The 2017 Open Enrollment Period for buying individual and/or family health insurance has closed.

You can enroll in a new health insurance plan outside of Open Enrollment ONLY if you have a qualifying life event (marriage or birth of a child, for example) that entitles you to a Special Enrollment Period. Otherwise, you will likely have to wait for the Open Enrollment Period for 2018. Open Enrollment Periods typically follow a yearly cycle.

Learn more about qualifying life events and Special Enrollment Period (SEP) opportunities at www.healthcare.gov.

Are you new to health insurance and need more help understanding what the Affordable Care Act means for your budget and coverage? Take our quick visual tour.

If you need help shopping for health insurance for a business you own or work for, check out Highmark’s Business Resource Center.

Reminder

About Financial Help:
  • The Patient Protection and Affordable Care Act (PPACA, or ACA) includes financial help to make health insurance more affordable for working families and people with modest incomes.
  • Depending on your household income and other factors, you may be eligible for an Advanced Premium Tax Credit (APTC), cost-sharing reduction (CSR), or both.
  • Learn about financial help and programs you may be eligible for. Check your eligibility and apply for savings on the Health Insurance Marketplace.
  • Highmark is one of many private insurance companies participating in the government-run Health Insurance Marketplace. Look for plans from Highmark companies when you shop there.

Highmark is here to be your health insurance partner, every step of the way.

Have Questions? Give us a call. Or ask us to call you for a free consultation.

Reminder

Plan Changes and Rate Increases

There were certain changes to many of our plans for 2017. These may have included, but are not limited to, changes in plan availability, changes in the deductible, out-of-pocket limit, and costs associated with common medical services.

  • Certain plans were discontinued and are no longer offered in 2017 in some markets where Highmark does business.

    • In some areas, Highmark Affordable Care Act (ACA) individual plans may no longer be available on the Health Insurance Marketplace (Healthcare.gov).
  • Some plan changes may have affected copayments, coinsurance and prescription drug coverage (for formulary/non-formulary generic, brand and specialty drugs).

  • If you are a current Highmark member, please take time to review your 2017 coverage.

Reminder

About Tax Penalties:
  • The Affordable Care Act (ACA) requires that most Americans have health insurance that qualifies as minimum essential coverage, or pay a government tax penalty.
The tax penalty in 2017 is higher than it was in 2016.
  • If you don’t have minimum essential health coverage in 2017, you will likely have to pay a government tax penalty.
  • For the 2016 tax year (taxes filed in 2017), the penalty is $695 per adult/$347.50 per child under 18, or 2.5% of your household income — whichever is more.
  • For the 2017 tax year (taxes filed in 2018), the government will adjust the penalty for inflation, and the percentage option will remain at 2.5%.

To learn more about the government’s tax penalty for not having health insurance visit Healthcare.gov.

Rate Changes

Notice: Rate changes for 2017 were approved in states where Highmark does business.

Please view the important Rate Increases Notice to learn more about increases that became effective in 2017.

Still have questions?

If you’re currently a Highmark member, you can call the number on the back of your Highmark ID card. We can help.

Rate Increase Notice

Please view the important Rate Increases Notice to learn more about increases that became effective in 2017.

What health care reform means for me

If You’re a Teen or Young Adult…

  • Under the Affordable Care Act, most young adults who can’t get coverage through their jobs can stay on their parents’ plans until they turn 26, whether or not they live at home, are married, or can be declared as dependents on their parent’s income tax return.
  • Coverage includes certain preventive services, free of copays or coinsurance. These include flu shots, HIV and cancer screenings, contraceptive counseling and FDA-approved birth control.
  • Under the ACA, you can’t be turned down or charged more for health insurance because of any health conditions in the past or present.
  • If your expected 2017 income is between $11,880 and $47,520* for an individual, and your job doesn’t offer affordable coverage, you may be eligible to receive Advanced Premium Tax Credits to help pay for insurance.

*Number valid for those living in 48 contiguous United States and DC.

If You’re Female…

  • All qualified health plans (QHPs) include maternity and newborn care. This includes support, supplies and counseling for breastfeeding.
  • All qualified health plans (QHPs) cover specific preventive services, free of copays or coinsurance. These include annual mammograms starting at age 40 and human papilloma virus (HPV) vaccines. Also included are screenings for cervical cancer, osteoporosis, diabetes, high blood pressure, depression, obesity, sexually transmitted diseases (STDs), interpersonal and domestic violence and help to stop using tobacco products.
  • Under the Affordable Care Act, you can’t be turned down or charged more for health insurance because of any health conditions in the past or present, including pregnancy.
  • Women cannot be charged more for insurance coverage because of their gender.

