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Marketplace & SHOP Insurance Information 





Health Insurance Marketplaces Overview

Each state will have a Health Insurance Marketplace where individuals and small businesses may purchase insurance. A Marketplace provides consumers with the ability to easily compare and purchase health insurance. A Marketplace can be operated by a state or by the federal government. Marketplaces operated by a state are called State-based Marketplaces. Marketplaces operated by the federal government are called Federally-facilitated Marketplaces.

There are two types of Marketplaces:

  • The Individual Marketplaces for individual consumers and their families
  • The SHOP Marketplaces for small business owners.


Functions of a Marketplace

The major functions of a Marketplace include:

  • Certifying health plans to participate in a Marketplace as QHPs
  • Determining individuals’ eligibility for enrollment in a QHP
  • Determining individuals’ eligibility for premium tax credits and cost-sharing reductions
  • Determining or assessing individuals’ eligibility for enrollment in Medicaid and/or the Children's Health Insurance Program (CHIP)
  • Facilitating individuals’ enrollment in a QHP
  • Carrying out certain plan oversight functions, including monitoring QHP issuers for continuing compliance with certification requirements
  • Facilitating employers’ applications and employee enrollments in coverage through SHOP

Note: Subsequent topics in this course will provide more information on affordability programs available in the Marketplaces, and the eligibility and enrollment rules and procedures related to these programs.

State-based Marketplaces and Federally-facilitated Marketplaces

Beginning October of 2013, consumers can apply and enroll in coverage through the Marketplaces in every state and the District of Columbia. Some states will establish their own Marketplaces, known as State-based Marketplaces. If a state chooses not to establish its own Marketplace, the Department of Health and Human Services (HHS) will either establish a Federally-facilitated Marketplace in that state, or will operate the Marketplace in partnership with the state. (These are called State Partnership Marketplaces, and they are one type of Federally-facilitated Marketplace.) All Marketplaces will carry out the same major functions.

 

Individual Marketplace & SHOP Insurance Plans

Marketplaces will perform a set of core functions: determining the eligibility of individuals and enrolling individuals in QHPs; certifying health plans as QHPs for operation within the Marketplaces; ensuring QHP accountability; facilitating eligibility determinations for governmental programs, such as Medicaid and Children's Health Insurance Program (CHIP); determining eligibility for advance payments of the premium tax credit and cost- sharing reductions for QHP enrollees.


The Individual Marketplace collects and verifies eligibility information from individuals, determines their eligibility for a QHP, and facilitates enrollment. The streamlined application process will assist in determining an individual's eligibility to enroll in Medicaid and CHIP, and in determining whether an individual is eligible for advance payments of the premium tax credit and cost-sharing reductions. The eligibility determination will use information provided by the applicant on citizenship, incarceration, income, and residency status through a streamlined system that allows the Marketplace to verify an applicant’s information through the Social Security Administration (SSA), the Internal Revenue Service (IRS) (IRS) and the Department of Homeland Security (DHS).

SHOP collects and verifies eligibility information from employers and employees, determines their eligibility for enrollment in a QHP, and facilitates enrollment. After an employer has entered basic information about their business and employees, SHOP will generate information on the range of premiums for all plans available. SHOP also facilitates enrollment for employees’ dependents if offered coverage by their employer. Eligibility for the small business tax credit is determined when an employer files his or her taxes each year.

 

The Affordable Care Act

The primary goal of the Affordable Care Act is to help millions of Americans obtain health insurance coverage. To achieve that goal, the Affordable Care Act provides new coverage options, gives consumers the tools they need to make informed choices about their health care coverage, and puts in place strong consumer protections. Agents and brokers will play an integral role in helping individuals understand and act on the coverage choices that the Affordable Care Act offers through Marketplaces.

A Marketplace is a mechanism for organizing health insurance options to help consumers and small businesses shop for coverage in a way that permits easy comparison of available plan options based on price, benefits and services, and quality. The Affordable Care Act includes many provisions to make health insurance coverage more accessible and affordable. Key components of the Affordable Care Act that will affect the consumer include:

  • Health law changes
  • Major consumer protections


Health Law Changes in the Affordable Care Act

The health law changes include:

  • Creation of Marketplaces, through which individuals who do not have access to public assistance programs or affordable employer-sponsored coverage may compare and purchase plans. Some individuals will be eligible for financial assistance through premium tax credits and/or cost- sharing reductions
  • Expansion of Medicaid in some states to cover individuals under age 65 whose household incomes are less than 138% of the Federal Poverty Level (FPL)
  • Introduction of a requirement that requires individuals to maintain minimum essential coverage, qualify for an exemption from coverage, or make a payment when filing their federal income tax returns.


Major Consumer Protections in the Affordable Care Act

The Affordable Care Act included many provisions designed to help ensure that consumers have access to effective health care coverage, and to limit their costs. Key provisions that you need to understand in order to best serve the consumer include:

  • Extension of health insurance coverage to children up to age 26
  • Expansion of the “guaranteed issue” requirement to ensure that health insurance issuers offer group and individual market policies to any eligible individual in a state, regardless of health status
  • Prohibition on charging consumers a higher premium based on health status or gender
  • Elimination of annual and lifetime coverage limits
  • Prohibition on coverage limitations or exclusions based on pre-existing conditions
  • Prohibition on precluding a qualified individual’s participation in an approved clinical trial, or discriminating against that individual based on such participation
  • Introduction of an 80/20 MLR rule to ensure that at least 80 percent of the premium dollars paid to a health insurance issuer are spent on providing health care


Young Adult Coverage

Under the Affordable Care Act, health plans that cover children must make coverage available to children up to age 26. Young adults can join or remain on a parent’s plan even if they are:

  • Married (coverage does not extend to married child’s spouse)
  • Not living with a parent • Not attending school
  • Not financially dependent on a parent
  • Eligible to enroll in their employer’s plan (starting in 2014)


Guaranteed Issue and Guaranteed Renewability

The Affordable Care Act requires health insurance issuers to offer all of their individual market and group market plans to any applicant in the state. It also requires health insurance issuers to accept any individual who applies for those policies, as long as the applicant agrees to the terms and conditions of the policy, including the payment of premiums. This provision is called “guaranteed issue.” Coverage offered through and outside the Marketplaces may restrict guaranteed issue coverage to certain enrollment periods. Additionally, the Affordable Care Act requires health insurance issuers to offer to renew or continue in force coverage at the option of the policyholder. This is called “guaranteed renewability.”


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