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FAQs & Resources

New health rules have taken effect. It is likely that you will be responsible for getting health coverage for yourself and your family, but you may also be able to get financial help from the federal government that could make coverage more affordable.

Below are common questions about the new health coverage options available in Illinois to help you make the best decision for you and your family.

1. How do I get health insurance?

If you live in Illinois, you can answer a few questions on this site to get to the right place to find the coverage that you need.

You can also talk to someone near you about your coverage options for free. There are people available to meet face-to-face or over the phone. You can start here to find:

  • Navigators: Specially trained counselors that are available to help answer your questions and find coverage for you or your family. You can click here to find a Navigator or call (866) 311-1119.
  • Agents or Brokers: Licensed professionals who are registered with the Marketplace and can help recommend specific health insurance plans for your family. Click here to go to the National Association of Health Underwriters (NAHU) website to search for an agent or broker near you.

 

2. Where will my health coverage come from?

Depending on your income and household size, this site will either guide you to the Health Insurance Marketplace or the online application for Medicaid. Both provide comprehensive health coverage that covers a similar set of benefits.

Click here to answer a few questions and find the right place to get coverage for you and your family.

3. What if I already have Medicaid? Some people call this medical assistance, medical card, All Kids, or public aid.

If you have Medicaid, you are already covered. You do not have to buy more health coverage.

4. What if I already have Medicare?

If you have Medicare, you are already covered. You do not have to buy more health coverage, and a Marketplace plan is not appropriate for you. There is one exception to this rule: If you are offered Medicare coverage, but you are responsible for paying a premium for Medicare Part A, you may be eligible to purchase a Marketplace plan with financial help if you choose not to enroll in Medicare. For more information on who is required to pay a premium for Medicare Part A, see Medicare Part A Costs.

The Marketplace does not sell Part D prescription drug plans, Medicare Advantage plans or Medigap coverage. If you have questions about your Medicare coverage or are looking for supplemental coverage for Medicare, please visit www.Medicare.gov, call 1-800-MEDICARE, or contact the Illinois Senior Health Insurance Program (SHIP) at (800) 548-9034.

Additionally, the Illinois Department of Healthcare and Family Services is a useful resource for frequently asked questions about how Medicare works with Medicaid.

There are a few things that are important for Medicare beneficiaries, or soon-to-be Medicare beneficiaries, to be aware of:

  • The Affordable Care Act has expanded preventive and wellness benefits to millions of people, including those on Medicare. These include yearly “Wellness” visits and coverage for many preventive tests and services – without paying a dollar out-of-pocket;
  • The ACA has also helped save money for Medicare beneficiaries in the prescription drug coverage gap (“donut hole”) with big discounts on covered generic and brand-name drugs;
  • Medicare’s Blue Button has been expanded to give you a better picture of your overall health by providing you with better access to your Medicare claims and personal health information; and
  • Medicare beneficiaries may not be sold duplicative coverage. This means that if a person is on Medicare, it is illegal for an insurance carrier to sell a Marketplace plan to him or her.

 

5. What if I already have insurance through my job?

If you have coverage from your job, you are covered. You do not need to buy more health insurance.  However, if your job offers you health insurance that is not affordable or good coverage, you may be eligible for financial help to purchase insurance on the Marketplace.

6. If I need help finding the right health insurance, who can I talk to?

You can talk to someone near you for free about your coverage options. There are people available to meet face-to-face or over the phone. You can start here to find:

  • Navigators: Specially trained counselors that are available to help answer your questions and find coverage for you or your family. You can click here to find a Navigator or call (866) 311-1119.
  • Agents or Brokers: Licensed professionals who are registered with the Marketplace and can help recommend specific health insurance plans for your family. Click here to go to the National Association of Health Underwriters (NAHU) website to search for an agent or broker near you.

 

7. What is the Health Insurance Marketplace?

The Health Insurance Marketplace is an online shopping website where you can compare your insurance options side-by-side. You may also qualify for financial help from the federal government to make coverage more affordable.

If you live in Illinois and need insurance, click here to answer a few questions on this site to get to the right place to find the coverage you need.

8. When can I shop for health insurance through the Health Insurance Marketplace?

If you are an Illinois resident and need insurance, the Marketplace will have the next Open Enrollment Period from November 15, 2014 through February 15, 2015. Anyone can enroll during the Open Enrollment Period, but you may be able to enroll sooner through a Special Enrollment Period.

