Obamacare user guide Q&As

Q&A table of contents
Question Link
When can I buy Obamacare insurance? Answer
How do I get a special enrollment period to sign up for insurance outside the open enrollment period? Answer
I’m thinking of not getting insurance and paying the penalty. What do I need to know? Answer
I think I’m exempt from the individual mandate. How do I get out of paying the penalty for not having insurance? Answer
What is an insurance premium? Answer
Is dental coverage available with any health care plans sold through the new insurance market? Answer
I have Medicare and am wondering if any coverage from the exchange would be better. Should I look for insurance through Access Health CT? Answer
If you are a contractor and your income is erratic, how do you know if you qualify for the federal assistance to discount your insurance premiums? (2013 question) Answer
Can a small employer buy coverage for workers through the individual market? Answer
Denied coverage in the past. Will they be penalized?: Answer
I have a major medical policy now. Will I need to buy additional coverage to avoid paying a penalty under Obamacare? Answer
What if I lose my job? Answer
Free insurance! Is it worth it? Answer
How do you get to the exchange? Answer
I found out that I qualify for a tax credit to buy insurance through the exchange. Can I get the same tax credit if I buy a plan outside the exchange? Answer
I have HUSKY. Should I sign up now? Answer
I’m 28 and don’t have a job or income. I don’t really want health insurance. Answer
I’m 35, single and earn $37,000 per year. Is there a health insurance plan that covers substance abuse treatment? Answer
I get coverage through my job but it’s very expensive to add my spouse and kids to the plan. Are there new options available to us through Obamacare? Answer
If the parents shop for insurance on the exchange and get subsidized coverage, will the children have to sign up for the same insurance and lose HUSKY? Answer
I don’t have health insurance. If I do absolutely nothing, when and how will they come after me and what are their enforcement tools? Answer
What is an insurance copayment? Answer
What is co-insurance? Answer
What is an insurance deductible? Answer
What is the out-of-pocket maximum on a health insurance plan? Answer
What is an insurance provider network? Answer
What is an insurance plan formulary? Answer
I’m out of work, signed up for insurance through the exchange and got a government subsidy for my monthly premium payments. If I get a job and switch to my new employer’s health care policy, will I have to pay the subsidy back to the government? And if so, how and when? Answer
What are insurance prices based on? Answer
Do insurance rate hikes apply to people with subsidies? Answer
My insurance plan doesn’t comply with Obamacare, but I was able to keep it this year because I renewed it at the end of 2013. Can I renew it again so I don’t have to find another plan? Answer
I qualified for a free insurance plan under Obamacare, but I still have to pay my insurance company a small amount each month. Why is that? Answer

When can I buy Obamacare insurance?

The next open enrollment period for people who buy private insurance on their own to sign up begins Nov. 1, 2015. At that point, people will be able to sign up for health plans that take effect Jan. 1, 2016. The sign-up period runs through Jan. 31. If you miss the deadline for signing up this year and decide you want coverage, you’ll have to wait — unless you qualify for an exception.

What’s the exception? It’s if you go through a “qualifying life event” that causes you to lose coverage or become eligible for another plan. Examples include losing your job, getting divorced or moving to another state. If any of those cause you to lose your insurance, you can sign up for private insurance through something known as a “special enrollment period.” Similarly, if you get married or have a baby, you can join your spouse’s plan or add your child to your plan.

Things that don’t qualify you for a special enrollment period: Getting sick and deciding you want insurance, or losing your old plan because you didn’t pay the premiums.

Another thing to keep in mind: People who qualify for Medicaid can sign up for that program at any time during the year.

How do I get a special enrollment period to sign up for insurance outside the open enrollment period?

The easiest way for people who want to buy coverage through the exchange to request a special enrollment period is to use the Access Health call center (1-855-805-4325), said Chad Brooker, a policy analyst at Access Health.

You will probably be asked to submit documentation to prove why you qualify for the enrollment exception, such as a letter confirming that your job no longer provides health care or a letter saying you no longer qualify for Medicaid.

People who qualify for special enrollment periods can also purchase insurance sold outside the exchange.

I’m thinking of not getting insurance and paying the penalty. What do I need to know?

The penalty for 2016 is 2.5 percent of your income above the tax return threshold or $695 per person, whichever is higher. It’s increased since the coverage requirement took effect in 2014.

