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Prepared by the American Association of Colleges of Nursing Updated August 2015

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Prepared by the American Association of Colleges of Nursing

Updated August 2015

What is the Health Insurance Marketplace?

The Health Insurance Marketplace was created through the Patient Protection and Affordable Care Act or ACA [Public Law 111-148] specifically in relation to Subtitle D—Available Coverage Choices for All Americans.

The core components of the ACA are the Individual Mandate and the State Exchanges. Individual Mandate requires most individuals to

obtain health insurance or pay a penalty in the form of a tax. In order to incentivize health insurance acquisition, the ACA provides cost assistance subsidies to individuals who qualify.

State Exchanges allow for each state to decide if they will create their own exchange, partner with the federal government, or have a federally-facilitated exchange for individuals to gain coverage.

Kaiser Family Foundation (2014). State Decisions For Creating Health Insurance Marketplaces, 2014 Retrieved from http://kff.org/health-reform/state-indicator/health-insurance-exchanges

Am I Eligible?

For an individual to be eligible for coverage through the Marketplace, they must meet the following criteria: Live in the United States Be a U.S. citizen, national, or

live lawfully in the United States

Cannot be incarcerated If you have Medicare

coverage, you’re not eligible to use the Marketplace to buy a health or dental plan

Healthcare.gov. (2015) Am I eligible for coverage in the Marketplace, Retrieved from https://www.healthcare.gov/am-i-eligible-for-coverage-in-the-marketplace/

How Do I Find Out What My State Is Offering?

Regardless of the state where you live, you can access the Marketplace to apply for coverage, compare your options, and enroll.

https://www.healthcare.gov/screener/

What Will I Need to Enroll?

Information about your household Social Security Numbers (or document numbers for legal

immigrants) Information about the professional helping you apply (if

you’re getting help) Information on how you file your taxes Employer and income information for every member of

your household who needs coverage (for example, from pay stubs or W-2forms—Wage and Tax Statements)

Policy numbers for any current health insurance plans covering members of your household

A completed Employer Coverage Tool for every job-based plan for which you or someone in your household is eligible

2016 income estimate Notices from your current plan that include your plan ID,

if you had health coverage in 2015

Healthcare.gov. (2015) Marketplace Application Checklist, Retrieved from https://marketplace.cms.gov/outreach-and-education/marketplace-application-checklist.pdf

How Can I Enroll: Apply on Line

Provide the following steps to help an individual or family obtain coverage:

Create an account. Go to the Marketplace and select your state to begin. Provide some basic information, and then choose a user name, password, and security questions for added protection. https://www.healthcare.gov/marketplace/individual/

Complete your application. Provide information about you and your family, like income, household members, current health coverage, and more

Pick a plan. See all the options you qualify for, including Medicaid and the Children’s Health Insurance Program (CHIP). The system will you know if you qualify for lower costs on private health coverage. Find out how to choose a plan that’s right for you.

Enroll. After you choose a plan, don't forget to enroll online and contact your insurance company to pay your first premium by the due date.

Healthcare.gov (2015). Health Insurance Marketplace Basics, Retrieved from https://www.healthcare.gov/get-covered-a-1-page-guide-to-the-health-insurance-marketplace/.

How Can I Enroll: Other Options

Apply by phone Call 1-800-318-2596, 24 hours a day, 7 days

a week (TTY: 1-855-889-4325). A customer service representative will work with you to complete the application and enrollment process.

Apply by mail Fill out a paper application and mail it in. Once

you get your eligibility notice, go online or contact our call center to pick a plan and enroll. Download the application form and instructions to begin

Local resources You may be able to apply online at a local

library or at a Community Health Center in your area.

When Can I Enroll? Key Dates for 2016 Open Enrollment

November 1, 2015: Open enrollment period for 2016

plans begins

December 31, 2015: Coverage ends for

2015 plans

January 1,2016: First date 2016

coverage can start

January 31, 2016 Open Enrollment Ends

If your patient has not enrolled in coverage by then, they generally cannot enroll in 2016 coverage until the next open enrollment period. The exceptions are life events such as having a child. If your patient does not have health insurance coverage in 2016, he or she may have to pay a penalty.

