Affordable Care Act Q&A with the Centers for Medicare and Medicaid Services

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Just two weeks remain until the opening of enrollment in the health insurance exchanges, a key component of the Affordable Care Act.

Much misinformation and confusion has accompanied the run-up to the Oct. 1 start of open enrollment in the exchange, also called a marketplace.

To help readers understand this new coverage option, Georgia Health News asked the Centers for Medicare and Medicaid Services for a list of frequently asked questions about the health insurance exchanges.

Here is the agency’s list of FAQs – and their answers.


How much will plans cost me in the insurance exchange or marketplace? Where can I go to find this information?

Prices will be available Oct. 1, when open enrollment starts and you can begin shopping. In the meantime, visit for the latest information about the health insurance marketplace.

Coverage for the new health plans will start Jan. 1.

What is the enrollment period each year if I miss the first one in 2013?

The initial open enrollment period ends March 31, 2014. After that, annual enrollment will begin again in October 2014.

Outside of open enrollment, you can’t enroll in marketplace coverage unless you have a “qualifying life event.’’ Those include moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby).

What is the cancellation policy if I miss a premium payment for an exchange or marketplace plan?

For consumers who are not eligible for a premium tax credit or subsidy, the cancellation policy follows state law from the Department of Insurance.

For consumers eligible for the credit or subsidy, there is a three-month grace period. If after three months, the premium amount owed is not paid in full (less the advanced premium tax credit if applicable), the coverage will be canceled. A person does not technically have coverage until the first month’s premium has been received.

What is the difference between a Silver plan, a Gold plan and a Platinum plan?

All private health insurance plans offered in the marketplace will offer the same set of “essential health benefits.’’ These are services all plans must cover.

Plans in the exchange or marketplace are primarily separated into four health plan categories — Bronze, Silver, Gold, or Platinum. These levels are based on the percentage the plan pays of the average overall cost of providing essential health benefits to members.

The plan category you choose affects the total amount you’ll likely spend for essential health benefits during the year. The percentages the plans will spend, on average, are 60 percent (Bronze), 70 percent (Silver), 80 percent (Gold), and 90 percent (Platinum). This isn’t the same as co-insurance, in which you pay a specific percentage of the cost of a specific service.

With a Bronze plan, you’ll likely pay a lower premium, but you’ll pay a higher share of costs when you get care. At the other end of the spectrum are Platinum plans, which will likely have the highest monthly premiums and lowest out-of-pocket costs.

Can you give me more information about preventive services for my children who will be covered by an exchange or marketplace plan?

Most health plans must cover a set of preventive health services for children at no cost when delivered by an in-network provider. This includes marketplace and Medicaid coverage.

All marketplace or exchange health plans and many other plans must cover a list of preventive services for children without charging you a co-pay or co-insurance. This is true even if you haven’t met your yearly deductible.

Those services include:

* Autism screening for children at 18 and 24 months

* Behavioral assessments for children at several ages

* Blood pressure screening for children at several ages

* Depression screening for adolescents

* Developmental screening for adolescents

* Hearing screening for all newborns

* Height, weight and BMI measurements

* Immunization vaccines for children from birth to age 18

* Obesity screening and counseling

* Sexually transmitted infection prevention and screening for adolescents at higher risk

* Vision screening

What are the eligibility requirements related to citizenship status? 

Most people will be eligible for health coverage through the health insurance marketplace.

To be eligible, you  must live in the U.S., must be a U.S. citizen or national (or be lawfully present), and can’t be currently incarcerated.

U.S. citizens living in a foreign country are not required to get health insurance coverage under the Affordable Care Act.

Generally, health insurance coverage in the marketplace covers health care provided by doctors, hospitals, and medical services within the U.S. If you’re living abroad, it’s important to know this before you consider buying marketplace insurance.

Questions? Call 1-800-318-2596, 24 hours a day, 7 days a week.

How can I find an affordable plan that will cover me if I have had breast cancer? 

Starting in 2014, health insurance plans can’t refuse to cover you or charge you more just because you have a pre-existing health condition.

Once you have insurance, the plan can’t refuse to cover treatment for pre-existing conditions. Coverage for your health conditions begins immediately. This is true even if you have been turned down or refused coverage due to a pre-existing condition in the past.

The only exception is for “grandfathered” individual health insurance plans — the kind you buy yourself, not through an employer. They do not have to cover pre-existing conditions. If you have one of these plans, you can switch to a marketplace plan during open enrollment and immediately get coverage for your pre-existing conditions.

Can you tell me if I am eligible for extra help paying my premiums?

When you use the health insurance marketplace, you may be able to get lower costs on monthly premiums or out-of-pocket costs, or get free or low-cost coverage.

You can save money in the exchange three ways. All of them depend on your income and family size.

  • You may be able to lower your costs on your monthly premiums.
  • You may qualify for lower out-of-pocket costs for co-pays, co-insurance and deductibles.
  • You or your child may get free or low-cost coverage through Medicaid or the Children’s Health Insurance Program, called PeachCare in Georgia.

Until Oct. 1, you can get a rough estimate of your potential costs and savings by using the Kaiser Family Foundation calculator.

Questions? Call 1-800-318-2596, 24 hours a day, 7 days a week.

How do I become an agent/broker? 

Contact the state Department of Insurance to discuss the requirements for becoming a licensed agent/broker.

How do I become a “certified application counselor”?

You can apply to become a certified application counselor organization by visiting

For more from Georgia Health News, go to

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deestafford 09/17/13 - 07:13 pm
This albatross has destroyed the best health care system

in the world. It was not done to improve health care but for the leftist statists to gain power over the people.

Nobody has a full understanding of how bad this thing will be. Any law that is 2200 pages long and current implementing instructions are eight times longer than the Bible and there are more to come.

Politicians and not medical personnel put this monstrosity together and it show.

Bodhisattva 09/18/13 - 03:57 am
We sure wouldn't want

We sure wouldn't want everyone to have access to affordable healthcare, especially if we use a plan based on one by that leftist Heritage Foundation. Strange, how in New York, were they are working with the law and helping their people with it, rate for private insurance that have qualified for the exchange have decreased 50%, but in Georgia, where Nathan Deal's PAC, Real PAC has gotten $1 million pouring in from the health care and insurance industry, and our Insurance Commissioner, Ralph Hudgens (whose whole campaign is pretty much funded by the same), who have laughed and joked about screwing the citizens of Georgia over to try to gum up the work on the Affordable Care Act on purpose, our rates in the exchange have gone up. Oh, it will work fine. If it doesn't in the states of the Old Confederacy, you can blame your elected GOP leaders who are deliberately making it difficult for you.

carcraft 09/19/13 - 12:49 pm
Keep repeating the liberal

Keep repeating the liberal lies Bod, it must be fun to wear the rose colored glasses every day. Fact of the matter is that when the debacle called the AFORDABLE CARE ACT started there were about 30 million uninsured. Due to Obama's economy we now have about 48 million uninsured. When the AFFORDABLE CARE ACT is fully implemented we will have about 30 million uninsured according to the CONGRESSIONAL BUDGET OFFICE. The trade off for having the 18 mllion (who aren't insured under Obama's economy) is higher premiums with reduced benefits and employers hiring fewer people and those that are hiring are hiring part time. Those who can least afford it , the newly employed, the young and those who are just starting families etc, are going to have foot the bill for the elderly. Yep it is just those evil republicans fault!!!! Keep on dreaming!!!

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