If you have coverage for part of the year, you’ll owe a prorated penalty. It’s calculated based on the number of months you didn’t have coverage, with each month costing you 1/12 of the full-year penalty.  So if you’re uninsured for six months in 2016, you’d owe half of 1 percent of your income.

If you’re uninsured for fewer than three consecutive months, you won’t have to pay a penalty.

Another thing to note: According to federal regulations, if you have insurance for at least one day in a given month, you are considered to be insured for that full month and wouldn’t owe a penalty for that month.

What happens if you don’t pay your penalty? The federal government can’t issue a lien, but it can deduct the amount from any refund you’re owed, according to the IRS.

I think I’m exempt from the individual mandate. How do I get out of paying the penalty for not having insurance?

In most cases, you’ll have to apply for an exemption.

To apply for an exemption, you’ll have to fill out this form if you live in Connecticut. (You can find it on the Access Health website, www.accesshealth.com, by clicking the “Can I opt out?” tab on the bottom right corner of the homepage.)

A team at the exchange will review the submitted forms and any supporting documents people include and determine if they meet the requirements for an exemption. For those who qualify, the team will also determine whether they will be granted an exemption for the full year or for part of the year.

One group that doesn’t need to apply for an exemption: People who don’t have enough income to be required to file a federal income tax return. The Internal Revenue Service has said people in that category, who are not subject to the individual mandate, don’t have to take any action to get an exemption.

There are several circumstances in which someone could be exempt from the individual mandate. They are:

  • If you’re uninsured for fewer than three months of the year;
  • If coverage is unaffordable to you — that is, if the cheapest option available would cost more than 8 percent of your household income;
  • If your income is too low for you to be required to file a tax return (in Connecticut, many people in this category would qualify for Medicaid);
  • Belonging to a federally recognized tribe;
  • Being a member of a recognized health care sharing ministry;
  • Being a member of a recognized religious sect with religious objections to insurance, including Social Security and Medicare;
  • If you’re incarcerated;
  • If you’re not in the country legally.

In addition, people could potentially qualify for a “hardship exemption” from the mandate if any of the following affected their ability to buy health insurance:

  • Being homeless;
  • Being evicted in the past six months or facing eviction or foreclosure;
  • Receiving a shutoff notice from a utility company;
  • Recently experiencing domestic violence;
  • Recently experiencing the death of a close family member;
  • Experiencing a fire, flood or other disaster that caused substantial damage to the person’s property;
  • Filing for bankruptcy in the past six months;
  • Having medical expenses they couldn’t pay in the past two years;
  • Having unexpected additional expenses as a result of caring for an ill, disabled or aging family member;
  • Having a child whom they will claim as a tax dependent who has been denied Medicaid and CHIP coverage and if a court order requires another person to provide medical support to the child; this exemption means the person would not have to pay a penalty on behalf of the child if he or she is uninsured;
  • Being ineligible for Medicaid because their state didn’t expand the program (this does not apply in Connecticut, which did expand its Medicaid program, known as HUSKY);
  • Being eligible for enrollment in private insurance through the exchange;
  • If, because of an eligibility appeals decision, they are eligible for enrollment in a private insurance plan through the exchange for a time when they weren’t enrolled in one;
  • If their individual-market insurance plan was canceled and they think other plans sold through the exchange are unaffordable;
  • If they experienced another hardship in obtaining insurance.
What is an insurance premium?

A premium is the up-front cost you pay to have insurance coverage. People usually pay premiums on a monthly basis

Is dental coverage available with any health care plans sold through the new insurance market?

Yes. You can buy a dental plan through Access Health, the state’s exchange. The policies are separate from the health insurance plans the exchange sells.

In addition, the health plans sold through Access Health must all cover dental care for children under 19.

I have Medicare and am wondering if any coverage from the exchange would be better. Should I look for insurance through Access Health CT?

Experts say don’t. Access Health, like the marketplaces in states across the country, is not intended for people with Medicare. It won’t sell Medicare policies or Medigap coverage. Experts say that if you have Medicare, you should make your decisions about Medicare Advantage, supplemental policies and Part D coverage the way you have in the past, and avoid Access Health.