If You’re a Family With Children…

  • All qualified health plans (QHPs) include pediatric vision and pediatric dental coverage, plus pregnancy and newborn care.
  • Under the Affordable Care Act, most young adults who can’t get coverage through their jobs can stay on their parents’ plans until they turn 26, whether or not they live at home, are married, or can be declared as dependents on their parent’s income tax return.
  • Under the ACA, you can’t be turned down or charged more for health insurance because of any health conditions in the past or present.

If You’re an American Indian or Alaska Native…

American Indians and Alaska Natives who are members of federally recognized tribes* have certain allowances in the Health Insurance Marketplace.
  • You don’t have to pay a government penalty if you don’t have health coverage.
  • You can enroll for Marketplace insurance coverage at any time of the year. Marketplace plans can be changed as often as once a month.
  • You more easily qualify for lower out-of-pocket costs (also called “cost-sharing reductions,” or CSRs). You may even be eligible for $0 cost-sharing if your expected income for 2017 is below a certain level – around $72,900** for a family of four. Other financial help may be available for Marketplace plans.
  • You can apply cost-sharing reductions to any “metal level” individual Marketplace product.
  • You have special cost and eligibility rules for Medicaid and the Children’s Health Insurance Program (CHIP).
  • If you enroll in a health insurance plan through the Marketplace, you can still get (or keep getting) services from the Indian Health Service, tribal health programs or urban Indian health programs.
  • When you submit an application to the government’s Health Insurance Marketplace, you’ll learn more about all the programs and financial help you’re eligible for.

*A Federally recognized tribe is any American Indian or Alaska Native tribe, band, nation, pueblo, village or community that the Department of the Interior acknowledges to exist as an Indian tribe.

**Number valid for those living in 48 contiguous United States and DC.

Learn more: www.healthcare.gov or http://www.ihs.gov

If You’re Healthy…

  • Most Americans will need to have health coverage in 2017 or possibly pay a government tax penalty. This penalty increases every year. Without health coverage, you would be also responsible to pay for health care services out of your own pocket.
  • Having health coverage helps protect you and your family from major financial loss if you have a serious illness or major accident.
  • If your expected 2017 household income is less than or equal to the equivalent of $97,200* for a family of four, you may be eligible for Advanced Premium Tax Credits (APTCs) that you can use right away to help lower your insurance premiums.
  • Depending on your household income and family size, you may also be eligible for financial help that could lower what you pay out-of-pocket when you receive health services. Copays and deductibles are two examples of out-of-pocket costs that may be reduced if you receive a cost-sharing reduction (also called “CSR”) from the government.
  • When you submit an application to the government’s Health Insurance Marketplace you’ll learn more about all the programs and cost savings you’re eligible for.

*Number valid for those living in 48 contiguous United States and DC.

To use the APTC you may purchase an individual Marketplace plan at any metal level. To use cost-sharing reductions (CSRs) you must purchase an individual Marketplace Silver Level plan.

If You Have Pre-Existing Conditions…

  • You can’t be turned down or charged more for insurance because of any past or present health conditions
  • As an important part of the Affordable Care Act, all individual and small group plans offer a core set of 10 Essential Health Benefits (EHBs). This means that all qualified health plans (QHPs) sold by private insurance companies, must provide coverage for core health care services, like doctor visits, hospitalization, emergency room care, prescriptions, mental health services and more.
  • Job-based and new individual plans won’t be able to exclude you from coverage or charge you a higher premium for a pre-existing condition, including a disability.
  • If your expected total 2017 household income is less than the equivalent of $97,200* for a family of four, you may be eligible for Advanced Premium Tax Credits (APTCs) that you can use right away to help lower your insurance premiums.
  • Depending on your household income and family size, you may also be eligible for financial help that could lower what you pay out-of-pocket when you receive health services. Copays and deductibles are two examples of out-of-pocket costs that may be reduced if you receive a cost-sharing reduction (also called “CSR”) from the government.
  • When you submit an application to the government’s Health Insurance Marketplace, you’ll learn more about all the programs and financial help you’re eligible for.

**Number valid for those living in 48 contiguous United States and DC.

To use the APTC you may purchase an individual Marketplace plan at any metal level. To use Cost-Sharing Reductions (CSRs) you must purchase an individual Marketplace Silver Level plan.

If You’re a Small Business Owner…

More choice and control over health spending.

