Health Insurance Marketplace FAQ

The way health care reform’s new Marketplace works is simpler than you might think.

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To learn about the basics of the new Health Insurance Marketplace and how it works, you may want to read Nolo’s article on the Health Insurance Marketplace. That article gives an overview of how the Marketplace works; here are some frequently asked questions about some of the details.

What if I Have a Preexisting Condition?

A preexisting condition won’t keep you from getting health coverage. Starting January 1, 2014, no insurance company can exclude you from coverage because you have a chronic or disabling illness or injury because you’ve received recent treatment for a medical condition. This also means an insurance company can’t charge you more if you have a preexisting condition. This applies both to plans sold in the Health Insurance Marketplace and group health insurance plans provided by employers. (Read Nolo’s article on the preexisting condition exclusion for more.)

That said, if you currently have an individual plan that excludes preexisting conditions, that plan is “grandfathered” and doesn’t have to change its rules. However, you are free to switch to a Health Insurance Marketplace Plan on October 1, 2013. Your preexisting condition will be covered when your new plan takes effect January 1, 2014.

What if I Am Pregnant and Want to Buy a Marketplace Plan?

An insurance company can’t deny you coverage because you are pregnant when you join a health insurance plan. However, insurance companies can still impose waiting periods for certain benefits. Fortunately, the health care reform law now puts a limit on these waiting periods. A waiting period for maternity care benefits can be no longer than 90 days. So if you are pregnant when you join a health care plan, the longest you have to wait before your insurance company has to pay for your maternity care, labor and delivery costs is 90 days, or three months.

What if I Work Part-Time and Want to Buy a Marketplace Plan?

If you are employed but you work part-time, you can purchase a plan through the Marketplace. If you aren’t eligible for your employer’s group health plan, depending on your income level, you may be eligible for lower policy premiums, thanks to the “advanced premium tax credit.” There are also cost-sharing subsidies that can make you eligible for lower out-of-pocket costs, depending on your income level.

If you are eligible for your employer’s group health plan even though you work part-time, you aren’t eligible for these cost savings, unless the coverage your employer is offering is not considered affordable. If you have to contribute more than 9.5% of your income toward your employer’s plan, it’s not considered affordable.

What if I Lose My Group Insurance Through My Job?

If you lose your group health insurance because you quit, get fired, or are laid off, you have the option of continuing your plan through COBRA for 18 months or of purchasing an individual plan through the Health Insurance Marketplace. You do not need to wait until an open enrollment period to sign up for a Marketplace plan if you lost your group insurance.

What If I’m Self-Employed? Can I Get an Individual Marketplace Plan?

If you're self-employed, meaning you run your own business or do freelance or contract work, and you don’t have employees, you can purchase any individual Marketplace plan.

If you have employees (not independent contractors), you're considered an employer and a small business.

What If I Run a Small Business With Employees?

If you run a small business and have employees, you will soon be able to use the SHOP Marketplace for employers. SHOP stands for Small Business Health Options Program. The SHOP Marketplace will include plans with the same essential health coverage as the individual Health Insurance Marketplace.

You may be able to qualify for a tax credit of up to 50% of the premium costs you pay for your employees if you obtain insurance through the SHOP marketplace. Your business is eligible it is has fewer than 25 full-time employees (or 25 full-time equivalents) who make an average of $50,000 or less. If you have fewer than 10 employees who are paid an average of no more than $25,000, you are eligible for the highest tax credit.

Read more about the small business health care tax credit on the IRS website. You can learn about requirements for larger employers in Nolo's article about the employer mandate in health care reform.

Can I Use My FSA to Pay for the Costs of a Marketplace Plan?

You can only use a flexible spending account (FSA) to pay for out-of-pocket costs associated with a Marketplace plan if your employer provides group health insurance using the SHOP Marketplace. If so, you can use your FSA to pay for deductibles, copayments, and other costs associated with your plan, but you may not use it to pay premiums.

How Can I Find Out More About What's Available in My State?

To find out the details on Obamacare in your city and state, visit legalconsumer.com's section on Obamacare.

by: , J.D.

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