Navigator Resource Guide

Everyone is required to have health insurance coverage — or more precisely, minimum essential coverage — or else pay a tax penalty, unless they qualify for an exemption. This requirement is called the individual responsibility requirement, or sometimes called the individual mandate. (26 U.S.C. § 5000A (a)).

When you file your tax return (most people will do this by April 15) you will have to enter information about your coverage (or your exemption) on the return. You will get a notice (i.e., Form 1095-A, 1095-B or 1095-C) from your insurance provider describing your coverage status during the previous year. If you do not, check with your insurance company, employer’s human resources department, Medicaid or CHIP office. You must file this form with your taxes. (26 U.S.C. § 5000A (b); IRS, Questions & Answers about Health Care Information Forms for Individuals (Forms 1095-A, 1095-B, and 1095-C)).

The penalty for not having coverage in 2016 and 2017 is the greater of:

• $695 for each adult and $347.50 for each child, up to $2,085 per family, or
• 2.5 percent of family income above the federal tax filing threshold, capped at the national average of the lowest cost bronze plan available through the marketplace

In later years, IRS will adjust the flat penalty amount of $695 by the cost of living adjustment annually; the percentage of income will remain the same. (26 U.S.C. § 5000A (c), IRS, Rev. Proc. 2016-55).

If you do not maintain minimum essential coverage and you don’t qualify for an exemption, you will need to pay a “shared responsibility payment” to the IRS on your tax return. If you are like most people, you will need to submit your return by April 15. (26 U.S.C. § 5000A (b)).

Yes. You may be eligible for an exemption if any of the following apply to you:

• Coverage is considered unaffordable because the cost of an employer-sponsored plan or lowest cost bronze plan through the marketplace is 8.13 percent or more of actual household income (as computed on a tax return) or projected household income; in 2017, that threshold is 8.16 percent of household income
• Coverage is considered unaffordable because the combined cost of employer-sponsored coverage for two or more family members is 8.13 percent or more of actual household income (8.16 percent in 2017)
• Are not a U.S. citizen, a U.S. national, or a resident alien lawfully present in the U.S.
• Are a U.S. citizen or resident living abroad*
• Had a gap in coverage for less than three consecutive months during the year
• Participate in a health care sharing ministry or are a member of a recognized religious sect with objections to health insurance
• Are a member of a federally recognized Indian tribe or eligible for services through an Indian Health Care Provider
• Are incarcerated
• Won’t file a tax return because your income is below the tax filing threshold
• You were determined ineligible for Medicaid solely because the state you resided in did not expand Medicaid
• Your household income is below 138% of FPL and at any time during the year, you were a resident of a state that did not expand Medicaid
• Are engaged in service through the AmeriCorps State and National, VISTA or NCCC program and are covered by short-term duration coverage or self-funded coverage provided under these programs
• Received pregnancy-only Medicaid coverage, coverage through enrollment of an unborn child in CHIP, or Medicaid medically needy coverage with limited benefits that is not considered minimum essential coverage
• Experienced a hardship making it difficult to purchase insurance (e.g., homelessness, eviction, foreclosure, death of a close family member, domestic violence, and unpaid medical bills). (26 U.S.C. § 5000A (e)); 79 Fed. Reg. 30240, May 27, 2014; IRS, Individual Shared Responsibility Provision-Exemptions: Claiming or Reporting; CMS, SHO#14-002, Minimum Essential Coverage).

*additional requirements apply, listed here

In general, most exemptions can be claimed when you file your taxes. There are some exemptions, however, that can only be claimed by applying to the marketplace for an exemption certificate. These are: you are a member of a recognzied religious sect objecting to health insurance, you have a "general hardship," your projected income makes coverage unaffordable, you are determined ineligible for Medicaid solely because the state did not expand the program, and you served in the AmeriCorps, VISTA or NCCC programs and had short-term duration coverage or self-funded coverage provided through these programs. The full list of available exemptions and how they can be claimed is available here.

The exemption for those whose gross income falls below the applicable return filing threshold is available automatically, meaning those who are eligible for this exemption do not have to file taxes although they can choose to file a return. If an individual qualifies for this exemption, the exemption applies to the individual’s spouse and anyone the individual would have claimed as a dependent. (45 C.F.R. § 155.605; IRS, Individual Shared Responsibility Provision-Exemptions: Claiming or Reporting).

People may apply for a hardship exemption from the marketplace if they have experienced difficult financial or domestic circumstances that prevent them from obtaining coverage — such as homelessness, death of a close family member, domestic violence, bankruptcy, substantial recent medical debt, or disasters that substantially damage a person’s property. People may also apply for a hardship exemption if obtaining coverage would be so burdensome as to cause the applicant to experience other serious situations like the deprivation of food, shelter, or other necessities. Consult your marketplace for more information about hardship exemptions. (26 U.S.C. § 5000A (e)(5); 78 Fed. Reg. 53646, Aug. 30, 2013; CMS, Exemptions from the Fee for Not having Health Coverage, Nov. 2015).

Unless you can get health insurance elsewhere (e.g., employer-sponsored plan or Medicaid, if eligible), then yes, because you won't have another chance to enroll into marketplace coverage unless you experience a life event qualifying you for a special enrollment. See Chapter 3 of this section for more information about open and special enrollment. (45 C.F.R. §§ 410 and 420).

Possibly — it depends on how long you were without coverage. Individuals are treated as having minimum essential coverage for a calendar month if they have coverage for at least one day during that month. Additionally, as long as the gap in coverage is less than three consecutive months, you may qualify for an exemption and not owe a payment. (26 U.S.C. § 5000A (e)(4); 78 Fed. Reg. 53646, Aug. 30, 2013).

No, if you are covered even one day during a month, you are considered to be insured for that month. Similarly, a person who is considered exempt from the individual responsibility requirement for even one day during a month is considered exempt for that month. (26 U.S.C. § 5000A (e)(4); 78 Fed. Reg. 53646, Aug. 30, 2013).

Probably not. U.S. citizens or residents living abroad can qualify for an exemption from the requirement to have minimum essential coverage as long as they meet certain requirements (e.g., U.S. citizen is a bona fide resident of a foregin country). (26 U.S.C. §5000A (f)(4);Individual Shared Responsibility Provision-Exemptions).

No. If the amount you would have to pay to actually cover your spouse and kids will be more than 8.16 percent of your family income in 2017 (8.13 percent in 2016), they won’t be penalized for not having health coverage. (26 U.S.C. § 5000A (e); 79 Fed. Reg. 30240, May 27, 2014).

Yes, unless you qualify for an exemption. See FAQ 1.1.5 for a list of exemptions.

To meet the coverage requirement, individuals must have “minimum essential coverage.” Most people that have health coverage today have a plan that will count as minimum essential coverage, and will not need to do anything more than continue the coverage that they have. If you have any of the following types of coverage, you likely have minimum essential coverage:

• Employer-sponsored coverage, including COBRA continuation coverage and retiree coverage
• Coverage purchased in the individual market, including a plan purchased in a health insurance marketplace
• Medicare Part A coverage and Medicare Advantage plans
• Most Medicaid coverage
• Most Children’s Health Insurance Program coverage
• Veterans health coverage administered by the Veterans Administration that are comprehensive
• Most types of TRICARE (coverage for members of the military)
• Self-funded student health coverage that began on or before Dec. 31, 2014 (for later plan or policy years, programs can apply to be recognized as minimum essential coverage, the list of approved plans is available here)
• Coverage for Peace Corps volunteers
• Refugee Medical Assistance from the federal Administration for Children and Families
• Department of Defense health benefit program for civilian employees known as “Non Appropriated Fund” personnel

All health insurers must provide individuals with a Summary of Benefits and Coverage, which uses a standard format to outline the benefits, cost-sharing and coverage limits of plans. The Summary of Benefits and Coverage must also state whether the plan meets minimum value and counts as minimum essential coverage.

If you don’t currently have coverage, will soon lose coverage, or are thinking of changing coverage, you can obtain minimum essential coverage by purchasing a plan on your state’s health insurance marketplace.

Some types of coverage sold outside a health insurance marketplace do not qualify as minimum essential coverage, such as discount plans, short-term policies, or policies that cover only cancer. These kinds of products are sometimes referred to as “excepted benefits.” They do not count as minimum essential coverage.

If you are uncertain whether your plan qualifies as minimum essential coverage, contact your employer’s human resources department or your health insurer. (26 U.S.C. § 5000A (f); 79 Fed. Reg. 4302, Jan. 27, 2014; 77 Fed. Reg. 8668, Feb. 14, 2012).

All health insurers and employer-sponsored group health plans must provide people with a Summary of Benefits and Coverage, which uses a standard format to outline the benefits, cost-sharing and coverage limits of plans. The Summary of Benefits and Coverage must also say whether the plan meets minimum value and counts as minimum essential coverage. (45 CFR 147.200(a)(2)(i)(G); 77 Fed. Reg. 8668, Feb. 14, 2012).

Yes, grandfathered plans count as minimum essential coverage. (26 U.S.C. §5000A (f)(1)(D)).

Individuals who enroll in minimum essential coverage that does not include pediatric dental benefits will not owe a tax penalty for lacking dental coverage. This might happen for a number of reasons. Pediatric dental benefits are included in essential health benefits and must be offered through marketplaces. Some marketplace plans offer dental benefits together in the same policy with other health benefits. In other cases, dental benefits are offered through stand-alone plans. Where stand-alone plans are offered, affordability of pediatric dental benefits may be a problem for some families. In addition, the essential health benefit rules do not apply to large employer plans or to self-insured employer plans, and so people enrolled in such plans may or may not have pediatric dental benefits. (45 C.F.R. § 155.1065; 45 CFR § 156.440(b); CMS, Exemptions from the Fee for Not Having Heatlh Coverage, Nov. 2015).

As the name implies, a short-term health insurance policy offers coverage for a period of less than 12 months (e.g., many offer coverage for just six months) and are renewable at the option of the insurance company. Though you may be given an opportunity to request to renew the policy, if you’ve made claims since you bought it, the insurer can refuse to renew it. This is also called a non-guaranteed-renewable policy. Short-term policies are not considered minimum essential coverage. Insurance companies that sell such policies are required to notify you that such policies are not considered minimum essential coverage. (26 U.S.C. §5000A (f)(3); 79 Fed. Reg. 4302, Jan. 27, 2014).

It depends. Medicaid coverage for pregnant women counts as minimum essential coverage in states that provide full Medicaid benefits under such pregnancy-related coverage or under pregnancy-related CHIP coverage that also provides full CHIP benefits. If the coverage only provides pregnancy related services, then it is not considered minimum essential coverage. There is a hardship exemption for people enrolled in pregnancy-only Medicaid coverage, coverage through enrollment of an unborn child in CHIP, or Medicaid medically needy coverage with limited benefits that is not considered minimum essential coverage (79 Fed. Reg. 4302, Jan. 27, 2014; IRS, Notice 2014-10; IRS, Notice 2014-71, CMS, SHO#14-002, Minimum Essential Coverage; CMS, Exemptions from the Fee for Not Having Heatlh Coverage, Nov. 2015).