  • Small businesses (50 or fewer full-time equivalent employees in 2017) can choose among qualified health plans in the Small Business Health Options Program (SHOP) offered in the Health Insurance Marketplace. Visit the Marketplace for updates on SHOP.

  • If you need help shopping for health insurance for a business you own for work for, check out Highmark’s Business Resource Center. You can also request a call from one of our licensed Highmark representatives to learn more.

Insurance Information You Need to Know

Common Questions About Health Care Reform Changes

What is health care reform?

Health care reform refers to the Patient Protection and Affordable Care Act (PPACA), also called the Affordable Care Act (ACA). On March 23, 2010, President Obama signed sweeping health reform legislation into law. “Obamacare” is another term some people use when they talk about this law.

Among the biggest provisions of the Affordable Care Act are the changes that expand access to coverage. These provisions strive to make health insurance available to more Americans.

Most U.S. citizens and legal residents are now required to have health insurance coverage or they may have to pay a penalty to the government.

What is the individual mandate?

A key part of the Affordable Care Act (health care reform), effective in 2014, includes the “individual mandate.” This mandate is another way of saying that most people living in the U.S. who don’t receive health insurance from their employer will be legally required to have minimum essential health insurance coverage, or possibly pay a tax penalty to the government.

  • If you didn’t enroll in a health insurance plan by January 31, 2017, you can only enroll in 2017 coverage if you have a qualifying life event, like getting married or having a child, for example. Otherwise, you will likely have to wait for the Open Enrollment Period for 2018 coverage. (Fall, 2017). Open Enrollment Periods typically follow a yearly cycle.

  • You’ll find plans from Highmark companies when you shop on the Health Insurance Marketplace. You can purchase coverage online, through local insurance agents, or by phone.

  • If you are already enrolled in employer-sponsored health coverage, the individual mandate penalty may not apply.

  • Other health plans that will satisfy the individual mandate requirement include Medicare, Medicaid, CHIP, TRICARE, state-based risk pools, and certain other government-sponsored coverage recognized by the U.S. Department of Health and Human Services (HHS).

You can learn more about health care reform policy by visiting the Health Insurance Marketplace.

Where can I shop for insurance?

If you didn’t enroll in a health insurance plan by January 31, 2017, you can only enroll in 2017 coverage if you have a qualifying life event, like getting married or having a child, for example. Otherwise, you will likely have to wait for the Open Enrollment Period for 2018 coverage. (Fall, 2017). Open Enrollment Periods typically follow a yearly cycle.  Learn more about qualifying life events and Special Enrollment Period (SEP) opportunities at Healthcare.gov.

Need More Help? Give us a call. Or ask us to call you for a free consultation.

What’s the Health Insurance Marketplace? (the “exchange”)

The Health Insurance Marketplace (the Marketplace) – sometimes referred to as the health insurance “exchange” – is a kind of virtual marketplace where individuals and small businesses can compare and buy insurance plans. Qualified health plans (QHPs) offered in the Marketplace are sold and run by private insurance companies, like Highmark.

The Marketplace simplifies your search for health coverage by gathering the options available in your area, all in one place. You can compare plans based on price and other features important to you before you make a choice. You’ll find information provided in plain language so you can understand your options.

What is a Qualified Health Plan (QHP)?

Under the Affordable Care Act, any qualified health plan (QHP) that is certified to be offered in the Health Insurance Marketplace must offer Essential Health Benefits (EHBs). A QHP has to follow established limits on cost-sharing. Cost-sharing includes amounts you may have to pay out of your own pocket for deductibles, coinsurance and copayments. QHPs must also meet other requirements such as guaranteed renewal of insurance, guaranteed acceptance—regardless of a person’s current health or health history—and other standards.

What is covered by QHPs?

Each health insurer in the government’s Health Insurance Marketplace offers various plans, which – by law – must include a core set of 10 Essential Health Benefits (EHBs).

What is the difference between “on-exchange” and “off-exchange” health insurance plans?

When a health insurance plan is referred to as an “on-exchange plan,” it means that type of plan is available when you shop through the government’s Health Insurance Marketplace. Plans sold in the Marketplace must meet certain government standards, such as providing coverage for a core set of 10 Essential Health Benefits (EHBs). The Marketplace (sometimes referred to as the “exchange”) is a virtual place where you can compare and shop for qualified health plans from private insurance companies – like Highmark – within your area.

Insurance companies will also continue to sell “off-exchange” plans. While these individual and small group plans may differ in some respects from the on-exchange products, they also offer a core set of Essential Health Benefits (EHBs). For example, the off-exchange individual and small group plans also include services for maternity and newborn care, emergency care, prescription drugs and more.

