Frequently Asked Questions

As the Health Insurance Marketplace progresses, questions come up. Fortunately, the Kaiser Family Foundation (KFF) has created a great, continuously updated, FAQs.

Click here for the KFF Comprehensive FAQ.

A number of questions have arisen during the course of Cover Arizona Coalition Public Forums held around the state. Members of the Cover Arizona Steering Committee and other experts have developed the answers below to help with popular questions.  These answers may be subject to change as state and federal policy and practice are clarified.

Q: Some consumers have reported that the Marketplace is incorrectly flagging them as incarcerated based on information received from electronic data sources.  Incarceration, or criminal legal history, makes someone ineligible for Qualified Health Plan (QHP) enrollment. How can someone resolve inaccurate information related to their legal criminal record?

A: Marketplaces verify incarceration status using data from the Social Security Administration’s Prisoner Update Processing System, the only national-level database that includes federal, state and local incarceration records that CMS has access to for the purposes of this verification. Consumer information is compared with this data using a combination of name, date of birth and social security number, all of which are required matching elements.

The Marketplace is aware that the release dates in the Social Security Administration’s incarceration records are not always up to date.  However, they are generally not more than two years out of date. The Marketplace is also aware that in certain cases consumers assert to have never have been incarcerated. To address this, we have updated the list of documents that a consumer may use to show he or she is not incarcerated to include documents that demonstrate that the consumer is living or active in the community, and therefore not incarcerated.  Now, consumers without incarceration release documents are able to resolve the confusion as easily as possible.

This is the list of documents that may be sent to resolve the inconsistency:

  • Unexpired State ID
  • Driver’s License
  • Work ID
  • Passport
  • Paystubs
  • Cell Phone Bill
  • A lease that covers the benefit year or a rent receipt
  • Federal, State, or Local benefit letter
  • Bank or Credit card statement showing transaction history
  • Clinic, doctor, or hospital records or bills for services provided
  • Medical claim explanation of benefits provided
  • School record/schedule showing enrollment
  • Military Record
  • Signed notarized statement from individual with alleged false incarceration inconsistency indicating they are living in the community; the statement must include the individual’s name, date of birth, address and phone number
  • Written statement from someone within the community which states the name, date of birth, address, phone number, their relationship to the individual with the incorrect incarceration information ,and that the individual is present and participating within the community
  • A written explanation as to why the applicant does not have any of this documentation

To resolve the situation, a consumer should upload documents to their Marketplace account on or mail copies the information to:

Health Insurance Marketplace
Dept. of Health and Human Services
465 Industrial Blvd.
London, KY 40750-0001

If mailing the information, please include the barcode page that came with the consumer’s eligibility letter, or write the consumer’s Application ID number on the document that’s submitted.

Applying for Coverage/Application Assistance

Q:  If someone does not have access to the internet, how can they apply for coverage?

A: In-person assisters (including navigators and certified application counselors) may help consumers access the internet application.   Brokers are also able to provide assistance, although they may direct the consumer to a more limited array of plans.  Consumers may also call the Marketplace hotline at 1-800-318-2596 to apply. People can also access applications on line at many libraries in Arizona, where they may also be given information on the Marketplace and provided with access to computers to apply.

Q:  Where can I find information on the locations of navigators and certified application counselors?

A: Information on the locations of navigators and certified application counselors can be found on  Locations can also be found at  Plans are also in the works to provide the information to 211, as well as Find Help Phoenix (

Q: How can I help people review the website if they do not speak English?

A: The federal Marketplace is offered in both English and Spanish.  Navigators are required to provide assistance to people in languages other than English. Other community helpers may also help translate the website to consumers without directing them to a particular health plan. Finally, consumers may be able to get assistance in their native language by calling the Marketplace hotline at 1-800-318-2596, 24 hours a day, 7 days a week.

Q: Don’t brokers get a fee for enrolling people?  Don’t they push a certain plan?

A: Insurance brokers do receive a commission from the health plans they represent when they sell insurance.  Brokers are not required to share with consumers the full array of plans offered on the Marketplace. However, insurance brokers are trained to help consumers make decisions about insurance. By providing consumers with sound advice, they are able to retain customers and grow their businesses.