In general, Medicaid coverage that does not offer comprehensive coverage or full Medicaid benefits is not considered minimum essential coverage. For example, a Medicaid program that only offers family planning services would not be considered minimum essential coverage. An exemption is available for the following types of Medicaid coverage that is not considered minimum essential coverage: pregnant women receiving pregnancy-only coverage or coverage through enrollment of an unborn child in CHIP, and medically needy coverage that is not comprehensive or offers full Medicaid benefits. (IRS, Notice 2014-71; CMS, SHO#14-002, Minimum Essential Coverage).

No, you are not required to drop your marketplace plan. You have a choice between your marketplace plan and the Medicaid coverage. You can continue on your plan throughout your pregnancy and continue receiving the premium tax credit. You can also remain on your marketplace plan and receive premium tax credits in situations where your unborn child qualifies for CHIP coverage. (IRS, Notice 2014-71; CMS, SHO#14-002, Minimum Essential Coverage).

Most people can shop for coverage in the marketplace. To be eligible you must live in the state where your marketplace is, you must be a citizen of the U.S. or be lawfully present in the U.S., and you must not currently be incarcerated.

Not everybody who is eligible to purchase coverage in the marketplace will be eligible for subsidies, however. To qualify for subsidies people will have to meet additional requirements having to do with their income and their eligibility for other coverage. (45 C.F.R. § 155.305; 26 U.S.C. § 36B (c)).

You should buy coverage in the marketplace in the state where you live. In order to meet marketplace residency requirements, you must live in the service area of the marketplace. This means you 1) live the state and 2) have the intent to reside there (even if you don't have a fixed address) or have a job or are looking for a job. (45 C.F.R. § 155.305 (a)(3)); CMS, FAQs on the Marketplace Residency Requirement and the Special Enrollment Period due to a Permanent Move, Jan. 19, 2016).

You can always shop for coverage on the marketplace, assuming you meet other eligibility requirements, but if you have access to job-based coverage, you might not qualify for premium tax credits. (26 U.S.C. § 36B (c)).

If you have Medicare, you cannot buy a plan in the marketplace except under limited circumstances. Companies that sell marketplace plans are prohibited from selling these plans to you if they know you are covered by Medicare except where the individual buying coverage has lost high risk pool coverage that they used to supplement Medicare.

However, a small number of individuals are enrolled in Medicare Part A and paying premiums (typically those who have not paid Medicare taxes for 10 years or more). These individuals may be eligible for a premium tax credit if they are not enrolled in Medicare, and coverage through a health insurance marketplace may be the best option for them. (Section 1882(d)(3)(A) of the Social Security Act; IRS Notice 2013-41).

If you are not a U.S. citizen, a U.S. national, or an alien lawfully present in the U.S., you are not eligible to buy a plan on the health insurance marketplace. However, you can shop for health insurance outside of the marketplace in the non-group market. Insurers outside of the marketplace are prohibited from turning you down based on your health status or your immigration status and must generally follow the same rules as plans in the marketplace. To obtain coverage, contact a state-licensed health insurance company or a licensed agent or broker. Your state Department of Insurance can help you find one. (45 C.F.R. § 155.305).

Yes. If your son is a member of your tax household, he can join your family plan on the health insurance marketplace, even if he lives out of state. However, your child may need to return home in order to access care within your plan’s network. If he or she gets health care services in another state, the providers may be outside your plan’s network and you may have to pay high co-payments or coinsurance. Your son is also likely eligible to buy coverage in the state where he attends school as long he can establish residency. If he does establish residency in the college state, he would have a greater choice of local in-network providers. (45 C.F.R. § 155.305 (a)(3); CMS, FAQs on the Marketplace Residency Requirement and the Special Enrollment Period due to a Permanent Move, Jan. 19, 2016).

It will depend on whether or not the health plan you choose covers your doctor. Some plans may offer a broader scope of covered providers than others. To make sure your doctor is covered under a plan, you should call the plan and ask. Note that it is important to ask the provider not just about the insurance company offering the plan, but whether he or she participates in the network of the specific plan the insurance company is offering. However, before selecting a new plan, you should also confirm with the plan directly that your doctor is in-network. While every plan on the marketplace must provide a link to its health provider directory, these lists are subject to change and may not be up-to-date.

Probably. Most people are eligible to buy a plan on the health insurance marketplace. However, depending on your household income and his access to other coverage options, he may not be eligible for premium tax credits to lower the cost of a marketplace plan. For example, if he is eligible for Medicare, he would not be eligible for premium tax credits. However, if he’s not eligible for Medicare and doesn’t enroll in your retiree health plan, he could be eligible for premium tax credits, assuming your household income is between 100 to 400 percent of the federal poverty level. (78 Fed. Reg. 25909, May 3, 2013).

While you are not eligible to purchase small group health insurance through the SHOP marketplace, you can purchase individual market coverage and may be able to qualify for premium tax credits and/or cost-sharing reductions through the health insurance marketplace for individuals. (79 Fed. Reg. 43622, July 28, 2014; 42 U.S.C. § 18071).

Yes. You must request any extension before the 90-day deadline runs out. You can request the extension in writing or through the marketplace call center. In your request you should include your name, a description of the supporting documents requested, the reason you need an extension, and the amount of additional time you need. You may want to ask a Navigator for help requesting an extension. (45 C.F.R. § 155.315 and 155.320).

If the marketplace hasn’t received the requested information within 90 days and you didn’t already ask for an extension, the marketplace will make a determination based on the information it has. If you disagree with that decision you can appeal. (45 C.F.R. §155.355).

You can request an appeal of any marketplace decision, including decisions about:

• Your eligibility to buy coverage in the marketplace
• Your eligibility to buy coverage outside the open enrollment period
• Your eligibility for Medicaid or CHIP
• Your eligibility for, or the amount of, premium tax credits or cost-sharing reductions, including the length of time the marketplace takes to make a determination
• Your eligibility for an exemption from the penalty for not having health insurance

After you have applied for coverage in the marketplace, you will get an eligibility notice that explains what you qualify for. If you don’t agree with that notice, you can file an appeal. The notice will explain the process you should follow if you want to appeal. For example, depending on your state and eligibility determination, you may need to file with your state Medicaid or CHIP agency rather than the marketplace. Your letter will explain which process is the one for you to use.

There are two ways to file a marketplace appeal:

1. Mail or fax in an appeal request form available at https://www.healthcare.gov/marketplace-appeals/. The marketplace secure fax line is 1-877-369-0129.
2. Mail the appeal request form or write a letter to:
   Health Insurance Marketplace
   Attn: Appeals
   465 Industrial Blvd.
   London, KY 40750-0061

To request an appeal, you’ll have to provide your name and contact information and an explanation of what you are appealing and why. You can submit documents to the marketplace that support your case. You can submit documents along with your initial appeal request or at any time during the appeal process, up until a hearing

The marketplace may offer you the option of receiving temporary benefits while your appeal is pending. You can accept the temporary benefits or waive them. If you accept temporary benefits during the appeals process and then lose your appeal, you might have to pay back the benefits you were ultimately determined to be ineligible for.

After you file an appeal, you will get the following from the marketplace:

• A letter that states that your appeal was received
• A letter asking for more information or documentation if needed
• A decision, which the marketplace must mail to you within 90 days of receiving your appeal request.

The marketplace will review your completed appeal once it is submitted. Then the marketplace will let you know its decision. If you still disagree with the decision, you can request a hearing. While you are waiting for the hearing to take place, the marketplace may contact you to try to resolve the dispute informally.

If you need help with your appeal:

• You can get help from an interpreter by calling 1-800-318-2596.
• You may want to ask a Navigator for help requesting an appeal. Visit https://localhelp.healthcare.gov/ to find help in your area.
• You can also appoint an authorized representative to help you. Visit https://www.healthcare.gov/marketplace-appeals/getting-help/ to learn how.

This will depend on the reason for your appeal and the documentation needed to decide your appeal. In general, the Marketplace must let you know of its decision and mail its response within 90 days of receiving your request. You can also contact the marketplace for more information about your appeal. (45 C.F.R. § 155.545 (b)).

Most lawfully present immigrants who meet Medicaid and CHIP program requirements, such as income and state residency, can enroll in Medicaid or CHIP after they have been in the United States for five years or more.

Some groups of lawfully present immigrants do not have to wait five years before they may enroll in Medicaid and CHIP. These include refugees, asylees, and other humanitarian immigrants; veterans and military families; and pregnant women and children in some states.

Some lawfully present immigrants who are authorized to work in the United States cannot enroll in Medicaid, even if they have been in the country for five or more years.

Undocumented immigrants may not enroll in Medicaid or CHIP coverage. (42 C.F.R. § 435.406; 42 C.F.R. § 457.320).

Most lawfully present immigrants can buy health insurance through the new health insurance marketplaces. This group includes lawfully present immigrants who cannot enroll in Medicaid.

Undocumented immigrants may not purchase coverage through the new health insurance marketplaces. (45 C.F.R. § 155.305).

Lawfully present immigrants can get tax credits to help pay premiums and cost-sharing for health insurance through the marketplaces. Like citizens, they can get tax credits to help pay premiums if they make between 100 percent and 400 percent of the federal poverty level. The amount they pay for care will also be lowered if they make between 100 percent and 250 percent of the federal poverty level. To get this help, they cannot be offered affordable health insurance through their job or be eligible for Medicaid.

Lawfully-present immigrants who make less than 100 percent of the federal poverty level also can get help paying premiums and cost-sharing if they cannot enroll in Medicaid based on their immigration status. Many lawfully-present immigrants cannot enroll in Medicaid until they have been in the United States for five or more years.

Undocumented immigrants cannot receive help paying for premiums or cost-sharing for marketplace coverage and may not buy health insurance through the marketplaces even at full cost. (42 U.S.C. § 18071; 26 CFR § 1.36B-2(b); IRS, Questions and Answers on the Premium Tax Credit).

Citizen and lawfully present family members can get health insurance coverage through Medicaid, CHIP, and marketplaces even if other family members are not lawfully present. Family members who are not lawfully present, including undocumented immigrants, may apply for health insurance for citizen and lawfully present family members. For example, an undocumented immigrant parent may apply for health insurance for a citizen child.

When a family with mixed immigration status applies for health insurance, it only has to give citizenship and immigration status for those family members applying for coverage. Non-applicants, such as a parent applying for a child, do not have to provide citizenship or immigration status. Non-applicants will be asked to provide a Social Security number, but do not have to provide one unless the family is applying for help with costs for marketplace coverage and the individual is the tax-filer for the household. (42 C.F.R. § 435.406; 42 C.F.R. § 457.320).

Only those individuals in a family who are applying for health insurance are required to provide citizenship and immigration status. Applicants also must provide a Social Security number if they have one.

Citizenship and immigration status for those applying for health insurance will be checked electronically with several systems, including the Social Security Administration, the Department of Homeland Security, and SAVE (Systematic Alien Verification for Entitlements).

If an individual’s status cannot be checked through an electronic match, the individual can give other documentation of his or her status. (45 C.F.R. § 155.315).