Obamacare provides for federal subsidies to cut the cost of insurance for many people buying coverage through the state marketplaces, but people who get Medicare don’t qualify for those discounts. There are two exceptions: People who qualify for Medicare because of end-stage renal failure, and people who don’t have enough work history to qualify for premium-free Medicare Part A will be eligible for federal subsidies if they buy coverage through Access Health.

Aside from people in those relatively small groups, “People with Medicare can never get tax credits, and in general, a qualified health plan through the exchange is really not going to be as good for them as, say, a standard Medigap policy,” said Andrea Callow, a policy attorney at the Center for Medicare Advocacy.

If you are a contractor and your income is erratic, how do you know if you qualify for the federal assistance to discount your insurance premiums? (2013 question)

When applying for coverage, you should do an estimation of what your income will be, said Chad Brooker, policy and legal analyst for Access Health CT, the Connecticut insurance marketplace created by Obamacare. He offered the following overview of how the income verification process will work:

The Access Health computer system will compare the income you enter for 2014 with what you reported on your 2012 tax returns. If your 2014 estimate is higher or up to 10 percent lower than what you made in 2014, it will accept that amount and calculate your eligibility for assistance based on that amount.

If the amount you enter for 2014 is more than 10 percent below what you earned in 2012, you’ll be asked to submit documentation to show why your income will be lower. You will have 90 days to do so. If it’s accepted, your potential financial assistance will be calculated based on that figure. If you don’t submit documentation, or it’s not accepted, you’ll still be able to buy insurance through Access Health, but you won’t be able to get any discount.

There are some checks and balances in the system: Ultimately, this will get reconciled when you pay your federal income taxes for 2014. If you end up making a lot more than you estimated when applying for insurance, you’ll have to pay back some of the financial assistance you got with your taxes. If you end up earning less than you projected, you could end up getting money back from the government, to compensate you for insurance premium subsidies you would have gotten based on your actual income.

Can a small employer buy coverage for workers through the individual market?: I’ve compared the Access Health small-group market’s “gold” plans (the most generous ones available) with the individual market’s “gold” plans from the same insurers. For the same ages and same coverage, the individual market policies are noticeably less expensive than those sold through the small-group market.
I am a small-group employer and cover two full-time employees, as well as myself and my family. Since the individual market plans cost less, would I have the option of paying our employees the equivalent of a premium and letting them buy it themselves?

You could terminate your employer-sponsored insurance plan and give your employees the money that you would have spent on their coverage, so they could buy their own.

But Brian Driscoll, chief operations officer at Ovation Benefits in Farmington, said there are two things to keep in mind if you do that:

The additional money you give your workers wouldn’t be tax-free, the way your contributions to an employer-sponsored health plan are. So if you decide to forgo spending $5,000 a person for the company’s health plan and instead pay all your workers an extra $5,000, they won’t actually be able to spend all of it to buy insurance because some will be taken out in taxes.

In addition, discounted premium rates are available to people buying coverage through the exchange, but qualification is based on income. “The more you make, the less you’re subsidized,” Driscoll said. So if you increase your employees’ income by giving them extra money to buy insurance, you’ll reduce the size of any discount they could receive.

Denied coverage in the past. Will they be penalized?: My parents do not have health insurance now. They have tried to get insurance in the past few years and have been denied. In 2014, if they don’t have health insurance, will the state have to give it to them under Obamacare? I don’t find it fair to be charged a penalty for not having health insurance if everyone denies you.

Some things changed in 2014 that will help your parents get insurance and avoid having to pay a penalty for being uninsured.

The state won’t be required to give them insurance (unless they earn below a certain income level, in which case they’d qualify for Medicaid). But they’ll have new options for buying private insurance.

First of all, insurance companies won’t be allowed to deny people coverage based on their medical histories, or to charge them more because they’ve had medical issues in the past. So even if they’ve been unable to buy insurance in the past, it should be possible for them to do so starting in January.

Depending on their income, they might have additional new options. If their income is low enough, they could qualify for Medicaid. If they earn too much for Medicaid, they might qualify for a discount on their premiums if they buy insurance through Access Health CT, the new marketplace for private insurance created by Obamacare.

I have a major medical policy now. Will I need to buy additional coverage to avoid paying a penalty under Obamacare?

If you buy health insurance on your own, any plan you buy or renew will be enough to keep you from having to pay a penalty under the federal health reform law.

