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What you need to apply for coverage:

• Information about your household size.
• Home and/or mailing addresses for everyone applying for coverage.
• Social Security Numbers.
• Document information for legal immigrations.
• Employer and income information for every member of your household(for example, from pay stubs or W-2 forms—Wage and Tax Statements).
• Notices from your current plan that include your plan ID, if you have or had health coverage in 2014.

Understand Your Options

The health plan category you choose determines how you and your plan share the costs of care. These categories have nothing to do with the quality or amount of care you get.

There are 4 categories or “metal levels” of coverage in the Marketplace. Plans in each category pay different amounts of the total costs of an average person’s care. This takes into account the plans’ monthly premiums, deductibles, copayments, coinsurance, and out-of-pocket maximums. The actual percentage you’ll pay in total or per service will depend on the services you use during the year.

 

 

 

Bronze: Your health plan pays 60% on average. You pay about 40%.
Silver: Your health plan pays 70% on average. You pay about 30%.
Gold: Your health plan pays 80% on average. You pay about 20%.
Platinum: Your health plan pays 90% on average. You pay about 10%.

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Essential Benefits

The essential health benefits include at least the following items and services:

• Ambulatory patient services (outpatient care you get without being admitted to a hospital)
• Emergency services
• Hospitalization (such as surgery)
• Pregnancy, maternity, and newborn care (care before and after your baby is born)
• Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
• Prescription drugs
• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

 

 

 

The Fee in 2015 and Beyond

The fee you pay if you don’t have health coverage.

If you don’t have health coverage in 2015, you may have to pay a fee. You also have to pay for all of your health care.

The fee is sometimes called the “penalty,” “fine,” “individual responsibility payment,” or “individual mandate.”

Important. Marketplace Open Enrollment ended March 31. You can now buy a Marketplace health plan only if you qualify for a special enrollment period. You can apply for Medicaid and CHIP any time.

Find out if you qualify for a Special Enrollment Period or Medicaid and CHIP. Open Enrollment for 2015 coverage starts November 1, 2015.

The fee in 2015 and beyond

For 2015, the fee is figured one of 2 ways. You’ll pay whichever of these is bigger:

2% of your income
$325 per person in your household

The way the penalty is calculated, a single adult with household income below $19,650 would pay the $95 flat rate. A single adult with household income above $19,650 would pay an amount based on the 1% rate. (If income is below $10,150, no penalty is owed.)

The penalty increases every year. In 2015 it’s 2% of income or $325 per person. In 2016 and later years it’s 2.5% of income or $695 per person. After that it’s adjusted for inflation.

If you’re uninsured for just part of the year, 1/12 of the yearly penalty applies to each month you’re uninsured. If you’re uninsured for less than 3 months, you don’t have to make a payment.

You’ll pay the fee on your 2014 federal income tax return. Most people will file this return in 2015.

Learn more about the individual shared responsibility payment from the Internal Revenue Service.

When the uninsured need care
When someone without health coverage gets urgent — often expensive — medical care but doesn’t pay the bill, everyone else ends up paying the price.

That’s why the health care law requires all people who can afford it to take responsibility for their own health insurance by getting coverage or paying a fee.

If you pay the fee, you’re not covered
It’s important to remember that even if you pay the penalty you still don’t have any health insurance coverage. You are still responsible for 100% of the cost of your medical care.

Minimum essential coverage
To avoid the penalty you need insurance that qualifies as minimum essential coverage. If you’re covered by any of the following, you’re considered covered and don’t have to pay a penalty:

Any Marketplace plan, or any individual insurance plan you already have
Any employer plan (including COBRA), with or without “grandfathered” status. This includes retiree plans
Medicare
Medicaid
The Children’s Health Insurance Program (CHIP)
TRICARE (for current service members and military retirees, their families, and survivors)
Veterans health care programs (including the Veterans Health Care Program, VA Civilian Health and Medical Program (CHAMPVA), and Spina Bifida Health Care Benefits Program)
Peace Corps Volunteer plans
Self-funded health coverage offered to students by universities for plan or policy years that begin on or before Dec. 31, 2014

Other plans may also qualify. Ask your health coverage provider.