Healthcare.gov. (2015). 2016 Open Enrollment. Retrieved from https://www.healthcare.gov/marketplace-deadlines/2016/

During open enrollment, if your patient enrolls Between the 1st and 15th days of the month, their coverage starts the first day of the next month. Between the 16th and the last day of the month, their coverage starts the first day of the second following month. So if they enroll on March 16, your coverage starts on May 1.

What Is Meant By The Tax Credit?

When you buy health insurance coverage in the Marketplace, you may qualify to receive a premium tax credit that lowers what you pay in monthly premiums. This premium is dependent upon household income and size.

To find out if you qualify for a tax premium, visit: https://www.healthcare.gov/will-i-qualify-to-save-on-monthly-premiums/. Here, you will be asked questions about your household which will determine if you qualify and the premium amount.

What are the Tax Credits and Penalties? As of 2015:

The average monthly premium for an individual after the advanced premium tax credit was applied was $105

More than 8 in 10 individuals with a Marketplace plan qualified for an advanced premium tax credit

The average advanced premium tax credit covers about 72 % of the gross premium

In 2016, anyone who does not have health insurance coverage will have to pay the penalty of either: $695 for each adult and $347.40 for each child, up to $2,085 per

family, or 2.5% of family income that is above the federal tax return filing

threshold for your filing status The penalty amount is capped at the cost of the national average for a

bronze level health plan available through the Marketplace in 2016.

Health and Human Services (2015). Health Insurance Marketplace 2015: Average premiums after advance premium tax credits through January 30 in 37 States using the healthcare.gov platform. Retrieved from http://aspe.hhs.gov/health/reports/2015/MarketPlaceEnrollment/APTC/ib_APTC.pdf

What Are The Essential Health Benefits?

Essential Health Benefits: A set of health care service categories that must be covered by certain plans, starting in 2014.

Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace. States expanding their Medicaid

programs must provide these benefits to people newly eligible for Medicaid.

Healthcare.gov. (2014) Glossary: Essential Health Benefits, Retrieved from https://www.healthcare.gov/glossary/essential-health-benefits/

What Are The Essential Health Benefits? (continued)

Services and devices that assist in recovery if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.

Preventive services including counseling, screenings, vaccines, and care for managing a chronic disease.

Pediatric services: This includes dental care and vision care for kids

Specific health care benefits may vary by state. Even within the same state, there can be small differences between health insurance plans. When you fill out your application and compare plans, you’ll see the specific health care benefits each plan offers.1

These essential health benefits include at least the following items and services:

Outpatient care

Emergency room visits

Inpatient hospital treatment

Prenatal and postnatal care

Mental health and substance use disorder services: behavioral health treatment, counseling, and psychotherapy

Prescription drugs

Lab tests

Healthcare.gov. (2014) Glossary: Essential Health Benefits, Retrieved from https://www.healthcare.gov/glossary/essential-health-benefits/

What Are No Cost Sharing Services?

All Marketplace plans and many other plans must cover the following list of preventative services without charging you a copayment or coinsurance.

Abdominal Aortic Aneurysm

one time screening Alcohol misuse screening

and counseling Aspirin use Blood pressure screening Cholesterol screening Colorectal cancer screening Depression screening Diabetes (type 2) screening

Diet counseling Hepatitis B & C screening HIV Screening HIV Screening Immunization vaccines Lung cancer screening Obesity screening and

counseling STI prevention counseling Syphilis screening Tobacco use screening

Healthcare.gov (2015). Preventive Health Service for Adults. Retrieved from https://www.healthcare.gov/preventive-care-benefits/

Where Can I Direct My Patients Who Have Questions I Cannot Answer?

Online

• Representatives are available to assist individuals via online chat: https://www.healthcare.gov/.

By Phone • Individuals and Families • A hotline is available 24

hours per day, seven days per week to assist individuals who have questions about enrollment.

• 1-800-318-2596 • TTY: 1-855-889-4325

In Person • Find people and

organizations in your community who can help you apply, enroll, and answer your questions.

• Visit https://www.healthcare.gov/contact-us/ and enter your zip code to be connected.