Individuals & Families Frequently Asked Questions


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Why should I have health insurance? 

You always hope that nothing will ever happen to you or your family. You don't plan to get sick, but most people will need medical attention at some point for an illness or injury. Having health insurance protects you from these high medical costs when something does happen. Health insurance protects you when you need medical care, and can protect you from having to pay major medical expenses for care.

Who can use the Marketplace?

Most Maine people will be able to purchase an affordable health plan on the Health Insurance Marketplace (HealthCare.gov). Mainers with Medicare are already covered so they do not need the Marketplace.  Employees and their families with insurance coverage through their jobs are not likely to buy health plans on the Marketplace.  Maine’s Marketplace is mostly for people who are uninsured and those whose employer-based coverage is too expensive and/or lacking in benefits.

Maine’s Marketplace also offers a Small Business Health Options program, or “SHOP.” The SHOP Marketplace is open only for businesses with 50 or fewer workers.

If my employer offers me insurance, can I shop on the Marketplace to get a better deal?

Even if your employer offers coverage, you can choose to buy a plan on the Health Insurance Marketplace; however, you may not be eligible for any financial assistance with premiums unless your income is between $11,620 to $46,690 for a single person (and $23,850 to $95,400 for a family of four) and your employer's plan covers less than 60% of allowed medical expenses in an average year or costs more than 9.5% of your household income to cover just the employee.

The cost of individual, family and small business plans that you can enroll in through the Health Insurance Marketplace is available on the Marketplace at www.healthcare.gov.

If I am buying coverage on my own, do I have to buy it on the Marketplace?

No. You can shop for a health plan on or off the Health Insurance Marketplace, but getting financial help that can lower the cost of your plan's monthly premium is only possible if you buy a plan sold through the Marketplace. Young adults who are under the age of 30 have some other options, including being covered under their parents' health plans (up to age 26) or buying a less costly, high deductible plan.

Why should I buy my health insurance from the online Marketplace?

The Health Insurance Marketplace is the only way you can get financial help to pay for your health insurance. You can still buy health insurance directly from companies or from insurance agents, but if you don't use the Marketplace, you cannot receive financial assistance to help pay for your insurance. Since the Marketplace opened, 9 out of 10 Mainers enrolling through the Marketplace have qualified for financial help to pay for their health insurance.

Who cannot buy a health plan on the Marketplace?

Immigrants who are in the country illegally and those who are seeking asylum in the U.S. are prohibited from buying insurance on the Health Insurance Marketplace. Legal immigrants are permitted to use the Marketplace and may qualify for some financial assistance with premiums and out of pocket costs if their income is no more than 400% of the federal poverty level (about $46,680 for a single person or up to $95,400 for a family of four). If you are on Medicare, you will not use the Marketplace since you are already covered.

Who runs the Health Insurance Marketplace?

Maine's Health Insurance Marketplace is run by the Centers of Medicare & Medicaid Services (CMS), a federal government agency. Maine's Bureau of Insurance (BOI) does not run the Marketplace. However, if you have problems or questions about your health insurance in general, you can call the Consumer Health Care Division of the BOI at 1-800-300-5000. All insurers offering plans in Maine are licensed by the BOI.

How does the Health Insurance Marketplace work?

For someone with access to a computer, it's relatively straightforward. Go online to the website, HealthCare.gov, and create a personal account. Then fill out an application and provide some basic information such as household size, location, income and citizenship status. The Marketplace then determines if you are eligible for Medicaid (MaineCare); if so, the online program will send you to the MaineCare site to finish applying for coverage. If not, it will tell you how much financial assistance you can receive to help lower the amount you would have to pay for your monthly premiums. If you qualify for this assistance, a payment will be sent directly by the government to the health plan insurer to pay a portion of the premium.

The Marketplace will then offer you a list of Maine's health plans and show you their premiums and out of pocket costs, including deductibles and co-payments. If you decide to buy one of those plans, in most cases, you will be directed to the insurer's website to make payment.

You can also fill out paper applications or apply over the phone. The Marketplace has a toll-free number that can be used with the HealthCare.gov website, or that you can call directly for assistance. You can also get free, in-person help from certified local community partners (also called "navigators," "certified application counselors" or "certified assisters") or certified insurance brokers. Use the Find Help tool to locate people near your home or workplace who can provide free assistance.

How can I get help when using the online Marketplace?

  • Use the toll-free telephone for healthcare.gov customer service: 1-800-318-2596.
  • Get free in-person assistance through certified assisters using the Find Help tool. These specially trained assisters cannot sell or recommend that you buy a particular plan.
  • Ask your insurance agent if he or she can help you choose and enroll in a plan that is right for you. A certified insurance agent can also continue to assist with claims and billing issues, provider issues and general customer service.

What kinds of insurance plans are available on the Marketplace?