Why do I need health insurance?

Even if you are healthy, one of the smartest things you can do is to protect yourself and your family with health insurance coverage. Illnesses and accidents are part of life. Having coverage can help you stay healthy, and protect you from large and unexpected medical costs that could put you in financial debt.

The Affordable Care Act requires that most U.S. citizens and legal residents have health insurance that provides “minimum essential coverage” or pay a tax penalty to the government. This means that if you do not have coverage you could be required to pay a penalty when you file your taxes at the end of the year.

If I already have health insurance, do I need to do anything?

You most likely won’t need to take any action if:

  • You already have affordable health insurance through your employer.
  • You already have private health insurance that you pay for yourself. (Check with your health insurance company to learn more about how health care reform may or may not affect your present plan.)
  • You already have health insurance through a government program. If you already receive Medicare, Medicaid, CHIP, or veteran’s benefits—or you have any other type of government health insurance—you do not need to do anything.

Who is exempt from the requirement to buy health insurance?

Most people must have qualifying health insurance or pay a fee (penalty). But people who qualify for a health insurance exemption don’t have to pay the fee.

There are different kinds of exemptions. They’re based on certain hardships and life events, health coverage or financial status, membership in some groups and other circumstance.

Learn about what counts as minimum health coverage and exemptions when you visit the Health Insurance Marketplace.

Income-related exemptions apply to:

  • People who would have to pay more than 8% of their expected 2017 income for health insurance, after taking into account any employer contributions or tax credits.
  • People with incomes that are below the amount required for filing a tax return.
    Other possible exemptions:
  • People who are members of certain religious groups.
  • Undocumented immigrants.
  • People who are incarcerated.
  • American Indians, Alaska Natives and other members of federally-recognized tribes.
  • Members of health care sharing ministries.
  • Those who have had a short-term gap (less than three months) in coverage.
  • Those who can prove that a “hardship” prevented them from becoming insured.

To learn more about tax filing thresholds please visit the Health Insurance Marketplace, or contact the Marketplace Call Center: 1-800-318-2596 (TTY: 1-855-889-4325).

How will I prove I have coverage?

You will not have to account for coverage or exemptions or make any payments until you file your federal income tax return. Insurers are required to provide everyone that they cover each year with information that will help demonstrate they had coverage in the tax year for which they are filing.

What Does it Cost?

How much will my health insurance cost?

The cost of your health insurance will depend on which plan you choose. Individual Marketplace (ACA) plans are categorized by four “metal levels”: Bronze, Silver, Gold or Platinum. These metal levels affect how much your premium will cost each month and how much you may expect to pay out-of-pocket for your share of costs – like copayments and deductibles, for example. All four metal level plans include the same core Essential Health Benefits (EHBs). Metal levels do not reflect the quality or amount of care that plans provide.

The Affordable Care Act includes two kinds of financial help to help make health insurance more affordable for working families and people with modest incomes. (You may also hear these referred to as “subsidies.”) One kind of savings is a tax credit that can lower the cost of your insurance premium right away. This is called an Advanced Premium Tax Credit, or APTC. Another kind of savings could lower the out-of-pocket costs you pay when you get care. This is called a cost-sharing reduction, or CSR.

What kind of financial help is available?

There are two kinds of savings from the government that may help you pay for some of the costs of your health insurance when you purchase an individual, qualified health plan (QHP) in the Health Insurance Marketplace.

Tax credits.

Also called an “Advanced Premium Tax Credit” (APTC). These are based on how much money you make each year and the number of people in your tax household (those included on your most recent income tax filing). If you qualify for a tax credit it can be applied in advance – paid directly to your insurance company – to help lower your monthly insurance premium. Eligibility for tax credits is based on a standard called the “federal poverty level” (FPL) that looks at your family income and the number of people in your family. The size of the tax credit is based on a sliding scale; those who make less money get a larger amount of financial support to lower the cost of their insurance coverage.

Cost-sharing reduction (CSR).

In addition to the tax credits that reduce your monthly premium payments, you may be eligible for cost-sharing reductions (CSRs) that could lower the amount you pay when you get care. Eligibility for a cost-sharing reduction is also based on income level and family size. Cost-sharing reductions are offered by the federal government to reduce the amount of money you have to pay for health care expenses such as copayments or coinsurance.

Advanced Premium Tax Credits are only available for individual, qualified health plans purchased through the Health Insurance Marketplace. Cost-sharing reductions (CSRs) are only available for certain individual, qualified health plans purchased through the Marketplace.