A Special Enrollment Period is a time outside of the Open Enrollment Period when you and your family have a right to sign up for health coverage. You can qualify for a special enrollment period of 60 days following certain life events.

These life events are called Qualifying Life Events and include moving to a new state, certain changes in your income, and changes in your family size. Click here to explore your coverage options if you believe you have experienced a Qualifying Life Event and may be eligible for a Special Enrollment Period. Special Enrollment Periods can give you up to 60 days to enroll in a Marketplace plan.

You can also talk to a trained counselor, called a Navigator, face-to-face about your options for free. Click here to find a Navigator in your community or call the Get Covered Illinois Help Desk at (866)311-1119 on Monday - Saturday from 8 a.m. to 8 p.m.

9. If I buy health insurance through the Marketplace, when does coverage begin?

Your coverage start date depends on when you buy your health insurance plan, or enroll in coverage. You can buy insurance through the Health Insurance Marketplace during the next Open Enrollment Period, starting in November, 2014. If you enroll through the Marketplace in November when the next Open Enrollment Period starts, your coverage will start on January 1, 2015.

You may be able to buy health insurance through the Marketplace now through a Special Enrollment Period if you experience a Qualifying Life Event, like getting married, having a baby, losing employer coverage, moving, or more. These life changes give you a Special Enrollment Period and give you up to 60 days to enroll in a Marketplace plan.

Your coverage start date will depend on your Special Enrollment Period:

Reason for Special Enrollment Plan Selection Date Effective Date of New Coverage
  • Move to a new state
  • Release from incarceration
  • Gaining immigration status as 'lawfully present'
  • Gain status as Indian
Between the 1st and 15th day of the month

Example: between April 1 and April 15

First day of the following month

Example: May 1 for example scenario

Between the 16th and the last day of the month

Example: between April 16 and April 30

First day of the second following month

Example: June 1 for example scenario

  • Gaining a dependent through Marriage
Any day of the month

Example: Any day in April

First day of the following month after you select a plan

Example: may 1 is you choose a plan in April

  • Future loss of minimum essential coverage you can anticipate up to 60 days in the future
Any day of the month First day of the month following the date of the loss of minimum essential coverage
  • Birth
  • Adoption
  • Place of adoption or foster care
Any day of the month Day the child was born, adopted or placed for adoption or foster care

Examples in this chart are for April 2014. But, your date will depend when you experience a qualifying life event.

If you are going to lose coverage, you may be able to enroll up to 60 days before you lose coverage to prevent a coverage gap.

10. How much will health insurance on the Marketplace cost?

There are a few things that will affect the cost of insurance for you, including your:

  • Age
  • Household size
  • Where you live
  • Tobacco use
  • Type of insurance plan that you buy

You may also be eligible to apply for a discount on monthly insurance costs based on your income.

11. What types of information will I need to get health insurance through the Health Insurance Marketplace?

To buy health insurance through the Marketplace and find out if you can receive financial help, it would be helpful to know your: 

  • Social Security number
  • Employer and income information
  • Tax information

Examples of documents that have this information include a social security card, paystubs, W-2 forms and other tax forms.

12. What if I can’t afford to pay for insurance and health care costs?

If you use the Health Insurance Marketplace to buy health insurance, you can apply for a break on monthly insurance costs and other health services. Financial help from the federal government may be available for people who make up to $45,960 as an individual and $94,200 as a family of four.

If you qualify for Medicaid, you will likely only have to pay a small amount for your health care and medical services, including when you get sick or go to the doctor.

Click here to answer a few questions on this site, which will get you to the right place to see your options for health coverage. You can apply for Medicaid all year. And if you’ve had a “qualifying life event,” which is a change in your situation, you may be able to enroll in a Marketplace plan through a Special Enrollment Period.

13. What health benefits are covered under Health Insurance Marketplace insurance plans?

By law, every insurance plan on the Marketplace will cover services called Essential Health Benefits. These include:

  • Outpatient services, like services or tests done at a medical center or doctor’s office that do not require you to stay overnight.
  • Emergency services, like medical care given to treat a sudden or unexpected illness in an emergency to keep you from getting worse.
  • Hospitalization, like services, tests or surgery that require you to stay the night in the hospital.
  • Maternity and newborn care, like services during pregnancy and after your baby is delivered, including breastfeeding.
  • Mental health and substance use disorder services, like services that improve your mental well-being or treat a mental illness or substance use problem. 
  • Prescription drugs, like medicines that require a prescription from your doctor. 
  • Habilitative and Rehabilitative services, like physical therapy, which helps you recover skills that you lost because you were hurt or disabled, or helps you develop and maintain the skills you need.
  • Laboratory services, like tests you take to diagnose an illness or problem.
  • Preventative and wellness services and chronic disease management like check-ups and screenings to help you stay healthy, and services to improve your quality of life by preventing or lowering the effect of a disease. This includes monitoring and educating you about your treatment. 
  • Pediatric care, including dental and vision care for children.