The law sets several new standards for insurance coverage, including prohibiting them from limiting the dollar value of coverage you receive in a lifetime and requiring that they cover at least 60 percent of customers’ medical costs. As of 2014, there are also limits on what people have to pay out-of-pocket for deductibles, copays and coinsurance ($6,350 for an individual, and $12,700 for a family plan; those are expected to rise in future years).

Any new insurance plan sold to individuals since Jan. 1, 2014 must meet those and other requirements set out in the health reform law.

The plan you have right now might not meet those requirements, but you might still be able to renew it next year if it’s what’s known as grandfathered. That means the plan existed before the health law passed in 2010 and has not changed significantly. People who have grandfathered plans can keep them as long as the insurer is still offering them, and will not face a penalty. Grandfathered plans can’t be sold to new members, though, so if you give up a grandfathered plan, you won’t be able to buy another one.

The bottom line: If you buy or renew a plan through the state’s individual market, you won’t have to pay a penalty.

What if I lose my job?: My company (which provides my insurance) is laying off people. If that were to happen to me, what would I have to do to have insurance again and not get penalized?

If you have a brief gap in coverage — up to three months during a year — you won’t face a penalty for being uninsured.

As for how to get insurance, you’d have a few options.

As is the case now, you’d be eligible to keep your current insurance through COBRA, but it would probably be fairly costly.

Your other options will depend on your income. If it’s low enough, you’d qualify for Medicaid. The income limit depends on your family size, whether you have minor children and what state you live in. If you have minor children and live in Connecticut, the limit is 155 percent of the poverty level. If you don’t have minor children, the limit is 138 percent of the poverty level.

If your income is too high to qualify for Medicaid, you might qualify for a discount on your premiums if you buy coverage through Access Health CT, the state’s health insurance exchange.

You could also buy insurance outside the exchange, but you wouldn’t be able to get any discounts on coverage that way.

Free insurance! Is it worth it?: I’m 63, single, and make about $31,200 a year in Fairfield County. What would it cost to buy insurance? (2013 question)

(The figures used in this answer are for 2014 plans and income levels. But the concepts apply to 2014 and beyond.)

Your age and county mean you’ll face among the highest prices for insurance in the state. But your income is low enough that, if you buy coverage through Access Health CT, you’ll qualify for a discount.

In fact, including the discount, you could actually get one type of plan for free, or close to it.

Since you earn under 400 percent of the poverty level, the federal health law says you won’t have to pay more than a certain percentage of your income to buy a particular health plan. In your case, your costs would be capped at 8.67 percent of income. That’s about $225 per month.

But it’s a little more complicated than that. That number represents what you’d have to pay to buy the second-cheapest silver tier plan sold by Access Health. Based on your age and county, that plan would cost $971 per month.

If you buy that plan and pay $225 per month, the federal government will pay the other $746. You’re free to buy any of the other plans sold through Access Health, but whatever you choose, the federal government will pay the same amount — $746 (the difference between the cost of the second-cheapest silver plan and your maximum cost for buying it).

There are four types of coverage — bronze, silver and gold. Bronze plans have the highest out-of-pocket costs. The silver plans cover more, so you’d have to pay less when getting care. The gold plans have the lowest out-of-pocket costs. (As of 2015, people can also buy a platinum plan, which has higher premiums but lower out-of-pocket costs.)

After factoring in your $746 discount, your monthly premium costs would be about:

Bronze: $0 to $51

Silver: $138 to $261

Gold: $269 to $380

As you can see, buying the cheapest bronze plan would actually leave you with nothing to pay in premiums because the plan’s cost, $705 per month, is less than your discount.

But it’s important to also look at what the different plans cover. Bronze plans have a $3,250 deductible, so you’d have to spend that much before the plan begins paying for medical care (with the exception of certain preventive services). After you hit the deductible, you’d have to pay 40 percent of the cost of many services.

By contrast, silver plans have a $3,000 deductible and a separate $400 deductible for prescription drugs. But the deductible applies to fewer services, and once you reach it, you’d have fixed copays, rather than having to pay a certain percentage of your medical costs.

The gold plans cost the most, but cover the most: The deductible is $1,000, and once you hit it you’d have fixed copays, rather than having to pay a certain percentage of the total cost of care.