How Do I Get Financial Help (Cost Savings)?

The government determines whether you’re eligible for help paying for health insurance.

Even if you think your income is too high to qualify for help, you may still be able to get financial help through the Health Insurance Marketplace (the “Marketplace”). To find out if you’re eligible for financial help or programs before you shop, you can submit a single application to the government. You’ll need your tax return from last year and certain household information. Allow about 30 minutes for this process.

2017 Federal Poverty Guidelines
Income percentage of the Federal Poverty Level
Family size 100% 138% 150% 200% 250% 300% 400%
1 $11,880 $16,394 $17,820 $23,760 $29,700 $35,640 $47,520
2 $16.040 $22,135 $24,060 $32,080 $40,100 $48,120 $64,160
3 $20,200 $27,876 $30,300 $40,400 $50,500 $60,600 $80,800
4 $24,360 $33,617 $36,540 $48,720 $60,900 $73,080 $97,440
5 $28,520 $39,358 $42,780 $57,040 $71,300 $85,560 $114,080
6 $32,680 $45,098 $49,020 $65,360 $81,700 $98,040 $130,720
7 $36,840 $50,839 $55,260 $73,680 $92,100 $110,520 $147,360
8 $41,000 $56,580 $61,500 $82,000 $102,500 $123,000 $164,000
Each additional person, add $4,160 $5,741 $6,240 $8,320 $10,400 $12,480 $16,640

2017 Federal Poverty Guidelines for Continental U.S. does not include FPL Guidelines for Alaska and Hawaii

More on How to Apply for Financial Help

Highmark is one of many private insurance companies participating in the government-run Health Insurance Marketplace. You’ll find our plans when you shop there. You can purchase coverage online, through local insurance agents, or by phone.

Learn about financial help and programs you may be eligible for. Check your eligibility and apply for savings on the Health Insurance Marketplace.

You’ll need:

  • Employer and income information for everyone in your family. For example, paystubs, W-2 forms, or wage and tax statements
  • Social Security numbers (or document numbers for any legal immigrants)
  • Birth dates for everyone you are applying for
  • Policy numbers for any current health insurance
  • Information about any job-related health insurance available to your family
  • Tribe name if you or a family member are an American Indian or Alaska Native

After you’ve submitted your application to the Marketplace, you can continue shopping for plans that match your needs and budget, including those from the Highmark family of brands.

About Metal Levels and Coverage

There are many types of plans to fit your budget and health needs.

What are Metal Levels?

The Affordable Care Act created four benefit levels of coverage – also called “metal levels.” The metal levels are Bronze, Silver, Gold and Platinum. The metal level of the plan you choose affects how much your premium will cost each month and how you expect to share the cost of care, such as out-of-pocket expenses you’re responsible to pay when you need care. Examples of out-of-pocket costs you share with your insurance company include copayments and deductibles.

Plans in all four metal levels include a core set of 10 Essential Health Benefits (EHBs) such as doctor visits, hospital stays, prescription coverage and more. The differences will be in what you pay when you need these services, and in how much your monthly premium will cost.

The metal level of a plan does not reflect the quality or amount of care that plans provide.

As a general guideline, based on the average insurance usage:

  • Bronze plans cover 60%, you pay 40%
  • Silver plans cover 70%, you pay 30%
  • Gold plans cover 80%, you pay 20%
  • Platinum plans cover 90%, you pay 10%

How do I choose the right plan category?

  • Bronze plans offer the lowest monthly premium and higher out-of-pocket costs for care. Bronze plans may be a good choice if you don’t plan to use much medical care.
  • Silver plans balance monthly premium with moderate out-of-pocket costs when you receive medical care. If you’re eligible for a government cost-sharing reduction (CSR), you must choose a Silver Marketplace plan to get the savings.
  • Gold plans have a higher monthly premium, but lower out-of-pocket costs for care than Silver. Gold plans may be a good choice for you if you expect to use a fair amount of medical care.
  • Platinum plans have the highest monthly premium, and lowest out-of-pocket costs for care. Platinum plans may be a good choice if you expect to use a lot of medical services.

  • Catastrophic (also called Major Events) plans protect a person from financial disaster in the event of a serious and expensive medical emergency, such as a heart attack or stroke.

    Catastrophic plans are typically for those who are single, under 30, have no ongoing medical issues and can pay large unexpected medical expenses to meet a high deductible in the event of an emergency. This type of plan may be available to cover family members if they are all under 30. A catastrophic plan also may cover individuals who have received a Certificate of Exemption because they are unable to afford coverage or who meet certain other categories of hardship.

