Tuesday, December 1, 2015

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

MCT Photo Service

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.

More coverage
  • Have a question about the healthcare law? Ask our expert
  • Does lack of income prevent me from buying coverage?
  • 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.

    Professor, Earle Mack School of Law & Drexel School of Public Health
    We encourage respectful comments but reserve the right to delete anything that doesn't contribute to an engaging dialogue.
    Help us moderate this thread by flagging comments that violate our guidelines.

    Comment policy:

    Philly.com comments are intended to be civil, friendly conversations. Please treat other participants with respect and in a way that you would want to be treated. You are responsible for what you say. And please, stay on topic. If you see an objectionable post, please report it to us using the "Report Abuse" option.

    Please note that comments are monitored by Philly.com staff. We reserve the right at all times to remove any information or materials that are unlawful, threatening, abusive, libelous, defamatory, obscene, vulgar, pornographic, profane, indecent or otherwise objectionable. Personal attacks, especially on other participants, are not permitted. We reserve the right to permanently block any user who violates these terms and conditions.

    Additionally comments that are long, have multiple paragraph breaks, include code, or include hyperlinks may not be posted.

    Read 0 comments
    comments powered by Disqus
    Latest Health Videos
    Also on Philly.com:
    letter icon Newsletter