefits

What does Minimum Essential Coverage mean?
What are Essential Health Benefits?
How does “Minimum Essential Coverage” differ from “Essential Health Benefits”?
When does the mandate to include the essential health benefit package take effect?

Pre-Existing Conditions

I have a pre-existing condition. How can I get coverage?
Can I now get coverage for my 6-year-old who has a pre-existing condition?

Preventive Care

ObamaCare requires non-grandfathered plans to provide coverage for “preventive care”. This coverage must be provided without cost sharing (e.g., coinsurance, deductible or copayment) for services provided in network. Interim final regulations were issued on July 14, 2010 and further clarify the requirements for preventive care. An amended interim final regulation was issued August 1, 2011, allowing for certain religious exemptions related to contraceptive services, and a final regulation was issued on February 15, 2012 confirming the exemptions. Also, on February 10, 2012, guidance was issued on the temporary safe harbor for certain entities that are not otherwise exempt from the contraceptive coverage mandate.

Does ObamaCare require coverage of preventive care?
What services are considered preventive care?
Do plans have to comply with notice requirements related to the designation of primary care provider and the direct access requirements for ob/gyn care?


What is the “wellness program”?

ACA Calculator

Does the calculator provide definitive estimates of what people will pay under ObamaCare?