*Members of federally recognized American Indian or Alaska Native tribes have certain cost sharing allowances that apply to any “metal level” plan sold in the Marketplace.

Always read your insurance plan carefully so you understand your coverage and what you will be responsible for.

More commonly asked questions about coverage:

Who can purchase coverage?

Under the Affordable Care Act (ACA), most U.S. citizens or legal residents who do not have access to affordable health insurance through an employer or another government program will be eligible to purchase minimum essential health insurance coverage. (Individuals in jail or prison may not purchase insurance through the Health Insurance Marketplace. They may also be ineligible for private health insurance in some geographic locations.)

Who can be covered on my plan?

  • You and your spouse can be covered on your plan.

  • You and your same- sex spouse or same-sex/opposite-sex domestic partner enrolling in a health care policy together, who are eligible under the plan guidelines.

  • You can also add newly eligible dependents to your existing Highmark member policy. *

*Does not apply to Short Term Blue members.

NOTE: Certain medical underwriting requirements may apply when adding new members to Grandfathered or transitional Medically Underwritten policies.

If you’re an existing Highmark member and want more information about this option, please call the Customer Service phone number on the back of your member ID card.

  • If your plan covers children, you can now add or keep your children on your health insurance policy until they reach 26 years of age, whether or not they live at home, are married, or can be declared as dependents on your income tax return. The only exceptions are if your child has an existing job-based plan, or can get his/her own job-based coverage.

  • Any child and teen not covered by other insurance (or eligible for Medical Assistance) can enroll in the Children’s Health Insurance Plan (CHIP). CHIP provides comprehensive health care coverage to any uninsured child up to age 19, regardless of household income. While many children qualify for free CHIP coverage, households with higher incomes may have to pay monthly premiums and copays for some services.

What is a “grandfathered” plan?

On November 14, 2013, President Obama announced that states could decide whether to allow small group and individual health insurance policies existing on October 1, 2013 to be renewed for a policy year starting between January 1, 2014 and October 1, 2014.

This flexibility means that Highmark consumers had a selection of options:

  • “Grandfathered 2010” health plans. The federal law specifies conditions for Grandfathered plans that existed in March 2010. Grandfathered health plans do not have to comply with some of the provisions of the Affordable Care Act. Therefore, they cannot be sold in the Health Insurance Marketplace.

Many people did not have access to this option because their policies changed after March 2010.

  • Fully compliant new ACA plans. These plans must include all ACA features, including the 10 Essential Health Benefits. Fully compliant ACA plans are sold directly through Highmark and also through the Health Insurance Marketplace.

  • A special extension rule applies if health coverage is provided on an insured basis under a collective bargaining agreement that was in effect on March 23, 2010. Specifically, the collectively bargained plan will be required to adopt all provisions under health care reform applicable to grandfathered plans when the bargaining agreement expires or terminates. Sponsors of collectively bargained plans should consult with their benefits counsel to compare the plan in effect on March 23, 2010, with the plan in effect at termination or expiration of the collectively bargained agreement to determine whether coverage is still grandfathered.

Contact your health insurance company for more information.

What does “minimal essential coverage” mean?

Minimal essential coverage is the minimum level of benefits that must be included in a health insurance plan in order for you to be considered insured and avoid paying a tax penalty. In order to meet these standards, all qualified health plans (QHPs) must include the same Essential Health Benefits (EHBs).

For questions about your specific coverage and whether it meets minimal essential coverage standards, contact your health insurance company.

What is a Summary of Benefits and Coverage Statement (SBC) and what does it mean to me?

Health insurance issuers and group health plans are required to give you an easy-to-understand Summary of Benefits and Coverage (SBC). An SBC is made available to you when you shop for an insurance plan, and you can also request one from your health insurance company. The SBC can help you better understand, evaluate and compare your health insurance choices. The SBC also includes details called “coverage examples,” which are comparison tools that allow you to see what the plan would generally cover in two common medical situations. You have the right to receive the SBC when you shop for or enroll in coverage or if you ask for a copy from your issuer or group health plan. You may also request a copy of a glossary of terms from your health insurance company or group health plan, which explains what every term means in plain language.

Essential Health Benefits (EHBs) and New Protections

Under the Affordable Care Act, all individual, qualified health plans (QHPs) now cover a core set of 10 Essential Health Benefits (EHBs). EHBs are covered in every Highmark plan sold in the Health Insurance Marketplace.