Dental coverage for adults will also be available through the Health Insurance Marketplace at an additional cost.

14. What if I have a pre-existing health condition?

You will be able to get insurance through the Marketplace. Beginning 2014, adults cannot be denied insurance, or charged more for current or past health issues. This protection is already in place today for children.

15. What kind of health insurance can I buy through the Marketplace?

The Marketplace will offer private health insurance plans that will be very similar to plans offered by employers and directly by private insurance companies.

In many cases, you can buy the same health insurance plans on or off the Marketplace, but the Marketplace may also offer financial help provided by the federal government to help make coverage more affordable.

16. How do I know if I qualify for Medicaid?

Click here to answer a few questions on this site to get to the right place to find the coverage that you need.

17. When and where can I apply for Medicaid?

You can answer a few questions on this site which will help determine if you should apply for Medicaid. If so, you will be guided to the online application.

You can apply for Medicaid anytime of the year. Medicaid does not have an Open Enrollment Period or Special Enrollment Periods like the Health Insurance Marketplace.

You can also talk to someone face-to-face for free about your options. Specially trained counselors called Navigators are available near you to meet with you, answer your questions and help you find coverage. Click here to find a Navigator, or call the Help Desk at (866) 311-1119.

18. Can I choose between Medicaid and the Marketplace?

You can only get financial help from one place. Your income will determine which option you qualify for.

Click here to answer a few questions on this site to get to the right place to find the coverage that you need.

 

19. What information will help me apply for Medicaid?

You will need to know information like:

  • Full names and date of birth for each family member applying
  • Information about your family’s income
  • Social Security number for each family member applying, if they have one

The more complete the information is, the faster your application can be processed. If you don’t have this information, it’s okay. Submit your application anyway. A case worker will contact you to get any more information needed.

You can also talk to someone face-to-face for free about your options. Specially trained counselors called Navigators are available near you to meet with you, answer your questions and help you apply for Medicaid. Click here to find a Navigator, or call (866) 311-1119.

 

20. When does my coverage start if I qualify for Medicaid?

Your coverage start date for Medicaid depends on when you apply and which Medicaid program you qualify for. In many cases, Medicaid is able to cover unpaid medical bills back to the date of your application, or even three months before that if they are for Medicaid-covered services provided by a Medicaid provider. This does not apply to some children in higher income groups. Also, some adults without dependent children are only eligible for coverage back to January 1, 2014. Medicaid cannot reimburse you for bills you paid to a provider or pharmacy.

You can also talk to someone face-to-face for free about your options. Specially trained counselors called Navigators are available near you to meet with you, answer your questions and help you find coverage. Click here to find a Navigator, or call the Help Desk at (866) 311-1119.

21. What health benefits are covered by Medicaid?

If you have Medicaid—also known as medical assistance, medical card, All Kids or public aid—you are covered for similar services as other private insurance plans, including: 

  • Hospital Inpatient Services - health care that requires overnight stays in a hospital.
  • Outpatient Services - treatment or tests provided in a clinic.
  • Emergency services - medical care to treat a sudden and severe illness or injury.
  • Maternity and newborn care - health care for pregnant women and their infants.
  • Medical Equipment and Supplies - items needed to manage a medical condition.
  • Mental health and substance abuse treatment - services to treat a mental illness or substance use problem.
  • Physician Services - doctor visits.
  • Prescription drugs - medicine that requires a doctor's prescription.
  • Rehabilitation - services like physical, occupational or speech therapy to help a person recover from injury or illness.
  • Family Planning - birth control and other reproductive health care services.
  • Lab and X-Ray Services - tests to diagnose an illness or problem.
  • Vision Care - eye exams and eyeglasses.
  • Pediatric care - regular check-ups and immunizations for children.
  • Dental Care for children - regular check-ups, dental sealants and other treatment for children.
  • Emergency Dental Care for adults - limited dental care for adults to treat emergency conditions.
22. How do new health care rules affect people on Medicare?