Q: If I become certified to provide enrollment assistance, do I have to provide help to everyone?

A: There is no requirement of CAC’s to help everyone, however their information will be posted on the CMS and other websites, so people may be contacted for help?
(Source: CMS Information Session, 09/25/13)


Q: How will I know if my drugs are covered by the plans?

A: The exchanges must include a summary of benefits and coverage for each plan. That includes information about what your co-payments would be for generic, brand name and specialty drugs. It should also provide a Web link to the plan’s list of covered drugs and how they are categorized by a particular plan.  You can find a list of formulary links on the website at
(Source: New York Times. A Guide to the New Health Insurance Exchanges)

Q: How will this affect my medications?

A:  The health reform law requires all non-grandfathered, non self-insured plans sold off the Marketplace and all plans that are sold on the Marketplace to cover prescription drugs. However, each plan may vary in terms of the particular brand of medication it covers.  Your best bet is to check with the plans you are comparing directly to determine whether their drug formulary covers the medications you need before selecting that plan.

Cost Sharing

Q: How are out-of-pocket costs limited under the ACA?

A: All non-grandfathered  group health plans (including self-insured plans and large employer plans) and plans offered through the Marketplace are subject to an out-of-pocket limit  (including copays, deductibles and co-insurance) under the new law.  The 2014 limit is $6,350 for individuals and $12,700 for a family.  The caps are lower for those with incomes below 400 FPL – based on a sliding scale.  (1/3 of HSA limit for those earning between 100-200% FPL; ½ of the HSA limit for those earning between 200-300% FPL; 2/3 HSA limit for those earning between 300-400% FPL).  The caps only apply to covered, in-network services.

These limits go into effect in 2014, but have been delayed to 2015 for plans with multiple administrators (such as plans with separate administrators for their pharmacy benefits versus medical expenses). If a plan does not currently impose an out-of-pocket maximum for prescription drugs, it does not have to impose an out-of-pocket maximum for prescription drugs until 2015.  The exception to the delay has been made for providers who use a separate administrator to manage their behavioral health benefits. Under the Mental Health Parity and Addiction Equity Act of 2008, health plans can’t apply separate out-of-pocket maximum limits for those benefits.  If a plan does not contract with multiple administrators, the out-of-pocket limit restrictions apply fully in 2014.

For individuals and families purchasing coverage through the marketplace, exposure to out-of-pocket costs is also limited in other ways. First, on the Marketplace, individuals can choose among various tiers of plans (e.g. platinum, gold, silver, bronze), paying more in premiums for higher level plans in exchange for lesser, estimated out-of-pocket costs.  These tiers are based on actuarial values of the offered plans.  These values are based on estimates of what a typical individual enrolled in the plan is likely to pay for covered services. Those with more significant health needs may pay more.

In addition, those living in households at or below 250% of the federal poverty level (e.g. $58,875 for a family of four) receiving silver-level coverage through the Marketplace will benefit from further limits on cost sharing.  The federal government will pay the insurer upfront, and enrollee cost sharing charges will be automatically reduced when the individual or family enrolls in the silver plan.  These reductions will effectively increase the actuarial value of the health plan, with the increase in value varying based on the income of the individual.  For those with incomes up to 150 percent of the federal poverty level , the actuarial value of a silver plan (typically 70 percent, meaning that for the average person enrolled, 70 percent of the costs would paid for by the plan) would increase to 94 percent (meaning that for the average enrollee, 94 percent of the costs would be covered by the plan).  For those in households earning between 151 -200 FPL, the actuarial value will be 87 percent. For those with incomes between 201 -250 FPL, the actuarial value will be 73 percent.

Finally, out-of-pocket costs will be limited for non-grandfathered group plans (not including self-insured plans) and plans offered on the exchange by allowing no cost-sharing for preventive services receiving an A or B rating by the US Preventive Services Task Force (USPSTF).  In instances where a preventive service is recommended for only high-risk individuals by the USPSTF, “high risk” is deemed by the health provider, allowing people with significant health needs even greater access to preventive services without cost sharing.
(Sources:  National Association of Health Underwriters “What in the World Happened with Out-Of-Pocket Limits This Week?” August 16,2013; “A Limit on Consumer Costs Is Delayed in Health Care Law” New York Times, August 12, 2013.  FAQs about Affordable Care Act Implementation Part XII, US Department of Labor;  “Cost Sharing Reductions: Beyond the Basics.” Center on Budget and Policy Priorities, June 19, 2013. “Subsidies to Buy Coverage in an Exchange.” American Plasma Users Coalition)

Q: What types of expenses are included in the out-of-pocket limits?

