Under the current health insurance laws, every American is required to be insured or they may face fines for not being under a health insurance health. Depending on your circumstances there are a number of ways to find insurance for yourself for the 2019 year. However, keep in mind that with the new set of laws introduced with the new administration, individuals who are not insured will not be required to pay a fine for not having insurance. This means that when you file taxes in 2020 and you were not insured for 2019, you will not be required to pay a fee. Furthermore, if you have been living abroad for more than 330 days you will not be required to pay a fine if you do not have insurance.

Despite the change of law, if you are in the market for an insurance policy there are a number of factors that may contribute to how you choose your health insurance. Some of the factors may include whether you are working for a small business, a big business, if you are working for the government, or you wish to search for insurance on your own through the marketplace. Each type of insurance requires a certain number of requirements in order to qualify for insurance.

Although there are certain requirements that need to be met in order to receive coverage, it is crucial to remember that an insurance company cannot deny coverage based on pre-existing medical conditions. Also, it may not discriminate against individuals based on their sexual orientation, their sex, their race, color, or creed.

If you feel you have been discriminated against or you feel that an insurance company is denying coverage without a legitimate reason, then it may be time to speak with a law expert about your case. An insurance company is required to provide insurance to all individuals that meet their basic qualifications. To speak with an attorney about your case, you may reach out to Stop Health Insurance Denials at 310-695-5241. We are ready to help you understand your case in more depth so that you have a better understanding of how you may proceed with your case.

The following section will discuss the basic eligibility requirements for each type of health insurance. However, if you wish to discuss your case in more detail you may speak with an insurance law expert. An insurance expert will be able to analyze your case and will be able to provide guidance through the various health insurance laws.

Health Insurance Edibility

In the United States, there are several health insurance coverage policies which you should know about in order to make a sound decision. As mentioned above, there are a number of health insurances that you may qualify for that meet your specific requirements. The following will touch on the basic eligibility requirements for the different types of health insurances.

Market Place Insurance

If you are looking for market place insurance coverage there are a few requirements to meet in order to successfully enroll. First, you must be a United States Citizen meaning you are a naturally born citizen or you hold proper documentation if you were born outside of the United States. Second, you must be living within the United States. This means you have a United States address that you currently live in for the major part of the year. Individuals who are required to travel due to work or for other reasons, and have an address in the United States, are considered to be living within the United States. However, if you are living abroad for more than 330 days you are not required to have insurance coverage.

In addition to the basic requirements mentioned above, you must also provide the following information to your insurance company. The following applies to individuals who are enrolling or re-enrolling for marketplace health insurance. Most information pertains to your household.

  • You will need to provide your home address
  • You will need to provide information about everyone who is applying for insurance in your household. This may include your children, your spouse, or any other dependents.
  • You should obtain the Social Security Numbers and Birth dates of all children and dependents that you will include in your insurance.
  • Your estimated household income for the upcoming year and the details about how you have filed your taxes.
  • You must obtain employer and income information for everyone who will be included in your insurance policy. This will include any pay stubs or W-2 forms.
  • You must obtain the policy number of any existing health insurance plan that you are currently covered by.
  • If you are enrolling to a new coverage plan you should obtain your most current personal plan ID

When you successfully enroll to a marketplace insurance policy you may request a ‘summary of your policy and benefits’ so that you have a clear understanding of the type of coverage you are purchasing. By law, marketplace insurance companies are required to provide (in clear English) the benefits and policies that guide your insurance plan. Additionally, they should include a glossary of the terms included in your agreement so that you have more clear understanding of the terms and conditions.

Every insurance policy you purchase will cover essential treatments that include the following:

  • Emergency care
  • Mental health services that include substance abuse and behavioral health treatment services
  • Surgery services and overnight hospital stays
  • If you suffer a chronic injury the health insurance plan should cover rehabilitative services
  • Prescription Drugs
  • Services to help prevent chronic diseases and how to manage the chronic illness
  • Pregnancy services for mothers before and after the child is born
  • Birth control
  • Breastfeeding coverage
  • Oral and Vision Services
  • Different types of screening services and laboratory services

There are several essential benefits that are included in your health policy. To learn more about these benefits you may visit our page on your rights as a policyholder or you are encouraged to request a summary of your benefits directly from your insurance provider.

Small Business Owners

If you are a small business owner there are a number of things you need to understand about employee health insurance. Small business owners should know that there are some options that make insurance options much cheaper than expected. If you are a small business owner with fewer than fifty employees, you may be eligible to receive coverage for your employees through the Small Business Health Options Programs (SHOP). SHOP offers affordable quality health insurance for the small business owner and his or her employees.

As of January 1, 2018, you are not required to register or create an account with HealthCare.gov. To sign up for this type of coverage you may work with an insurance agent, broker, or directly with the insurance company.

Small Business Insurance Eligibility

A business owner has the ability to apply for SHOP coverage year-round. This means that no matter when you start your business you will have the option to apply for employee insurance. To be eligible for SHOP coverage your business must meet certain requires that include the following:

  • The first requirement for SHOP is that you have at least one full-time employee (FTE). The employee cannot be your spouse, a member of your family, or co-owner. Additionally, if you have more than fifty full-time employees you may not qualify for SHOP. Keep in mind that you are not required to provide health insurance for independent contractors. Independent contractors operate under a different name that is not tied to your business, therefore, they are not considered full-time employees.
  • In consideration of the 1-50 requirement mentioned above, a small business owner is not required to offer insurance coverage to part-time employees. A full-time employee is an employee that works on average 30 hours or more during the work week. However, a small business has the option to provide insurance coverage to part-time workers or seasonal workers if they choose.
  • At least 70 percent of the employees you offer insurance to should accept your insurance. This means that if you have fifteen employees at least ten employees should register for SHOP insurance. You may use the Marketplace Minimum Participation Rate Calculator to help you determine the minimum participation required. Note that each state has a different threshold on the minimum participation number required.
  • Finally, your business must be registered in the United States.

