Wednesday, November 12, 2014

“Hey, Doc,” who must enroll in the marketplace? What if I don’t? What are the penalties for not having health insurance?

Enrollment for the health insurance marketplace begins in three days — Nov. 15. Texas physicians want to ensure you have the information you need to start the enrollment process. They week’s “Hey, Doc” segments discuss who must enroll for health insurance and possible penalties for those who decide not to purchase insurance.

Q. Who must enroll? What if I don't?

A. As of 2014, the individual mandate of the Affordable Care Act (ACA) requires most people to have some form of health insurance coverage, or pay a penalty. (See “When Can I Sign Up?” or watch the “Hey, Doc video.”) If you have coverage in one or more of these ways, 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 ACA marketplace that meets the new ACA requirements; or
  • A "grandfathered" health plan: a health plan in existence before the health reform law (March 23, 2010) that is exempt from some of the new ACA requirements. 
The Obama administration has also said that if your insurer renewed an old policy that doesn’t meet the new ACA requirements, that might still satisfy the mandate for 2015. Check with your insurance company.

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

Additionally, the ACA says certain uninsured people don’t have to pay the penalty. Generally, you may qualify for an exception 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 Alaska 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, you will have to pay a penalty, which increases each year.

Q. What are the penalties for not having health insurance?

A. If you didn’t have insurance in 2014, and you didn’t qualify for one of the exemptions, you will have to pay a penalty when you file your taxes at the end of the year. The penalties increase each year.
  • For 2014, you will pay either $95 per adult and $47.50 per child, or 1 percent of your family income, whichever is greater.
  • In 2015, the fines begin at $325 per adult and $162.50 per child, or 2 percent of your family income, whichever is greater.
  • In 2016, the fines increase to as much as $695 per adult and $347 per child, or 2.5 percent of family income, whichever is greater.
  • After 2016, the penalties will be adjusted based on inflation.

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