In general, getting health insurance through Medicaid, CHIP, or the marketplaces will not prevent an individual from obtaining lawful permanent status or citizenship. (HealthCare.gov, Immigrant Families and the Marketplace).

Medicaid, CHIP, and the marketplaces must protect individuals’ information and keep it private. Information can be used only for eligibility and enrollment purposes. (45 C.F.R. § 155.260).

Most immigrants who are residents lawfully present in the U.S., including “green card holders,” must have health insurance coverage or they will pay a tax penalty unless they qualify for an exemption. Check with your marketplace for more information about how the requirement applies to you, or if you want to apply for an exemption.

Immigrants who are not lawfully present in the U.S. will not pay a tax penalty if they do not have health insurance. (26 U.S.C. § 5000A).

Lawfully present immigrants generally include:

• Lawful permanent residents (or “green card holders”);
• Persons fleeing persecution, including refugees and asylees;
• Other humanitarian immigrants, including those granted temporary protected status;
• Cuban/Haitian entrants; and
• Survivors of domestic violence, trafficking, and other serious crimes.

See https://www.healthcare.gov/immigration-status-and-the-marketplace/ for more information and other groups that are lawfully present. (26 U.S.C. § 5000A (d)(3)).

Some undocumented youth have been given temporary permission to stay in the United States under a program called Deferred Action for Childhood Arrivals. These individuals are lawfully present in the United States and can be granted work authorization and Social Security numbers. However, they are not eligible for Medicaid, CHIP, or the marketplaces.

Hospitals are required to provide emergency care and treatment to all individuals regardless of immigration or insurance status, though afterwards they can bill for their services. In addition, individuals may get low-cost care at community health centers.

Individuals may purchase health coverage through an employer or a spouse’s employer or the individual insurance market outside of the marketplace. Some states and counties also offer health programs for immigrants. (HealthCare.gov, Immigrant Families and the Marketplace, available at https://www.healthcare.gov/what-do-immigrant-families-need-to-know/).

In general, you can only enroll in non-group health plan coverage during the open enrollment period. For 2017 coverage, the open enrollment period for marketplaces begins November 1, 2016 and extends through January 31, 2017. Once the open enrollment period is over, individuals and families will not be able to enroll in marketplace health plans until the next open enrollment period. However, if you experience certain changes in circumstances during the year, you will have a special 60-day opportunity to enroll in marketplace health plans, outside of the open enrollment period. In addition, if you have an individual insurance policy that is cancelled outside the open enrollment period, you will have a special 30-day opportunity to enroll.

Individuals and families buying non-group coverage on their own, outside of the marketplace, can also only enroll in coverage during open enrollment periods and special enrollment opportunities.

American Indians and Alaska Natives can enroll in coverage throughout the year, not just during open enrollment periods or special enrollment opportunities. (HealthCare.gov; Important Marketplace deadlines; 45 C.F.R. § 155.420; 45 C.F.R. § 155.350).

You can enroll in Medicaid or CHIP at any time during the year, not just during open enrollment. (42 C.F.R. § 435.906)

If everyone were allowed to wait until they were sick to buy coverage, premiums would be very expensive. An open enrollment period encourages healthy people to buy a plan to protect themselves from unanticipated events during the year. Health insurers need a mix of healthy and sick people to make premiums fair for everyone.

In general, you can only buy or change your private, non-group health plan coverage outside of the open enrollment period if you have a qualifying life event that entitles you to a special enrollment opportunity. Some events that trigger a special enrollment opportunity are:

• Loss of other coverage (for example, if you lose your employer-sponsored coverage because you quit your job, were laid off, or if your hours were reduced, or if you lose student health coverage when you graduate). Note that loss of coverage because you didn’t pay premiums or voluntarily terminate employer-sponsored coverage does not trigger a special enrollment opportunity.
• Gaining a dependent (for example, if you get married or give birth to or adopt a child). Note that pregnancy does NOT trigger a special enrollment opportunity.
• Marriage.
• Loss of dependent status (for example, “aging off” a parent’s plan when you turn 26) or death of an enrollee or dependent.
• Moving to another state or within a state and gaining access to new plans. You must meet the marketplace residency requirements: 1) you are living at the location and 2) intend to reside at the location or have or are looking for employment.
• Exhaustion of COBRA coverage; voluntarily dropping COBRA coverage outside of open enrollment will not trigger a special enrollment period.
• Losing eligibility for Medicaid or the Children’s Health Insurance Program.
• For people enrolled in a marketplace plan, income increases or decreases sufficient to change eligibility for premium tax credits and/or cost-sharing reductions.
• For people who live in a state that did not expand Medicaid, but would otherwise be eligible, income increases to change eligiblity for premium tax credits and/or cost-sharing reductions.
• Change in immigration status from a non-eligible status to an eligible one.
• Enrollment or eligibility error made by the marketplace or another government agency or somebody, such as an assister, acting on their behalf.

Note that some triggering events will only qualify you for a special enrollment opportunity in the health insurance marketplace; they do not apply in the outside market. For example, if you gain citizenship or lawfully present status, the marketplace must provide you with a special enrollment opportunity.

When you experience a qualifying event, your special enrollment opportunity will last 60 days from the date of that triggering event. There are a few exceptions to the 60 day timeframe. If a qualified individual or his dependent loses minimum essential coverage, then the individual has 60 days before or after the last date of coverage. This includes loss of employer-based coverage, Medicaid-related pregnancy coverage, and Medicaid-related medically needy coverage. Additionally, if an individual is a Native American or Alaskan Native, he or she can enroll into a Marketplace plan or change his or her Marketplace plan once per month. The marketplace will ask you to provide verifying documents for the following qualifying events: loss of other coverage, moving, having a baby, gaining of a dependent through adoption or court order, getting married to verify the special enrollment. In general, you will have 30 days to submit the documentation. (45 C.F.R. § 155.420(d); CMS, SHO#14-002, Minimum Essential Coverage; CMS, FAQs on the Marketplace Residency Requirement and the Special Enrollment Period due to a Permanent Move, Jan. 19, 2016).

If you buy a plan between November 1 and December 15, 2016, and make your first premium payment by the due date specified by your plan, your new coverage will start on January 1, 2017. After December 15, 2016, if you buy a plan between the 1st and 15th of the month and pay your premium by the plan’s due date, your coverage becomes effective on the first day of the following month. If you enroll between the 16th and the last day in December and January, and pay your premium by the plan’s due date, your coverage will become effective the first day of the second following month. In other words, if you buy your coverage on December 16th, 2016, your coverage will be effective February 1, 2017. Likewise, if you buy a plan on January 16th, 2017, your coverage becomes effective on March 1, 2017. (45 C.F.R. § 155.410).

Yes, for coverage through 2017. The ACA is current law and in general, insurers participating on healthcare.gov are required by federal and state law to continue providing coverage throughout the year. You have a right to purchase health insurance for 2017 now during open enrollment. You must sign up for 2017 coverage by December 15, 2016 to have your coverage start on January 1. If you miss the December 15th deadline, you have until January 31, 2017 to sign up although your coverage won’t start until February 1 or March 1, depending on when you signed up in January.

No, it does not. However, when the baby is born you will be eligible for a special enrollment opportunity. You can enroll your baby in coverage at that point. You (and your spouse and any other children you have) can also change health plans during this special enrollment opportunity. (45 C.F.R. § 155.420).

No. You qualify for a “special enrollment period” and can purchase individual coverage, so long as you do so within 60 days of losing your employer plan. If you know the date your coverage will end, your special enrollment period can begin 60 days prior to the end of your coverage, so you can enroll in time to avoid a gap in coverage. (45 C.F.R. § 155.420).

It depends. If you are currently enrolled in a marketplace health plan and are newly eligible for a premium tax credit, or if you’ve had a change in eligibility for premium tax credits or cost-sharing reductions, you may enroll in a new plan on the health insurance marketplace at any time during the year, so long as you do so within 60 days of your change in status. However, if you are not currently in a marketplace plan, you do not qualify for a special enrollment period. (45 C.F.R. § 155.420).

If you are currently enrolled in a plan on the health insurance marketplace, you may buy a new marketplace plan if you lost eligibility for premium tax credits, so long as you do so within 60 days of your change in status. However, if you want to buy health insurance outside the health insurance marketplace, you will need to wait until the open enrollment period. (45 C.F.R. § 155.420).

NOTE: Check the rules of your state’s marketplace. States have the flexibility to expand special enrollment opportunities for consumers buying coverage outside the Marketplace.

If you are an eligible American Indian, you may enroll in or change plans on the health insurance marketplace one time per month. (45 C.F.R. § 155.420).

No, in general, once you sign up for a plan, you are locked into that coverage for 12 months, or until the next open enrollment period. A change in health status doesn’t make you eligible for a special enrollment opportunity. (45 C.F.R. § 155.420).

Only if it’s still open enrollment. For 2017 coverage, you can change plans any time during Open Enrollment regardless of when coverage was effectuated. Open Enrollment is scheduled to end January 31, 2017. After open enrollment, you can only change plans if you have a change in circumstance qualifying you for a Special Enrollment Period. See this FAQ for more on events that trigger a special enrollment period.

Yes, in this situation, you meet the marketplace residency requirements of the state you live in for 8 months and the state you work in for 4 months. Since the residency requirements are met, you are eligible for a special enrollment right to sign up for a new plan when you move to the new state. (CMS, FAQs on the Marketplace Residency Requirement and the Special Enrollment Period due to a Permanent Move, Jan. 19, 2016).

Yes. You have the “intent to reside” in Florida for six months, which the marketplace does not consider a “temporary absence” from your home state. Because you will be there for at least an “entire season or other long period of time,” you are eligible to enroll in Florida under a permanent move special enrollment period. You will also qualify for a SEP when you move back to your home state in the spring. (CMS, FAQs on the Marketplace Residency Requirement and the Special Enrollment Period due to a Permanent Move, Jan. 19, 2016).

No, you do not meet the marketplace residency requirements for the permanent move special enrollment since your absence is temporary and do not intend to live in the state where you’re receiving treatment, but rather intend to be in the state to receive treatment. Current guidance is clear that residency requirements are not met in this circumstance. (CMS, FAQs on the Marketplace Residency Requirement and the Special Enrollment Period due to a Permanent Move, Jan. 19, 2016).

It depends. You may be eligible to buy coverage in the state where you attend school as long you can establish residency; otherwise your residency is determined by your parents or caregivers’ residency. If you can establish residency, then you may qualify for a permanent move SEP. (CMS, FAQs on the Marketplace Residency Requirement and the Special Enrollment Period due to a Permanent Move, Jan. 19, 2016).

Premium tax credits will be available to U.S. citizens and lawfully present immigrants who purchase coverage in the marketplace and who have income between 100 percent and 400 percent of the federal poverty level . Premium tax credits are also available to lawfully residing immigrants with incomes below 100 percent of the poverty line who are not eligible for Medicaid because of their immigration status. (Generally, immigrants must lawfully reside in the U.S. for five years before they can become eligible for Medicaid.)

