Individual (Non-Group) FAQs

Due to the complexity of the law that may require very fact-specific analysis, this material is not intended to be legal, accounting, or other professional advice, and is provided only as general information. Last reviewed: Oct. 6, 2015.

Frequently Asked Questions:

What are the deadlines to apply and enroll in private health coverage for 2016? Open enrollment starts November 1, 2015, and ends January 31, 2016.

What if I need my coverage to start on January 1, 2016? You must apply and enroll in a health plan  between November 1 and December 15, 2015, for coverage to start on January 1, 2016. If you miss that deadline, you should still apply as soon as possible. Your coverage will start in February or March, depending on when you apply. The end of open enrollment is January 31, 2016. You cannot apply and enroll after that time.

Enroll between 11/1/15 – 12/15/15 Enroll between 12/16/15 – 1/15/16 Enroll between 1/16/16 – 1/31/16
 Coverage is effective 1/1/16 Coverage is effective 2/1/16  Coverage is effective 3/1/16

What is open enrollment?
If you don’t have health coverage, open enrollment is the only time of year you can apply for tax credits and subsidies, switch plans, or enroll in a qualified health plan. If you already have coverage through your job (and expect you will still have this coverage next year) or you have coverage through Medicare, Medicaid or Children’s Health Insurance Program (CHIP) then this open enrollment period doesn’t apply to you. Other health insurance types like employer coverage and Medicare have their own open enrollment periods. Medicaid and the CHIP, which are programs for low-income individuals and families do not have a limited enrollment period. You can apply any time and don’t need to renew your coverage until you receive a renewal letter.

I enrolled through HawaiiHealthConnector.com last year and have a local plan. What do I need to do to continue my coverage?

Everyone who has coverage through the Connector today will have to reenroll. Hawaii Health Connector cannot transfer its clients’ identifying information to HealthCare.gov because of strict security protocols. When you reenroll your identity will be verified through the account you create at HealthCare.gov. Please make sure to enroll as soon as possible between November 1 and December 15, 2015, to ensure there is no gap in coverage.

I have coverage through my employer. Does ACA open enrollment affect me? No. The ACA open enrollment period is only for people who are seeking individual (non-group) health insurance coverage.

My employer-provided health insurance doesn’t cover my family, so they don’t have health insurance. Can I get coverage for them through ACA open enrollment? Yes, people who don’t have health insurance may purchase coverage through HealthCare.gov or the federal Marketplace Call Center at 1-800-318-2596.

I am currently receiving benefits through Medicaid. Do I have to reenroll through the Marketplace? No. You do not have to reenroll in your Medicaid benefits. This open enrollment period does not affect you. Medicaid has an annual opportunity for you to change your plan if you choose in October. You will receive a packet in the mail telling you what to do.

I am not sure if I qualify for Medicaid. Where should I start? If you aren’t sure, you can start at MyBenefits.Hawaii.gov. If you fill out an application there but don’t qualify for QUEST Integration / Medicaid, the Department of Human Services will send your application to HealthCare.gov. They will contact you to let you know how to apply for private coverage and receive any tax credits you qualify for.

Who can use HealthCare.gov as part of Hawai‘i’s state-supported marketplace? Starting November 1, 2015, lawfully present Hawai‘i residents buying health insurance for themselves or their families can purchase coverage through HealthCare.gov. If you receive health coverage through your job, but your family isn’t covered, you can also purchase coverage for your family through the marketplace.

What kind of help is available to lower the cost of health coverage? Individuals and families seeking health coverage may be eligible for help with paying for coverage based on income and family size.

How do I get help to apply? Starting November 1, 2015, you can call the federal Marketplace Call Center at 1-800-318-2596, 24 hours a day, 7 days a week, or meet with a certified Connector Kōkua in your neighborhood. Here are all the contact details.

I heard that Hawai‘i residents can set up an account early at HealthCare.gov. Should I do that? Applying and enrolling for 2016 coverage can be done after November 1, 2015. Some people may want to start early and set up an account and go through the identification verification process. If you decide to set up an account early, don’t forget to note your user ID and password because you will need them in order to come back and apply and shop between November 1, 2015, and January 31, 2016.

What happens if I don’t get coverage?

  • If you do not have the Minimum Essential Coverage and do not qualify for an exemption from the purchase mandate, you must pay a penalty to the IRS.  The penalty for the first year is up to $95/adult and $47.50/child, or 1% of the family income, whichever is greater.
  • The penalty will increase over time and in 2016 will be as much as $695/adult, and $347/child (up to $2,085 for a family) or 2.5% of family income, whichever is greater.
  • The amount you will owe in penalties will be pro-rated to reflect the number of months you were without coverage.

