FAQS

Health Insurance Eligibility & Enrollment

Am I eligible for Marketplace health insurance?

You are eligible to buy coverage on the Health Insurance Marketplace if you:

• Are a US citizen or are legally present in the US and

• Are not currently in jail or prison

Am I eligible for financial help to lower the costs of my Marketplace health insurance?

You may be eligible for help paying for your health insurance if you are eligible for Marketplace coverage AND you:

• Have a yearly household income that falls anywhere in the table below;

and

• Are NOT offered health insurance through your job OR the health insurance that is offered is more than 9.5% of your yearly household income and/or it does not cover at least 60% of the cost of benefits (This Employer Coverage and Tax Credits worksheet may be helpful, if you think this situation applies to you. Additionally, speak with your employer because you will need to show proof of what your employer’s plan costs and what it covers).

You may get financial help if your income falls between these amounts.

Income Range for the Open Enrollment Period (for 2021 Coverage) by Family Size

Single Person $12,760 to $51,040

Family of 2 $17,240 to $68,960

Family of 3 $21,720 to $86,880

Family of 4 $26,200 to $104,800

Family of 5 $30,680 to $122,720

When can I enroll in health insurance?

The next open enrollment period is November 1, 2021 to January 15, 2022.

In order for coverage to start on January 1st, you must enroll between November 1 - December 15, 2021. You may qualify for a special enrollment period, outside of open enrollment, if you experience a life-changing event such as marriage, birth, moving to another state, or a loss of coverage. To see if you qualify, go to healthcare.gov or call the Health Insurance Marketplace at 1-800-318-2596.

What information and/or documents do I need when I am ready to enroll?

Income Documents: W2 or recent pay stubs, Social Security benefit letter, and information on any other income you receive — even if you don’t pay taxes on it

Employer’s information: Phone # and address

Citizenship & Immigration Documents: If you are not a US citizen by birth, you will need a citizenship certificate, immigration documents, refugee travel documents, green card, or other eligible status documents

How do I apply for Marketplace health insurance?

Online

• Go to www.healthcare.gov

• Create an account — you will need an email address for this

• You can complete your application and even select a plan online. You may be able to pay your first premium too.

By Phone

• Call 1-800-318-2596

• Complete the application with the phone representative

• The representative will tell you how much, if any, financial assistance you are eligible for and discuss the available plans. You can even select a plan over the phone.

In-Person

• Visit LocalHelp.HealthCare.gov to find free in-person help in your area

• Schedule an appointment with an enrollment assister, who will help you enroll

• Bring the documents listed above to your appointment

Have more questions? These short videos might help: How Health Insurance Works and How To Get Your Money's Worth From Your Health Insurance.

Am I eligible for Medicaid in Georgia?

In general, you should apply for Medicaid if your income is low and you match one of these categories:

• You think you are pregnant

• You are the parent or caretaker of a child or teenager under the age of 19

• You are a child or teenager under the age of 19

• You are age 65 or older

• You are legally blind

• You have a disability

• You need nursing home care

Note: Your child may be eligible for Medicaid if he or she is a U.S. citizen or a legal immigrant — even if you are not. Eligibility for children is based on the child’s status, not the parent’s; however, the parent’s income is counted toward the income limit.

To learn more about Medicaid eligibility and how to apply see our Medicaid Fact Sheet

How do I apply for Medicaid in Georgia?

You can apply:

Online (any type of Medicaid): gateway.ga.gov
By phone: 877-423-4746
In person at your county Division of Family and Children Services : Find your local DFCS office here

If you are aged (65 or older), blind or disabled:

Apply for Supplemental Security Income (SSI) and Medicaid by contacting your local Social Security office. Call 800-772-1213 or visit www.ssa.gov

If you are deaf or hard of hearing call the TTY number 800-325-0778

Note: If you apply for Medicaid for your children and learn they are not eligible because of income, ask about PeachCare for Kids. Families that earn too much money for Medicaid may be able to enroll their children in PeachCare for Kids. For example, a family of 4 can have an income of up to $61,110 in 2015 to qualify.

