FAQs about the Affordable Care Act
1. Affordable Care Act Marketplace Basics
What Is an Open Enrollment period?
The open enrollment period is when you can purchase or change a health insurance plan through the Affordable Care Act (ACA) Marketplace. Open enrollment currently begins in early November and ends in mid-January. Those dates have varied over the years. Check healthcare.gov for the most current dates.
What is the Marketplace?
The Marketplace, also called the Exchange/s, is where you can compare and purchase qualified healthcare policies. Some states have their own Marketplaces. Other states utilize the federal Marketplace. For more information, visit healthcare.gov or call 1-800-318-2596 (TTY: 1-855-889-4325).
What is a Qualified Healthcare Plan (QHP)?
A QHP provides the essential health benefits and adheres to other regulatory requirements (such as maximum copayment and Out Of Pocket limits) required by the federal or state Marketplace that certified the plan.
Can I purchase or change a Marketplace insurance plan outside of the Open Enrollment period?
Yes, if you experience what is called a “Qualifying Life Event” or you are a member of a federally recognized tribe or are an Alaskan Native.
What is a Qualifying Life Event?
A significant change in your circumstances – such as getting married, having a child, moving to another state, unemployment/new job, or other changes in your health, income or health insurance coverage.
How do I purchase/chase my insurance following a Qualifying Event?
You can call 1-800-318-2596 (TTY: 1-855-889-4325) or go to healthcare.gov and log into your account to report the change. Shortly after you’ve filed the report, you should receive an eligibility notice that will tell you whether you qualify for a “Special Enrollment Period” (which typically means that you have 60 days to shop for or change your health plan via the Marketplace). Your eligibility notice will also provide information about any subsidies you may be entitled to claim.
What is a subsidy?
Financial assistance aimed at helping people pay for their ACA mandated healthcare insurance. ACA subsidies include a “premium tax credit” which can be paid directly to your health insurance company to lower the cost of your monthly premium payments. Or you can claim the premium tax credit as a refund on your tax return.
How do I qualify for a subsidy?
The Marketplace automatically calculates the amount of your subsidy based on family income and other information. You’ll be asked to reply to questions that will qualify your eligibility for assistance when you first sign up for your Marketplace account. It’s your responsibility to update that information if and when necessary.
Do I have to report all income changes to the Marketplace?
Yes. If you’re making less money, you may qualify for an increased subsidy. And if you make more money than you’d estimated and don’t report it, you run the risk of losing your coverage and/or having to make a large reimbursement payment when you file your taxes. When you report increased income, any subsidy you’re receiving will be adjusted accordingly.
Is it safe to provide personal financial data to the Marketplace website?
The government has provided tips to help combat potential Marketplace fraud.
Do I have to buy my insurance through the Marketplace?
No, you can buy insurance wherever you choose. But subsidies are offered only to those who do purchase their policy through the Marketplace. You should also be aware that not all health insurance plans purchased outside of the federal or state-run Marketplace may be a Qualified Health Plan (QHP).
2. Dental Care Coverage and the Affordable Care Act
Does the Marketplace offer dental insurance?
Yes. You may purchase dental insurance as part of some health plan offerings, or as a separate plan.
Can I purchase just my dental insurance via the Marketplace?
You can buy a dental plan through the federal Marketplace only when you purchase a health plan. But some state exchanges (Colorado, Connecticut, Vermont, and Maryland) allow residents to purchase stand-alone dental plans without purchasing healthcare insurance.
Is dental coverage mandatory for adults under the ACA?
No, you are not required to purchase dental coverage for people who are 18 years of age or older.
Is dental coverage mandatory for children?
Dental insurance for children is considered an essential benefit under the health care law. But it’s (usually) not mandatory.
If you are purchasing health coverage for a person who is 18 years old or younger, dental coverage must be available – either as part of the plan (embedded) or through a stand-alone plan. But under federal law you are not required to purchase pediatric dental insurance, though a few states do require it.
Does embedded coverage provide dental care for my entire family?
