HealthInsuranceFAQs An AHP can cut costs by pooling small employers, but most are legally MEWAs, which have a history of insolvencies and fraud. They’re regulated under both federal ERISA rules and state insurance law, so confirm an AHP is properly licensed and financially sound before joining.
You are, the client company. Using a PEO or staffing firm doesn’t move the ACA employer mandate or 1095-C reporting to the PEO. The client stays the common-law employer and ALE, though the PEO can offer coverage and file the forms on the client’s behalf.
Yes. Almost every employer covered by the Fair Labor Standards Act must give each employee a written notice about the Health Insurance Marketplace and their coverage options. New hires must get it at the time of hiring (within 14 days, per DOL), whether or not they enroll.
Yes, and it’s now permanent. Federal law lets an HDHP cover telehealth and other remote care before you meet the deductible without losing HSA eligibility. The temporary pandemic rule was made permanent by the One Big Beautiful Bill.
Yes, as of January 1, 2026. A new law lets someone enrolled in a qualifying direct primary care arrangement still contribute to an HSA and pay the DPC fee from it tax-free. The fee must be capped at $150/month for one person ($300 for a family).
Because premiums are set by geographic rating area. Insurers can vary an individual or small-group premium by location (along with age, tobacco, and family size), so the same plan can cost more in one area due to local competition, provider prices, and state rules.
Not by itself. Offering MEC to at least 95% of full-time employees avoids the larger no-offer penalty, but a bare MEC plan that is unaffordable or lacks minimum value can still trigger the smaller penalty when an employee gets a subsidized Marketplace plan.
A lot. A short-term plan can deny you or charge more for a pre-existing condition, leave out essential benefits like maternity, mental health, or drugs, and cap what it pays. It also doesn’t count as minimum essential coverage.
Employers can offer an ICHRA to specific defined classes of employees instead of everyone, applying the same terms within each class. Permitted classes include full-time, part-time, salaried, hourly, seasonal, new hires, and those in the same insurance rating area.
Not for everything. Preventive care is free even before you meet your deductible, and many plans cover some services (like a primary care visit or generic drugs) for just a copay first. For most other care, you pay full cost until you hit the deductible.
Yes. If a major life-changing event lowered your income, you can ask Social Security to recalculate your IRMAA using more recent income, with Form SSA-44. Qualifying events include marriage, divorce, the death of a spouse, work stoppage, and loss of income.
They’re exempt from several ACA protections: no required free preventive care, no guaranteed appeal rights, no doctor-choice or ER protections, and no rate review. They must still end lifetime limits, cover adult children to 26, and provide a Summary of Benefits and Coverage.
No. A catastrophic plan isn’t a qualified health plan for the premium tax credit, so subsidies and cost-sharing reductions can’t lower its cost. If you qualify for that help, a Bronze or Silver plan is usually a better value because the savings apply to it.
It depends on your state. In states that expanded Medicaid, you qualify on income alone up to 138% of the federal poverty level. In non-expansion states, eligibility is narrower and some low-income adults fall into a coverage gap with no Medicaid or Marketplace subsidies.
Medicaid and CHIP are state-run, federally funded programs giving free or low-cost coverage to lower-income adults, families, children, pregnant women, seniors, and people with disabilities. Eligibility is mainly income-based and varies by state; apply any time of year.
Generally no. Under the Newborns’ and Mothers’ Health Protection Act, a plan that covers maternity must pay for at least a 48-hour hospital stay after a vaginal birth (96 hours after a cesarean). You and your doctor can choose to leave earlier, but the insurer can’t require it.
Yes. You can choose a Marketplace health plan that includes dental, or buy a separate stand-alone dental plan, but only if you’re also enrolling in a health plan. Separate dental plans have their own premium, and adult plans may have waiting periods.
It must be available, though you don’t have to buy it. Children’s dental (age 18 and under) is an ACA essential health benefit, so a dental option must be offered, in a health plan or as a separate dental plan. Adult dental is not an essential health benefit.
Yes, for most plans. Marketplace and most other plans must cover breastfeeding support, counseling, and equipment, including a breast pump, at no cost for as long as you breastfeed. Grandfathered plans are the main exception.
In most cases, yes. Marketplace and most plans must cover FDA-approved contraceptive methods and counseling for women with no copay, coinsurance, or deductible in-network. Certain religious employers are exempt; vasectomies and abortion-inducing drugs are not required.
Generally no. Under the ACA, an insurer can’t retroactively cancel (rescind) your coverage over an honest mistake on your application. Rescission is allowed only for fraud or intentional misrepresentation, and only with advance notice.
Yes, in almost all cases. Federal law gives you guaranteed renewability: your insurer must renew your coverage at your option. It can refuse only for narrow reasons like nonpayment or fraud, never because you got sick or used a lot of care.
You get a grace period first. With a Marketplace plan and the premium tax credit, it is usually three months (if you have already paid at least one month that year). Miss the full amount by the end and coverage can be canceled back to your first unpaid month.
No. Your monthly premium is what you pay to have coverage, separate from your deductible and out-of-pocket maximum. Only cost-sharing, like deductibles, copays, and coinsurance for covered care, counts toward those limits.
Your deductible, copayments, and coinsurance for covered in-network care count toward it. Once you reach your out-of-pocket maximum, the plan pays 100% of covered benefits. Premiums, out-of-network care, and non-covered services do not count.