The biggest change you will notice is better coverage for prescription medicines. You will receive the same services you have always received. You do not need to buy additional coverage.

23. Am I required to have health insurance?

Yes. Beginning in January, 2014 almost everyone will be required to have health insurance. If you are not covered, you may have to pay a penalty when you file your 2014 taxes.

How do I avoid a penalty?

If you answer a few questions on this site, you will be able to get to the right place to get coverage and avoid paying a penalty. If you missed the Open Enrollment Period, you still may be able to enroll in coverage. Click here to explore your coverage options.

Your answers will help determine if you qualify for Medicaid or if you should buy insurance through the Health Insurance Marketplace. Both will provide comprehensive coverage.

You also will not have to pay a penalty if you already have quality health coverage. You may already be covered if you get insurance through your job, have insurance directly from an insurance company or are currently a part of a government program including Medicaid, All Kids, Medicare or a Veterans Affairs (VA) health care program.

24. Is there a penalty if I do not have insurance in 2014?

Yes, almost everyone is required to have health insurance under the new health care law. If you are not covered, you may have to pay a penalty when you file your 2014 taxes for the months that you did not have coverage.

The penalty in 2014 is calculated one of two ways. You’ll pay whichever of these amounts is higher:

  • 1% of your yearly household income above the tax filing threshold.
  • $95 per person for the year ($47.50 per child under 18). The maxiumum penalty per family using this method is $285.

If you’re uninsured for just part of the year, 1/12 of the yearly penalty applies to each month you’re uninsured. If you’re uninsured for less than 3 months, you don’t have to make a payment.

How do I avoid a penalty?

If you answer a few questions on this site, you will be able to get to the right place to get coverage and avoid paying a penalty. If you missed the open enrollment deadline, you may still be able to get some type of coverage. Click here to explore your coverage options.

Your answers will help determine if you qualify for Medicaid or if you should buy insurance through the Health Insurance Marketplace. Both will provide comprehensive coverage.

You also will not have to pay a penalty if you already have health coverage. You may already be covered if you get insurance through your job, have insurance directly from an insurance company or are currently a part of a public program including Medicaid, All Kids, Medicare or a Veterans Affairs (VA) health care program.

You also may not have to pay the penalty if you qualify for an exemption or if you are below the tax filing threshold.

25. Are there people who will not have to pay a penalty for not having health insurance?

Yes. The penalty may not apply to you if:

  • You are a member of a recognized health care sharing ministry
  • You are in jail or prison
  • You are an undocumented immigrant
  • You are part of a federally recognized religion that prevents you from accepting insurance benefits, such as the Amish church
  • You are a member of a recognized American Indian tribe
  • Your income is below the federal income tax filing threshold. In 2012 this was:
    • Annual income below $9,750 for an individual under age 65
    • $19,500 for a married couple filing jointly with both people under age 65
  • You do not have access to affordable health insurance. This means:
    • Health insurance would cost more than 8 percent of your income.

Resources

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Choosing the right health insurance plan for your employees can be confusing. Below are common questions about the new health insurance options available through the Illinois Small Business Health Options Program (SHOP) Marketplace.

1. What is the Small Business Health Options Program? This is also known as the SHOP Marketplace.

The Small Business Health Options Program, or SHOP Marketplace, is a section of a new health insurance shopping website called the Health Insurance Marketplace. The SHOP Marketplace is specifically built for small business owners and nonprofit organizations to easily find and provide health insurance for employees.

On the SHOP Marketplace, small business owners and leaders of nonprofit organizations can compare plans side-by-side and learn how to buy health insurance for their employees.

If you are a small business owner or leader of a nonprofit organization, you may also qualify for a federal tax credit when you buy insurance through the SHOP Marketplace. This is called the Small Business Health Care Tax Credit. It can help you pay up to half of your employees’ premiums, which is the amount that insurance costs each month.

Click here to use the SHOP Marketplace and start viewing your employee coverage options.

2. Do all of my employees have to accept health insurance if I offer it?

No, only 70 percent of your full-time employees have to take the health insurance you offer in order to use the SHOP Marketplace. This is called a Minimum Participation Requirement.

  • Employees with coverage through another employer plan, Medicare, Medicaid, the military, or veterans' programs are not included in the calculation.
  • Employees with individual non-group private coverage are included in the calculation.

This rule does not apply from November 15 to December 15 each year. From November 15 to December 15 each year, there will be no minimum participation requirement on the SHOP Marketplace.This means that you will not lose the ability to buy coverage through the SHOP Marketplace if you do not have a certain number of employees accept the insurance you offer.

