Health Care Reform FAQ

Can an insurance agent help me buy health insurance on the Marketplace?


My health insurance company sent me a letter stating that my policy will be canceled. What are my options?

If your plan is being canceled, talk to your insurance agent or company. Some insurance companies in North Dakota are renewing canceled plans under a federal administrative “fix” called a transitional policy. Before making a decision to renew a canceled plan, however, please consider the following:

  • The benefits of the renewed plan will be the same but your costs could increase.
  • If you had a pre-existing condition exclusion or other limitations in your previous plan, they will still exist.
  • The level of benefits and other requirements in a renewed plan may not be as comprehensive as plans being sold effective Jan. 1, 2014 that comply with the Affordable Care Act (ACA).
  • These transitional options will not be offered forever. This is only a temporary option.

If your canceled plan is not being renewed by your company, you can shop for health insurance in the traditional existing North Dakota market or on the federally-facilitated Marketplace.

Can I buy a catastrophic health insurance plan?

People under the age of 30 and people with hardship exemptions may buy a catastrophic health plan. A catastrophic plan generally requires policyholders to pay all medical costs up to a certain amount, usually several thousand dollars. Catastrophic health plans do not have to cover everything other plans have to cover, so carefully review the benefits, deductibles, co-pays and coinsurance.

People 30 and over who have received a hardship exemption may be able to buy a catastrophic plan. Hardship exemptions are granted to some people based on income or other circumstances that prevent them from getting coverage. If your individual insurance plan has been canceled and other plans aren't affordable, you can apply for a hardship exemption to purchase catastrophic coverage.

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I don't have health insurance. Will I have to get it and what happens if I don't? 

U.S. citizens and legal residents were required to have qualifying health coverage beginning in 2014. Those without coverage pay a tax penalty of the greater of $695 per year up to a maximum of three times that amount ($2,085) per family or 2.5 percent of their household income. After 2016, the penalty has been increased annually by the cost-of-living adjustment. Exemptions are granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, those for whom the lowest cost plan option exceeds 8 percent of an individual's income, and those with an income below the tax filing threshold.

I want health insurance, but I can't afford it. What should I do? 

Depending upon your income, you might be eligible for Medicaid. Low-income adults, including those without children, are eligible, as long as their income doesn't exceed 138 percent of the federal poverty level.

How will the legislation affect the kind of insurance I can buy? Will it make it easier for me to get coverage, even if I have health problems? 

Insurers are barred from rejecting applicants based on health status. Insurers can no longer exclude coverage for specific medical problems for children with pre-existing conditions, nor can they any longer set lifetime coverage limits for adults and kids.

Can I still have a Health Savings Account (HSA)?

Yes. Nothing in the legislation infringes upon the ability of an individual to contribute to a Health Savings Account (HSA) or discourage an individual from doing so. The minimum level of coverage required to meet the individual mandate was specifically designed to allow for the purchase of a qualified high deductible plan that would complement the HSA.

I am self-employed. Will the new law impact my health insurance choices?

Yes. Beginning Jan. 1, 2014, self-employed individuals and their families must be included in the small group market in all states and will have the option of purchasing coverage through the Marketplace.

What is a Marketplace (formerly called an Exchange)? 

One of the requirements of the new law is a mandate that states have health insurance Marketplaces to help individuals and small businesses purchase coverage. Consumers can access and compare multiple prices in a centralized location-thereby maximizing their purchasing power. North Dakota's Marketplace is operated by the federal government.

The law mandates that insurers participating in a Marketplace offer four types of plans meeting certain minimum actuarial standards - platinum, gold, silver and bronze - as well as a catastrophic plan for young adults. Insurers can also sell outside of the Marketplace.

I have been denied coverage because I have a pre-existing condition. What will this law do for me?

Insurers are prohibited from discriminating against individuals with pre-existing conditions in offering or pricing health insurance policies. In addition, for those with qualifying incomes, subsidies are available to reduce premiums and cost-sharing for plans purchased through the Marketplace.

I work for a small business. Will they offer health insurance now? 

It depends on the size of the firm. Companies with fewer than 50 workers won't face any penalties if they don't offer insurance. Companies can get tax credits to help buy insurance if they have 25 or fewer employees and a workforce with an average wage of up to $50,000. Beginning in 2015, firms with more than 50 employees that do not offer coverage have to pay a fee of up to $2,000 per full-time employee if any of their workers get government-subsidized insurance coverage in the Marketplace. The first 30 workers will be excluded from the assessment.

I'm over 65. How will the legislation affect seniors? 

The Medicare prescription drug coverage gap will be reduced. Also, drug company discounts on brand-name drugs and federal subsidies and discounts for all drugs will gradually reduce the gap, eliminating it by 2020.

