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Navigating health reform
Health Insurance Marketplace: What Individuals and Small Businesses Need to Know
Update: Recently the U.S. Department of Health and Human Services (HHS) announced it would delay the online enrollment feature for the federal SHOP exchange until November 2014. However, small businesses in states using the federal SHOP exchange may still enroll their employees in coverage through an agent, broker, or insurer that offers a certified SHOP plan and has agreed to certain HHS standards. HHS has stated that they intend to extend the current deadline for January 1, 2014 coverage to December 23. For states not using the federal exchange, though, the deadlines for small employers to complete enrollment in a SHOP plan with January 1, 2014 coverage may be earlier than December 23.
On January 1, 2014, the health insurance marketplace (or exchange) will become a new way for individuals and employees of small businesses to obtain health insurance coverage. Open enrollment is scheduled to begin on October 1, 2013.
The marketplace is intended to be an easy way to shop for health insurance — it will have all options available in one place and a comparison of price, benefits, quality, and other factors.
In 2014, the U.S. Department of Health and Human Services (HHS) expects that 25 million Americans will have access to quality health insurance. In addition, up to 20 million people, including families, may qualify for assistance to make coverage more affordable. In 2016, the marketplace will be available to those working for businesses with 100 full-time employees and full-time equivalents, and in 2017 each state has the option to expand the marketplace to employers with more than 100.
By law, the marketplace must be functioning on October 1, 2013, and it must include provisions to determine eligibility for premium tax credits or cost-sharing subsidies toward individual or family health insurance based on an individual’s prior year tax return. An individual cannot get marketplace cost-sharing subsidies if he or she is eligible for employer-sponsored coverage that is deemed affordable and meets minimum value.
Although there is no requirement to purchase health insurance through the marketplace, to receive premium tax credits or cost-sharing subsidies, an individual or small employer must purchase coverage through the marketplace (not in the outside market).
Essential health benefits
While insurance plans are offered by private companies, the marketplace will be run by either the federal government (federally based exchange) or by your state (state-based exchange). The insurance plans offered in the marketplace will cover the same core set of benefits, called the “essential health benefits.” These include:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder
- Prescription drugs
- Rehabilitative and habilitative service and devices
- Laboratory services
- Preventative and wellness services and chronic disease management
- Pediatric services, including oral and vision care
In addition, a plan may not turn someone away or charge more due to an illness or medical condition, or charge women more than men for the same plan. Find out if your state is operating the marketplace at HealthCare.gov. If your state runs the marketplace, you will get health coverage information through your state’s website.
A growing number of states have released approved 2014 premiums and other details about individual and small group insurance plans that will be available in the marketplaces, but these rates do not take into account premium tax credits or cost-sharing subsidies. In addition, the federal government must give final approval to these plans in September. States that have declined to run their own marketplace and who will have federally run exchanges still must have premiums approved at the federal level.
Some states such as Arkansas, Illinois, Missouri, and New Hampshire have approved their rates but have not released any information about premiums. The HHS expects most information regarding the marketplaces will not be released until October 1, 2013.
Small business marketplace enrollment
Small businesses may enroll in the marketplace starting October 1, 2013, and purchase employee coverage that will begin on January 1, 2014. The marketplace for small businesses is referred to as the Small Business Health Options Program, or the “SHOP Exchange.” This is a streamlined way for small employers and small tax-exempt entities to shop for health insurance coverage. Small businesses may enroll directly through the SHOP Exchange or through a broker registered with the SHOP.
Small employers using the SHOP Exchange may be eligible to receive the tax credits available under the Affordable Care Act (ACA).
Individual marketplace enrollment
Individuals who want to participate in the marketplace must live in its service area, be a U.S. citizen or national, or be a non-citizen who is lawfully present in the United States for the entire period for which enrollment is sought and is not incarcerated.
The marketplace will list all of the health plans available in your area, including the monthly premium costs for private insurance plans, and will state if you qualify for premium tax credits, cost-sharing subsidies, Medicaid, or the Children's Health Insurance Program (CHIP).
The ACA includes a community-based navigator program, where individuals trained on the regulations will provide outreach, education, and enrollment resources for individuals. You can apply for marketplace insurance in-person with the help of a navigator or other qualified helper. You can also apply online or by mail. HHS is working with local libraries and community colleges to assist those who do not have computer or web access. Application help is available 24/7 at 800-318-2596 and online.
Health insurance exchange employee notice
All employers are required to provide their current employees with the Health Insurance Exchange Notice no later than October 1, 2013, regardless if they do or do not offer coverage. This notice informs employees of the existence of the exchange, the services offered, and contact information. For employees hired after October 1, 2013, the notice must be provided upon hire. Model notice language is available on the Department of Labor website for employers who offer a health plan as well as employers who do not.
Planning for open enrollment
Individuals and businesses can stay informed about open enrollment by:
- Signing up at HealthCare.gov to receive email or text updates about the marketplace
- Finding out which marketplace will serve you
- Learning about the different types of health coverage available through the marketplace
- Determining if you will have employer-sponsored coverage in 2014, and if not, how to obtain insurance through the marketplace or other sources
- Starting the marketplace application process to find out if you are eligible for premium tax credits or cost-sharing subsidies