1. Ambulatory patient services

Covers health services where an overnight hospital stay is not required, such as doctor visits to treat an injury or illness, an outpatient treatment or home health care services.

2. Emergency services

Includes coverage for emergency room services, ambulance service or treatment at an urgent care center.

3. Hospitalization

Covers an in-patient hospital stay, as determined by your doctor.

4. Maternity and newborn care

Includes coverage for prenatal and postnatal care, pregnancy complications, delivery and other health services for mothers and infants.

5. Mental health and substance use disorder services, including behavioral health treatment

Covers both inpatient (hospital) and outpatient (ambulatory) services.

6. Prescription drugs

Covers medications prescribed by your doctor.

7. Rehabilitative and habilitative services and devices

Includes coverage for physical therapy, occupational therapy, speech therapy, prosthetics and other medical equipment.

8. Laboratory services

Covers X-rays, blood tests, MRIs and other health-related tests.

9. Preventive and wellness services and chronic disease management

Includes coverage for exams, certain screenings and assistance to manage chronic conditions like diabetes. For women, this also includes FDA-approved contraceptives.

10. Pediatric services, including oral and vision care

Covers dental check-ups, routine eye doctor visits and eyeglasses for children, along with immunizations and other preventive care services.

Preventive care services.

All ACA plans cover certain preventive care services at 100% (no member copay or cost-sharing), as long as the services are through an in-network provider. Preventive services include no-cost screenings for adults (such as mammograms and colonoscopies), tobacco use treatments and more. Among preventive services for children are vaccines, autism screenings and obesity counseling. Preventive measures for women include free well-woman visits; screening for gestational diabetes; domestic violence screening; support, supplies and counseling for breastfeeding and contraception. Be sure to read your insurance plan for full details.

More young adults with insurance.

All health plans must allow young adults to remain as dependents on their parents’ health plan until they turn 26, whether or not they live at home or can be declared as dependents.

No annual or lifetime limits.

Health insurers can’t set annual or lifetime limits on coverage of Essential Health Benefits, or cancel your coverage if you get sick. This is true for plans or policy years starting January 1, 2014 or later.

Enrollment Dates

  • If you didn’t enrolled in a health insurance plan by January 31, 2017, you can only enroll in 2017 coverage if you have a qualifying life eventlike getting married or having a child, for example. . Otherwise, you will likely have to wait for the Open Enrollment Period for 2018 coverage. Open Enrollment Periods typically follow a yearly cycle.

Learn more about qualifying life events and Special Enrollment Period (SEP) opportunities at Healthcare.gov.

  • You’ll find plans from Highmark companies when you shop on the Health Insurance Marketplace. You can purchase coverage online, through local insurance agents, or by phone.

Special Enrollment Provision

  • American Indians, Alaska Natives and other members of federally recognized tribes* have special enrollment periods that allow them to get insurance outside the yearly enrollment dates.

  • Members of federally recognized tribes who enroll in a plan through the Health Insurance Marketplace still get (or keep getting) services from the Indian Health Service, tribal health programs, or urban Indian health programs.

*A Federally recognized tribe is any American Indian or Alaska Native tribe, band, nation, pueblo, village or community that the Department of the Interior acknowledges to exist as an Indian tribe.

For more information on this provision, visit www.healthcare.gov.

Qualifying Life Events:

Once you have selected individual health insurance coverage it usually stays in effect and cannot be changed until the next Open Enrollment Period. However, certain qualifying life events may make you eligible to change your health insurance plan before the next Open Enrollment Period.

Learn more about qualifying life events and Special Enrollment Period (SEP) opportunities at Healthcare.gov.

Penalties

What are the penalties if I don’t have insurance?

Most people will be required to have health insurance or will likely pay a government penalty if they don’t. Coverage may include employer-provided insurance, coverage when someone buys insurance on their own, or through government programs such as Medicaid, Medicare, CHIP and TRICARE, for example.

Certain individuals are exempt from the requirement to obtain coverage or pay the penalty, including people who would have to pay more than 8% of their income for health insurance, people with incomes below the threshold required for filing taxes, those who are members of certain religious sects, undocumented immigrants, people who are in jail or prison, and members of federally recognized tribes such as American Indians and Alaska Natives.

For the 2016 tax year, the penalty will be 2.5% of annual income or $695 per adult and $347.50 per child under 18, whichever is greater. This means that if you do not have coverage, you will be required to pay a penalty when you file your taxes at the end of the year.

For the 2017 tax year, the penalty will remain at 2.5% and the flat fee will be adjusted each year based on inflation.