All health insurance plans offered on the Marketplace are qualified health plans and cover all essential health benefits required by law. There are four different types: bronze, silver, gold and platinum. Younger adults (under age 30) can also purchase a catastrophic plan.

The different types of plans do not reflect the quality or amount of care covered. The types differ as to how much your premium costs each month and the total amount of out-of-pocket costs you’ll have. Some general guidelines:

  • Bronze level plans tend to have the lowest premiums but higher out-of-pocket costs. Plans like this may be good for people who are relatively healthy and do not need a lot of medical care or prescription drugs.
  • Gold or platinum level plans generally have higher premiums and lower out-of-pocket costs. The platinum level plans tend to have the highest premiums on the Marketplace, but you will pay less out-of-pocket costs with these plans.
  • Maine’s Marketplace also offers a catastrophic plan for people under the age of 30 or for those who are exempt from the requirement to purchase insurance. Catastrophic plans have a lower premium cost, but generally require you to pay all of your medical costs out-of-pocket up to a certain amount - usually several thousand dollars. These plans are intended to protect from major injuries or illnesses, not for everyday doctor visits. Individuals buying catastrophic plans are not eligible for financial assistance to help pay for this coverage.

How much will my monthly premiums be?

Your monthly premiums depend on several things: where you live, the plan you pick, your age, family size, annual income, and in some instances, whether you’re a smoker or not. One of the most important factors is your annual income since this will determine if you’re eligible for lower cost premiums and out of pocket expenses.

Will these new health plans really be affordable?

The Health Insurance Marketplace offers quality health insurance plans at the lowest possible cost. Also, many people will qualify for assistance with paying for their health insurance costs, or may qualify for public health care programs at low or no cost.

What if I can't afford the premiums?

Some people will qualify for financial assistance to pay their health plan premiums. Under the Affordable Care Act, people with lower incomes can qualify for assistance on a sliding scale to help pay premiums from 100% up to 400% of the federal poverty level - which is from $11,670 to about $46,680 for an individual and $23,850 to $95,400 for a family of four. There’s also help with cost-sharing for individuals and families with incomes of up to 250% of the poverty level ($29,125 for an individual or $59,625 for a family of four). People who sign up for a plan must pay a portion of their household income—ranging from 2% to 9.5%—toward the cost of the premium, based on how much they make.

Does everyone buying insurance through the Marketplace get financial assistance?

No, financial assistance is limited to people who meet specific income requirements. In addition, people with access to insurance through their jobs but who decide to purchase insurance on the Marketplace instead are eligible for financial help with premiums only if their employer’s plan does not cover at least 60% of estimated medical expenses or if it would cost the worker more than 9.5% of household income. Since Maine did not adopt the eligibility changes to MaineCare (Medicaid), there will be some people with low incomes who will not have access to coverage through MaineCare or qualify for financial assistance for plans offered on the Marketplace.

What information will I need to enroll?

  • Social Security numbers (or document numbers for any legal immigrants who need insurance)
  • Birth dates of all the family members you are going to enroll
  • Employer and income information for everyone in your family (for example, from paystubs or W-2 forms, wage and tax statements)
  • Policy numbers for any current health insurance
  • Information about any job-related health insurance available to your family.

When you enroll in a marketplace plan, is it for a year or longer? Can an insurer drop you?

As long as you keep up with your monthly premium payments and don't lie on your application for insurance by claiming that you're younger than you really are (as an example), your health plan can't drop you. 

Generally, people will be able to enroll in or change plans once a year during the annual open enrollment period. For coverage in 2016, open enrollment for the Marketplace runs from November 1, 2015 through January 30, 2016. For coverage starting on January 1, 2016, you must enroll or re-enroll by December 15, 2015. If there is a major change in your circumstances, you can change plans or add or drop someone from coverage outside the regular annual enrollment period. This could happen if you lose your job, for example, or get married, divorced or have a child.

What happens if I miss or can’t pay the premium?

People receiving financial assistance through the premium tax credits get a 90-day grace period to catch up on late premiums.  Once the grace period has passed, you will generally have to wait until the next annual open enrollment period in the fall to re-enroll in coverage.  If you are uninsured for more than three months, you could be assessed the penalty for not having insurance coverage (see next question).

Will I have to pay a penalty if I don’t have health insurance?

One feature of the Affordable Care Act is that starting January 1, 2014, all Americans will have to be covered by a health insurance plan. Many people in Maine will be eligible for public programs or will qualify for assistance to help pay for a health plan offered on the Marketplace. If you don’t have health insurance in 2016, you’ll pay the higher of these two amounts:

  • 2.5% of your yearly household income (Only the amount of income above the tax filing threshold, about $10,150 for an individual in 2014, is used to calculate the penalty.) The maximum penalty is the national average premium for a Bronze plan.
  • $695 per person ($347.50 per child under 18) The maximum penalty per family using this method is $2,085.

Exemptions from the penalty
Some people may qualify for an exemption from buying health insurance. Learn more...

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