I have my own surgical insurance. Do I still need to pay fees?

Question: I have self-purchased hospital/surgical insurance that only covers expenses incurred with a surgery. Does this qualify as “minimum essential health insurance” and get me off the hook for the fee?


Answer: Your insurance plan would not meet the law’s requirement for “minimum essential coverage” because it does not include all of the necessary “essential health benefits.” Policies must include benefits in ten categories that go beyond surgery, including ambulatory services, maternity and newborn care, and prescription drugs. You can find more detail on coverage requirements on the healthcare.govwebsite.

An exception might apply if you initially purchased your plan before March 23, 2010, the date the Affordable Care Act was passed. Some plans sold before that date qualify for “grandfathered” status, which means they can satisfy the law’s mandate that individuals maintain coverage even though they do not include the full range of required benefits. However, for a plan to qualify as grandfathered, it must have remained in its original form since March 23, 2010 without significant changes to benefits, premiums, co-payments or deductibles. If you think your plan might qualify, you should check with the insurance company, which can give you a definitive answer.

If your plan does not meet the coverage requirements and is not grandfathered, you would be subject to the penalty for being uninsured if you keep it. If you purchase a new policy, the insurance companymust provideyou with a Summary of Benefits and Coverage that clarifies whether the coverage is sufficient to exempt you from the penalty.


Robert I. Field, Ph.D., J.D., M.P.H. is a professor of law at the Earle Mack School of Law and professor of health management and policy at the School of Public Health at Drexel University. He also writes for The Field Clinic blog. Ask Rob your questions about the new healthcare law.