What’s the best for you? It depends on many factors, including how much medical care you’ll need and how much risk you’re willing to take on. But it’s worth taking into account both the premium costs and the out-of-pocket costs you’ll face if you buy the plan.

How do you get to the exchange?

You can go online to www.accesshealthct.com. You can also speak to a representative by phone at 1-855-805-4325.

I found out that I qualify for a tax credit to buy insurance through the exchange. Can I get the same tax credit if I buy a plan outside the exchange?

No, you can’t get the tax credit for a plan sold outside the exchange.

Under the federal health law, people whose income falls below a certain level (400 percent of the poverty level) are eligible for federal financial assistance to buy insurance. That comes in the form of a tax credit. You can choose to get it in a lump sum when you file your taxes, or you can have the federal government pay some or all of the tax credit to your insurance company each month, reducing the amount you have to pay in premiums.

Those tax credits are available only to people who buy insurance through state-based exchanges (Connecticut’s is called Access Health CT). You can still buy insurance outside the exchange, but you won’t get any federal help paying your premium.

My family and I are covered by HUSKY (Connecticut’s Medicaid program), but we won’t be eligible after May.  After that I may need Obamacare coverage, but everything I’ve read says I need to sign up for it before the open enrollment period ends.  So should I sign up now? I don’t want to lose the free prescriptions and doctor visits that HUSKY covers if I don’t have to yet, but can I sign up for Obamacare after open enrollment ends?

The end of the open enrollment period is the last date for people who want individual-market insurance for the year to sign up for coverage (in 2016, that date is Jan. 31). But there’s an exception: If you find yourself in need of insurance later in the year because of a change in circumstances, such as losing a job, getting divorced or losing eligibility for Medicaid, you’ll be able to request a “special enrollment period” and sign up at that time.

So in your case, there’s no reason to drop your HUSKY coverage now. Instead, you can maintain your current coverage until it ends and request a special enrollment period to get insurance to replace it after May. You’ll have 60 days from the date of the change in circumstances (in your case, the end of your HUSKY eligibility) to sign up for new coverage.

To learn more about requesting a special enrollment period, click here.

I’m 28 and don’t have a job or income. I don’t really want health insurance. What do I do about Obamacare? I don’t want to be locked up for not having insurance. How do I avoid it?

The government can’t put you in prison for not having health insurance. The penalty for not having insurance is a fine: in 2016, it will be 2.5 percent of your income or $695, whichever is higher.

If you don’t have any income at all, you’re exempt from the mandate for having coverage. People whose income is too low to require them to file a tax return (usually below about $10,000 for a single person) don’t have to pay a penalty for not having coverage.

But if you live in Connecticut or one of the other states that expanded their Medicaid programs as part of Obamacare, chances are you qualify for health care coverage through that program at little or no cost to you (in Connecticut, Medicaid clients don’t pay anything for coverage).

I’m 35, single and earn $37,000 per year. Is there a health insurance plan that covers substance abuse treatment?

Yes. In fact, under Obamacare, all health plans sold or renewed starting this year must cover a set of 10 “essential health benefits,” including substance abuse and mental health services.

Other essential benefits that many individual-market plans didn’t previously cover include maternity care and pediatric dental and vision care.

Any health plan you buy through your state’s exchange or outside the exchange will have to cover those benefits. But depending on your plan’s benefit design, you might have to pay a significant amount of money out-of-pocket when you get care. The lowest-priced plans available to most people shopping on Connecticut’s exchange, for example, have deductibles that are $5,000 or higher, meaning that you’d have to spend $5,000 on medical care before the plan begins covering the costs (with the exception of certain preventive services, which your plan must cover at no charge to you). Plans with higher premiums tend to have lower deductibles, so it might be worth considering the higher monthly fee if you know you’re going to need more services.

Because your income is below 400 percent of the poverty level, you would qualify for a health plan with discounted premiums, as long as you buy your insurance through the exchange. You could still buy a plan outside the exchange, but you wouldn’t get the discount.

Plans that were sold or renewed before Jan. 1 don’t have to cover all the essential health benefits, but those plans can’t be sold to new customers anymore because they don’t meet the health law’s requirements.

I get coverage through my job but it’s very expensive to add my spouse and kids to the plan. Are there new options available to us through Obamacare?