Health plans that don’t qualify as coverage
Health plans that don’t meet minimum essential coverage don’t qualify as coverage in 2014. If you have only these types of coverage, you may have to pay the fee. Examples include:

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

If My Employer Does Offer Coverage

If you have coverage from a job (or a family member’s job), you’re considered covered and won’t have to pay the fee that uninsured people must pay.
Changing to a Marketplace plan
If you have job-based coverage, you may be able to change to a Marketplace plan. But you might not qualify for premium tax credits or other savings that can make Marketplace insurance more affordable. This will depend on:

 

• The type and cost of insurance your employer provides
• Your income and household size

If you have a job-based plan, you’re considered covered
Any job-based health plan you have qualifies as minimum essential coverage.
This means you don’t have to change to a Marketplace plan to avoid the penalty that uninsured people pay.

If My Employer Doesn’t Offer Coverage

If you’re a part-time worker without job-based coverage, you may be able to buy health insurance in the Marketplace and get lower costs based on your income.

If your employer doesn’t offer health insurance to part-timers:

Employers aren’t required to provide health insurance for part-time employees, even if they provide coverage for full-time employees.

If you’re a part-time worker and your employer doesn’t offer you coverage, you can use the Health Insurance Marketplace to find a plan. You may be able to get lower costs on your monthly premiums and out-of-pocket costs based on your household size and income.

You may also qualify for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP).

You’ll learn if you qualify for these options when you fill out your Marketplace application.

Minimum Essential Coverage

Health plans that qualify as minimum essential coverage

If you’re covered by any of the following types of plans, you’re considered covered under the health care law and don’t have to pay a penalty or get a health coverage exemption.

Any Marketplace plan, or any individual insurance plan you already have
Any job-based plan, including retiree plans and COBRA coverage
Medicare Part A or Part C
Most Medicaid coverage
The Children’s Health Insurance Program (CHIP)
Most individual health plans you bought outside the Marketplace, including “grandfathered” plans. (Not all plans sold outside the Marketplace qualify as minimum essential coverage.)
If you’re under 26, coverage under a parent’s plan
Self-funded health coverage offered to students by universities for plan or policy years that started on or before Dec. 31, 2014 (check with your university to see if the plan counts as minimum essential coverage)
Health coverage for Peace Corps volunteers
Certain types of veterans health coverage through the Department of Veterans Affairs
Most TRICARE plansThis link takes you to a website not operated by the federal government. The site may have different privacy and security policies.
Department of Defense Nonappropriated Fund Health Benefits ProgramThis link takes you to a website not operated by the federal government. The site may have different privacy and security policies.
Refugee Medical Assistance
State high-risk pools for plan or policy years that started on or before December 31, 2014 (check with your high-risk pool plan to see if it qualifies as minimum essential coverage)
See a more detailed list of types of plans that do and don’t count as minimum essential coverage from the IRS.

Health plans that don’t count as coverage

Some products that help pay for medical services don’t qualify as minimum essential coverage. If you have only this kind of product, you may have to pay the fee. Examples include:

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

Cost Sharing

Cost Sharing Reduction

A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments. You can get this reduction if you get health insurance through the Marketplace, your income is below a certain level, and you choose a health plan from the Silver plan category. If you’re a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits.

If you’re a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, you may qualify for additional cost-sharing reductions.

To learn if you qualify for lower costs on health insurance coverage, find your estimated 2015 household income and household size on the chart below.

The column on the left tells you if you may qualify for premium tax credits, lower out-of-pocket costs, or low-cost health care through Medicaid.

Learn how to estimate your income for the Marketplace.

Quick Check: Do I qualify to save on health insurance coverage?

This health care savings chart shows if you may qualify for lower costs on coverage in the Health Insurance Marketplace based on your household income and family size.

Qualifying Events

Life events that may qualify you for a Special Enrollment Period

Getting married
Having a baby
Adopting a child or placing a child for adoption or foster care
Losing other health coverage
Moving to a new residence
Gaining citizenship or lawful presence in the U.S.
Leaving incarceration
For people already enrolled in Marketplace coverage:
Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions
Note: Voluntarily quitting a Marketplace plan mid-year doesn’t qualify you for a Special Enrollment Period.

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