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Blog > 2014 > December > Health Care Reform: Health Insurance Mar...
December 04, 2014

Health Care Reform: Health Insurance Marketplace FAQs

by admin

Guest post by Todd McLaughlin, Advisor at Apex benefits

What is a Health Insurance Marketplace?

The Health Insurance Marketplace is a new way to find health coverage that fits your budget and meets your needs. With one application, you can see all your options and enroll. The Marketplace is sometimes known as a health insurance Exchange.
When you use the Marketplace, you'll fill out an application and find out whether you can get lower costs on your monthly premiums for private insurance plans. You'll also find out if you qualify for:

  • Lower out-of-pocket costs; or
  • Free or low-cost coverage available through Medicaid or the Children's Health Insurance Program (CHIP).

Insurance plans in the Marketplace are offered by private companies, and they all cover the same core set of benefits, known as essential health benefits. No plan can turn you away or charge you more because you have an illness or medical condition, and plans can't charge women more than men.
What does Marketplace health insurance cover?
All private health insurance plans offered in the Marketplace will offer the same set of essential health benefits.

These benefits include at least the following items and services:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization
  • 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

Am I eligible for coverage in the Marketplace?
Most people will be eligible for health coverage through the Marketplace.
To be eligible for health coverage through the Marketplace, you:

  • Must live in the United States
  • Must be a U.S. citizen or national (or be lawfully present)
  • Can't be currently incarcerated

What if I have a pre-existing health condition?
Being sick doesn't keep you from getting coverage. An insurance company can't turn you down or charge you more because of your condition.
How can I get lower costs on Marketplace coverage?
When you use the Marketplace you may be able to get lower costs on monthly premiums or out-of-pocket costs, or get free or low-cost coverage.
You can save money in the Marketplace in three ways. All of them depend on your income and family size.

  1. You may be able to lower costs on your monthly premiums when you enroll in a private health insurance plan.
  2. You may qualify for lower out-of-pocket costs for co-payments, coinsurance and deductibles.
  3. You or your child may get free or low-cost coverage through Medicaid or CHIP.

When you fill out your Marketplace application, you'll find out how much you can save. Most people who apply will qualify for lower costs of some kind.

Will I qualify for lower costs on monthly premiums?
When you get health insurance coverage in the Marketplace, you may be able to get lower costs on monthly premiums, and therefore lower the costs of your coverage. You'll see the amount of savings you’re eligible for when you fill out your Marketplace application. Prices shown for insurance plans will reflect the lower costs.
These lower costs are accomplished with a tax credit called the Advance Premium Tax Credit. The tax credit can be applied directly to your monthly premiums, so you get the lower costs immediately.
The amount you save depends on your family size and how much money your family earns. In general, people at the following income levels will qualify to save in 2014. The lower your income, the higher your savings will be.

  • Up to $45,960 for individuals
  • Up to $62,040 for a family of 2
  • Up to $78,120 for a family of 3
  • Up to $94,200 for a family of 4
  • Up to $110,280 for a family of 5
  • Up to $126,360 for a family of 6
  • Up to $142,440 for a family of 7
  • Up to $158,520 for a family of 8

You may also be able to get lower out-of-pocket costs, depending on your income and family size.

How do I estimate income?
When you apply for lower costs in the Marketplace, you’ll need to estimate your household income for 2014. For most people, you can use your household’s adjusted gross income for this estimate.
Another way to estimate your income is to add up the following items for all the people in your household, based on what you think they’ll receive in 2014:

  • Wages
  • Salaries
  • Tips
  • Net income from any self-employment or business
  • Unemployment compensation
  • Social Security payments

Other kinds of income to include when estimating your 2014 income are rental income, interest, dividends, capital gains, annuities, alimony and some retirement and pensions.

What is modified adjusted gross income?
When you fill out the Marketplace application, a number called “modified adjusted gross income” (MAGI) will be used.

MAGI is generally your household’s adjusted gross income plus any tax-exempt Social Security, interest and foreign income you have. It’s used to determine your eligibility for lower costs on Marketplace coverage, and for Medicaid and CHIP.

You don’t have to figure out this income yourself. The math will be done for you when you apply through the Marketplace or your state agency.

For Medicaid, it also matters if you’ve had a change in household income since your last tax return. When you apply you’ll need to tell us your household income for 2014, taking into account changes that you know about.


What kinds of health insurance don't qualify as coverage?
Health plans that don't meet minimum essential coverage no longer qualify as acceptable coverage for purposes of the individual mandate. If you have only these types of coverage, you may have to pay the fee. Examples include:

  • Coverage only for vision care or dental care
  • Workers' compensation
  • Coverage only for a specific disease or condition
  • Plans that offer only discounts on medical services

What key dates do I need to know?

There are three key dates you'll want to mark on your calendar:

  • November 15, 2014: 2015 Open Enrollment starts
  • December 31, 2014: Coverage ends for Marketplace plans bought in 2014
  • February 15, 2015: Open enrollment ends

For more information about the Marketplace or for help selecting and individual insurance plan contact Todd at or 317-806-5149 today.


Category: Money Smart, Tags: Health Insurance
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