Visit the Health Insurance Marketplace or more information about tax penalties for not having coverage.

How will I prove I have coverage?

You will not have to account for coverage or exemptions or make any payments until you file your federal income tax return. Insurers are required to provide everyone that they cover each year with information that will help demonstrate they had coverage in the tax year for which they are filing.

Employers and Small Business

Small Business Tax Credit

A tax credit is available to make it more affordable for small businesses and tax-exempt employers to offer health insurance to their employees. For-profit and tax-exempt employers with 25 or fewer full-time equivalent (FTE) employees can apply today for tax credits.

For tax years beginning in 2014 or later, the minimum credit is 50% of premiums paid for small business employers and 35% of premiums paid for small tax-exempt employers.

To be eligible for the credit, a small employer must pay premiums on behalf of employees enrolled in a qualified health plan offered through a Small Business Health Options Program (SHOP) Marketplace or qualify for an exception to this requirement. The credit is available to eligible employers for two consecutive taxable years.

In addition, we suggest that you consider the following IRS links in determining the credit:

http://www.taxpayeradvocate.irs.gov/calculator/SBHCTC.htm#Link-Employees

http://www.irs.gov/uac/Small-Business-Health-Care-Tax-Credit:-Questions-and-Answers

Special Notice: Effect of Sequestration on Small Business Health Care Tax Credit — Tax Exempt Employers Only

Due to sequestration, refund payments issued to certain small tax-exempt employers claiming the refundable portion of the Small Business Health Care Tax Credit under Internal Revenue Code section 45R, are subject to sequestration. This means that refund payments processed on or after Oct. 1, 2015, and on or before Sept. 30, 2016, issued to a tax-exempt taxpayer claiming the Small Business Health Care Tax Credit under section 45R will be reduced by the fiscal year 2016 sequestration rate of 6.8 percent (regardless of when the original or amended tax return was received by the IRS). The sequestration reduction rate will be applied unless and until a law is enacted that cancels or otherwise impacts affects the sequestration, at which time the sequestration reduction rate is subject to change. Sequestration only affects the refundable portion of the Small Business Health Care Tax Credit filed by tax-exempt employers. Sequestration does not impact Small Business Health Care Tax Credit claims by non-tax-exempt employers, as the credit is not a refundable credit for non-tax-exempt employers.

Affected taxpayers will be notified through correspondence that a portion of their requested payment was subject to the sequester reduction and the amount.

Other Frequently Asked Questions

What is the impact on people with low income?

Many low-income earners will have more health insurance options.

Learn about financial help and programs you may be eligible for. Check your eligibility and apply for savings on the Health Insurance Marketplace.

For more information contact the Marketplace Call Center 24 hours a day, 7 days a week: 1-800-318-2596 (TTY: 1-855-889-4325).

Does the Affordable Care Act reduce insurance premiums?

The impact of the ACA on the cost of health insurance will vary from individual to individual. Some Americans with private health insurance are likely to see higher rather than lower health insurance prices. This is because of the way the law finances coverage for more Americans.

Health care reform may reduce the personal cost of insurance for some people through Advanced Premium Tax Credits and cost-sharing reductions, but not because the increases in medical costs are being brought under control.

Who is considered a dependent under health care reform?

Under the Affordable Care Act, any dependent (adult child) of yours under the age of 26 can be covered under your health insurance plan. Your child can have coverage whether or not they are financially dependent on you, live with you, go to school, have a job or are married. The only exceptions are if your child has an existing job-based plan, or can get his/her own job-based coverage.

What is actuarial value?

In the individual and small group insurance markets, actuarial value is a way to express the average value of benefits in a health insurance plan. It shows you the percentage of benefit costs that a health insurance plan expects to pay for a standard population. Placing an average value on health plan benefits can help you compare different health plans.

What is a medical loss ratio?

The Medical Loss Ratio, or MLR, is a provision of the Affordable Care Act that generally requires insurance companies to use at least 80 cents out of every dollar in premiums they receive to pay for medical claims and activities that improve care quality.

What is a health navigator?

A navigator is someone who is qualified to furnish information about health insurance plans in the Marketplace to individuals and small employers—and to help them with enrollment. Navigators can help you find out if you are eligible for a tax credit, cost-sharing reduction or other programs, like Medicaid or CHIP. They can also help you with basic health program enrollment. The Affordable Care Act also requires navigators to have expertise working with specific populations such as low-income populations or other groups such as American Indians/Alaska Natives, people with disabilities or individuals with limited English proficiency. For more information about navigators, check out www.healthcare.gov.