It depends how affordable it is for you — not your family — to buy coverage through your employer.

Under the Affordable Care Act, people can buy insurance through the state’s health insurance exchange with discounted premiums, subsidized by the federal government, if their incomes fall below 400 percent of the poverty level (that’s about $97,000 for a family of four). But if you have the option of getting health insurance through an employer, you’re only eligible for subsidies to buy an exchange plan if your employer-sponsored coverage would cost more than 9.5 percent of your household income.

What about family coverage? Your family’s eligibility for an exchange subsidy is also based on whether employee-only coverage is considered affordable (that is, 9.5 percent of your household income or less). So if your company’s insurance meets that affordability standard and the company offers family coverage, regardless of how expensive the family part of it is, your family won’t qualify for subsidies to buy a plan on the exchange.

The rules on this have changed since the health law was passed. It was initially anticipated that a family would qualify for exchange subsidies if family coverage from an employer’s plan exceeded what’s considered affordable. But the IRS issued a regulation with a different standard, making it so that a family would not be eligible for subsidized exchange plans if the employer offered coverage that was affordable to an employee and also offered family coverage.

Chad Brooker, a policy analyst for Access Health CT, Connecticut’s exchange, said some companies have addressed this issue by dropping their family coverage. That makes family members of their workers eligible for subsidized exchange plans if they meet the income requirements.

One other thing to note: Although it’s not a new option, you might be able to get lower-cost coverage for your kids if your income is less than 323 percent of the poverty level (about $76,066 for a family of four). Kids up to age 19 can qualify for free or subsidized coverage as part of the state’s HUSKY B program. For more on HUSKY B eligibility, click here. Eligibility in the program is not related to whether you get insurance through your job or not.

Many of the employees of the company I work for have children who are covered by HUSKY (Connecticut’s Medicaid program). If the parents shop for insurance on the exchange and get subsidized coverage, will the children have to sign up for the same insurance and lose HUSKY?

No. In fact, it’s likely that there will be many families in which adults buy private insurance through the exchange while their kids receive coverage through HUSKY B (a form of subsidized public coverage similar to Medicaid).

That’s because the income limit for kids to receive HUSKY is higher than the limit for adults.

Parents’ qualifications for discounted insurance is not related to whether their children get HUSKY or not.

The federal health law prohibits people who qualify for Medicaid (or the Children’s Health Insurance Program, which is known as HUSKY B in Connecticut) from receiving subsidies to buy private insurance through the exchange. So kids who qualify for HUSKY B aren’t eligible for discounted insurance, even if their parents are.

I don’t have health insurance. If I do absolutely nothing, when and how will they come after me and what are their enforcement tools?

You’ll face a financial penalty if you don’t have health insurance, unless you qualify for an exemption (more on that below). The penalty is charged with your taxes, so you’d have to pay when you file your 2016 tax returns. In 2016, the penalty is 2.5 percent of your household income or $695, whichever is higher.

You can’t be arrested for not having insurance.

There’s a chance you won’t be subject to the penalty. You’re exempt from the mandate to have health insurance if you are:

  • Not in this country legally
  • A member of an Indian tribe
  • Incarcerated
  • A member of a religious sect that has objections to health insurance
  • A member of a health care sharing ministry
  • Very poor (you have too little income to file a tax return. Many people in this category will qualify for Medicaid, which is free in Connecticut.)
  • Someone for whom insurance would be considered too expensive to buy, even with employer contributions and/or federal subsidies
  • Uninsured for fewer than three months during a year
What is an insurance copayment?

A copayment is a fixed amount that you must pay when you get medical care. For example, you might have to pay a $20 copayment when you go to a primary care doctor and a $30 copayment when you see a specialist. The copayment is a set amount and does not vary based on what the service costs.

What is co-insurance?

Co-insurance is a type of out-of-pocket cost some people face when they get medical care. It requires people to pay a certain percentage of the cost of care. For example, if you have a 40 percent coinsurance, it means that you are responsible for 40 percent of the cost of the care you receive. Unlike copayments, in which patients pay a set amount, co-insurance costs will vary depending on what the care costs.

What is an insurance deductible?

