This section applies to people, such as self-employed Oregonians, who buy their own coverage. This can be for an individual or a family.
In 2014, everyone will qualify for health insurance, regardless of health. This is already true for children under age 19 who have pre-existing conditions. Learn more.
Requirement to buy health insurance: Most people must purchase basic health insurance coverage or pay a penalty.
Amount of penalty: The annual penalty for lacking essential coverage will be the greater of a flat amount per individual or a percentage of taxable income. After 2016, the flat dollar amount is indexed to inflation. The penalties are phased in.
- In 2014, the annual penalty will be $95 per adult and $47.50 per child, up to a family maximum of $285 or 1 percent of family income, whichever is greater.
- In 2015, the penalty will
- be $325 per adult and $162.50 per child, up to a family maximum of $975 or 2 percent of family income, whichever is greater.
- In 2016, the penalty will be $695 per adult and $347.50 per child, up to a family maximum of $2,085 or 2.5 percent of family income, whichever is greater.
Who does not have to buy insurance: Members of certain religious groups and Native Americans tribes; undocumented immigrants, people who are in prison; people whose incomes are so low they don’t file taxes; and people who would have to pay more than 8 percent of family income for insurance.
Benefit changes: Individual and small group plans sold after Jan.1, 2014, must include essential benefits in 10 categories:
- Ambulatory (outpatient) services
- Emergency services
- Maternity and newborn care
- Mental health and substance abuse disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
Knowing how much your plan covers: Plans will be labeled to help consumers understand the level of coverage they are buying. The levels of coverage are:
- Bronze – The plan must cover 60 percent of expected costs for the average individual
- Silver – The plan must cover 70 percent of expected costs for the average individual
- Gold – The plan must cover 80 percent of expected costs for the average individual
- Platinum – The plan must cover 90 percent of expected costs for the average individual
Insurers can sell more than one plan in each of the categories although Oregon requires all insurers to sell one standardized bronze plan and one standardized silver plan. These plans will have identical benefits, making it easier for consumers to compare different companies based on price, provide networks, customer service and other factors.
Catastrophic plans: These health plans must have essential benefits but do not have to meet the actuarial values of other plans, meaning they do not have to cover at least 60 percent of estimated medical costs. They can have higher deductibles. These plans can be sold only to people under 30 and to others exempt from buying insurance because of financial hardship.
Limiting out-of-pocket costs: All plans sold or renewed in 2014, must limit consumers’ annual out-of-pocket costs (such as co-pays) to approximately $6,350 for individual and $12,700 for families. These limits will be indexed to average premium growth in future years.
Health Savings Accounts (HSA): Nothing in the law prevents individuals from contributing to a Health Savings Account (HSA), or discourages 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 health plan that would complement the HSA.
Lifetime coverage limits: Insurance companies cannot place a dollar limit on how much they will cover over the lifetime of a member.
Annual coverage limits: Rules are phasing out annual limits on any “essential benefits” although some employers/insurers received waivers from this requirement. The requirement applies to all but grandfathered individual plans. For plans issued or renewed on or after Jan. 1, 2014, annual dollar limits on coverage of essential benefits will be prohibited.
Subsidies: Low- and moderate-income individuals and families whose employers do not subsidize health insurance coverage will be eligible for financial assistance to buy coverage through Cover Oregon. The amount of these tax credits and subsidies, which will reduce premiums and out-of-pocket costs for deductibles, co-payments and co-insurance, will depend upon the size of your family and your household income. For example, a family of four making up to $94,200 (400 percent of the federal poverty level) will be eligible for tax credits to help lower monthly premiums.
Buying insurance through an exchange: On Oct. 1, 2013, Cover Oregon will launch an online marketplace where individuals and small employers can compare health plans and get financial help.
Key services are “apples-to-apples” comparisons of health plans and costs, one application to enroll in health insurance plans and public programs (such as Medicaid), quality ratings for insurance companies and plans; and financial assistance (for qualifying individuals). Learn more.
No one is required to buy health insurance through Cover Oregon. However, subsidies are only available for plans sold in the exchange. Cover Oregon’s calculator will help determine if you qualify. You can purchase coverage on the exchange’s website or through your agent if he or she is approved to sell exchange plans.