Arizona Health Insurance Guide 2023
Information, tools, and access to online health insurance quotes for Arizona Residents of Arizona have access to a variety of private insurance company-offered health insurance policies for both individuals and groups.
Through HealthCare.gov, the government exchange, you may also purchase individual and family coverage from participating private insurers. You may also acquire insurance through the federal exchange if you are a sole proprietor without any workers. Additionally, you could be qualified for several federal and state programs like COBRA and Medicaid.
Patient Protection and Affordable Care Act of 2010 and Arizona
The Patient Protection and Affordable Care Act, usually referred to as ObamaCare, the Affordable Care Act, or simply the ACA, went into effect in 2010. After being passed, the law’s provisions have continued to be implemented gradually. Most U.S. citizens and legal residents must obtain qualified health insurance starting on January 1, 2014, or they must pay an annual tax penalty for each month they do not have insurance.
The “individual mandate” is what is meant by this. The grace period lasts till March 31, 2014. Starting in 2014, the fine for not having qualifying coverage is $95 for adults and $47.50 for children, or up to 1% of your taxable income (maximum of $285 per family), whichever is larger. For the remainder of 2017 and beyond, the fine will rise yearly.
Arizona Small Business Coverage
If you own a small business in Arizona (50 or fewer full-time-equivalent employees – FTEs), you can purchase qualifying coverage for your employees through SHOP, the Small Business Health Options Program, or through a private broker or insurance agent. However, you may qualify for tax credits worth up to 50% of your premium costs if you use SHOP.
Beginning in 2016, SHOP will be open to employers with up to 100 FTEs. Under the Employer Shared Responsibility provision of ACA, beginning in 2015, all employers with 50 or more FTEs must offer employees at least one plan that is ACA-compliant or face fines of $2,000 per employee.
ACA Standardized Benefits
Plans offered by private insurers may offer additional benefits and individual states may require additional benefits, but all qualifying plans must offer these 10 standardized essential benefits:
- Ambulatory patient service
- Emergency services*
- Maternity and newborn care*
- Mental health and substance use disorder services including behavioral health treatment*
- Prescription drugs*
- Rehabilitative and habilitative services and devices
- Preventive and wellness and chronic disease management for adults and children, including 100% coverage for some services*
- Pediatric service, including oral and vision care*
*Lifetime dollar limits on these essential health benefits have been eliminated.
Arizona Additional Mandated Benefits
Arizona currently mandates that the following benefits, which exceed ACA requirements, must be provided or offered by private providers authorized to sell health insurance policies within the state:
- Home health care services in lieu of hospitalization – for individual and group disability and HMDO plans
- Chiropractic care – for individual and group disability and HCSO/HMDO plans
- Off-label prescription drugs – for cancer if the policy covers prescriptions drugs – for individual and group disability, HCSO/HMO and HMDO plans
- Clinical trials – if the policy covers patient cost – for individual and group disability and HMDO plans
- Reconstructive surgery following mastectomy – for individual and group disability and HMDO plans
- Diabetes care management – supplies and equipment – for individual and group disability and HMDO plans
Arizona Available Standardized Plans
To help you more easily compare costs and benefits, ACA designates that all qualifying plans be one of four metals: Bronze, Silver, Gold, and Platinum. Each is based on the average amount of healthcare costs the plan will cover shown as a percentage of what is covered by your insurance company and what is paid for by you. All insurers participating in the federal or state healthcare exchange must offer, at minimum, Silver and Gold plans. All metal plans have a shared maximum out-of-pocket amount that you can be charged in any calendar year.
|Metal Plan||Insurer Pays||You Pay|
In addition, if you are under 30 or meet the criteria for a hardship exemption, you can purchase a catastrophic plan that is compliant with ACA requirements.
Premiums charged for any of the qualifying metal plans may be based on:
- Your age
- Tobacco use
- Where you live – determined by rating area
- The number of family members enrolling with you
Under ACA, no one can be denied coverage or charged significantly higher premiums because of past health history (pre-existing conditions) or gender. There can be no look-back or waiting periods imposed. Policies are effective on issues. All coverage is renewable if you choose to renew it. Plans can only be canceled for non-payment of premiums or fraud. The guaranteed issue provision applies to all non-grandfathered plans.
ACA Financial Assistance
You may qualify for financial assistance in the form of tax credits to help with monthly premiums and subsidies to help with out-of-pocket costs.
Tax credits can be applied to any of the four metal plans to lower your monthly premiums. They are paid directly to your insurance provider by the federal government. Your tax credit is based on your estimated income for the calendar year, in advance of filing your federal return. Note that if your actual income exceeds the eligibility limit, you will have to reimburse the government for the difference. Tax credits are only available to Arizona residents who purchase coverage from HealthCare.gov.
Subsidies to help Arizona residents with out-of-pocket expenses such as copayments are only available for Silver plans purchased through HealthCare.gov and are only offered to those who earn up to 250% of the federal poverty level.
The following types of health insurance plans are available in Arizona for individuals and families. They may be purchased through private providers or providers participating in Arizona through the federal exchange, HealthCare.gov.
Preferred Provider Organizations (PPOs)
You have access to a network of healthcare providers participating in your selected PPO. You do not have to select a Primary Care Physician or obtain a referral to see any in-network provider. Some PPOs may require that you meet a deductible before their portion of the coverage begins.
Health Maintenance Organizations (HMOs)
Most HMOs require you to select a Primary Care Physician to coordinate your healthcare and provide referrals to specialists. HMOs typically charge a fixed copayment for each doctor visit and other care provided. Depending on the HMO, there may be a low deductible or no deductible in addition to the copayments. All services must be obtained through the HMO’s network unless otherwise stated in your plan.
High-Deductible Health Plans with Health Savings Accounts (HDHP w/HSAs)
These plans give you more control over your out-of-pocket expenses by offering lower monthly premiums with higher deductibles. They are typically combined with HSAs that allow you to set aside interest-earning pretax funds (through your employer’s payroll deduction) or tax-deductible funds you deposit in a private account. These funds can be drawn on to cover your healthcare costs. Any interest accrued is tax-deferred and any unused funds can roll over from year to year. See your tax advisor for information specific to your situation.
Flexible Spending Accounts (FSAs)
ACA provisions allow you to continue to make tax-free contributions of up to $2,500 per year to an FSA. These can be used for out-of-pocket healthcare expenses not covered by your insurance plan. This includes many over-the-counter (OTC) preparations, devices, and equipment as allowed by law. However, you will need to obtain a prescription for OTC items and submit an itemized receipt to qualify for the tax deduction.