Healthcare Reform Timeline

Frequently Asked Questions



Plans that are not grandfathered provide coverage for routine patient costs received by a member who is participating in an approved clinical trial. Coverage includes phase I clinical trials and expands the types of conditions beyond cancer. 

Plans cover routine costs associated with a phase I, phase II, phase III, or phase IV clinical trial that is being done to prevent, detect, or treat cancer or a life-threatening disease or condition (a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted). Routine patient costs are considered the medically necessary services that would be otherwise covered by a health plan if the member was not a part of a clinical trial.

To qualify, a clinical trial must be at least one of the following:

  • Federally funded
  • Conducted under an investigational new drug application reviewed by the Food and Drug Administration
  • A drug trial that is exempt from having such an investigational new drug application

This information is subject to change based on new or revised laws or regulations, and additional coverage rules and limitations may apply. For more information on how these benefits may apply to your coverage, please check your subscriber agreement or call Customer Service.


Yes. Dependents up to age 26 can be covered whether or not they: 

  • Are married
  • Are students
  • Live with their parents
  • Are financially dependent on their parents
  • Are eligible for coverage through their employers*


  • If they are married, their spouses cannot be covered.
  • If they have children of their own, the children cannot be covered under their grandparents’ plan.

Coverage remains effective until the first of the month following the dependent’s 26th birthday. For more information about dependent coverage, please read this fact sheet.



Individuals are responsible for ensuring that they, and any dependents, have minimum essential coverage. Coverage from any of the following would be considered minimum essential coverage:

  • Government-sponsored programs including: Medicare, Medicaid, Children’s Health Insurance Program coverage, TRICARE, coverage through Veterans Affairs, and Health Care for Peace Corps volunteers
  • Employer-sponsored plans, including continued coverage under COBRA or similar state laws, retiree plans, grandfathered plans and other plans offered in the small or large group market
  • Individual market plans
  • Student health insurance plans 
  • Other coverage designated as minimum essential coverage by the Department of Health & Human Services and/or the Treasury

Health plans provide full coverage for many preventive services with no cost sharing (deductibles, copays,  or coinsurances) when members visit in-network doctors. Preventive care is healthcare that is aimed at screening for and preventing disease, including:

  • Flu shots and other immunizations 
  • Blood tests 
  • Other screenings such as mammograms, Pap tests, and colonoscopies
  • Other preventive services covered under federal healthcare reform

When state law is more generous than the federal mandates for preventive services, we follow state law. For more information about preventive care services, please read this sheet.


Buying coverage

You can purchase coverage during open enrollment. In 2015, open enrollment is from November 15, 2014 to February 15, 2014.

The start date of your coverage is based on the date you submit your application. If we receive your application by the 15th of the month, your coverage will be effective the first of the next month. Applications received after the 15th will be effective the following month. For example:

  • For applications received from December 1 to December 15, coverage is effective January 1.
  • For applications received from December 16 to December 31, coverage is effective February 1.

If open enrollment has ended and you lose your coverage or your situation changes, you may be eligible to enroll in a plan. Please contact us for details.


Buying coverage

Yes. People in the following groups don’t have to pay a penalty for not having health coverage:

  • Individuals with a religious conscience exemption (applies only to certain faiths)
  • Incarcerated individuals
  • Undocumented aliens
  • Individuals who cannot afford coverage (e.g., required contribution exceeds 8 percent of household income)
  • Individuals with a coverage gap of less than three months
  • Individuals in a hardship situation (as defined by the Secretary of Department of Health & Human Services)
  • Individuals with income below the tax filing threshold
  • Members of Indian tribes
Buying coverage

In addition to offering tax credits to make coverage more affordable, the government is providing a cost-sharing reduction program.  The government helps by paying part of your copays, coinsurance, and deductible. This helps limit the amount that you have to pay out of pocket for services.

If your household income is between 100 percent and 250 percent of the federal poverty level (up to 300 percent for Native Americans), you may be eligible to enroll for a plan with cost-sharing reductions.  In general, people at the income levels below will qualify to save in 2015.*

  • Up to $29,175 for individuals
  • Up to $39,325 for a family of 2
  • Up to $59,625 for a family of 4

*These amounts are based on 2014 numbers and are likely to be slightly higher in 2015. Amounts are different for each family size, up to eight.

Buying coverage
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