Marketplace Eligibility, Enrollment Periods, Plans and Premiums
What is the health insurance Marketplace?
Health Insurance Marketplaces (also known as Exchanges) are new organizations that will be set up to create more organized and competitive markets for buying health insurance. They will offer a choice of different health plans, certifying plans that participate and providing information to help consumers better understand their options. Through the Marketplace, individuals and families will be able to shop for coverage if they need to buy health insurance on their own. Premium and cost sharing subsidies will be available through the Marketplace to reduce the cost of coverage for individuals and families, based on their income. Individuals and families with very low incomes will also be able to find out at the Marketplace if they are eligible for coverage through Medicaid and CHIP. Finally, small businesses can also buy coverage for their employees through the Small Business Health Options Program (SHOP) Marketplace.
There will be a health insurance Marketplace in every state for individuals and families and for small businesses. Some Marketplaces will be operated by the State and have a special state name (such as CoveredCalifornia or The Maryland Health Connection.) In other states where the federal government runs the Marketplace, it will be known called The Health Insurance Marketplace of [state name.]
How do I find my state Marketplace?
Links to all state Marketplaces can be found at www.healthcare.gov
Who can buy coverage in the Marketplace?
Most people can shop for coverage in the Marketplace. To be eligible you must live in the state where your Marketplace is, you must be a citizen of the U.S. or be lawfully present in the U.S., and you must not currently be incarcerated.
Not everybody who is eligible to purchase coverage in the Marketplace will be eligible for subsidies, however. To qualify for subsidies (also called premium tax credits) people will have to meet additional requirements having to do with their income and their eligibility for other coverage.
I live in one state, but drive across the border every day to work in a different state. What Marketplace should I use to buy coverage?
Generally, you should buy coverage in Marketplace in the state where you live.
I’m eligible for health benefits at work but want to see if I can get a better deal in the Marketplace. Can I do that?
You can always shop for coverage on the Marketplace, assuming you meet other eligibility requirements, but if you have access to job-based coverage, you might not qualify for premium tax credits.
Can I buy a plan in the Marketplace if I don’t have a green card?
If you are not a U.S. citizen, a U.S. national, or an alien lawfully present in the U.S., you are not eligible to buy a plan on the health insurance Marketplace. However, you can shop for health insurance outside of the Marketplace in the non-group market. Insurers outside of the Marketplace are prohibited from turning you down based on your health status or your immigration status and must follow generally the same rules as plans in the Marketplace. To obtain coverage, contact a state-licensed health insurance company or a licensed agent or broker. Your state Department of Insurance can help you find one.
When can I enroll in private health plan coverage through the Marketplace?In general, you can only enroll in non-group health plan coverage during the Open Enrollment period.
For 2016 coverage, the Open Enrollment period begins November 1, 2015 and extends through January 31st, 2016. Once the Open Enrollment period is over, individuals and families will not be able to enroll in Marketplace health plans until the next Open Enrollment period. However, if you experience certain changes in circumstances during the year, you will have a special 60-day opportunity to enroll in Marketplace health plans, outside of the Open Enrollment period.
For individuals and families buying non-group coverage on their own, outside of the Marketplace, you can only enroll in coverage during Open Enrollment periods and special enrollment opportunities, as well.
American Indians and Alaska Natives can enroll in coverage throughout the year, not just during Open Enrollment.
When can I enroll in Medicaid through the Marketplace?
You can enroll in Medicaid or CHIP at any time during the year, not just during Open Enrollment.
When can small employers enroll in coverage through the SHOP Marketplace?
Small employers can buy coverage for their employees through the SHOP Marketplace at any time during the year.
Can I buy or change private health plan coverage outside of Open Enrollment?
In general, you can have a special enrollment opportunity to sign up for private, non-group coverage during the year, other than during Open Enrollment period, if you have a qualifying life event. Events that trigger a special enrollment opportunity are:
When you experience a qualifying event, your special enrollment opportunity will last 60 days from the date of that triggering event.
States have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.
I signed up for a Bronze plan with a high deductible during Open Enrollment. Now, six months later, I need surgery and would rather be in a different plan with a lower deductible. Can I change plans?
No, in general, once you sign up for a plan, you are locked into that coverage for 12 months, or until the next Open Enrollment period. A change in health status doesn’t make you eligible for a special enrollment opportunity.
I have COBRA and it’s too expensive. Can I drop it during Open Enrollment and enroll in a Marketplace plan instead?
During Open Enrollment, you can sign up for a Marketplace plan even if you already have COBRA. You will have to drop your COBRA coverage effective on the date your new Marketplace plan coverage begins. After Open Enrollment ends, however, if you voluntarily drop your COBRA coverage or stop paying premiums, you will not be eligible for a special enrollment opportunity and will have to wait until the next Open Enrollment period. Only exhaustion of your COBRA coverage triggers a special enrollment opportunity.
I have COBRA and am finding it difficult to afford, but Open Enrollment is over. Can I drop my COBRA and apply for non-group coverage outside of Open Enrollment?
No, voluntarily dropping your COBRA coverage or ceasing to pay your COBRA premiums will not trigger a special enrollment opportunity. You will have to wait until you exhaust your COBRA coverage or until the next Open Enrollment (whichever comes first) to sign up for other non-group coverage.
I’m leaving my job and will be eligible for COBRA. Can I shop for coverage and subsidies on the Marketplace instead?
Yes, leaving your job and losing eligibility for job-based health coverage will trigger a special enrollment opportunity that lasts for 60 days. You can apply for Marketplace health plans and (depending on your income) for premium tax credits and cost sharing reductions during that period. If you enroll in COBRA coverage through your former employer, however, you will need to wait to the next Marketplace Open Enrollment period if you want to switch to a Marketplace plan.