To learn more about Medicaid eligibility and how to apply see our Medicaid in Georgia factsheet.

How much will health insurance cost me?

No one plans to get sick or hurt, but everyone needs medical care at some point. Health insurance helps pay for these costs and protects you from very high medical bills. While each health insurance plan is different, there are common terms that you should know to help you figure out how much you will pay for coverage.

There are 4 different kinds of health insurance costs that you might have to pay: a premium, deductible, co-pays, and co-insurance.

The amount and type of costs that you will pay depends on the type of plan that you choose.

PREMIUM

A premium is a monthly bill you pay to your health insurance company, just like when you pay your electricity or water bill. You have to pay your premium even if you do not receive any medical care that month.

• Pay Monthly: Write down the due date of your monthly payment.

• Keep records of each payment.

Important Note: Choosing a plan with a low monthly premium could mean that other out-of-pocket costs (such as co-pays and deductibles) will be even higher.

DEDUCTIBLE

A deductible is the amount of money you must spend on your health care services each year before your health insurance plan starts to pay some of the cost.

• The deductible includes your co-pays, and other costs you have to pay to receive health care. (It does not include your premiums.)

• You can find your deductible amount on your Summary of Benefits form. If you can’t find this form, you can call the member services line for your health plan. The number is on your insurance card.

CO-PAYS

Co-pays are the fixed amount you pay when you use health care services. You pay a small amount each time you visit the doctor or fill a prescription. Different types of health care services have different co-pays.

• Your co-pays are listed on your health insurance card. For example, it might say PCP for primary care provider or ER for emergency room.

• Important: There are no co-pays for preventive care.

CO-INSURANCE

Once you have paid the amount of your deductible, you may have to pay “co-insurance” for certain services. This charge is part or a percentage (%) of the total cost of the service. Co-insurance is your share of the costs, usually 10 to 30%.

For more information and examples about these and other health insurance concepts, download our fact sheet.

What is a special enrollment period (SEP) and do I qualify?

The time, outside of Open Enrollment, when someone can enroll in or switch Marketplace health plans. A special enrollment period (SEP) can occur at any time during the year. You can qualify for an SEP by experiencing a qualifying life event.

An SEP lasts for 60 days, starting from the date of the qualifying life event. If you do not enroll in health insurance during those 60 days, you will have to wait to enroll until the next open enrollment period.

If you have experienced any of the following life events, you may qualify for a Special Enrollment Period (SEP):

• Adoption or fostering a child

• Birth of a child

• Marriage

• Divorce

• Moved to another state or a place outside of your plan’s coverage area

• Loss of coverage (from loss of job for any reason)

• Loss of Medicaid / PeachCare eligibility

• COBRA coverage has ended

• Turned 26 years of age

• Became a U.S. citizen or legal resident

• Got out of prison

• You are earning more money, you have fewer people in your house, or other change that ends a previously granted hardship exemption

If you have experienced one of these life events and believe you qualify for an SEP, you can apply the following ways:

• Online at www.healthcare.gov

• By phone at 1 (800) 318-2596

• You can find free in-person help by going to localhelp.healthcare.gov

As of June 2016, you are also required to provide proof of SEP eligibility such as, rental agreement or home deed for move-based SEP, marriage certificate, immigration document showing the effective date of change of status, or health coverage termination letter. If you do not provide this proof of eligibility within the given time you will lose your coverage. You can refer to the Marketplace eligibility document to see what has been required of you.

To learn more about qualifying and applying for an SEP, see the SEP fact sheet.

How do I get health insurance for my kids?

Your children may be eligible for health insurance even if you are not. Look at our children's health insurance fact sheet to see if your children can get covered today.

Where can I get health care even if I am uninsured?

Even if you are uninsured, you can still see a doctor, get health insurance for your children, and share your story. Here is what you need to know.

Health Insurance Terms & Concepts

What is a premium?

• Pay Monthly: Write down the due date of your monthly payment.

• Keep records of each payment.

Important Note: Choosing a plan with a low monthly premium could mean that other out-of-pocket costs (such as co-pays and deductibles) will be even higher.