In addition, to be eligible for the premium tax credits, individuals must not be eligible for public coverage—including most Medicaid, most Children’s Health Insurance Program coverage, Medicare, or military coverage—and must not have access to health insurance through an employer. There are exceptions to when you can apply for premium tax credits when you have other coverage. For example, there is an exception in cases when the employer plan is unaffordable because the employee’s share of the premium exceeds 9.66 percent of the employee’s household income in 2016 and 9.69 percent in 2017. There is also an exception in cases where the employer plan doesn’t provide a minimum level of coverage or actuarial value (the plan's share must be at least 60 percent of the cost of covered benefits for a standard population). (26 C.F.R. § 1.36B-2(b); 77 Fed. Reg. 30377, May 23, 2012; IRS Rev. Proc. 2014-37, July 24, 2014).

In general, if you have any of the following types of coverage, you would be ineligible for premium tax credits through the marketplace:

• Employer-sponsored coverage, unless the coverage is unaffordable (your required contribution to the premium for self-only coverage costs more than 9.66 percent of household income in 2016, 9.69 percent in 2017) or does not meet minimum value (an actuarial value of less than 60 percent);
• Government-sponsored coverage, including Medicare Part A coverage, Medicare Advantage plans, most Medicaid coverage and the Children’s Health Insurance Program coverage, Veterans health coverage and TRICARE (coverage for members of the military);
• Coverage for Peace Corps volunteers. (26 C.F.R. § 1.36B-2(c); 77 Fed. Reg. 30377, May 23, 2012; IRS Rev. Proc. 2014-37, July 24, 2014).

Beginning in 2015, employers with 100 or more employees who do not offer health benefits to full-time workers could face a fine, but they will not face a fine for failing to offer health benefits to employees’ dependents. If they do not offer coverage to their workers, they face a penalty if an employee qualifies for premium tax credits in the marketplace. Beginning in 2016, employers with 50 or more employees that don’t offer health benefits to their full-time workers may also be liable for a penalty. Beginning in 2016, employers will also be required  to offer health benefits to dependent children; however, employers are not required to offer coverage to the spouses of employees.

Meanwhile, because your spouse is not offered health benefits through your job, s/he may be eligible to apply for coverage and premium tax credits through the marketplace. (26 U.S.C. § 4980H; 79 Fed. Reg. 8544, Feb. 12, 2014; 26 C.F.R. § 1.36B-2(c); 77 Fed. Reg. 30377, May 23, 2012).

You can always shop for coverage on the marketplace, but your family members won’t be eligible for tax credits to help pay the premium. When people are eligible for employer-sponsored coverage, they can only qualify for marketplace premium tax credits if the employer-sponsored coverage is unaffordable. The way this is calculated, coverage is unaffordable only if your cost for coverage for a single person under the employer plan is more than 9.66 percent of your household income in 2016 and 9.69 percent of your household income in 2017. So although you may feel your family coverage is unaffordable in practical terms, it is considered technically affordable.

If your family members end up uninsured because family coverage is unaffordable, they will not have to pay a tax penalty under the “individual mandate.” (26 C.F.R. § 1.36B-2(a), 77 Fed. Reg. 30377, May 23, 2012; IRS Rev. Proc. 2014-62).

The term “minimum value” means that your job-based plan would cover at least 60 percent of an average group of people’s covered health costs including hospitalization and physician services. Most employer plans will meet this test, but some may not. The marketplace application includes a form with questions about job-based coverage. You should take this form to your employer and ask them to fill it out. With that information the marketplace will determine whether the plan meets minimum value. If it doesn’t, you may be able to qualify for premium tax credits to help pay for marketplace coverage. (45 C.F.R. § 156.145; 77 Fed. Reg. 30377, May 23, 2012; 78 Fed. Reg. 25909, May 3, 2013).

Whether your employer’s health plan meets minimum value will depend on a number of factors. The marketplace application includes a form with questions about job-based coverage. You should take this form to your employer and ask them to fill it out. Your Summary of Benefits and Coverage for the plan will also tell you if the plan meets minimum value. With that information the marketplace will determine whether the plan meets minimum value. If it doesn’t, you may be able to qualify for premium tax credits to help pay for marketplace coverage. (45 C.F.R. § 156.145; 77 Fed. Reg. 30377, May 23, 2012; 78 Fed. Reg. 25909, May 3, 2013).

Most people are eligible to shop for coverage in the marketplace. However, you can only qualify for premium tax credits if your job-based plan — whether it is a grandfathered plan or not — is unaffordable or if it doesn’t meet minimum value. Whether your employer’s health plan meets minimum value will depend on a number of factors. The marketplace application includes a form with questions about job-based coverage. You should take this form to your employer and ask them to fill it out. Your Summary of Benefits and Coverage for the plan will also tell you if the plan meets minimum value. With that information the marketplace will determine whether the plan meets minimum value. If it doesn’t, you may be able to qualify for premium tax credits to help pay for marketplace coverage. (45 C.F.R. § 156.145; 77 Fed. Reg. 30377, May 23, 2012).

For certain types of coverage, if you are eligible but not enrolled, then you can still qualify for premium tax credits. These include:

• Retiree health coverage offered by a former employer
• COBRA coverage (when offered when you've lost your job)
• Student health plan coverage
• Medicare Part A coverage requiring payment of premiums

However, if you are eligible for job-based coverage (that is affordable and meets minimum value) or for Medicaid or CHIP, but you didn’t enroll, then you are not eligible for premium tax credits. Note that if you are eligible for COBRA because you had a reduction in hours at work, you will need to show that the COBRA coverage is unaffordable or to fails to meet minimum value in order to be eligible for premium tax credits. (26 C.F.R. § 1.36B-2(b) and (c); 77 Fed. Reg. 30377, May 23, 2012; IRS, Notice 2013-12; 79 Fed. Reg. 30240, May 27, 2014).

You can add your children to your marketplace plan, but because they are eligible for your state’s Children’s Health Insurance Program (CHIP), they are not eligible for premium tax credits. The exception to that is if you live in a state that has a waiting period for enrolling in CHIP. During the waiting period, your children are eligible for a premium tax credit; when the waiting period has ended and they can enroll in CHIP, your children will become ineligible for the tax credit. (26 C.F.R. § 1.36B-2(c); IRS, Notice 2013-12).

Yes, having an individual policy does not disqualify you from buying coverage through a health insurance marketplace with premium tax credits. As long as you meet the other eligibility criteria for premium tax credits, you will likely qualify. Even if you don’t qualify for premium tax credits, you may want to look at the coverage options in the health insurance marketplace, to see if there is a plan that would work better for you than the one you have now. In order to avoid a gap in coverage, be sure you don’t cancel your plan before your marketplace coverage will begin.

Yes. You may apply for premium tax credits and enroll in a health plan through the health insurance marketplace, as long as you drop your student health plan before coverage begins through the marketplace. (26 C.F.R. § 1.36B-2(b) and (c); 77 Fed. Reg. 30377, May 23, 2012).

It depends on whether you are still working. If you are eligible for COBRA because you lost your job, just being eligible for COBRA doesn’t affect your eligibility for premium tax credits or cost-sharing assistance if you enroll in a marketplace plan. However, if you are eligible for COBRA because your hours at work were reduced and you are no longer eligible for your job-based plan, you will have to show that your COBRA is unaffordable or fails to meet minimum value in order to qualify for premium tax credits. (26 C.F.R. § 1.36B-2(b) and (c); 76 Fed. Reg. 50931, Aug. 17, 2011; 78 Fed. Reg. 25909, May 3, 2013).

It depends. If your household income qualifies you for cost-sharing reductions as well as a premium tax credit, you will probably get a better deal with a silver level plan. You can use premium tax credits to buy a plan in any of the four coverage levels (bronze, silver, gold or platinum), but the cost-sharing reductions only apply to plans in the silver level. Depending on your health status and the level of cost-sharing assistance you would get, a very low premium bronze plan may be a better deal for you, but if your health care use turns out to be more than you anticipated, you will likely have a high deductible and higher out-of-pocket costs, with no cost-sharing reductions to help lower those. (26 C.F.R. § 1.36B-2; 45 C.F.R. §155.340; CMS Actural Value and Cost-Sharing Reductions Bulletin, Dec. 16, 2011).

Premium tax credits are available to people who buy marketplace coverage and whose household income is between 100 percent and 400 percent of the federal poverty level. (26 C.F.R. § 1.36B-2(b)).

No, assets are not counted. So the value of your house, car, retirement savings, etc. will not affect your eligibility for premium tax credits. (IRS, Questions and Answers on the Premium Tax Credit).

No, your income is too low to qualify for premium tax credits, but check with your state’s marketplace to see if there are other options you might be eligible for. Note that if you are a lawfully present immigrant and have an income below 100% of the federal poverty level, and are in the waiting period for your state's Medicaid coverage, you are eligible for premium tax credits. (26 C.F.R. § 1.36B-2(b)).

Yes. If you do not file taxes, you are not eligible to receive premium tax credits. Also, if you are currently receiving premium tax credits and don't file a tax return, you will not be able to receive premium tax credits in the future. The I.R.S. may contact you to pay back some or all of the premium tax credit you received. For example, if you received premium tax credits in 2015 and did not file a tax return, you will be not be eligible to receive premium tax credits to help pay for marketplace coverage in 2017. The marketplace will notify you when your coverage is renewed if you are not eligible for premium tax credits because you received premium tax credits in the past and did not file a tax return when your coverage is renewed. (26 C.F.R. § 1.36B-2; CMS, Guidance on Reenrollments and Redetermination for Marketplace Coverage for 2016).

Yes. If you did not file and reconcile your premium tax credits for 2015, you will not be eligible for premium tax credits and cost-sharing reductions for 2017 coverage. In general, you can file your taxes, reconcile premium tax credits and attest to this through your marketplace application. If you do this by December 15, 2016 and if you are eligible, you will receive premium tax credits and cost-sharing reductions starting January 1, 2017. If you do nothing, the marketplace will re-enroll you into 2017 coverage, but without premium tax credits and cost-sharing reductions.

Be sure to file your 2015 taxes and reconcile your premium tax credits before the end of open enrollment so that you can be considered eligible for premium tax credit and cost-sharing reductions. (26 C.F.R. § 1.36B-2; CMS, Guidance on Reenrollments and Redetermination for Marketplace Coverage for 2016).

No, you will not have to pay back the premium tax credits you get if the marketplace said you were eligible for premium tax credits and your income drops below 100 percent of poverty. In fact, you may get a refund. When you file your taxes, the credit you receive will be compared to the credit you should have received based on your actual income for the year. If your income goes down, you will get a refund for the difference between the two. (26 C.F.R. § 1.36B-2).

Eligibility for premium tax credits is based on your Modified Adjusted Gross Income, or MAGI. When you file a federal income tax return, you must report your adjusted gross income (which includes wages and salaries, interest and dividends, unemployment benefits, and several other sources of income). MAGI modifies your adjusted gross income by adding to it any non-taxable Social Security benefits you receive, any tax-exempt interest you earn, and any foreign income you earned that was excluded from your income for tax purposes.