A deductible is the amount of money you must spend on covered medical expenses before your plan begins paying for your care. If you have a $3,000 deductible, for example, you would have to spend $3,000 on medical care before the plan begins to pay for your care. But health plans differ in how the deductibles are handled. In some plans, nearly all services are subject to the deductible, meaning that you have to pay the full cost of those services before the plan chips in for your care. In others, only some services are subject to the deductible while others are covered partially or fully by the plan, even if you haven’t yet met the deductible.

  • It’s important to know what services are subject to the deductible. Some plans have separate deductibles for medical care and prescription drugs.
  • It’s important to know what happens once you meet your deductible. Some plans pay the full cost of care, leaving you to pay nothing. But some require you to pay a fixed copayment when you get care, while others require you to pay co-insurance — that is, a certain percentage of the cost of care.
  • Because of the federal health law, all plans must cover preventive services at no charge to the member, regardless of whether you’ve met your deductible or not.
  • The money you spend on your health insurance premiums do not apply to the deductible.
What is the out-of-pocket maximum on a health insurance plan?

This is the most you can be required to spend on medical care covered by your insurance in a given year. Premiums do NOT count toward this figure.

What is an insurance provider network?

Insurance companies contract with doctors, hospitals and other health care providers, who agree to accept a set fee for seeing members of that insurance company’s plans. The providers who contract with an insurance company are considered to be in that insurer’s network. In many plans, patients who see a provider that is not in the plan’s network will have to pay significantly — because their plan benefits might require them to pay more out-of-pocket and because the providers who aren’t in the insurer’s network aren’t bound by the fee level the insurer negotiates.

Some health plans sold through Connecticut’s health insurance exchange, Access Health CT, have different provider networks than plans sold outside the exchange by the same insurers. So if you buy a plan through the exchange, it’s important to check whether providers take that particular plan, not just whether they take the insurance company’s coverage.

What is an insurance plan formulary?

This is the list of the medications covered by an insurance plan. Health plans categorize drugs into tiers, which require different levels of out-of-pocket costs for members who buy them. Because different insurers have different formularies, it’s important to check how a drug you use is covered by any plan you’re considering.

I’m out of work, signed up for insurance through the exchange and got a government subsidy for my monthly premium payments. If I get a job and switch to my new employer’s health care policy, will I have to pay the subsidy back to the government? And if so, how and when?

You might have to repay a portion of the subsidy, but whether you do and how much it would be depends on your total income for the year.

If you end up owing money, you’d pay it to the government when you file your taxes next year.

Here’s how this works:

The subsidies people get to discount their premiums are actually tax credits, paid in advance to your insurance company when your monthly premiums are due. (You can also elect to have some or all of the tax credit paid to you as a lump sum tax refund next year, but that means you’ll get less up-front assistance paying your insurance premiums each month.)

The amount of the tax credit you get in advance is based on an estimate of what your total income will be this year. The actual amount you’re entitled to won’t be known until the end of the year, when it’s clear how much you actually earned. And if there’s a difference, that will be reconciled through your taxes.

If your income was lower than estimated when you applied for coverage, you could be entitled to a larger tax credit and get some money back. If your income was higher than estimated when your subsidy was calculated, you could owe money to the government for some or all of the cost of the tax credit you received.

If that’s the case, the amount you have to repay will be based on your income. For people who earn below 400 percent of the poverty level – that is, people whose income qualifies them for a subsidy – the amount of repayment will be capped.

But if at the end of the year, it turns out that your income was too high to have received any subsidy, you’ll have to pay back the full amount.

Connecticut’s exchange, Access Health CT, asks people whose incomes change to report it within 30 days. That way, the exchange can adjust their subsidies to match their new income levels and reduce the need to repay any of the tax credit later.

What are insurance prices based on?

Other keywords: premiums, insurance, bronze plan, silver plan, gold plan, platinum plan

Each person’s premium cost is based on four factors: Age, county, the specific plan and the insurance company offering it.

The calculations start with something known as a “base rate.” Each insurance company has a different one, ranging from $195 to $380. That figure gets multiplied by three different numbers, corresponding to the person’s age, county and plan choice.

Age is the biggest variable: A person who is 64 will pay three times as much as a 21-year-old.

Location also matters. In general, people in Fairfield County pay the most for insurance, but the extent to which a county raises or lowers a person’s premiums varies by insurance company.

