Health Reform and Your Insurance Options

The world of health insurance is going through a lot of changes. If you’re trying to get your bearings, take a look at what’s different since the health reform bill became law. The highlights: No one can be denied coverage because of health problems they had in the past. […]

The world of health insurance is going through a lot of changes. If you’re trying to get your bearings, take a look at what’s different since the health reform bill became law.

The highlights:

  • No one can be denied coverage because of health problems they had in the past. This is known as a “preexisting condition.” In addition, health insurance companies cannot charge you more if you have a preexisting condition.
  • If you have children who are 19 to 26, they can stay on your insurance plan.

  • Insurance plans, with some exceptions, now cover some preventive medical services. You won’t need to pay a co-payment or reach the deductible first. These preventive services include certain vaccinations and screenings.

Health insurance Marketplaces are set up in each state or by the federal government. Marketplaces, also known as Exchanges, are websites where you can shop for coverage, enroll in a health plan, and find out if you qualify for a government subsidy to help pay your premium.

What You’ll Find in the Health Insurance Marketplace

What is it? The health insurance Marketplace is a  way to shop for and buy health coverage. It lets you compare the costs and benefits of different plans.

Each state has a Marketplace. The federal government oversees the Marketplaces in some states, while other states run their own.

All plans sold on the Marketplace must include 10 essential health benefits:

  1. Outpatient care
  2. Emergency care
  3. Hospitalization

  4. Pregnancy, maternity, and newborn care

  5. Mental health and substance use treatment

  6. Prescription drugs
  7. Rehabilitative and habilitative care
  8. Laboratory services
  9. Preventive and wellness services
  10. Pediatric care, including vision and dental

In addition to offering standardized benefits, Marketplace plans must fit into one of four “tiers” based on how much of your medical expenses are covered:

  • Platinum – on average covers 90% of your medical expenses
  • Gold – on average covers 80%
  • Silver – on average covers 70%
  • Bronze – on average covers 60%

Plans can’t turn you down because you have a health problem or you’ve had one in the past.*

Who can use it? To get health insurance from an exchange, you must:

  • Be a U.S. citizen or legal immigrant
  • Not be in prison
  • Lack access to affordable coverage through an employer


Because of that, the Marketplaces are primarily for people who are buying insurance on their own, as well as small businesses.

How does the Marketplace help me find a plan? Your Marketplace has tools and information to help you select between options, such as:

  • Comparing the benefits and costs of available plans
  • Information in simple language about how each plan works
  • A toll-free phone number you can call for help
  • Calculator that shows you how much your options cost
  • Help with enrolling in government programs such as Medicaid if you’re eligible

When can I enroll? Marketplaces have an open enrollment period (usually in the fall) when you can shop for coverage and enroll in a plan. You must enroll in a plan during that timeframe, or you will have to wait until the next open enrollment period, unless you have special circumstances. You may be eligible for a special enrollment period if you had a qualifying event such as losing your job or other insurance coverage. If you are eligible for Medicaid, you can enroll at any time during the year.

Can I get help paying for coverage? Many people will be able to get tax credits to lower the cost of their coverage. In 2018, you can get tax credits if you have a yearly income between:

  • $12,060 and $48,240 for a single person
  • $24,600 and $98,400 for a family of four

Am I required to have health insurance? The tax reform bill Congress passed in 2017 eliminated the penalty for people who do not have health insurance beginning in 2019. The penalty is still in effect for 2018, so unless you meet one of the exceptions, you will have to pay a penalty if you do not have insurance. The exceptions include:

  • You belong to a religion that has religious objections to insurance.
  • Insurance would cost more than 8.05% of your income, even with help from an employer or the tax credits.
  • Your income is so low that you aren’t required to file a tax return ($10,000 for an individual; $20,000 for a family).
  • You would have been eligible for Medicaid, but you live in a state that did not expand its program.
  • You live in an area with no marketplace plans or only one insurer selling plans.
  • The only plan available in your area covers abortion and you oppose abortion.



* Under a proposed rule, insurance companies will be able to sell short-term health plans that do not include the 10 essential health benefits and deny coverage for pre-existing conditions.


WebMD Medical Reference
Reviewed by Sarah Goodell on June 01, 2018



Henry J. Kaiser Family Foundation: “The affordable care act three years post-enactment;” “Preventive services covered by private health plans under the affordable care act;” “Explaining health care reform: Questions About Health Insurance Exchanges;” “Establishing health insurance exchanges: an overview of state efforts; ” “Frequently asked questions;” and “The Requirement to Buy Coverage Under the Affordable Care Act.”

American College of Physicians: “Health Insurance Tax Credits for Individuals and Families.” “What’s changing and when;” “About the Health Insurance Marketplace” and “Checklist for individuals and families.”

© 2018 WebMD, LLC. All rights reserved.

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