Frequently Asked Questions

Most U.S. citizens and legal residents are eligible for ACA coverage. You must live in the United States and not be incarcerated. Additionally, you cannot be enrolled in Medicare, Medicaid, or have access to affordable employer-sponsored insurance that meets minimum value standards. Eligibility for premium tax credits depends on your household income being between 100% and 400% of the federal poverty level.

The annual open enrollment period runs from November 1 to January 15 in most states. If you miss this window, you may qualify for a special enrollment period if you experience certain life events like losing job-based coverage, getting married, having a baby, moving to a new state, or experiencing changes in income. Special enrollment periods typically last 60 days from the date of the qualifying event.

Yes! One of the key protections of the ACA is that insurance companies cannot deny coverage or charge higher premiums based on pre-existing health conditions. This includes conditions like diabetes, heart disease, cancer, or any other health issue you may have had before applying for coverage. All ACA plans must cover essential health benefits and provide coverage for pre-existing conditions.

To complete your enrollment, you'll typically need: Social Security numbers for all household members applying for coverage, employer and income information (pay stubs, W-2 forms, or tax returns), policy numbers for any current health insurance, and immigration documents if applicable. Having this information ready will help streamline the enrollment process.

Metal tiers indicate how you and your plan share costs. Bronze plans have the lowest premiums but highest out-of-pocket costs (60% plan/40% you). Silver plans offer moderate premiums and out-of-pocket costs (70% plan/30% you). Gold plans have higher premiums but lower out-of-pocket costs (80% plan/20% you). Platinum plans have the highest premiums but lowest out-of-pocket costs (90% plan/10% you). All tiers cover the same essential health benefits.

All ACA plans must cover 10 essential health benefits: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services, laboratory services, preventive and wellness services, and pediatric services including oral and vision care. Many preventive services are covered at no cost to you.

It depends on whether your doctor participates in your chosen plan's provider network. Each insurance plan has a network of doctors, hospitals, and other healthcare providers. Before enrolling, check if your preferred healthcare providers are in the plan's network. If they're not, you may pay more for out-of-network care or may need to find new in-network providers.

HMO (Health Maintenance Organization) plans typically require you to choose a primary care physician and get referrals for specialist care. They usually have lower premiums but less flexibility. PPO (Preferred Provider Organization) plans offer more flexibility to see any provider without referrals, both in and out of network, but typically have higher premiums. Your choice depends on your preference for flexibility versus cost savings.

Premium tax credits are financial assistance that lowers your monthly insurance payment. They're available to individuals and families with household incomes between 100% and 400% of the federal poverty level. The amount you receive is based on a percentage of your income, with lower-income households receiving larger subsidies. You can choose to receive the credit in advance to reduce your monthly payments, or claim it as a refund when you file your taxes.

Cost-sharing reductions (CSRs) are additional savings that lower your out-of-pocket costs for deductibles, copayments, and coinsurance. They're available only if you choose a Silver plan and have a household income between 100% and 250% of the federal poverty level. CSRs effectively upgrade your Silver plan to provide Gold or Platinum-level cost protection while maintaining the Silver premium price.

Your premium is the amount you pay each month for your health insurance coverage, regardless of whether you use medical services. Your deductible is the amount you must pay out-of-pocket for covered healthcare services before your insurance begins to pay. For example, if you have a $2,000 deductible, you'll pay the first $2,000 of covered medical expenses yourself before your insurance starts covering costs.

Yes! Self-employed individuals are eligible for premium tax credits and cost-sharing reductions based on their household income. Your eligibility is determined by your modified adjusted gross income, which includes your self-employment income. Additionally, you may be able to deduct your health insurance premiums as a business expense on your tax return if you meet certain requirements.

You should report income changes to the Health Insurance Marketplace as soon as possible. Significant changes in income can affect your eligibility for premium tax credits and cost-sharing reductions. If your income increases substantially, you may need to repay some advance premium tax credits when you file your taxes. If your income decreases, you may qualify for more financial assistance and should update your application to receive the additional help.