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Individual Marketplace Reforms

Questions answered

Minimum Essential Coverage

The Affordable Care Act requires individuals who are ineligible for an exemption to have minimum essential coverage for themselves and their dependents. Minimum essential coverage is the type of health care coverage an individual needs to have in order to meet the individual responsibility requirement under the Affordable Care Act.  Coverage purchased in the individual market including through a Federally-facilitated Marketplace, as well as coverage under government programs such as Medicare, Medicaid, CHIP and TRICARE, and coverage under an employer-sponsored plan, meet this requirement. 

Individuals who are ineligible for an exemption and do not have coverage by 2014 may be required to pay a fee. The fee is $95 for plan year 2014.

In most states agents and brokers can assist consumers in meeting this requirement by helping them receive an eligibility determination, apply for financial assistance programs, and choose and enroll in a qualified health plan (QHP).

Coverage of Pre-existing Health Conditions Regardless of Age

The Affordable Care Act prohibits health insurance issuers from limiting or excluding coverage related to pre-existing health conditions, regardless of the age of the covered individual. For persons under age 19, this provision became effective for policy years beginning on or after September 23, 2010. Health insurance issuers also cannot charge an individual more because of pre-existing conditions.

Health insurance issuers are also required to re-issue a health plan to any applicant without medical underwriting, which means that health insurance issuers cannot increase premiums at renewal for existing customers because they incurred claims, or experienced worsening health during a policy year. Health insurance issuers may terminate coverage for enrollees who submitted false information on their applications and those who have not paid premiums before the end of the payment grace period.

Allowable Basis for Premium Variations

Under the Affordable Care Act, premiums can only vary based on the following factors: age, family composition, geographic area, and tobacco use.


  • Premium rates cannot vary by age for enrollees under the age of 21.
  • Premium rates cannot vary by age for enrollees age 64 or older.
  • Premium rates can vary by age for enrollees between the ages of 21 and 63, on each birthday, until a person turns 63.
  • Older enrollees cannot be charged more than 3 times the amount that younger enrollees are charged.

Family Composition:

  • Premiums may vary based on family composition. 

Geographic Area:

  • Geographic rating areas are established by each state. If a state does not choose its geographic rating areas, it will default to rating areas established by the Department of Health and Human Services (HHS).

Tobacco Use:

  • Tobacco users cannot be charged more than 1.5 times the rate of non-users.


Health Insurance Coverage Standards

Under the Affordable Care Act, all health insurance issuers that offer QHPs (Qualified Health Plans) must:

  • Provide, at a minimum, a package of benefits, known as essential health benefits (EHB)
  • Eliminate annual dollar limits on EHB, effective for all plans beginning in 2014
  • Eliminate lifetime dollar limits on EHB, effective for all plans issued on or after September 23, 2010
  • Cover certain preventive services without requiring cost sharing
  • Cap annual out-of-pocket spending

In addition, health insurance issuers are prohibited from rescinding coverage, except in cases of fraud or intentional misrepresentation of material fact.

Next Topic: Child and Young Adult Coverage

Agents and Brokers are required to be trained to assist consumers with the application and decision making process. Using an Agent to enroll in a ObamaCare Health Plan will be the primary choice of many americans. After all agents have the inside track on companies and their promptness to handle claims and pay benefits in atimely fashion.

Our Agents are available 7 days a week.

We offer a free consultation which entails speaking one on one with a knowledgable Agent that has been state licensed and trained to answer your questions.

Next Topic: Coverage Basics

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*ExploreObamacare.com is not affiliated with any government agency. All information provided is for informational purposes only and no guarantee of the accuracy is hereby implied. The information was the product of researching the Affordable Care Act Bill and is subject to change.
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