How long after I enroll in a plan will coverage take effect?
In most states if you enroll in a private health insurance plan any time between November 1, 2015 and December 15, 2015 and make your first premium payment by the due date specified by your plan, your new health coverage starts January 1, 2016.
After that, if you enroll between the 1st and 15th day of the month and pay your premium by the due date, your coverage begins the first day of the next month. So if you enroll on January 10, 2016, your coverage begins February 1, 2016.
If you enroll between the 16th and the last day of the month and pay your premium by the due date, your effective date of coverage will be the first day of the second following month. So if you enroll on January 16, 2016, your coverage starts on March 1, 2016.
What health plans are offered through the Marketplace?
All health plans offered through the Marketplace must meet the requirements of “qualified health plans.” This means they will cover essential health benefits, limit the amount of cost sharing (such as deductibles and co-pays) for covered benefits, and satisfy all other consumer protections required under the Affordable Care Act.
Health plans may vary somewhat in the benefits they cover. Health plans also will vary based on the level of cost sharing required. Plans will be labeled Bronze, Silver, Gold, and Platinum to indicate the overall amount of cost sharing they require. Bronze plans will have the highest deductibles and other cost sharing, while Platinum plans will have the lowest. Health plans will also vary based on the networks of hospitals and other health care providers they offer. Some plans will require you to get all non-emergency care in-network, while others will provide some coverage when you receive out-of-network care.
What health benefits are covered under Marketplace plans?
All qualified health plans offered in the Marketplace will cover essential health benefits. Categories of essential health benefits include:
Will covered benefits under all Marketplace plans be the same? How can I compare?
Not necessarily. All Marketplace health plans are required to cover the ten categories of essential health benefits. However, insurers in many states will have flexibility to modify coverage for some of the specific services within each category. Any modifications must be approved by the Marketplace before plans can be offered. All health plans must provide consumers with a Summary of Benefits and Coverage (SBC). This is a brief, understandable description of what a plan covers and how it works. The SBC will also be posted for each plan on the Marketplace web site. The SBC will make it easier for you to compare differences in health plan benefits and cost sharing.
Plans might differ in other ways, too. For example, the network of health providers might be different from plan to plan.
I notice Marketplace plans are labeled “Bronze,” “Silver,” “Gold,” and “Platinum.” What does that mean?
Plans in the Marketplace are separated into categories — Bronze, Silver, Gold, or Platinum — based on the amount of cost sharing they require. Cost sharing refers to health plan deductibles, co-pays and co-insurance. For most covered services, you will have to pay (or share) some of the cost, at least until you reach the annual out of pocket limit on cost sharing. The exception is for preventive health services, which health plans must cover entirely.
In the Marketplace, Bronze plans will have the highest deductibles and other cost sharing. Silver plans will require somewhat lower cost sharing. Gold plans will have even lower cost sharing. And Platinum plans will have the lowest deductibles, co-pays and other cost sharing. In general, plans with lower cost sharing will have higher premiums, and vice versa.
I also notice “Catastrophic Plans” that look even cheaper. What are those and can I buy one if I want?
Insurers can also offer “Catastrophic” plans. Catastrophic plans have the highest cost sharing. In 2015, Catastrophic plans will have an annual deductible of $6,600 ($13,200 in family plans). You will have to pay the entire cost of covered services (other than preventive care) until you’ve spent $6,600 out of pocket; after that your plan will pay 100 percent of covered services for the rest of the year. Not everybody will be allowed to buy Catastrophic plans. They are only for adults up to age 30, and for older people who can’t find any other Marketplace policy that costs less than 8 percent of their income.
How can I find out if my doctor is in a health plan’s network?
Each plan sold in the Marketplace must provide a link on the Marketplace web site to its health provider directory so consumers can find out if their health providers are included.
The provider network information that insurance companies provide may or may not tell you whether a provider is accepting new patients, or whether a provider speaks your language. It is up to your Marketplace to require insurers to provide you with this information.
What happens if I end up needing care from a doctor who isn’t in my plan’s network?
Plans are not required to cover any care received from a non-network provider, though many plans today do, at least to some extent. If you do receive care out of network, it could be costly to you. Generally plans that provide an out-of-network option cover such care at a lower rate (eg, 80% of in-network costs might be reimbursed but only 60% of non-network care.) In addition, when you get care out of network, insurers may apply a separate deductible and are not required to apply your costs to the annual out-of-pocket limit on cost sharing. Non-network providers also are not contracted to limit their charges to an amount the insurer says is reasonable, so you might also owe “balance billing” expenses.
If you went out of network because you felt it was medically necessary to receive care from a specific professional or facility – for example, if you felt your plan’s network didn’t include providers able to provide the care you need – or if you inadvertently got non network care while hospitalized if the anesthesiologist or other physicians working in the hospital don’t participate in your plan network – you can appeal the insurer’s decision. If there is a Consumer Assistance Program in your state, staff in this program can help you file your appeal.
How can I find out if a health plan covers the prescription drugs that I take?Health plans in the Marketplace must include a link to their prescription drug “formulary” with other on-line information about the plan. The “formulary” is a list of prescription drugs the plan will cover. If you don’t find your drug on the formulary but your doctor says it’s medically necessary for you to take that specific drug, you can appeal for an exception to the plan formulary. If there is a Consumer Assistance Program in your state, staff in this program can help you file your appeal.
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I graduated from Western Carolina University and have spent the last twenty years working with our local residents, helping them with everything from customer service and mortgage lending to insurance.
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