Get the coverage you deserve. Today.
Under the Affordable Care Act (sometimes called Obamacare), health insurance is more affordable than ever. AND you may be surprised to know that you may qualify even if you’ve been told differently.
Click the +/- to the right for FAQs
The Open Enrollment period for 2016 coverage runs from November 1, 2016 to January 31, 2017. If you miss Open Enrollment, keep reading to find out what to do.
You might still be able to sign up for health insurance if you have a qualifying life event. These include:
- – Losing other coverage
- – Moving to a different zip code
- – Getting married or divorced
- – Having or adopting a child
- – Turning 26 and losing your parents’ insurance
- – Gaining eligible immigration status (becoming lawfully present in the US)
- – Having a change in income (getting or losing a job, working more or fewer hours)
- – Being released from incarceration
If you have any of these situations, you must apply for insurance within 60 days or you will lose your chance.
Anyone can sign up for health insurance through the Marketplace, as long as they are lawfully present in the US.
You may qualify for financial assistance based on your income and family size.
If you already have access to insurance through your employer, qualify for Medicaid, CHIP, or Medicare, or make over 400% of the Federal Poverty Level for your family size, you can still buy a plan, but you won’t have access to cost assistance like tax credits for lower premiums or subsidies for lower out-of-pocket costs.
Getting sick or injured can happen to anyone at anytime
The average cost of an emergency room visit is $2000.
Insurance gives you free preventative care including birth control and annual check-ups at the doctor keep you healthy
If you can afford health insurance but choose not to buy it, you will have to pay a fee when you file your taxes ($695 or more per uninsured person per year)
If you have a job-based plan, you will not have to pay the penalty at the end of the year.
Children can stay on their parent’s health insurance plans until they turn 26. It does not matter if you are married, living with your parents, in school, claimed as a dependent, or eligible to enroll in your own employer’s plan.
However, your parents are not required to cover you if they do not claim you as a tax dependent. If you do not have coverage through your parents, and they do not claim you as a tax dependent, you may be eligible to buy a plan through the Marketplace with financial assistance.
Health insurance plans must cover a set of core benefits, which include:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care (both before and after birth)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
Preventative care is routine care that is recommended for people of your age and sex who are not having any symptoms, issues, or problems. Under the Affordable Care Act, most insurance companies must cover all preventative care at no cost to you. Click here for a complete list of preventative services.
For women, some common preventative services include well-woman visits and birth control, mammograms, immunizations, lab tests, screenings and other services intended to prevent illness or detect problems before you notice any symptoms.
For example, coverage of well-woman visits, which is an annual preventive care visit for adult women to obtain recommended services, can include:
- Contraception methods and counseling
- Cervical cancer screening
- Breast exam
- Human papillomavirus (HPV) testing beginning at age 30, and for every 3 years thereafter
- Sexually transmitted infections counseling
- Human immunodeficiency virus (HIV) counseling and screening
- Domestic/Intimate partner violence screening and counseling
Most health plans must cover these preventive services without cost.
Diagnostic medical care involves treating or diagnosing a problem you’re already having. This can include monitoring existing problems, checking out new symptoms, or following up on abnormal test results. If a visit or test is non-preventive or diagnostic, insurance charges such as a deductible, copay, or coinsurance will apply.
If a diagnostic service is performed during the same health care visit as a preventive service, you may have copayment and coinsurance charges. Preventative visits can also turn in to non-preventative/diagnostic visits, depending on the results of screening.
For example, many people come to Planned Parenthood for STI screenings. If you are not experiencing any symptoms, and no one has told you to get tested due to likely exposure, testing is usually considered to be a preventative care expense. On the other hand, if you have reason to believe that you have an STI when you come in for testing, it will be considered a non-preventative/diagnostic service and insurance charges will apply. In either case, if your tests come back positive for an STI, any treatments (such as prescription drugs) will be billed as non-preventative/diagnostic, since they are treating a problem that already exists.
If you have questions about what is considered preventative and what is not, call Planned Parenthood to speak to a Marketplace Assister who can help.
