“Hey, Doc” Answers Questions About Insurance Mandate

Oct. 14, 2013

This week, 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 exempt.

TMA’s fifth week of “Hey, Doc” education programming

Who must enroll? What if I don’t?

The individual 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’ health program);
  • Employer-sponsored coverage;
  • Insurance bought on your own in or outside of the marketplace; or
  • 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.

Additionally, the 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 income;
  • You don’t earn enough income to have to file a tax return;
  • You are uninsured for less than three months in a row; 
  • 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 obtaining coverage.

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 greater.

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?

Not necessarily. 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 into:

  • 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 parents’ plan.
  • If you already have coverage, you can still look at your options in the marketplace, but you may not qualify for financial assistance.

Does the individual mandate mean I have to buy health insurance through the marketplace?

No. The 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.

Below is TMA’s “Hey, Doc” upcoming content schedule through Nov. 30, 2013.

All About the Plans
Week of 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
phone:(512) 370-1382
cell: (512) 413-6807

Pam Udall  

Contact: Brent Annear
phone: (512) 370-1381
cell: (512) 656-7320

Brent Annear  

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