The other factor is the type of plan a person picks. Bronze plans have the lowest premiums, but require members to pay the largest share of their medical costs. Platinum and gold plans, by contrast, have the highest monthly premiums, but cover a larger share of members’ medical expenses. Silver plans are in the middle.

Do insurance rate hikes apply to people with subsidies?

The majority of people who buy insurance through the exchange don’t pay the plans’ “sticker price.” That’s because they receive discounts on their premiums, subsidized by the federal government.

The subsidies aren’t going away, so people whose income is low enough will still qualify for discounted premiums.

Here’s how subsidies work: They’re set so people who qualify won’t have to pay more than a certain percentage of their income on insurance premiums for a midlevel plan. People can use the dollar amount of that discount to purchase any exchange plan.

My insurance plan doesn’t comply with Obamacare, but I was able to keep it this year because I renewed it at the end of 2013. Can I renew it again so I don’t have to find another plan? (2014 question)

No. In fact, more than 50,000 Connecticut residents have health plans that they won’t be able to keep past this year because they don’t meet the requirements of the Affordable Care Act.

States had the option of allowing people to keep insurance plans that don’t comply with the health law, but Connecticut decided not to do so.

You probably remember the big debate about canceled policies last year. Because Obamacare placed new requirements on health plans, insurance companies notified customers last fall that their policies didn’t comply with the law and would be discontinued. That prompted an outcry from people who had heard President Obama repeatedly pledge that people who liked their plans could keep them.

Obama responded by giving states the option of allowing insurance companies to renew policies that didn’t comply with the health law. Gov. Dannel P. Malloy decided not to allow it, saying that insurance companies did not plan to extend the policies anyway and that if the plans were extended, they would likely come with significant rate hikes.

But many people managed to avoid having to give up their old plans by renewing them early, before the new insurance rules took effect on Jan. 1. Other people bought new policies at the end of 2013 to avoid having to buy plans that met the new requirements, which generally cost more.

At the time, the expectation was that it was a 12-month reprieve, and that people would have to buy new plans when those expired. But earlier this year, the federal government announced that people would be allowed to keep their noncompliant plans for another two years, if their states and insurers allowed it.

But the Connecticut Insurance Department and the Malloy administration decided against allowing people to extend their noncompliant plays beyond 2014. The reasoning, according to a department spokeswoman, is that since no new members can join the noncompliant plans, the risk pools will continue to shrink, likely leading those who have the policies to face higher premiums.

The department is allowing people who bought their plans in December 2013 to continue them through the end of the year, if the carriers allow it, to avoid having to buy a new plan for the month between when the old plans are set to expire and when new plans take effect Jan. 1.

Things are different for people who have old plans that are considered grandfathered — that is, plans that were purchased before the health law passed in 2010 and have not changed substantially since then. Even so, insurance companies can decide to stop offering grandfathered plans, so if you have one and want to keep it, it depends whether your insurer will allow it.

I qualified for a free insurance plan under Obamacare, but I still have to pay my insurance company a small amount each month. Why is that?

It’s because of federal restrictions on paying for abortion coverage and the insurance company’s choice to offer it.

Under Obamacare, people with low or moderate incomes can receive federal financial assistance to discount their insurance premiums. For some people, the amount of the federal subsidy exceeds the cost of the premium, allowing them to receive coverage without having to pay any monthly fee.

So why is it not entirely free? By law, federal money can’t be used to pay for coverage of elective abortions. That means that if an insurance plan covers elective abortions, the money to cover that benefit can’t come from the federal government.

For people who pay all or a portion of their own premiums, that abortion fee comes out of their contribution. But if the federal government is funding someone’s entire premium, there’s an issue.

As a result, people who don’t pay any premium for their coverage must pay for the abortion coverage out of their own pockets. Each insurer determines how much money it needs from each member to cover elective abortions, and is supposed to keep that amount in a separate account to pay for the coverage, said Chad Brooker, policy analyst for Access Health CT, the state’s health insurance exchange.

For ConnectiCare Benefits and HealthyCT, the fee is $1 per month. Anthem Blue Cross and Blue Shield charges a percentage of people’s premiums, so the amount varies.

Insurance companies that sell plans on the exchange had the choice of whether to cover elective abortions, and all chose to do so, Brooker said.

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