It can get very confusing when discussing health insurance. Here is a glossary of common health insurance words:
Affordable Care Act (ACA), also known as Obamacare – A law passed in 2010 that made many changes in how Americans get health insurance. It created a website, the Health Insurance Marketplace, as a new way to buy health insurance.
Benefits – The health care service or items, such as medicines or medical equipment your health insurance plan covers.
Catastrophic coverage – An insurance plan in the Health Insurance Marketplace that offers limited coverage for health care services. This plan is only available for adults under age 30 or adults who get a hardship waiver.
Certified Application Counselors (CACs) – People who provide free help to consumers enrolling in the Health Insurance Marketplace. CACs work at local community organizations, hospitals or health centers.
COBRA coverage – If you lose your job, you can temporarily keep your employee health insurance – but you must pay all of the monthly premiums yourself, including the share the employer used to pay.
Co-Insurance – Your share of the cost for health care services after you have paid your deductible amount each year (see “deductible”). Co-insurance is a percentage of the cost of treatment. For example, your plan may have 20% coinsurance after a $1000 deductible. If you have already met your deductible and you go for a doctor visit that costs $100, your share will be $20 and your insurance plan’s share will be the remaining $80.
Copayment – A fixed amount you may pay at time you receive a health care service – for example, you may pay $15 when you go for a doctor visit. If a service is offered with a copayment, it usually means that you will pay that flat rate whether or not you have met your plan’s deductible.
Cost sharing reductions – Money the government pays to help cover out-of-pocket health care costs for people who qualify. You must be enrolled in a Silver Plan through the Marketplace in order to get cost sharing reductions.
Deductible – The amount you must pay out of your own pocket for your covered health care services each year – for example, $1,000. Once you reach your deductible amount, your insurance plan will begin sharing the cost with you (see “co-insurance”). (An exception is preventative care, which you never have to pay for out of pocket.
Employer-sponsored insurance plan – Insurance you get through your job. Employers that offer an insurance plan pay a share of their employees’ monthly premiums.
Essential health benefits – The 10 kinds of health care services most insurance plans must now cover, including care to help prevent disease, care for children, emergency care, prescription drugs, and more.
Excluded services – Health care services that are not covered and not paid for by your insurance plan.
Explanation of Benefits (EOB) – A written explanation from your insurance company about a request for payment, or claim, they have gotten from you or your health care provider. The EOB shows how much money the insurance company paid and how much money you must pay (if any) for the covered health care service or item. The EOB is not a bill. If you owe any money, you will get a bill from your health care provider.
Federal Poverty Level (FPL) – A measurement of how much a person or family needs to earn so that they can pay for food, clothing, housing and other necessary things. The government decides what the FPL is for each year.
Health Insurance Marketplace – An online marketplace where you can buy a Qualified Health Plan (Bronze, Silver and Gold in Missouri) or Catastrophic coverage from private insurance companies.
In-Network Co-Insurance – The percent (for example, 20%) you pay for the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.
Marketplace Assisters – People who provide free help to consumers enrolling in the Health Insurance Marketplace, like CACs and Navigators.
Medicaid – A government health insurance program for Americans who have a low income or a disability. In Missouri, this program is called “MO HealthNet” for adults, and “MO HealthNet for Kids” for children up to age 19.
Medicare – A government health insurance program for Americans who are age 65 or older, certain younger people with disabilities, and people who have end-stage renal disease (kidney failure).
Navigators – People who are certified to provide free help to consumers enrolling in the Health Insurance Marketplace.
Network – The facilities, provider, and suppliers your health insurer or plan has contracted with to provide health care services.
Network providers, in-network providers – Health care providers, including doctors, hospitals and other suppliers, who contract with your insurance plan to give health care services to you at a lower cost. In-network providers are also called “preferred” providers.
Open Enrollment – A period of time when you can enroll in an insurance plan in the Marketplace. You can also change to a different plan in the Marketplace during this time. This year, Open Enrollment was from November 1, 2015 to January 31, 2016.