As under current law, once seniors spend a certain amount on medications, they will get "catastrophic" coverage and pay only five percent of the cost of their medications. Meanwhile, government payments to Medicare Advantage, the private-plan part of Medicare, were frozen as of 2011 and cut in the following years. If you're an enrollee, you could lose extra benefits that many of the plans offer, such as free eyeglasses, hearing aids and gym memberships. The law made all Medicare preventive services, such as screenings for colon, prostate and breast cancer, free to beneficiaries.

Do I have to do anything to receive Medicare Part D "donut hole" savings?

No. See the schedule below for information on what you'll pay for drugs while you are in the coverage gap:

2014 47.5 percent for brand-names and 72 percent for generics
2015 45 percent for brand-names and 65 percent for generics
2016 45 percent for brand-names and 58 percent for generics
2017 40 percent for brand-names and 51 percent for generics
2018 35 percent for brand-names and 44 percent for generics
2019 30 percent for brand-names and 37 percent for generics
2020 25 percent for brand-names and 25 percent for generics


How does the new law affect Medicaid? 

The new health law includes an increase in Medicaid payment rates, bringing them up to the same level as those from Medicare. A large chunk of the increase in insurance coverage under the law comes from expanding Medicaid, the federal-state program for low-income Americans, to cover 16 million more people, including people with incomes up to 138 percent of the federal poverty level. For more information about Medicaid, contact the North Dakota Department of Human Services Medicaid Division.

What changes were made to Medicare enrollment periods? 

The Medicare Part D annual enrollment period is Oct. 15-Dec. 7 every year. During this time, beneficiaries can enroll or switch Medicare Advantage Plans. They can also change drug plans.

The Medicare Advantage open enrollment period moved to Jan. 1-Feb. 14. Beneficiaries can disenroll from a Medicare Advantage Plan and go back to Original Medicare during this time, with the option of adding a prescription drug plan. Beneficiaries cannot buy a Medicare Advantage Plan or switch to another Medicare Advantage Plan during this time. For those beneficiaries who choose to go back to Original Medicare, the change will take effect on the first day of the following month.

The general enrollment period for Medicare Part B did not change.

When will the new preventive care improvements begin?

All Medicare beneficiaries receive preventive services without cost-sharing as of Jan. 1, 2011. In addition, an annual wellness visit to create a personalized prevention plan is now provided under Medicare.

I have a Medicare Supplement (Medigap) Plan. Do I have to make any changes to my plan under the new law?

No, the Affordable Care Act (ACA) does not require seniors to change their Medigap coverage. However, the law will be adding cost-sharing requirements to plans C and F that were sold after Jan. 1, 2015.

What if I make too much to qualify for Medicaid but still can't afford coverage? 

You might be eligible for government subsidies to help you pay for private insurance through the Marketplace. Premium subsidies are available for individuals and families with incomes between 138 and 400 percent of the federal poverty level. The subsidies are on a sliding scale. In addition, if your income is below 400 percent of the poverty level, your out-of-pocket health expenses will be limited.

How will the legislation affect young adults? 

If you're an adult younger than 26, you can stay on your parent's insurance coverage as long as you are not offered health coverage at work. In addition, people in their 20s will be given the option of buying a "catastrophic" plan that will have lower premiums. The coverage will largely only kick in after the individual has $6,000 in out-of-pocket expenses.

If I have already left my parent's insurance plan, can I move back to their coverage?

You may be eligible to re-enroll in your parent's plan. Contact your parent's insurance carrier to determine if you meet eligibility requirements for the plan.

If I no longer have to pay a separate premium for my Comprehensive Health Association of North Dakota (CHAND) coverage, will my overall health care costs be less if I move to my parent's insurance plan?

Not necessarily. You should compare the Comprehensive Health Association of North Dakota (CHAND) benefit plan design to the benefit design of your parent's plan to determine if the differences in out-of-pocket expenses are significant. In addition, you will want to determine if your parents will be required to contribute any additional premium to add you to their plan.

What happens if I have already moved from the Comprehensive Health Association of North Dakota (CHAND) to my parent's plan?

Generally, you must be without the Comprehensive Health Association of North Dakota (CHAND) coverage for 12 months before being eligible for coverage again. However, if you have maintained qualified previous health insurance coverage, you may be able to re-enroll with CHAND at an earlier date under the provisions of the Health Insurance Portability and Accountability Act (HIPAA). Please contact CHAND for more information.

How much is all of this going to cost? Will it increase my taxes? 

If you have a high income, you will face higher taxes.

What will happen to my premiums? 

The grim fact is that health care spending is likely to continue rising faster than general inflation well into the future, resulting in higher premiums. While some individuals and families with health problems may see their premiums decrease significantly under the new rating rules, premiums will continue to increase from year to year for most Americans.