What is a deductible?

A deductible is the amount of money you must spend on your health care services each year before your health insurance plan starts to pay some of the cost.

• The deductible includes your co-pays, and other costs you have to pay to receive health care. (It does not include your premiums.)

What is a co-pay?

A co-pay is the fixed amount you pay when you use health care services. You pay a small amount each time you visit the doctor or fill a prescription. Different types of health care services have different co-pays.

• Your co-pays are listed on your health insurance card. For example, it might say PCP for primary care provider or ER for emergency room.

• Important: There are no co-pays for preventive care.

What is co-insurance?

What is a prescription drug formulary?

A formulary is the list of prescription medicines approved by your health insurance company. Buying medicines that are in your plan’s formulary will save you money. Formularies use a system called “tiering” to categorize medicines by price. This is what tiering looks like:

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What is an out-of-pocket maximum?

An out-of-pocket maximum is the amount you will have to pay for the year if you get all of your health care “in-network.” Once you have reached this amount, your health insurance pays 100% of your medical costs. The out-of-pocket maximum starts over each year.

• NOTE: The out-of-pocket maximum does not include your monthly premium or “out-of-network” health care.

• You can find your out-of-pocket maximum on the Summary of Benefits and Coverage (SBC) form.

How do tax penalties and exemptions work?

The Affordable Care Act (ACA) requires everyone to have health insurance. However, some people may choose not to buy health insurance or may be unable to buy it. If you do not enroll you may be penalized on your taxes UNLESS you qualify for an exemption. A tax penalty means that your refund may be reduced or you could pay more if you owe taxes at the end of the year.

To understand how this applies to you, download our interactive fact sheet.

What does "in-network" mean?

In-network doctors have a contract with your health insurance company. That means that you pay less to visit “in-network” doctors. It is important to know whether a doctor is in- or out-of-network. Services from out-of-network doctors are more expensive for you.

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To find the names of local doctors who are in your insurance plan’s network you can:

• Contact your insurance company by phone. The number is on the back of your insurance card.

• Look on your health insurance company’s website for the “Provider Directory”

• Look in the company’s provider brochure or directory to see which providers will accept your plan. (The most up-to-date directory is on your insurance company’s website. They may also send it to you in the mail.)

• Call your doctor’s office and ask them: 1. Do you take my insurance? 2. Are you in my plan’s network?

Accessing Health Care Services

What do I do after I get health insurance?

Now that you have health insurance, there are some things that you should do to get the most out of your insurance plan.

Pay your premium

You must pay your first premium before your coverage will be active. You can do this online when you select a plan or over the phone by calling the insurance company. You will need your insurance plan ID to pay. You need to pay your premium each month to stay covered.

Get Your Card

Your insurance company will send you a card in the mail with your plan’s information. You may also be able to get a printable card from your insurer’s website. The card has important information printed on it, like your plan number, group number, and contact information for the company. It is important to always take your card with you to doctor’s appointments.

Find a doctor

Find a doctor who you can see when you need medical care. It’s important to find one that accepts your insurance. Your insurance company can give you a list of doctors in your area that accept your plan. If you already have a doctor that you want to keep, call their office and ask if they accept your insurance. You should check with both your insurance company and your doctor to make sure the doctor is “in-network.”

Make an Appointment

You can get a wellness check-up every year for free. During your check-up, your doctor will ask you questions about your health, take your vital signs (like blood pressure and heart rate), and may do some routine tests to check for diseases. When you go to your appointment, make sure you bring:

Photo ID

Your health insurance card

Your family medical history — the doctor will ask about it

A list of any medications you are taking

Any questions you have for the doctor — it helps to write them down so you don’t forget

Stay Well

After your appointment, follow any instructions that your doctor gave you. It’s very important to get any prescriptions that you were given. Take your medicine exactly as the doctor told you to. If you get sick or injured throughout the year you can make an appointment to get checked out. Unless it is a life-threatening situation, going to your doctor is much less expensive than going to the emergency room.

To learn more about how to use your health insurance, see our "You're Covered, Now What" fact sheet.

How do I find a doctor?