A: The out-of-pocket limits include all individual copays, including prescription drug co-pays as well as deductibles and co-insurance.
(Sources: Patient Protection and Accountable Care Act Section 1302;  Patient Cost Sharing Under the Affordable Care Act, Kaiser Family Foundation, April 2012)

Eligibility for the Marketplace and Subsidies

Q: Is there a go-bare period before people can get coverage on the Marketplace?

A: There is no requirement that you be uninsured for you to seek coverage in the Marketplace.

Q: If my spouse has employer-based coverage, can my children and I get coverage through the Marketplace?

A: If your household income is less than 133% of the Federal Poverty Level, you and your kids can get coverage through Medicaid (AHCCCS) beginning on January 1, 2014.

If your income is above that level, you and your kids can get coverage through the Marketplace, but you may not be able to get a subsidy to help pay for coverage.  If your spouse’s employer offers family coverage that is deemed adequate and affordable under the law ,the subsidy for coverage is not available for you or your kids.

However, if your spouse’s employer only offers coverage to your spouse, you and your children may be able to enroll in the marketplace and receive a subsidy for coverage, assuming you meet income eligibility and other requirements.

(Source: Kaiser Health News “ For Some People Covered Through Work, An Exchange Might Be a Good Option for the Family.”

Q: Can Americans living abroad participate and where can we find options?

A: Americans who live abroad are generally discouraged from purchasing a plan under Obamacare for two reasons. First, the health insurance you buy on the exchanges is unlikely to have coverage options outside the United States, so it won’t help much with seeing a doctor. Second, the individual mandate does not apply to Americans living abroad.

Health Savings Accounts

Q: If I have a health savings account, how is the affected by the Marketplace or the ACA?

A: Insurers and employers will continue to offer high deductible plans with health savings accounts. However, existing non-grandfathered plans with very high deductibles may not necessarily meet the  law’s requirement that plans pay for 60 percent or more of allowed medical expenses or meet the health law’s cost-sharing limits.  High deductible plans combined with health savings plans will also be offered through the Marketplace.
(Sources: Kaiser Health News “Many Consumers with High-Deductible Plans are Concerns About Haelth Law Changes.” August 6, 2013.  See also New York Time A Guide to the New Health Insurance Exchanges

Individual Mandate

Q: If a family has multiple members, will they each be hit with the penalty for the individual mandate if they lack coverage?

A: The penalty is assessed per member of the household, with amounts differing for adults and children.  There is also a maximum amount that can be assessed per household.  For 2014, the amount is $95 per adult and $47.50 per child– with a maximum of $285 per household or 1 percent of household income – whichever is greater.  The penalties go up in subsequent years.

Some people will be exempt from paying the penalty, such as people who are exempt from filing a tax return, undocumented or incarcerated individuals, those who would experience financial hardship (paying more than 8 percent of their income on health coverage), members of Indian tribes, and those who are part of a religion opposed to acceptance of health coverage.
(Source: The Henry Kaiser Foundation. The Requirement to Buy Coverage under the Affordable Care Act.

Q: Do I have to be enrolled in coverage all of 2014 to be exempt from the individual mandate penalty?

A: The penalty is pro-rated by the number of months without coverage, though there is no penalty for a single-gap in coverage of less than three months.


Q: What happened to children on KidsCare in 2014?

A: For children enrolled in the original KidsCare program (children who were enrolled in KidsCare before December 21, 2009 when the state instituted a freeze on the program), they will be able to continue being covered by KidsCare to the age of 18 as long as they pay their premiums and meet income qualifications.

For children enrolled in KidsCare II (children enrolled after the enrollment freeze took effect), coverage for KidsCare II will terminate as of January 1, 2014.  Children eligible for Medicaid will automatically transition to AHCCCS.  Families of children eligible for the Marketplace will be sent a notice by AHCCCS, indicating that they may qualify for subsidies, referring them to the Marketplace.