Out-of-network providers – Health care providers, like doctors and hospitals, who have not contracted with your insurance plan. Out-of-network providers are also called “nonpreferred” providers. If you go to these providers, your health plan may not help you pay.
Out-of-pocket costs, also known as cost sharing – Money that you pay for health care services yourself, out of your own pocket. These costs include deductibles, copayments and coinsurance. They do not include monthly premiums and may not include costs for services you get outside your provider network.
Out-of-pocket maximum – A limit on your out-of-pocket costs. After you have reached your out-of-pocket maximum for the year, your insurance company will pay 100% of your covered health care. Out-of-pocket maximum costs differ from plan to plan.
Pre-existing condition – A health problem you had before your health insurance started. Under the Affordable Care Act, insurance companies can no longer deny you coverage or charge you more based on your health history.
Premium – The monthly bill you pay for your health insurance.
Qualified Health Plan – An insurance plan that provides the 10 essential health benefits and meets other standards put forth by the Affordable Care Act. The Bronze, Silver and Gold plans sold in the Missouri Health Insurance Marketplace are qualified health plans.
Special Enrollment Period – A period of time outside of Open Enrollment when some people can enroll in an insurance plan, or change their insurance plan, in the Marketplace. In general, you may get a Special Enrollment Period when you have a qualifying life event. (See “What do I do if I missed the Open Enrollment period?” above.)
Summary of Benefits and Coverage (SBC) – A written summary that insurance companies must provide for each plan they offer. The SBC shows a plan’s covered benefits and costs.
Tax credits, advance premium tax credits – Money the government gives you to help you pay your monthly insurance premium, if you qualify.
Urgent Care – Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Each plan has different in-network providers and hospitals which can have lower costs than out-of-network providers.
A Marketplace Assister can help you find a plan that covers a doctor and hospital near your home. You can also go to your plan’s website or call the customer service number on your insurance card to find a covered provider in your area.
You can go to any Emergency Room, even if it is not in your network if you are having a true medical emergency. Your visit will be covered as an in-network visit.
However, if it is not a true emergency (for example if it is something your regular doctor could handle, but it is a weekend or after-hours), it is best to make sure you go to an In-Network hospital or urgent care center. Otherwise, you will pay the higher Out-of-Network rates.
Smokers can be charged up to 50% more for their premiums.
The Affordable Care Act requires that all plans cover smoking cessation therapy (including smoking cessation drugs) at no cost to you.
Once the open enrollment period is over you may still be able to get enrolled. If you have a life event that qualifies you for a special enrollment period you can sign up for health insurance within 60 days of that life event. (See “What do I do if I missed the Open Enrollment Period?” above.)
Insurance companies that offer plans through the Marketplace include:
- Anthem/BlueCross BlueShield
- Cigna- available in the St. Louis Metro area only
- Humana- Available in Southwest Missouri Only
You don’t have to do anything…you’re covered!
If your employer insurance costs less than 9.66% of your annual income, you will not be eligible for the financial help that makes Marketplace health insurance cheaper.
If your employer insurance costs more than 9.66% of your annual income, you will be eligible and may choose to purchase insurance through the Marketplace.
Planned Parenthood’s Marketplace Assisters will be able to help you determine your eligibility and walk you through all your coverage options.
Unfortunately, Missouri did not pass Medicaid Expansion. That means that some Missourians make too much to get insurance through Medicaid, but don’t make enough to get federal financial help to buy insurance through the Marketplace. They fall in a coverage “gap.”
If you are in this situation, you will not have to pay the penalty for going without insurance. Contact a Marketplace Assister for more information about how to file for an exemption to the penalty.
If you live in St Louis City or County, you can also apply for Gateway to Better Health, a program designed to help people in the Medicaid gap get health care.
If you are a woman you may be eligible for the Uninsured Women’s Health Program.
Planned Parenthood offers one-on-one enrollment help with certified Marketplace Assisters for no-charge. You may even qualify for financial assistance.
Schedule your appointment today.
St. Louis 314-531-7526 | Joplin 417-781-6500 | Springfield 417-883-3800
Not in St. Louis or Southwest Missouri – find enrollment help in your zip code.