Note that eligibility for Medicaid and CHIP is also based on MAGI, although some additional modifications may be made in determining eligibility for these programs. Contact your marketplace or your state Medicaid program for more information. (26 C.F.R. § 1.36B-1; IRS, Questions and Answers on the Premium Tax Credit).

Yes, all of your Social Security benefits will be counted as income in determining your eligibility. Note, however, that Social Security benefits for tax dependents that fall below the tax filing threshold do not count towards the household income. (IRS, Questions and Answers on the Premium Tax Credit; 42 C.F.R. § 435.603;

No, child support payments you receive are not counted. (IRS, Taxable and Non-Taxable Income).

Alimony that is paid is deducted from gross income to determine adjusted gross Income. It will be excluded from income in determining your eligibility for subsidies. Center on Budget and Policy Priorities, The Health Care Assister's Guide to Tax Rules, updated Oct. 2014).

No. Inheritances are not counted. (Center on Budget and Policy Priorities, The Health Care Assister's Guide to Tax Rules, updated Oct. 2014).

Worker’s compensation payments are generally not taxable, so they would not be counted in determining your eligibility. (Center on Budget and Policy Priorities, The Health Care Assister's Guide to Tax Rules, updated Oct. 2014).

Scholarship and fellowship payments for tuition and fees and course-related expenses required of all students are not counted as income in determining your eligibility. Payments for room and board are included. (Center on Budget and Policy Priorities, The Health Care Assister's Guide to Tax Rules, updated Oct. 2014).

The answer depends on whether she earns enough income to be required to file a federal income tax return on her own. Generally, kids aren’t required to file a return or pay taxes on their income if they earn less than $6,200 (in 2014). If your daughter earns less than that in a year, you would not count her income as part of your household income, but if she earns more than that amount, you would count it. (IRS, Publication 929).

Probably not. In order to qualify for premium tax credits you and your spouse must file a joint tax return, unless you are a survivor of domestic abuse or certify that you are an “abandoned” spouse and that you are unable to locate your spouse after “reasonable diligence.” (79 Fed. Reg. 43622, July 28, 2014).

It depends. A common law marriage – a marriage established when a couple presents themselves to the world as married but does not have a marriage license – is recognized in only a minority of states. If you live in a state that recognizes common law marriage, then you are considered married and should indicate that on your Marketplace application. You are still considered married even if you moved to a state that doesn’t recognize common law marriage after living in a state that did recognize your marriage. If your state does not recognize common law marriage, then you cannot indicate you are married on your Marketplace application. (Center on Budget and Policy Priorities, The Health Care Assister's Guide to Tax Rules, updated Oct. 2014; 26 CFR § 1.36B-2; IRS, Publication 501 (2014), Exemptions, Standard Deduction, and Filing Information).

A household, for purposes of determining eligibility for premium tax credits, includes any individuals for whom a taxpayer claims a personal exemption on the federal tax form. That includes yourself, your spouse, and dependents. Dependents include children who meet certain requirements:

• U.S. citizen or resident of the U.S., Mexico or Canada
• Live with you for more than half the year
• Under age 19 at the end of the year (or under age 24 if a full-time student); a child is considered to live with the taxpayer while he or she is temporarily away from home due to education, illness, business, vacation or military service.
• Doesn’t provide more than 50 percent of his or her own support

Other individuals who can count as dependents include relatives, in-laws or full-time members of your household who are:

• U.S. citizen or resident of the U.S., Mexico or Canada
• Receive more than 50 percent of their support from you
• Are related to you or live in your home all year
• Make less than $4,000 in 2015 (threshold for 2016 will be updated when published by the IRS), generally excluding Social Security

A household can include individuals even if they are ineligible for tax credits (for example, individuals who are not lawfully present). Your household size can change during a year due to family changes, including the birth or adoption of a child, a child moving out of the house, and divorce or legal separation. When such changes take place you should report them to the marketplace as they may affect your eligibility for subsidies. Family changes also can trigger a special enrollment opportunity when you can change health plans outside of the regular open enrollment period.

Note that the definition of household for determining eligibility for premium tax credits sometimes differs from the definition of household for determining Medicaid eligibility. Ask your marketplace for more information about who should be counted in your household. (Center on Budget and Policy Priorities, The Health Care Assister's Guide to Tax Rules, updated Oct. 2014; 45 C.F.R. § 155.420(d)).

Because you are not married, you will be considered two separate households for the purposes of determining eligibility for premium tax credits and Medicaid. Assuming that neither of you are claiming any dependents on your tax returns, you will each be considered as a household of one and your own income will be used to determine eligibility for premium tax credits and Medicaid as well as the amount of any premium tax credit and cost-sharing reduction you may qualify for. If you are eligible for premium tax credits, you will each receive a separate determination of the amount of your credit and whether you are eligible for a cost-sharing reduction. Whether you can use your credits to buy a family policy rather than two individual policies will depend on the offerings in your state marketplace. (26 C.F.R. § 1.36B-2(b). (IRS, Questions and Answers on the Premium Tax Credit; 42 U.S.C. § 10871).

Yes, you will be considered as a household of two for both Medicaid and premium tax credits. However, your grandchild will be considered as her own household for Medicaid and CHIP and your income will not count in determining her eligibility for these programs. Assuming she does not have her own income she will likely be eligible for Medicaid or CHIP and not eligible for premium tax credits for coverage in the marketplace. You could of course purchase coverage for her in the marketplace but you would not be eligible for a premium tax credit to help pay for her plan if she is eligible for Medicaid or CHIP. Whether you could include her on your policy would depend on what insurers offer in your marketplace. (Center on Budget and Policy Priorities, The Health Care Assister's Guide to Tax Rules, updated Oct. 2014).

The marketplaces in all states treat same-sex married couples the same as opposite-sex couples. Assuming you file or plan to file your federal income taxes as a married couple, you can apply for premium tax credits as a married couple. (Healthcare.gov, Same-sex married couples).

Assuming you are eligible for premium tax credits, the amount of your credit will be calculated based on how you file your taxes. If, for example, you each claim one of your children, you each will be considered as a household of two. The income of each household would be evaluated separately to calculate eligibility for and the amount of premium tax credits and cost-sharing reductions. Using a different example, if you claim both children as dependents on your tax return, then you and your children will be considered a household of three, and your income will be the basis for determining subsidy eligibility for the three of you. Your partner will be a household of one and his/her eligibility for premium tax credits will be determined separately.

As for the type of coverage your family can purchase, that may vary based on the marketplace rules where you live. For example, some insurers may offer family coverage only to married couples. If you buy one policy for the entire family, all the tax credits you are eligible for can be used to reduce the premium for that policy. If you buy separate policies, you can allocate the premium tax credits across two plans. (Center on Budget and Policy Priorities, The Health Care Assister's Guide to Tax Rules, updated Oct. 2014).

You should. Because you support both of them financially, you should claim them both as a dependent. Your daughter cannot claim her son as her dependent because she is a dependent herself. (26 CFR § 1.36B-1(f); 26 CFR § 1.152-1).

Yes, assuming the other tests for claiming an adult child as a dependent are met. In the case of an adult, non-disabled child, he or she must be under 24, a student for at least 5 months of the year, and not provide more than half of his or her own support (i.e., rent, food, etc). (26 CFR § 1.36B-1(f); 26 CFR § 1.152-1).

Possibly. To claim her as a dependent, she cannot provide more than half of her own support, which includes rent or the fair rental value of the home, food, utilities, and home repairs. Expenses related to your daughter’s clothes, education, medical, travel and other expenses are included. Support from your child can come from taxable and nontaxable income, such as wages and Social Security. It can also include student loans, but does not include any scholarships she receives. And only funds that contribute to your daughter’s support are included. If she puts all her wages into a savings account, that money would not be included as support paid by the child. (26 CFR § 1.36B-1(f); 26 CFR § 1.152-1).

Possibly. If her gross income is less than $3,950 (in 2014) and you pay more than half of her support, then you may be able to claim her as a dependent. She does not need to live with you. (26 CFR § 1.36B-1(f); 26 CFR § 1.152-1; IRS, Publication 501 (2014), Exemptions, Standard Deduction, and Filing Information).

Yes. If your income is between 100 percent and 250 percent of the federal poverty level, you can also qualify for cost-sharing reductions. These will reduce the deductibles, co-pays, and other cost-sharing that would otherwise apply to covered services.

The cost-sharing reductions will be available through modified versions of silver plans that are offered on the marketplace. These plans will have lower deductibles, co-pays, coinsurance and out-of-pocket limits compared to regular silver plans. Once the marketplace determines you are eligible for cost-sharing reductions, you will be able to select one of these modified silver plans, based on your income level. (Patient Protection and Affordable Care Act § 1402, 42 U.S.C. § 18071).

No, you can only get cost-sharing reductions by enrolling in a silver marketplace plan. You will not receive cost-sharing reductions if you enroll in a bronze, gold, or platinum plan. Note that this is different from the rule for premium tax credits. You can apply premium tax credits to all four types of plan. However, if you are eligible for both kinds of help (that is, if your income is between 100 percent and 250 percent of the federal poverty level), you can only receive both types of subsidies if you enroll in a silver plan. (CMS, Actuarial Value and Cost-Sharing Reductions Bulletin, Dec. 16, 2011).

No. Premium tax credits are only available for coverage purchased in the marketplace. (26 C.F.R. § 1.36B-2).

You can apply the premium tax credit to any bronze, silver, gold, or platinum plan offered through the marketplace. Premium tax credits cannot be applied to Catastrophic plans. If you are also eligible for cost-sharing reductions, be aware that these can only be obtained through silver plans offered in the marketplace. (26 C.F.R. § 1.36B-2; 26 U.S.C. 5000A (f) and 42 U.S.C. § 18071).

Premium tax credits can be applied to a separate dental plan only when a consumer qualifies for a tax credit larger than the total cost of their health plan premium. In this case, any "leftover" tax credit amount may be applied to the part of the dental plan premium that covers essential health benefits (that is, dental benefits for children, but not for adults). However, because the tax credit is calculated based on the cost of the second-lowest-cost silver plan in a marketplace, consumers will likely find there is no “leftover” tax credit unless they purchase a very inexpensive Marketplace plan, such as a bronze plan with a very high deductible. Cost-sharing reductions are not available for stand-alone dental plans. (26 U.S.C. 36B(b)(3)(E); 45 C.F.R. § 156.440).

That’s up to you. You can have 1/12 of your annual premium tax credit paid directly to your health plan each month to reduce your monthly premium right away. Or, if you can afford to, you can pay the entire health plan premium yourself up front and collect the premium tax credit in a lump sum next year when your file your tax return. Or you can have some of the tax credit paid directly to your insurer in advance but save some to be collected at year end.

Keep in mind that when you apply for the premium tax credit this fall, during open enrollment, you won’t necessarily know for sure what your income will be for the next year, so you will apply based on your best estimate of your income. Later, when you file your tax return, the IRS will compare your actual income to the amount of premium tax credit you claimed in advance. If you underestimated your income and claimed too much premium tax credit, you might have to pay back some or all of the difference. If you didn’t receive all of the premium tax credit you’re entitled to during the year, you can claim the difference when you file your tax return.