A small business owner may want to consider the following before applying for an insurance policy through SHOP. Some of the factors that may be considered are the following: the type of coverage you will offer (medical, dental or both), how much you will pay for the premium accounts, whether you will offer insurance to part-time employees, the date to begin coverage, and how long a new employee must wait before being added to the company health insurance policy.

Medium and Large Businesses

Like small businesses, large and medium-size businesses are required to provide insurance to their employees. A medium size business is one that employs 50 to 99 full-time individuals. On the other hand, a large business is one with over fifty full-time employees. As mentioned earlier, seasonal workers and part-time workers are not considered full-time employees and the company can decide if these individuals will be included into the health insurance plan. Since January 1, 2015, large businesses are required to offer health insurance options to their employees. The insurance options that are offered to employees working in large business firms must meet the minimum essential coverage requirements offered through the Affordable Care Act. The ‘minimum essential coverage’ requirements include: laboratory services, prescription drugs, mental health and substance abuse disorder services, maternity care, newborn care, emergency services, hospitalization, preventative and wellness services, ambulatory services, chronic disease management, oral and vision services, pediatric services, rehabilitative services. According to the Affordable Care Act a large company is required to provide insurance that covers these basic treatments and procedures.

Employers that do not offer the insurance coverage that meet the minimum essential coverage requirements will be required to pay what is called the "Employer Shared Responsibility Provisions". Employers that do not comply with the Affordable Care Act will be required to pay a certain fine depending on the following. If an employer does not offer coverage and has at least one employee on a premium tax credit, the company will be required to pay two thousand dollars for every full-time employee. This fee will not include the first thirty employees in the assessment. Additionally, under the Internal Revenue Code Section 4980D, employers that fail to offer insurance that meets the basic coverage requirements will be required to pay one hundred dollars per day for each employee.

However, if you are a medium or large business employee, you have the option to opt out from the health coverage offered to you by your company. You may already be insured through your personal health care plan or through your spouse’s health insurance plan you may choose not to opt out of the business health insurance policy.

Medium and large businesses are required to offer full-time employees an affordable insurance package that covers basic costs. As described above, if the employer fails to provide affordable health insurance the company may be required to pay a certain amount of money. 

Small businesses, medium and large size businesses, have the obligation to provide health insurance coverage to their employees. When business entities fail to provide insurance coverage, they will owe a certain amount of money to the Internal Revenue Service (IRS) for failure to provide insurance that covers basic costs. An employee is eligible for health insurance coverage provided by the company whenever he or she is a full-time employee. A full-time employee is a person that works at least thirty hours a week. Small businesses and larger business entities have different responsibilities when it comes to providing health care insurance. Small businesses may seek Small Business Health Options Program (SHOP) unlike businesses with more than fifty employees. If you wish to learn more about your insurance coverage obligations, you are encouraged to speak with a qualified insurance expert or lawyer.

Keep in mind that with the new set of laws introduced with the new administration, most of those fees underlined in the Affordable Care Acct will no longer apply. To learn more about the laws that apply to your business size you may visit the National Conference of State Legislatures

Federal Employee

A federal employee also has the right for insurance coverage from their agency. A federal employee is a person that is employed by the United States government. This includes people working at the White House, military personnel, anyone working under the legislative branch, the judicial branch, the executive branch, the department of agriculture, the department of commerce, the department of defense etc. If you are a federal employee, you are eligible to receive health insurance coverage through the Federal Employees Health Benefits (FEHB) Program. The FEHB program can provide insurance coverage to your spouse and to children in your household under the age of 26. Like with other health insurance plans, the FEHB program offers the following preventative services: doctors’ visits, lab tests, prescription coverage, surgery, x-rays, maternity care, mental health services, physical therapy, urgent care and more at no extra cost.

FEHB Eligibility

To be eligible for FEBH you must be currently a federal employee or a retired federal employee. As stated above, you may also receive coverage if you are married to a federal employee.

Federal employees can enroll in the FEBH program within sixty days of being employed. The costs will ultimately depend on the type of program that you select. However, your employing agency is required to pay 70% of your premium and you are required to pay the remaining 30%. To enroll you may apply using the SF 2809 form.

Find a Health Insurance Lawyer Near You

When applying for health insurance there are several factors that you will have to take into consideration. First and foremost, you will need to understand the type of insurance coverage that is right for you. This can be done by assessing your specific health needs. Your health insurance should reflect coverage for your health concerns. Another factor includes your employer. As mentioned above, there are different insurance policies and plans that apply to individuals working in small businesses, medium-size businesses, and large size business. There are also different health insurance packages offered exclusively to federal employees. As with each health insurance coverage plan, you need to ensure that you are eligible for that specific plan. However, keep in mind that an insurance company may not reject coverage based on prior health concerns and may not reject coverage to a person based on their sex, national origin, color, creed, or sexual orientation.

If you are being denied insurance coverage and you know you meet the basic eligibility requirements, then you might want to speak with a legal professional about your case. By law, your business is required to offer affordable health insurance to all employees. Furthermore, an insurance company has the obligation to provide coverage whenever the policyholder makes a claim that is covered by the insurance agreement. To speak with an attorney about your issues with your insurance provider, you may contact the Stop Health Insurance Denials at 310-695-5241