Native Americans

Q: How do the tribes or tribal members have access to the Marketplace?

A: Tribal members – including those who receive services through Indian Health Services – are able to receive coverage through Medicaid and the Marketplace. Like other residents, they may also be eligible for federal subsidies to buy coverage through the Marketplace.  The benefit of having coverage through Medicaid or the Marketplace is that Native Americans may have broader access to specialists and treatments than they may be able to access through Indian Health Services.  By promoting access to coverage through the Marketplace and Medicaid among Native Americans, limited IHS dollars may be stretched farther since IHS is a payer of last resort.

A number of provisions in federal law pertain specifically to tribal members. First, they are able to enroll in the Marketplace on a monthly basis – they are not limited to enrolling during an open enrollment period.  Second, there is no cost sharing for Native Americans at or below 300 percent of the Federal Poverty Level (approximately $70,650 for a family of four in 2013).  Finally, there is no cost sharing for those receiving services through Indian Health Services, Tribal and Urban Indian organizations or contracted facilities.
(Source: AIAN QA Marketplace 9 6 12_revised TTAGcomments.docx)

Q: Will Native Americans be able to access services through the exchange at non-IHS facilities?

A: Yes. This will expand access to care for Native Americans, but also mean that IHS facilities will likely compete for business with other health care providers.

Q: As an AI/AN, am I required to have health care insurance?

A: No, members of federally recognized tribes and AI/ANs and other people (like the spouse o or child of an eligible Indian) who are eligible for or get services through an I/T/U will be exempt from (don’t have to pay) the shared responsibility payment. Thus, you do not have to apply for health insurance, but you must apply for this exemption.

(Source: Call AIAN QA Marketplace 9 6 12_revised TTAGcomments.docx)

Q: How can AI/ANs apply for an exemption from the shared responsibility payment?

A: To get an exemption, members of federally recognized tribes may apply through the Marketplace or provide the appropriate information when they file their federal income tax return.  AI/ANs who aren’t members of federally-recognized tribes, but who are eligible for or get services from an I/T/U, must apply through the Marketplace and will  need to verify their AI/AN status or eligibility for services through an I/T/U.
(Source: Call AIAN QA Marketplace 9 6 12_revised TTAGcomments.docx)

Open Enrollment, Exceptions

Q: Is there an open enrollment period for Medicaid?

A: People who are eligible can apply for and receive Medicaid at any time. There is no set time period for enrolling in Medicaid.

Individual Mandate and Penalties

Q: Is it true that the only way that the individual mandate penalty is collected is from any income tax refund the person otherwise would receive; i.e., no refund, no penalty? If so, why do people claim that everyone must be insured or pay a penalty?

A: This is half-true: For people who do not buy health insurance coverage, the federal government will deduct the tax penalty from a refund. If you don’t have a refund, the Internal Revenue Service will send you a bill for that same amount, much like they do for any other taxes you owe.

The thing that will be different about this fine, though, is there’s not much the federal government can do after sending you this bill. They cannot garnish your wages for example, or put a lien on your house. The tax penalty will, however, remain on your IRS bill in subsequent years. You can read more about the issue here.

Pre-Existing Insurance Plan (PCIP)

Q: What if I am enrolled in PCIP?

A: Coverage through the federal Pre-Existing Condition Insurance Plan (PCIP) ends December 31, 2013. You must take action by December 15 to avoid a coverage gap. You can enroll in the Marketplace or Medicaid, depending on your income.

Tax Credits/Subsidies

Q: Should I use my entire subsidy at once? How can I avoid owing taxes?

A: The premium subsidies are delivered in the form of a refundable tax credit, which can be used immediately to reduce your monthly premiums.

You can use it all right away, or you can use part of it, or none at all. If you expect your income to remain the same, you might use the entire credit. But if your income is likely to rise, it may pay to use only a portion of the subsidy. That way, you’ll avoid owing money to the I.R.S. at tax time.

If your income does change, report it to the exchange. If your income drops, you may be eligible for a larger credit. Changes in family size should also be reported. How much you may owe will all get reconciled on your taxes in the spring of 2015.
(Source: New York Times A Guide to the New Health Insurance Exchanges