If you’re uncertain about your income, it’s also important to remember that you can modify the amount of premium tax credit during the year if your income changes. So, for example, if you are unemployed now, you can apply for a premium tax credit based on your current low income; then if you get a new job during the year, you must report this increase in income to the marketplace within 30 days, which may reduce the amount of premium tax credit you’re receiving at that time. (26 C.F.R. §1.36B-4; 77 Fed. Reg. 30377, May 23, 2012; 45 C.F.R. § 155.330).

On the health insurance marketplace website, you will find an Application for Health Coverage and Help Paying Costs. You can apply online, submit a paper application, or call your marketplace call center and apply over the phone. The Application will ask you basic information about yourself (and any family members who are applying for coverage with you) including your Social Security number and information about your citizenship or immigration status. It will also ask employment and income information, including what’s on your most recent income tax return. Once you’ve submitted the application, the marketplace will let you know if you qualify for help paying for Qualified Health Plans it offers. It will also let you know if you (or any members of your family) may be eligible for coverage through Medicaid or the Children’s Health Insurance Program.

To complete the Application for Health Coverage and Help Paying Costs online, you will need to create a secure personal account with a login ID and password. (HealthCare.gov, How to apply for health coverage).

The members of your family can enroll in separate plans in a health insurance marketplace, for example, because a grown child lives in another part of the state or because your spouse needs a plan with a different provider network than the one you choose. The premium tax credit will be allocated to the plans in which different family members enroll. However, you may have higher out-of-pocket costs if you have separate plans (for example, with separate deductibles) as opposed to one family plan (with one deductible for the entire family). (76 Fed. Reg. 50931, Aug. 17, 2011).

No, you will make your premium payments directly to the health insurance company. Once you’ve selected your plan, the marketplace will direct you to your insurance company’s website to make the initial premium payment. Insurance companies must accept different forms of payment and they cannot discriminate against consumers who do not have credit cards or bank accounts. The insurance company must receive and process your payment at least one day before coverage begins. Make sure you understand your insurance company’s payment requirements and deadlines and follow them so your coverage begins on time. Your enrollment in the health plan is not complete until the insurance company receives your first premium payment.

Note that if you have qualified to receive an advanced premium tax credit, the government will pay the credit directly to your insurer and you will pay the remainder of the premium directly to the insurer. (77 Fed. Reg. 30377, May 23, 2012).

No. Insurers offering coverage in the health insurance marketplace are required to provide a variety of payment methods and cannot require a consumer to pay by automatic bank withdrawals (sometimes called electronic funds transfers, or EFT.) Federal rules require the insurer to accept paper checks, cashier’s checks, money orders, and all general-purpose pre-paid debit cards, as well as EFT. These methods must be available to consumers for both the initial premium payment (at enrollment) and ongoing payments. (45 C.F.R. § 156.1240).

At least within the health insurance marketplace, insurers are required to accept money orders and pre-paid debit cards. They do not have to accept credit card or debit card payments unless states make that a requirement, although many insurers currently accept all of these forms of payment. Therefore, it may vary from state to state and between insurers. (45 C.F.R. § 156.1240).

Yes, your brother can make a premium payment on your behalf, as well as your church or any charity that doesn't make financial help available based on health status. (79 Fed. Reg. 15240, March 19, 2014; CMS, Third Party Payments of Premiums for QHPs in the Marketplace, Feb. 7, 2014).

The answer depends on whether you are receiving advanced premium tax credits. For people receiving advanced premium tax credits, if a payment due date is missed, insurers must provide a 90-day grace period during which consumers can bring their premium payments up-to-date and avoid having their coverage terminated. However, the grace period only applies if an individual has paid at least one month’s premium.

If, by the end of the 90-day grace period, the amount owed for all outstanding premium payments is not paid in full, the insurer can terminate coverage dating back to the end of the first month of non-payment.

In addition, during the first 30 days of the grace period, the insurer must continue to pay claims. However, after the first 30 days of the grace period, the insurer can hold off paying any health care claims for care received during the grace period, which means the enrollee may be responsible to cover any health care services they receive during the second and third months if they fail to catch up on the amounts they owe before the end of the grace period. Insurers are supposed to inform health care providers when someone’s claims are being held. This could mean that providers may request that you pay out-of-pocket for care or may not provide care until the premiums are paid up so that they know they will be paid. Alternatively, providers may provide care and if your coverage is subsequently terminated, may bill you for the total cost of services. If you pay your premiums in full by the end of the 90 day grace period, your coverage will be reinstated and claims during that time will be paid.

People not receiving advanced premium tax credits are expected to get a much shorter grace period; currently, the general practice is 31 days but it may vary in each state. (45 C.F.R. § 156.270; CMS, FFM and FF-SHOP Enrollment Manual, Setion 6.5; 45 C.F.R. § 155.430(d)(5)).

If you are receiving advanced premium tax credits, the insurer is required to pay your claims during the first 30 days of the grace period. After that, during the second and third month of the grace period, the insurer is allowed to hold your claims and only pay them if and when you get caught up in your premium payments before the end of your 90-day grace period. (45 C.F.R. § 156.270(d)).

Yes. A person receiving an advanced premium tax credit has a 90-day grace period to pay all premiums that are owed. If the amount owed for all outstanding premium payments is not paid in full by the end of the grace period, the insurer can terminate coverage. The insurer would then have to return funds it received from the federal government for all but the first 30 days of the grace period. (45 C.F.R. § 156.270;CMS, FFM and FF-SHOP Enrollment Manual, Setion 6.5).

This fall you and your husband will apply as a household of two. When the baby is born, you must update your family information with the marketplace within 30 days to reflect that you have become a household of three. At that point, you may qualify for a larger premium tax credit. (For example, in 2017, if you and your spouse together earned $30,000, as a household of two you would be required to contribute 6.43 percent of your household income toward the premium, or $193/month, for the benchmark plan in the marketplace. This is because your income falls within 200 percent of the federal poverty level. Once the baby is born and you are a household of three, you would only be required to contribute 4.08 percent of your income, or $122/month). With your income and the expansion of your household, your household will fall within 150 percent of the federal poverty level. When you report your new family status to the marketplace you will also have a 60-day special enrollment opportunity to add the baby to your plan, and you will be able to change health plans during that period if you want to do that. (26 C.F.R. § 1.36B-3; 45 C.F.R. § 155.330).

You should indicate that you are married when you apply for coverage, but plan to update your status once your divorce is finalized. While the IRS determines your marital status on the last day of the calendar year, applicants for premium tax credits should provide their current status on their application. (26 CFR §1.36B-4; 77 Fed Reg 30377, May 23, 2012).

When you apply for the premium tax credit, you will be asked to estimate your expected income for the upcoming year. Often a good place to start is to consider what your income is this year, or what income you reported on your tax return last year. However, if your circumstances have changed since then, for example, if you recently lost your job, you should make your best estimate of what your income will be next year. The health insurance marketplace will compare your income estimates against records at the Internal Revenue Service, Social Security Administration and other sources. If your estimate and official records don’t match, but you meet all other eligibility requirements, you will be asked to provide documentation to support your income projections.

If you don’t have that documentation handy, the marketplace will provide premium tax credits for up to 90 days while you gather and submit your documentation for verification.It is very important that you provide any documentation requested by the marketplace in a timely manner; if you don’t, your premium tax credits might be reduced or terminated.

Keep in mind that if you estimate your income incorrectly and end up claiming more help than you are eligible for, you may have to pay back some or all of the premium tax credit you received. If you over-estimate your income and end up claiming less help than you are entitled to, the difference will be refunded to you when you file your income taxes the following year. (45 C.F.R. § 155.320 (c); 45 C.F.R. § 155.310 (k); 45 C.F.R. § 155.320 (c); 26 C.F.R. § 1.36B-4).

It’s common for income to fluctuate, particularly if you are self-employed, perform seasonal work, or have multiple jobs. To achieve the most accurate premium tax credit amount, you should report income changes to the health insurance marketplace within 30 days. Otherwise, if you claim a premium tax credit during the year and your actual 2015 income edges over 400 percent FPL, you will need to pay back the full credit amount. To avoid this result, if you estimate your income will be close to 400 percent FPL, you could also consider waiting until you file your taxes to take all or a portion of the premium tax credit on your tax return instead of receiving advance payments. (26 C.F.R. § 1.36B-4; 77 Fed. Reg. 30377, May 23, 2012).

That depends on what your actual income turns out to be. If your income goes over 400 percent FPL you will have to repay the full advance premium tax credit amount you received. If your actual modified adjusted gross income is higher than what you projected but less than 400 percent FPL, there are repayment limits based on income. On your tax return, you will compare the actual amount of advance premium tax credit you received during 2015 to the amount you should have received based on your modified adjusted gross income, and then pay back the excess up to the repayment limit. (26 C.F.R. § 1.36B-4; 77 Fed. Reg. 30377, May 23, 2012).

No, your final premium credit amount will be determined based on your income for the year as reported on your tax return. The fact that it ended up being 130 percent of the poverty line does not mean you have to pay back the premium tax credit you received. In fact, your final credit amount will likely be larger than the amount you received in advance. (26 C.F.R. § 1.36B-4; 77 Fed. Reg. 30377, May 23, 2012).

There is no limit to the number of times a person may report income, family or insurance-eligibility changes to the marketplace. Changes that are reported by enrollees will be verified by the marketplace. Then the marketplace will send you a notice (called a redetermination notice) showing your revised eligibility for premium tax credits and cost-sharing reductions. In addition, people can always ask the marketplace to provide them with a monthly advance premium credit below the amount the marketplace determines based on the household’s income if they want to minimize the chance of needing to owe money at the end of the year.

The adjustment will take effect by the first day of the month following the date of the redetermination notice. For example, if an enrollee reports a change in income on June 25 and the marketplace verifies the change and sends a redetermination notice to the enrollee on July 3, the change will be implemented on August 1. (45 C.F.R. § 155.330).

The adjustment will take effect by the first day of the month following the date of the redetermination notice. For example, if an enrollee reports a change in income on June 25 and the marketplace verifies the change and sends a redetermination notice to the enrollee on July 3, the change will be implemented on August 1. (45 C.F.R. § 155.330).

If this is your first time applying for the premium tax credit, then yes. There is no requirement to have filed a tax return for any prior year in order to qualify for a premium tax credit for the first time. However, there is a requirement to file a return in the year in which you receive a premium tax credit (e.g., if a premium credit is received in 2015, the taxpayer must file a 2015 tax return) and reconcile your premium tax credit. Otherwise, you will not be eligible for premium tax credit in the future. For example, if you received premium tax credits in 2015 and did not file a tax return and reconcile premium tax credits received, you will be not be eligible to receive premium tax credits to help pay for marketplace coverage in 2017. The marketplace will notify you if you are not eligible for premium tax credits because you received premium tax credits in the past and did not file a tax return when your coverage is renewed. The I.R.S. may also contact you to pay back some or all of the premium tax credits you received. (26 C.F.R. § 1.36B-2; CMS, Guidance on Reenrollments and Redetermination for Marketplace Coverage for 2016).

