Monday, October 14, 2013

Hey, Doc: Who Must Enroll in the Marketplace? What if I Don't?

We know health reform is big and confusing. Some parts of the law started in 2010. Other parts are rolling out over the next several years. Texas physicians and the Texas Medical Association have carefully studied the law to help you understand what the changes mean to your health care. 

As the Affordable Care Act (ACA) continues to roll out, Me&My Doctor’s “Hey Doc” series will answer your frequently-asked questions, as well as some you might not have thought to ask.  

Check out part six in this series.

Q. Who must enroll? What if I don’t?

A. The individual mandate of the ACA requires most people to have some form of health insurance coverage as of January 2014, or pay a penalty. If you have coverage through one or more of these sources, you will satisfy the mandate:

  • Government-sponsored insurance (such as Medicare, Medicaid, the Children’s Health Insurance Program, TRICARE, the veterans’ health program);
  • Employer-sponsored coverage;
  • Insurance bought on your own in or outside of the marketplace; or
  • A grandfathered health plan in existence before the health reform law (March 23, 2010).

If you do not have coverage, the marketplace is a new place to shop for health insurance in addition to the traditional private insurance market. It also can help you determine if you are eligible for financial assistance toward your insurance costs or if you are eligible for a state government health program.

Additionally, the ACA exempts certain uninsured people from having to pay the penalty. Generally, you may qualify for an exemption if:

  • Coverage is unaffordable based on your household income;
  • You don’t earn enough income to have to file a tax return;
  • You are uninsured for less than three months in a row; 
  • You are in one of the following groups: incarcerated individuals, undocumented immigrants, American Indians and Alaskan natives, participants of a health care sharing ministry, or members of a recognized religious sect opposed to having health insurance; or
  • You experience certain hardships preventing you from obtaining coverage.

If you don’t qualify for one of the exemptions, and you don’t have insurance coverage next year, you will have to pay a penalty. In 2014, fines begin at $95 per adult and $47.50 per child, or 1 percent of family income, whichever is greater. The penalties then increase in 2015, and in 2016 they will be as much as $695 per adult and $347 per child, or 2.5 percent of family income, whichever is greater.


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