A Primary Care Provider (PCP) is the doctor, physician’s assistant, or nurse practitioner who you visit when you need your yearly check-up, are sick or have a minor injury, or need other routine and preventive medical care.

You can get recommendations for a provider from a several different places, including:

• Friends, neighbors, and relatives

• Your dentist, pharmacist, eye doctor, previous provider, or other health professional

• Advocacy groups — these can be an especially good resource if you need to find the best provider for a specific chronic condition or disability

In-Network vs. Out-of-Network

It’s important to pick a PCP that is in your insurance plan’s network of doctors (known as “in-network”). Usually, you get the best deal when you use doctors in your plan’s network because they have contracts to provide you with better rates. Your insurance plan may not pay at all for care from an out-of-network provider, which means you could pay much more.

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To learn more about how to find a doctor see our fact sheet on finding a primary care provider.

Problems with Your Coverage

How do I file a complaint or appeal?

You have health insurance to help pay for health care services that you need and to protect you from high medical bills. Sometimes, you and your insurance company may disagree on what you should pay and what they should pay. If your health insurer will not pay for something that you think is covered, you have the right to appeal. Insurers have to tell you why they have denied your claim or ended your coverage. The following information will help you file an appeal with your insurer or file a complaint against them.

To find out all of the steps involved with filing a complaint or appeal, download our fact sheet.

Health Insurance & Your Taxes

How does health insurance affect my taxes?

When you file your taxes each year, you have to tell the IRS about your health insurance coverage. If you (or anyone in your household) purchased health insurance through the Health Insurance Marketplace (also called healthcare.gov), there is important information that you need to know before you file your income taxes.

If you buy your health insurance through the Marketplace, you may get some financial help. That is called an Advanced Premium Tax Credit (APTC). Think of the APTC like a coupon that you get every month to lower the cost of your health insurance premium. APTCs are only available for plans purchased through the Marketplace and your income must fall within a certain range to qualify.

If you qualify for an APTC, you can decide how much of it you want to use each month. How much of your tax credit that you decide to use will affect your tax return. For example, if you use all of your available tax credit each month, you may get a smaller refund or even owe money back. If you use only part of your available tax credit, you are more likely to get the rest of it back as a tax refund or owe less back.

If you are worried about owing money back, be sure to contact the Marketplace anytime your income changes during the year. That way, they can adjust your APTC to make sure you are getting the right amount.

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Before you file your taxes

Form 1095-A

You will get Form 1095-A in the mail from the Marketplace if you or anyone in your household enrolled in health insurance through the Marketplace. It should arrive by early February. You can also download the form through your Marketplace account. Form 1095-A tells the IRS how much you received from the Marketplace in Advance Premium Tax Credits. You will get a Form 1095-A even if you only had Marketplace coverage for part of 2015.

Important: DO NOT file your taxes until you have your Form 1095-A.

To learn more about how health insurance affects your taxes, see our health insurance and taxes fact sheet.

Additional Resources

How do I find information that specifically addresses health coverage needs for LGBT people?

The following resources include special considerations for the LGBT community when enrolling in health coverage or accessing care.

Click here to learn more about transgender healthcare.

Click here to learn more about health insurance options for Georgia's LGBT community.

I am HIV positive. What do I need to know about getting health insurance?

The Affordable Care Act (ACA) makes health insurance more affordable, more accessible, and more complete for all Georgians. As a person living with HIV/AIDS (PLWHA), healthcare and health insurance are especially important so that you stay healthy and well.

See our "Healthcare for People Living with HIV/AIDS" fact sheet to learn more.

How can I find additional resources about health insurance?

GHF has created materials to answer your questions about health insurance. Check out these resources the answers to your questions.

Enrollment Toolkit - Use this collection of fact sheets to find more information on how to enroll and how to use your coverage once you are enrolled.

Health Insurance User's Manual - Use this resource to keep track of your health coverage and make sure you are getting the most out of it.

Get Insured. Stay Insured. - These short videos will walk you through how to get insurance, choose a provider, take advantage of preventative services, and shop around once you have health insurance.