Common Pitfalls

In the past, some people found it impossible to find health coverage that was affordable and met their needs. Starting in 2014, there are more options than before. Now, there should be an option for almost everybody, even if you have a disability. The exact health coverage that will be right for you will depend on things like your family’s income, whether you have access to employer-sponsored coverage, your age, where you live, if you use tobacco products, and whether you have a disability.

If you have the option of employer-sponsored coverage or public health programs like Medicare or NC Medicaid, they are probably your best bet.

If you don’t, you will probably end up getting an individual plan through HealthCare.gov and the government may help you pay for that plan. Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

Note: It is very important to have health coverage, but starting in 2019 there is no tax penalty if you don't have coverage.

HealthCare.gov is the best option for getting an individual plan. There are four big reasons it is best to use HealthCare.gov:

1. It’s the only place where you can get government help paying for your premiums and other health expenses.
2. It will automatically figure out if you or your family is eligible for a public health coverage program like NC Medicaid. If you are, you can sign up for that program instead of an individual plan.
3. HealthCare.gov has customer services representatives available over the phone at 1-800-318-2596 or 1-855-889-4325 (TTY).
4. It’s totally free to use the marketplace to shop for insurance plans—there are no commissions and no hidden fees.

Open enrollment for individual plans has ended for this year. People in certain situations can still sign up for a health plan under special enrollment rules.

Usually, you can only sign up for an insurance plan through HealthCare.gov during a certain time called open enrollment. To sign up for an individual plan that will cover you during 2025, you must sign up between November 1, 2024 and January 15, 2025.

If you do not sign up during that time, you will usually not be allowed to sign up for an individual plan through HealthCare.gov until another year has passed. That means you might not be able to get coverage for an entire year.

There are certain situations when you can sign up for an individual plan through HealthCare.gov even though it is not the usual open enrollment period:

• Your household income is at or below 150% of FPG
• If you lose other health coverage you had
• If your income changes and you gain or lose eligibility for government help paying for your coverage
• If you become a legal resident of the United States
• If you move
• If there was a mistake in your enrollment
• In other life-changing circumstances, such as having a child or getting married

Note: American Indians do not have these restrictions on enrollment.

If your employer offers you health coverage that would cost you, for your policy alone, less than 9.02% of your family’s income and that coverage meets a certain benefits level, you won't qualify for government help to reduce the premium on an individual plan purchased through HealthCare.gov.

That means that if you decide to purchase an individual health plan, you will have to pay the full price, which will likely be more than you would have paid had you used the coverage provided by your employer. If your employer, your parent’s employer, or your spouse’s employer offers you health insurance, in most cases it will be less expensive than if you were to buy an individual plan.

Note: Before 2023, the spouse or children of an employee would not qualify for subsidies on HealthCare.gov if the employer offered coverage that was affordable for the employee's policy alone, even if the cost to add the rest of the family wasn't affordable. This was called the "family glitch." Learn more about affordability rules for family members and how it affects eligibility for tax credits on HealthCare.gov.

There may be situations where it makes more sense for different members of your family to get health coverage in different ways. Do not feel that just because one member of your family gets a certain plan, the entire family needs to get that plan.

For example, let’s say you work for a company that only offers health coverage for you and your children, but not your spouse. You could take the coverage for yourself and your spouse could get coverage on HealthCare.gov. Since your employer doesn’t offer coverage for your spouse, your spouse might even qualify to get government help paying for an individual plan through tax subsidies.

If your income is low enough, your children could sign up for NC Medicaid, even if you and your spouse don’t qualify for it.

As you can see, in some situations it can make sense for a single family to get totally different types of coverage for different family members.