Oct. 14, 2013
TMA is discussing the ACA’s health insurance requirement, what it means, who
must buy health insurance, penalties for not having coverage, and who is
fifth week of “Hey, Doc” education programming
enroll? What if I don’t?
mandate of the ACA requires most people to have some form of health insurance
coverage as of January 2014, or pay a penalty. If you have coverage through one
or more of these sources, you will satisfy the mandate:
- Government-sponsored insurance (such as Medicare,
Medicaid, the Children’s Health Insurance Program, TRICARE, the veterans’
- Employer-sponsored coverage;
- Insurance bought on your own in or outside of the
- A grandfathered health plan in existence before the
health reform law (March 23, 2010).
If you do not
have coverage, the marketplace is a new place to shop for health insurance in
addition to the traditional private insurance market. It also can help you
determine if you are eligible for financial assistance toward your insurance
costs or if you are eligible for a state government health program.
ACA exempts certain uninsured people from having to pay the penalty. Generally,
you may qualify for an exemption if:
- Coverage is unaffordable based on your household
- You don’t earn enough income to have to file a tax
- You are uninsured for less than three months in a
- You are in one of the following groups: incarcerated
individuals, undocumented immigrants, American Indians and Alaskan
natives, participants of a health care sharing ministry, or members of a
recognized religious sect opposed to having health insurance; or
- You experience certain hardships preventing you from
If you don’t
qualify for one of the exemptions, and you don’t have insurance coverage next
year, you will have to pay a penalty. In 2014, fines begin at $95 per adult and
$47.50 per child, or 1 percent of family income, whichever is greater. The
penalties then increase in 2015, and in 2016 they will be as much as $695 per
adult and $347 per child, or 2.5 percent of family income, whichever is
If I have
insurance through my work or my spouse or my parents, do I have to give that up
and buy insurance through the marketplace?
Generally, if you already have health insurance, you satisfy the ACA’s
requirement to have coverage. But there are a few things you may want to look
- Check with your employer to make sure it will
continue providing coverage in 2014 and beyond.
- Check the status of your current plan to make sure
it meets the new minimum requirements under the ACA. If you have your own
insurance or a job-based plan that existed before the health reform law
was enacted in 2010, it may be grandfathered in and nothing needs to
change. Check with your insurance company or employer to find out.
- Children under the age of 26 can stay on their
- If you already have coverage, you can still look at
your options in the marketplace, but you may not qualify for financial
individual mandate mean I have to buy health insurance through the marketplace?
individual mandate means you will have to have some form of health insurance,
unless you qualify for an exemption. (See “Who must enroll? What if I don’t?”)
But the marketplace is just one option for purchasing it on your own. Insurers
do not have to participate in the marketplace, so you still can buy health
plans the same way you do today, directly from health insurers, or through your
employer if offered. You also can still get public insurance, if you qualify,
directly from Medicaid, Medicare, or other government agencies.
is TMA’s “Hey, Doc” upcoming content schedule through Nov. 30, 2013.
Oct. 21: Who can sell me this insurance? How do I pick a plan?
How many plans can I pick from? Can I keep the plan I have now?
Week of Oct. 28:
What is covered by this insurance?
Week of Nov. 4:
What different kinds of insurance can I buy? What is “catastrophic insurance”?
Week of Nov. 11:
What will it cost me to buy this insurance?
Week of Nov. 18:
What are the subsidies? Who gets a subsidy? How do I apply for a subsidy?
TMA is the largest state medical society in the nation,
representing more than 47,000 physician and medical student members. It is
located in Austin and has 112 component county medical societies around the
state. TMA’s key objective since 1853 is to improve the health of all Texans.
Contact: Pam Udall
cell: (512) 413-6807
Contact: Brent Annear
phone: (512) 370-1381
cell: (512) 656-7320
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