The biggest challenge a young adult may face in his or her first year of independent tax filing is verifying income, since one of the prime sources of income data is a prior year tax return. However, other methods of verification are available; for instance, the marketplace will have access to monthly wage data that can verify current income. In the case of someone who is self-employed or who has fluctuating income, additional documentation of income may be accepted. The fact that a young adult has not filed in the past will not prevent him or her from receiving premium tax credits when applying for the first time. (45 C.F.R. § 155.320 (c)).

If an applicant did not file taxes in a prior year, income will be verified by the marketplace through use of electronic wage data. If the information cannot be verified electronically, the applicant may be asked to submit additional paper documentation within 90 days, such as pay stubs, a work contract, or other verification of income. (45 C.F.R. § 155.320 (c)).

That depends on your income and the plans available in your area. To give a general idea, a typical silver plan might have an annual deductible of $2,000 to $3,000 and an annual out-of-pocket limit on all cost-sharing of $6,500. But if your income is between 100 percent and 150 percent of the federal poverty level, the cost-sharing reductions will modify a silver plan so that the annual deductible might be closer to $0 and the annual out-of-pocket limit on all cost-sharing would be no more than $2,250.

If your income is between 150 percent and 200 percent of the federal poverty level, the cost-sharing reductions will modify the silver plan so that the annual deductible might be around $500 and the annual out-of-pocket limit would be no more than $2,350.

If your income is between 200 percent and 250 percent of the federal poverty level, the cost-sharing reductions will be more modest. At this income level, your annual out-of-pocket limit will be reduced to no more than $5,700.

Check the marketplace website for more information about cost-sharing reductions in silver plans in your area based on your level of income. (42 U.S.C. § 18071; 80 Fed. Reg. 10750, Feb. 27, 2015).

No. Unlike premium tax credits, which are reconciled each year based on the income you actually earned, cost-sharing reductions are not reconciled. (42 U.S.C. § 18071).

All health plans offered through the marketplace must meet the requirements of “qualified health plans.” This means they will cover essential health benefits, limit the amount of cost-sharing (such as deductibles and co-pays) for covered benefits and satisfy all other consumer protections required under the Affordable Care Act.

Health plans may vary somewhat in the benefits they cover. Health plans also will vary based on the level of cost-sharing required. Plans will be labeled bronze, silver, gold, and platinum to indicate the overall amount of cost-sharing they require. Bronze plans will have the highest deductibles and other cost-sharing, while platinum plans will have the lowest. Health plans will also vary based on the networks of hospitals and other health care providers they offer. Some plans will require you to get all non emergency care in-network, while others will provide some coverage when you receive out-of-network care.

Beginning in 2017, insurers in your marketplaces may offer “Simple Choice Plans.” Simple Choice Plans at each metal level will have standardized benefits with the same fixed deductible, out-of-pocket costs, and cost-sharing amounts. The purpose of these “Simple Choice Plans” is to simplify the consumer shopping experience since consumers will know that certain features like the deductible and cost-sharing amounts under such plans will be the same within a metal tier. Simple Choice plans also cover some important services before the deductible, such as primary care, generic drugs, and some specialty services. (45 C.F.R. Part 156; 45 C.F.R. § 156.140; 45 C.F.R. §§ 156.130 and 156.230; 81 Fed. Reg. 12204, Mar. 8, 2016).

All qualified health plans offered in the marketplace (as well as non-grandfathered individual plans sold outside the marketplace) will cover essential health benefits. Categories of essential health benefits include:

• 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
• 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, including dental and vision care

The precise details of what is covered within these categories may vary somewhat from plan to plan. (45 C.F.R. § 147.150).

Some marketplace health plans offer coverage of dental benefits and others do not. In addition, all marketplaces offer separate, stand-alone dental plans for children and often for adults, as well. Consumers who wish to have dental coverage should examine whether the plans they are comparing include coverage for dental benefits. Those who purchase a stand-alone dental plan should be aware that a separate plan means separate premiums, deductibles, co-pays, and a separate limit on total out-of-pocket costs. (45 C.F.R. § 155.1065).

In general, marketplace health plans are required to cover the 10 categories of essential health benefits. However, insurers in many states will have flexibility to modify coverage for some of the specific services within each category. Any modifications must be approved by the marketplace before plans can be offered. All health plans must provide consumers with a Summary of Benefits and Coverage (SBC). This is a brief, understandable description of what a plan covers and how it works. The SBC will also be posted for each plan on the marketplace website. The SBC will make it easier for you to compare differences in health plan benefits and cost-sharing.

Plans might differ in other ways, too. For example, the network of health providers might be different from plan to plan.

In 2017, some insurers may offer “Simple Choice Plans” in some states. For these plans, the covered benefits will have the same fixed deductible, out-of-pocket costs and cost-sharing amounts for certain services. In particular, certain services, such as primary care, generic drugs, and some specialty care services may be covered under the deductible. (45 C.F.R. §§ 156.110, 156.115; 45 C.F.R. § 156.200; 45 C.F.R. § 147.200(a)(2)(i)(G); 45 C.F.R. § 156.230; 81 Fed. Reg. 12204, Mar. 8, 2016).

Plans in the marketplace are separated into categories — bronze, silver, gold, or platinum — based on the amount of cost-sharing they require. Cost-sharing refers to health plan deductibles, co-pays and coinsurance. For most covered services, you will have to pay (or share) some of the cost, at least until you reach the annual out-of-pocket limit on cost-sharing. The exception is for preventive health services, which health plans must cover entirely.

In the marketplace, bronze plans will have the highest deductibles and other cost-sharing. Silver plans will require somewhat lower cost-sharing. Gold plans will have even lower cost-sharing. And platinum plans will have the lowest deductibles, co-pays and other cost-sharing. In general, plans with lower cost-sharing will have higher premiums, and vice versa. (45 C.F.R. § 156.130; 45 C.F.R. § 147.130; 45 C.F.R. § 156.140).

Each plan sold in the marketplace must provide a link on the marketplace website to its health provider directory so consumers can find out if their health providers are included. Health plans are also required to update their provider lists at least once a month. A doctor look-up tool is available on Healthcare.gov so that consumers can determine whether or not a doctor is included in a health plan’s network. However, as an extra measure, you may want to call your provider to confirm that he or she is “in-network” if it matters to you or if the cost-sharing you’d be required to pay for “out-of-network” care is significant.

The provider network information from insurance companies must also tell you whether a provider is accepting new patients or whether a provider speaks your language. (45 C.F.R. § 156.230; 80 Fed. Reg. 10750, Feb. 27, 2015).

Health plans in the marketplace must include a link to their prescription drug “formulary” (a list of covered drugs) with other on-line information about prescription drug coverage such as tiering structures and whether any restrictions exist to accessing covered drugs. The "formulary" should be easily accessible meaning that it can be viewed on the health plan's public web site through a clearly identifiable link or tab without creating an account or entering a policy number. The health plan must provide the "formulary" for the health plan and not a general list for the insurer. If you don’t find your drug on the formulary but your doctor says it’s medically necessary for you to take that specific drug, you can apply for an exception to the plan formulary. A prescription look up tool is also available on Healthcare.gov for consumers to determine whether or not a health plan covers a prescription drug. (45 C.F.R. § 156.122).

Under the health care law, dental insurance is treated differently for adults and children 18 and under.Dental coverage for children is an essential health benefit. This means it must be available to you, either as a covered benefit under your health plan or as a free-standing plan. This is not the case for adults. Insurers don’t have to offer adult dental coverage. (45 C.F.R. § 156.110 and § 155.1065).

Each health insurance marketplace can decide whether to require all insurers to cover pediatric dental benefits or whether to allow the sale of stand-alone dental policies. When stand-alone dental policies are allowed, health insurers in the marketplace might not be required to cover pediatric dental benefits. If your health plan covers dental benefits, you will pay one premium for everything. If you get dental benefits through a stand-alone plan, you will have to pay a separate premium for the dental benefits. (45 C.F.R. § 155.1065).

No, the premium tax credit will not be increased to also cover the cost of a stand-alone dental plan. (45 C.F.R. § 156.440).

No. You do not need to have pediatric dental coverage to avoid the penalty. (See 78 Fed. Reg. 12834, Feb. 25, 2013).

If you see a provider that is not included in your plan’s contracted network of providers (i.e., “out-of-network”), depending on your plan, that care may or may not be covered. Either way, you are likely to pay more for that care. You may have a separate deductible to meet for out-of-network care, and/or be required to pay higher co-payments or coinsurance for the care you receive. It’s important to note that the limit on out-of-pocket costs that plans must meet applies only to services received in-network. Any care you get outside your plan’s network will not apply to the limit set in law (in 2017, $7,150 for individuals, $14,300 for families) and may not have any limit at all. (81 Fed. Reg. 12204, Mar. 8, 2016).

A “Catastrophic Plan” is a qualified health plan offered through the marketplace that covers essential health benefits and requires the highest level of cost-sharing allowable for essential health benefits. In 2017, under a “catastrophic policy,” the annual deductible for covered services is $7,150 for an individual ($14,300 for a family policy.) After you have satisfied the deductible, the plan will pay 100 percent for covered essential health benefit services for the remainder of the year. “Catastrophic policies” may also be sold by insurers outside of the health insurance marketplace. Not everybody will be allowed to buy Catastrophic Plans. They are only for adults up to age 30, and for older people who can’t find any other marketplace policy that costs less than 8.13 percent of their projected income in 2016 (8.16 percent in 2017). (45 C.F.R. § 156.155; 81 Fed. Reg. 12204, Mar. 8, 2016).

In general, only young adults up to the age of 30 are eligible to buy a Catastrophic Plan. However, older adults can buy a Catastrophic Plan if no other qualified health plan offered through the marketplace would cost less than 8.13 percent of projected income (8.16 percent of income in 2017). This includes older adults whose health insurance policies have been cancelled because they are not compliant with the Affordable Care Act. (45 C.F.R. § 156.155).

No. Catastrophic Health Plans are not eligible for premium tax credits or cost-sharing reductions. (45 C.F.R. § 155.305).

The Multi-State Plan program was established under the Affordable Care Act to provide people with additional coverage options in the health insurance marketplace. A Multi-State Plan is one that has been approved to participate on the health insurance marketplace by a federal government agency, the U.S. Office of Personnel Management. This is the same agency that administers the health plan for federal government employees. (45 C.F.R. Pt 800).

In 2015, there were Multi-State Plans in 35 states and the District of Columbia, but by 2017 the law requires that all 50 states have Multi-State Plans. (OPM, Multi-State Plan Program and the Health Insurance Marketplace).

No. Multi-State Plans may only be sold through the health insurance marketplace. (45 C.F.R. § 800.10).

Not necessarily. In 2014, Multi-State Plans were offered through the Blue Cross Blue Shield Association. In 2015, some Health Cooperatives were also offering Multi-State Plans in addition to Blue Cross Blue Shield Association. Some Multi-State Plans will reimburse as “in-network” care rendered by providers in other state Blue Cross Blue Shield plan networks, but others may not. This information should be provided in the description of the Multi-State Plan’s features on your state’s health insurance marketplace. (45 C.F.R. § 800.109).

