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Changes to health insurance effective January 1, 2014

Consumers will see a number of major changes in plans sold or renewed on or after January 1, 2014:

  • Plans must include new consumer protections. Health insurers can no longer deny or refuse to renew coverage because of a pre-existing medical condition. They also can't charge a higher premium due to a person's gender or health condition.
  • Insurers must cover routine medical costs if a person participates in a clinical trial for cancer or other life-threatening diseases. Insurance plans also can't put annual dollar limits on essential health benefits.
  • Individuals who can afford it must have basic health insurance coverage, referred to in the ACA as "minimum essential coverage."
  • Individuals and families who need help affording coverage may have access to financial assistance when they shop in the new health insurance exchanges.

Coverage on and off the Marketplace

Individual health insurance coverage can be purchased on the Health Insurance marketplace or in the individual market. A health insurance agent may be able to help you in both.

Marketplace Coverage

Individual health insurance policies can be purchased on HealthCare.gov. The marketplace allows you to see all of the plan options available to you.

Tax credits and subsidies are available to individuals who qualify, but these are only available to you if you buy your plan from the marketplace. You cannot get these subsidies or tax credits if you buy your health insurance outside the marketplace.

All marketplace health insurance plans cover the essential health benefits outlined in federal law, and all are considered "qualified health plans." Buying a plan from the marketplace will keep you from paying the tax penalties outlined by the individual mandate.

If you need help enrolling in coverage through the marketplace, there are several different ways to get assistance.

Ask your insurance agent

Many insurance agents who are already licensed to sell health insurance are also qualified to help you enroll in a plan through the marketplace. Ask your insurance agent if he or she can help you.

Health insurance Navigators and Certified Application Counselors (CACs)

Nebraska has a group of trained individuals who are qualified to help answer your questions about the marketplace. These people have taken educational classes to understand health insurance and the marketplace, and are unbiased sources of information. For more information on Navigators, please contact Community Action Partnership of Nebraska and the Ponca Tribe.

Navigators and Certified Application Counselors have to register with the state. Find your registered Navigators and Application Counselors.

Marketplace call center

The marketplace has a dedicated call center to answer your questions and address your concerns about buying a plan online. To reach this call center, call 800-318-2596.

The Nebraska Insurance Department Consumer Assistance Hotline is always available to answer any questions you might have about your health insurance. You can reach us at: 877-564-7323.

Coverage off the Marketplace

Individual health insurance policies are still available to purchase off the Marketplace from health insurance agents and directly from health insurance companies. You are not eligible for any tax credits or subsidies when purchasing off the Marketplace.

Coverage off the Marketplace will cover all of the essential health benefits outlined in the Affordable Care Act. As long as it is not a limited benefit policy, the coverage you purchase should qualify as adequate coverage and you will not be required to pay the individual mandate penalty.

Call your insurance agent or insurance company if you have questions about your insurance coverage plan. The Nebraska Insurance Department can also help answer your questions.

Pre-existing conditions

Health insurance companies may not deny you coverage on or off the marketplace just because you have a pre-existing condition. If you have a pre-existing condition, it is important to get enrolled in coverage during the open enrollment period, which begins November 1, 2016 for coverage beginning January 1, 2017. If you do not get enrolled before open enrollment ends January 1, 2017 , you may not be able to get coverage until the next open enrollment period for 2018.

Determining how much you pay for insurance

Plans available on and off the marketplace typically have a network of providers available and set a maximum amount you will pay out of your pocket, in addition to your premium. These costs include a deductible, copayments and coinsurance. You have these responsibilities:

  • Pay your premiums - if you stop paying, your coverage will end.
  • Meet your deductible - you must pay the deductible before you insurance company begins to pay for some services other than preventive care.
  • Pay your coinsurance and copayments - you will pay these until you meet the out-of-pocket limit.
  • Meet your out-of-pocket limit - This is the maximum amount you pay for in-network service in one year.

Individual responsibility

Beginning January 1, 2014, almost all individuals must have health insurance or pay a tax penalty, with some exceptions. For the year 2016, the maximum penalty for a family is $2,085 or 2.5% of their income whichever is higher.

Cancellations of insurance policy

Insurance companies cannot cancel or rescind your health insurance policy because you made an honest mistake on your insurance application. The insurance company can still cancel your coverage if you submit false or incomplete information on purpose, or if you don't pay your premiums.

Essential health benefits

All qualified health plans must cover a list of "essential health benefits" beginning January 1, 2014. These include:

  • ambulatory services
  • emergency services
  • hospitalization
  • maternity and newborn care
  • mental health and substance use disorder services, including behavioral health treatment
  • prescription drugs
  • rehabilitative and habilitative services and devices
  • laboratory services
  • preventive and wellness services and chronic disease management
  • pediatric services, including dental and vision care

Any health insurance plan purchased on or off the Health Insurance Marketplace will cover the items listed above.

Grandfathered health plans

Any individual health policy purchased on or before March 23, 2010, may be considered "grandfathered." Grandfathered plans are health insurance plans that are exempt from certain changes required under the Affordable Care Act. Plans lose this "grandfathered" status if the policy makes significant changes that reduce benefits or increase cost to consumers. A health plan must disclose to its policyholders if it considers itself to be "grandfathered."

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