10 Most-asked questions

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Q:

What is health care reform?

A:

The term “health care reform” refers to the federal Affordable Care Act (ACA), and any state laws passed to put it in place. It was designed to help more people get affordable health care coverage and better medical care.

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Q:

Can anyone get health care coverage?

A:

Only a U.S. citizen or legal resident can purchase coverage through the health benefit exchanges. If you’re a non-U.S. citizen, other coverage may be available to you outside of the exchanges. Health plan issuers can no longer deny coverage because you have a medical condition, and you don’t have to pass a medical exam to qualify for coverage.

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Q:

Do I have to buy health care coverage from the health benefit exchange?

A:

No. A health benefit exchange is just one of the ways people can shop for health care coverage. However, you can only get state or federal financial help from the government if you buy coverage through an exchange. (Exception: Residents of the District of Columbia, purchasing health care coverage on their own must buy coverage from DC Health Link.)

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Q:

Who has to buy health care coverage?

A:

Most people are required to have a basic level of health care coverage. You’re allowed to have 1 break in the year.

You can only have one break in coverage, and it must be for less than 3 months. Some people, however, don’t have to buy coverage, based on their income or other eligibility. For info about getting a waiver, go to your state’s health benefit exchange.

State or jurisdiction URL
California CoveredCA.com
Colorado connectforhealthco.com
District of Columbia dchealthlink.com
Georgia healthcare.gov
Hawaii healthcare.gov
Maryland marylandhealthconnection.gov
Oregon healthcare.gov
Virginia healthcare.gov
Washington state wahealthplanfinder.org

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Q:

When can I buy health care coverage?

A:

If you have health care coverage through your employer, you should get more details about your next enrollment period from your employer.

If you don’t have health care coverage, you can buy individual or family health care coverage directly from us or through the health benefit exchanges during the annual open enrollment period. Check with your exchange for open enrollment dates. (Exception: Residents of the District of Columbia who are purchasing health care coverage on their own must buy coverage from DC Health Link.)

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Q:

What if I can’t afford to buy health care coverage?

A:

To help you pay for coverage and/or care, you may get federal financial assistance if you're a U.S. citizen or legal resident. The amount of help is based on the size of your family, your income, and the cost of coverage in the health benefit exchanges.

You may qualify for additional state financial assistance, even if you haven't qualified for federal financial assistance in prior years.

For general income guidelines and to see if you qualify for federal financial help, visit buykp.org. You can also compare plans, calculate your rate, or apply online.

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Q:

Why should I buy health coverage?

A:

Your health coverage does more than help you stay well. It also offers you peace of mind. By having coverage, you know you’re making it easier to get the care you need – as well as avoid the stress of unexpected health expenses.

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Q:

What are the Health Benefit Exchanges?

A:

Health benefit exchanges, sometimes called marketplaces, are federally or state-run places where people can buy health care coverage. You can reach the exchanges through their websites, call centers, and physical locations. This means you can get coverage online, over the phone, or in person. You can compare and choose health plans offered by private companies, get answers to questions, and find out if you're eligible for financial assistance or special programs.

Health benefit exchanges also operate a Small Business Health Options Program (SHOP) or, in the state of California, Covered California for Small Business. Small-business employers with 1 to 50 full-time-equivalent employees (1 to 100 full-time-equivalent employees in California and Colorado) can buy coverage for their employees.

Employers with 25 or fewer full-time-equivalent employees may qualify for a tax credit, which is only good for 2 years, for coverage purchased through the SHOP or Covered California for Small Business.

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Q:

What services do the metal health plans cover?

A:

The Affordable Care Act (ACA) requires the metal health plans to cover what are called “essential health benefits”. These benefits fall within 10 broad categories of health care services.

Specific services and supplies, terms of coverage, and exclusions vary by state or jurisdiction.

Covered services include preventive care visits, immunizations, and screenings (such as mammograms and other cancer screenings). Maternity, newborn, and pediatric care are also covered, as are emergency and hospital care. Laboratory services, prescriptions, and mental health (including substance abuse) services are covered as well.

Some plans — known as grandfathered plans — aren’t required to cover all these services. See “What is a grandfathered plan?” for a description of this type of coverage.

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Q:

What is a “grandfathered” plan?

A:

Health care coverage that was in existence on or before March 23, 2010, and that meets certain requirements. Grandfathered plans aren’t legally obligated to comply with some of the requirements under the Affordable Care Act (ACA).

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Q:

Where can I find my plan information?

A:

You can review details about your plan at kp.org/plandocuments and in your current Summary of Benefits and Coverage.

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Q:

Where can I find my 1095 tax statement?

A:

If you bought your plan through the health benefit exchange, visit your exchange website to view and download your 1095-A tax statement. If you bought your plan directly through Kaiser Permanente and chose to receive your 1095 tax statements electronically, you can go online at kp.org/proofofcoverage to view and download your 1095-B or 1095-C tax statements through the link kp.org/mytaxdocs.

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