What is the individual mandate?

  • The individual mandate is a provision of the ACA that requires you, your children and anyone else that you claim as a dependent on your taxes to obtain an acceptable level of health insurance (“Minimum Essential Coverage”) in 2014 and thereafter.  Some exemptions may apply.  Beginning in 2014, if a person does not obtain a policy with Minimum Essential Coverage and is not eligible for an exemption, the person must pay a penalty.
  • Generally, Minimum Essential Coverage means coverage including:
    • Government-sponsored plans (e.g., Medicare Part A, Medicaid, Children’s Health Insurance Program, TRICARE, certain Veterans programs, Peace Corp program, Nonappropriated Fund Health Benefits Program)
    • Eligible Employer-sponsored plans
    • Eligible Individual plans
    • Grandfathered health plans
    • Transitional Grandmothered health plans that existed Oct. 1, 2013
    • Other coverage that qualifies as Minimum Essential Coverage
  • Some exemptions may apply including:
    • Members of recognized religious sects
    • Members of health care sharing ministries
    • Exempt noncitizens (e.g., a lawful “nonresident alien” for tax purposes; anyone not lawfully present in the U.S.)
    • Incarcerated persons
    • Individuals with no affordable coverage

IRS provides more information on how to report or apply for exemptions as well as how to demonstrate compliance with Minimum Essential Coverage on their website at http://www.irs.gov/Affordable-Care-Act.

What is catastrophic coverage and does it satisfy the Individual Mandate requirement?

  • Catastrophic coverage does not satisfy Individual Mandate requirements. Catastrophic coverage may be better than nothing since it can minimize risk to individuals hit by serious illness or injury of going bankrupt as a result of no coverage.
  • Typically, catastrophic coverage offers lower monthly premiums so it may be more affordable, but result in higher out of pocket payments for services used (but this is not always the case).

What is a health insurance marketplace?

  • A marketplace is an entity created by ACA to help individuals and small businesses purchase health insurance coverage.
  • The State of Hawaii has a state-based marketplace that partners with the federal online marketplace HealthCare.gov to offer local health plans to Hawai‘i residents.
  • Through HealthCare.gov those who qualify will receive premium assistance tax credits.

Am I required to purchase through Healthcare.gov?

  • No, you can go directly to your health plan. But if you qualify for tax credits or premium assistance, you can get those only through HealthCare.gov.

How much will the plans cost and how much assistance can I get?

  • The amount that you will pay for a health plan depends on the plan you choose and the amount that you may be able to receive for federal premium assistance.
  • All small group and individual plans under ACA will have different levels of cost-sharing; these are called ‘metal levels’ and range from low to high as bronze, silver, gold and platinum.
  • All health plans sold “through” the HealthCare.gov must also be offered “off” the marketplace with the same benefits at the same price.
  • The difference between the metal levels is based on how much of the medical costs your health plan will pick up and how much you pay through copays and coinsurance. For example:

Metal Level
Plan Pays
You Pay

Platinum
90%
10%

Gold
80%
20%

Silver
70%
30%

Bronze
60%
40%

  • Out-of-pocket costs, such as deductibles and copays, are subject to a maximum limit on out-of-pocket expenses.
  • Your cost-sharing burden will differ depending on what plan is selected and income.
  • For individuals and families with qualifying incomes, tax credits may be available to reduce premiums and cost-sharing for plans purchased through the marketplace.

I have been denied coverage because I have a pre-existing condition. What will the ACA do for me?

  • Since 2014, insurers are be prohibited from discriminating against adults with pre-existing conditions in selling or pricing health insurance policies. This has been the case for children since 2010.

What are the Essential Health Benefits and what do they provide?

  • Health plans sold in the individual and small group markets must be qualified and certified to cover ten benefit categories called Essential Health Benefits (EHBs).
  • EHBs are not required for qualifying “transitional” plans (also called “grandmothered” plans).
  • The ten EHB categories of services are listed below:
  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care (for children up to 19 years of age).

The EHBs must also:

  • Comply with Mental Health Parity and Addiction Equity Act of 2008
  • Balance comprehensiveness and affordability for those purchasing coverage
  • Starting with plan years or policy years that began on or after September 23, 2010, health plans can no longer impose a lifetime dollar limit on spending for these services.

I am eligible for Medicaid – do I have to go on a Medicaid plan?

You may always refuse coverage of a Medicaid plan and purchase a commercially available plan. However, if you refuse Medicaid coverage, you will not be eligible for federally funded premium assistance programs.