3. What are the benefits of offering employees health insurance through the SHOP Marketplace?

Financial Help to Provide Insurance for Employees

If you buy employee health insurance through the SHOP Marketplace, you may qualify for a federal tax credit that could pay for up to half of employee premium costs. This is the monthly cost of insurance paid by the employer.

Easy to Navigate and Use

The SHOP Marketplace helps you easily compare coverage and costs side-by-side.

You can talk to someone near you for free about your employee coverage options. There are people available to meet face-to-face or over the phone. You can start here to find:

  • Navigators: Specially trained counselors that are available to help answer your questions and find coverage for your business. You can click here to find a Navigator or call (866) 311-1119.
  • Agent or Broker: Licensed professionals who are registered with the Marketplace and can help recommend specific health insurance plans for your business. If you currently use an agent or broker, be sure to ask them if they are registered. Click here to find an Agent or Broker near you.

Employee Productivity and Motivation

Offering health insurance helps you attract and keep quality employees who might otherwise work for one of your competitors that offer health insurance. Having access to quality health care helps workers stay healthier and more productive on the job.

4. What if only a small amount of my employees want coverage?

You cannot buy employee health insurance through the SHOP Marketplace unless 70 percent of your full-time employees accept the plan that you offer. This is called a minimum participation requirement.

  • Employees with coverage through another employer plan, Medicare, Medicaid, the military, or veterans' programs are not included in the calculation.
  • Employees with individual non-group private coverage are included in the calculation.

This rule does not apply from November 15 to December 15 each year. From November 15 to December 15 each year, there will be no minimum participation requirement on the SHOP Marketplace. This means that you will not lose the ability to buy coverage through the SHOP Marketplace if you do not have a certain number of employees accept the insurance you offer.

5. Do I have options if I am self-employed?

If you are self-employed – meaning you run a business with no employees – you can use the Health Insurance Marketplace to buy insurance as an individual instead of going through the SHOP Marketplace. Depending on your income, you may also qualify for financial help to make insurance more affordable.

If you are self-employed and need health insurance, click here to answer a few questions and get to the right place to get coverage.

6. When can I view the options for health insurance plans for my employees?

You can get to the SHOP Marketplace directly from this site now. Click here to view your options and see whether you are eligible for a federal tax credit to help cover premium costs, or the amount that insurance costs each month.

7. Can I use my current broker?

Contact your broker to find out if they are registered with the Marketplace. If your broker is registered, they are qualified to help you use the website to find the best health insurance option for your business. Click here to find an Agent or Broker that can provide help in your area.

8. Am I required to provide health insurance for my employees?

Small Businesses with Less Than 50 Full-Time Equivalent Employees

No. If your business has fewer than 50 full-time equivalent employees, you are considered a small business and will never have to pay a penalty for not providing insurance for your employees.

As an employer, the size of your business is determined by the number of full-time equivalent employees, which is a calculation that deals with total hours worked rather than total number of employees.

To see the full definition of a full-time equivalent, click here.

Large Businesses with 50 or More Full-Time Equivalent Employees

If you are a large business, you will not have to provide health insurance for your employees in 2014. If you are a business with 100 or more employees, you will have to pay a penalty known as a Shared Responsibility Payment if you do not offer insurance that meets certain standards in 2015. Businesses with 50-99 employees will be subject to a Shared Responsibility Payment beginning in 2016 if they do not offer coverage.

As a large business, you may have to pay the Shared Responsibility Payment if you do not offer health insurance to your full-time workers and their dependents, or if the insurance that you do offer is not considered affordable or doesn't meet the minimum value standards. Affordability means that the price your employees pay for monthly premiums for employee-only coverage does not exceed 9.5 percent of their income. The Minimum Value Requirement means that the plan will pay at least 60 percent of the total cost of medical services for the standard population.

Penalties will be:

  • For large businesses not offering coverage: $2,000 per full-time employee (not including the first 30 workers)
  • For businesses offering coverage that is not affordable or does not provide minimum value: $3,000 per full-time employee getting a premium tax credit
9. Am I required to provide insurance for my employees’ families?

If you are a small business with fewer than 50 full-time employees, you are not required to provide health insurance for your employees or their families.

If you provide coverage to your employees, but not their families, your employees’ families can still purchase insurance through the Health Insurance Marketplace.

Resources

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