No. Starting in 2014, as insurance policies are sold or renewed, health plans are not allowed to charge you more based on your health status or pre-existing condition. (45 C.F.R. § 147.108).

Yes, in most states you can, within limits. Federal rules allow insurers to charge older adults (e.g., in their sixties) up to three times the premium they would charge younger adults (e.g., in their early twenties). (45 C.F.R. § 147.102(a)(1)(iii)).

Family premiums will reflect the composition of family members, their ages and their tobacco use. To compute a “family premium,” insurers will add together a separate premium for each adult age 21 and older. In addition, insurers can charge a separate premium for up to three children under age 21. In your example, your family premium will reflect three adult premiums and three child premiums. (45 C.F.R. § 147.102).

“Tobacco use” means a person has used a tobacco product an average of four or more times per week for the past six months. A state can increase the number of times per week or reduce the “look-back” period to less than six months. Check with your state marketplace to learn more about tobacco surcharges and how they work.

The surcharge on tobacco users can only be applied to an individual who can legally purchase a tobacco product in the state. Thus, the surcharge does not generally apply to a person under age 18. (45 C.F.R. § 147.102(a)(1)(iv); 78 Fed. Reg. 13406, Feb. 27, 2013).

Yes, in most states you can. Insurers are allowed to increase premiums by up to 50 percent more for people who use tobacco, although many insurers apply a lower surcharge for tobacco use. If you qualify for premium tax credits, this tobacco surcharge will not be covered by the tax credit. States are allowed to limit tobacco surcharges and a few have decided to prohibit tobacco rating by health insurers. (45 C.F.R. § 147.102(a)(1)(iv); 78 Fed. Reg. 13406, Feb. 27, 2013).

No. A tobacco surcharge is not covered by the health insurance premium tax credits. The premium tax credit will reduce what you have to pay for the regular health insurance premium, but you will have to pay the entire additional tobacco surcharge. For example, if the regular premium for a policy is $200 per month and you qualify for a premium tax credit of $75 but you also use tobacco and so would be subject to a 50 percent tobacco use surcharge, you would have to pay $225 for that policy ($200 for the regular premium minus $75 for your premium tax credit plus $100 for the tobacco surcharge).

No. If the cost of health insurance, taking into account both your premium tax credit and the tobacco surcharge, exceeds 8.13 percent of your income (8.16 percent in 2017), you are not subject to the penalty for failure to obtain insurance. (26 U.S.C. § 5000A (e)(1)).

If you report inaccurate or false information about your tobacco use on an application, an insurer is allowed to retroactively impose the tobacco surcharge to the beginning of the plan year. However, the insurer is not allowed to cancel your coverage because of the false or incorrect information. (78 Fed. Reg. 13406, Feb. 27, 2013; IRS, Proc. 2014-37, July 24, 2014).

You would be subject to the tobacco surcharge when you renew your plan the following year. (78 Fed. Reg. 13406, Feb. 27, 2013).

For the most part, yes. Health plans inside and outside the health insurance marketplace must provide the same basic set of benefits, and they are no longer allowed to exclude coverage of a pre-existing condition. In addition, plans both inside and outside must provide a minimum level of financial protection to their policyholders. Specifically, plans must cover at least 60 percent of what the average person would spend on covered benefits and there is a cap on the maximum amount you will pay out of pocket ($7,150 for an individual and $14,300 for a family in 2017).

There are some key differences between plans sold inside and outside the health insurance marketplace. First, you may only obtain premium tax credits and cost-sharing reductions through the health insurance marketplace. Second, plans sold through the health insurance marketplace must be certified by the marketplace as meeting minimum coverage and quality standards. Plans sold outside the marketplace may not always meet those standards particularly if the plan is grandfathered or otherwise doesn't need to comply with ACA protections (i.e., grandmothered or transitional plans). See ACA Consumer Protections for Private Coverage in Other Resources for more information about grandfathered and grandmothered plans. (45 C.F.R. § 147; 26 U.S.C. § 36B; 45 C.F.R. § 156.130; 81 Fed. Reg. 12204, Mar. 8, 2016).

First, depending on your income, you may be eligible for premium tax credits or cost-sharing reductions to help lower the cost of coverage. You can only obtain those tax credits and cost-sharing reductions if you buy a plan through the health insurance marketplace.

Second, if you use the health insurance marketplace, you can compare plans and shop with confidence that all the plans displayed have been certified as meeting a minimum standard for coverage and quality.

Third, if you experience an income change during the year that makes you eligible for financial assistance, you will only be eligible to enroll in a plan with financial help if you are already enrolled in a marketplace plan. If you are uninsured or enrolled in an off-marketplace plan, an income change alone will not qualify you for a special enrollment period. (45 C.F.R. § 156.440; 45 C.F.R. §§ 156.200 to 298).

You will have an opportunity to enroll in a health plan during open enrollment period that for 2017 coverage runs from November 1, 2016 to January 31, 2017. You may also be eligible to enroll in a plan during a special enrollment period.

NOTE: Some states may allow for longer or additional open enrollment periods. (HealthCare.gov; Important Marketplace deadlines).

To meet the coverage requirement, individuals must have “minimum essential coverage.” Most people that have health coverage today have a plan that will count as minimum essential coverage, and will not need to do anything more than continue the coverage that they have. If you have any of the following coverage, you likely have minimum essential coverage:

• Employer sponsored coverage, including COBRA continuation coverage and retiree coverage
• Coverage purchased in the individual market, including a plan purchased in a health insurance marketplace
• Medicare Part A coverage and Medicare Advantage Plans
• Most Medicaid coverage
• Most Children’s Health Insurance Program coverage
• Veteran’s health coverage administered by the Veterans Administration that are comprehensive
• Most types of TRICARE (coverage for members of the military)
• Self-funded student health coverage that began on or before Dec. 31, 2014 (for later plan or policy years, programs can apply to be recognized as minimum essential coverage, the list of approved plans is available here)
• Coverage for Peace Corps volunteers
• Refugee Medical Assistance from the federal Administration for Children and Families
• Department of Defense health benefit program for civilian employees known as “non-appropriated fund” personnel

If you don’t currently have coverage, will soon lose coverage, or are thinking of changing coverage, you can obtain minimum essential coverage by purchasing a plan on your state’s health insurance marketplace. You can also buy a traditional individual or family health insurance policy outside of the marketplace, but be aware that some types of coverage do not qualify as minimum essential coverage, such as discount plans, fixed indemnity plans , or plans that provide coverage only for a specific disease (i.e., cancer-only). Such plans are required to notify you if they don’t qualify as minimum essential coverage. If you receive such a notice, you may have to pay a tax penalty for not having adequate coverage.

If you are uncertain whether your plan qualifies as minimum essential coverage, contact your employer’s human resources department or your health insurer. (26 U.S.C. § 5000A (f)(1); 79 Fed. Reg. 4302, Jan. 27, 2014).

It is important to understand that a health care sharing ministry is not health insurance, and may not provide the kind of financial protection you can obtain through a health plan on the health insurance marketplace. However, if you are a member of a health care sharing ministry, you are exempt from the tax penalty for failing to maintain minimum essential coverage.

Typically health sharing ministries operate by having all of their members pay a monthly “share” or fee. Those fees are then used to pay other members’ medical bills, if they qualify and if the reason for needing care was not due to “un-Christian” behavior. Names and the current needs of members are published in a monthly newsletter, and members are able to support each other financially and through prayer.

Health care sharing ministries do not have to comply with the consumer protections outlined in the Affordable Care Act, and many states have exempted them from the state’s insurance laws. As a result, consumers could be at greater financial risk in these programs than they would be in traditional insurance. In particular, if there’s a dispute between you and the heath care sharing ministry about covered benefits, or if you’re having trouble getting your medical bills paid, many state insurance regulators do not have jurisdiction to help you. (26 U.S.C. § 5000A (d)(2)(A) and (B); 78 Fed. Reg. 39494, July 1, 2013).

A discount medical plan is not health insurance, and will not provide the kind of financial protection that you can obtain through a health plan on the health insurance marketplace. Companies selling these plans are supposed to notify their policyholders that the plan does not qualify as minimum essential coverage under the Affordable Care Act, meaning the consumer could be required to pay a tax penalty if they do not obtain health insurance. However, consumers should be aware that some of these discount plans may use marketing materials that suggest they provide traditional insurance.

Generally, consumers who sign up for a discount plan must pay an upfront enrollment fee plus a monthly subscription. In exchange, the plan offers discounts on medical services from doctors, hospitals and dentists. However, a number of state insurance regulators have had to shut down these plans because of fraudulent activity, and often the discounts they provide are no better than what you could negotiate on your own. Consumers who suspect that a discount plan is falsely advertising itself as health insurance should report the company to the State Department of Insurance. (45 C.F.R. § 147.200(a)(2)(i)(G); 77 Fed. Reg. 8668, Feb. 14, 2012; National Conference of State Legislatures, Health Care Discount Plans: State Role and Regulation, material added Jan. 2012).

A mini-med plan is a type of health insurance, but it comes with a low annual or lifetime dollar limit on benefits. Its sale to individuals is banned under the Affordable Care Act. If you believe you are enrolled in or are sold a mini-med plan, contact your state insurance department (see Other Resources for a list of state Departments of Insurance). You can also call the federal toll free help line at 1-800-318-2596. (45 C.F.R. § 147; CMS, Annual Limits Policy, Protecting Consumers, Maintaining Options, and Building a Bridge to 2014.

A fixed indemnity plan is not traditional health insurance and enrollment in one does not constitute minimum essential coverage under the Affordable Care Act. These companies are supposed to provide policyholders with a notice that the coverage is not minimum essential coverage. If you have one of these plans and no other coverage, you will be subject to the law’s tax penalty for failing to have health insurance.

Historically, fixed indemnity policies have been income replacement policies, to help compensate people for time out of work. The plan will provide a fixed amount of money per day or over a set period while the policyholder is in the hospital or under medical care. The amount provided is often far below the patient’s actual costs. Thus, consumers can find that they pay more in premiums than they get in return. Consumers who suspect that a fixed indemnity plan is falsely advertising itself as health insurance should report the company to the state department of insurance. (See Other Resources for a list of state Departments of Insurance). (45 C.F.R. § 147.200(a)(2)(i)(G); 77 Fed. Reg. 8668, Feb. 14, 2012; 79 Fed. Reg. 30240, May 27, 2014; CMS, ACA Implementation FAQs-Set 11).

A short-term insurance policy, which is defined as a policy that covers you for less than a 12-month period, is not considered traditional health insurance and does not constitute minimum essential coverage under the Affordable Care Act. If you are enrolled in one of these plans, even if it lasts 364 days, you will be subject to the law’s tax penalty for failing to have health insurance. In addition, short-term policies are exempt from many of the Affordable Care Act’s consumer protections, and as a result the policy may not provide the kind of access to health services and financial protection that you may need or want. You should carefully review the terms of the policy and any limits or exclusions before purchasing it. (45 C.F.R. § 144.103; 77 Fed. Reg. 16454, March 21, 2012; 26 U.S.C. § 5000A).