It depends on the terms of your plan. Some Marketplace plans only provide pediatric dental care, which typically will not cover family members who are age 19 and over. Check the coverage documentation for the plans you are considering purchasing to understand exactly what and who is covered.
What if I purchase my family insurance outside of the Marketplace?
Because pediatrics dental care is a legally an “essential benefit,” when you are purchasing insurance directly the insurance provider will ask if you already have a kids’ dental plan. If you don’t, depending on the state you live in, the company may have to sell you a plan that includes pediatrics dental coverage (whether you have kids or not). In other states, you may have to prove or confirm that you have or will soon purchase a pediatrics dental plan.
Can I receive a subsidy if I purchase a stand-alone dental plan?
No, stand-alone dental plans on the Marketplace don’t qualify for federal subsidies.
I am on Medicare, which doesn’t provide dental care coverage. Can purchase a dental plan through the Marketplace?
It depends on where you live. If your state runs its own ACA Marketplace, you may be able to obtain a standalone dental plan. If the federal government runs your state’s exchange, you will not be able to purchase dental coverage through the Marketplace.
3. Evaluating Marketplace Stand-Alone Dental Insurance
What does a “guaranteed” premium mean?
The rate that you see on the Marketplace website is the rate you will pay for that dental plan.
What is an “estimated” premium?
The rate displayed on the Marketplace website is an estimate of what you will pay for the plan. The policy’s price will factor in additional information such as your dental health, occupation, and other data.
What is an “Out Of Pocket Limit”?
That’s the maximum amount that you pay for covered dental services during one calendar year. Once you reach your out-of-pocket limit, the plan then pays for all covered care. (Out-of-pocket costs are separate from your monthly premium payments.)
What is the typical Out Of Pocket Limit for Marketplace dental plans?
On average, for a stand-alone plan, $700 for an individual and $1,200 for a family.
Will a dental care plan I purchase through the Marketplace cover preexisting conditions?
Unlike an ACA-compliant healthcare plan, there is no requirement for a dental coverage plan to cover preexisting conditions. Dental care plans may also charge higher premiums in response to a health problem and do not have to offer third-party reviews for denied services.
Can each state interpret the ACA’s dental coverage regulations differently?
Yes. States can determine a multitude of parameters, ranging from the types of dental services approved plans must cover to the number of dentists in a plan’s network.
How do I know which services aren’t covered?
Carefully read the “Excluded Services and Other Covered Services” section in the dental plan’s “Summary of Benefits and Coverage” document.
4. Discount Dental Plans and the ACA
Are discount dental plans qualified under the ACA?
Dental savings plans are not insurance. They are an affordable alternative to insurance that provide plan members with savings on their dental care. Dental savings plans do not require accreditation under the Affordable Care Act.
Do discount dental plans have annual limits?
No, there are no annual limits that would limit the amount of times you can receive discounted dental care.
Are there long waiting periods before I can use the service?
Most plans activate within 3 business days.
Can I receive savings for treatments addressing pre-existing conditions?
Yes, you can save on all procedures included in the dental savings plans you selected. You can even choose plans that focus on providing significant savings for specific sorts of care such as dentures and bridges, orthodontics, tooth extractions and/or cosmetic procedures.
Do I have to file a claim to claim the savings?
No, you pay your reduced rate directly to the dentist, when you receive care.
Does every dental care provider offer reduced fees to discount dental plan members?
Savings are available through participating providers only.
Why might I want a discount dental plan in addition to dental insurance?
Some insurance plans don’t fully cover specialty or elective procedures, so you might choose a dental savings plan to address the gaps in your insurance coverage. You may also opt to utilize a dental savings plan to save on services when your dental insurance hits its annual cap rate. And some in-network providers may offer discounts to plan members who are using insurance.
Why might I want a discount dental plan as an alternative to dental insurance?
Dental savings plans provide an affordable way to get the care you need, when you need it. There are no caps on annual coverage, no deductibles, and no claims paperwork to file and track. There are no worries about getting treatment for pre-existing conditions or waiting periods before you can get particular treatments. Additionally, dental savings plans provide savings on services that traditional dental insurance doesn’t typically cover, such as cosmetic procedures and braces.
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