<img src="//bat.bing.com/action/0?ti=5067266&amp;Ver=2" height="0" width="0" style="display:none; visibility: hidden;">

Health Insurance Marketplaces

As part of the Affordable Care Act (ACA), health insurance coverage for individuals will become available through new individual health insurance marketplaces (also called "exchanges"). Outlined here are four (4) key facts for individuals, businesses, and insurance professionals about how the individual health insurance marketplaces will work.

Each state's individual health insurance marketplace opened October 1, 2013 with coverage beginning January 1, 2014.

 

How do the Health Insurance Marketplaces work?

Here's an outline of how the individual health insurance marketplaces work.

Step 1: Individual goes to his or her state's individual health insurance marketplace website (look up a state's marketplace website here).

Step 2: Individual completes 1 of 2 applications:

  • Application for Insurance with Tax Credit 
  • Application for Insurance without Tax Credit 

Applicants only need to fill out one application. See sample Marketplace applications here.

Step 3: Individual health insurance marketplace displays all available plan options within metallic tiers with displayed cost factoring in tax credit. All plans are guaranteed-issue, and portable (meaning the policy is not tied to employment).

Step 4: Individual selects plan.

Step 5: Individual health insurance marketplace bills individual for his or her portion of premium (i.e. the total premium minus tax credit) and marketplace forwards payment to the carrier.

When are the Enrollment Periods?

The plans offered through the individual health insurance marketplace are guaranteed issue (cannot be denied because of pre-existing condition). But, there's a catch. Consumers can only enroll in guaranteed issue health insurance during designated enrollment periods.

  • Open Enrollment 2015: November 15, 2014 to February 15, 2015

  • Special Enrollment Periods, After a Triggering Event*

Why Enrollment Periods? The enrollment periods ensure that individuals and families don’t wait until they get sick to enroll in coverage.

*Outside of the open enrollment period, individuals can enroll in or change from one plan to another as a result of the following triggering events:

  • Loss of minimum essential coverage.
  • Marriage, birth, adoption, or placement for adoption.
  • Gaining citizen or national status.
  • Gaining access to new qualified health plans (QHPs) as a result of a permanent move.
  • A qualified individual’s enrollment or non-enrollment in a plan is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Health Insurance Marketplace or HHS, or its instrumentalities as evaluated and determined by the Health Insurance Exchanges.
  • An enrollee demonstrates to the Health Insurance Marketplace that the plan in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee.
  • An individual is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a QHP. For example, the marketplace must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan.

Unless specifically stated otherwise, an individual or enrollee has 60 days from the date of a triggering event to select a plan. 

What Types of Plans Are Available?

All individual plans sold on the individual health insurance marketplaces must meet the federal ACA definition of a Qualified Health Plan (QHP). The plans will be offered by level of coverage for essential health benefits (EHB), to allow consumers to compare plans on an "apples to apples" basis.

The four metallic levels are: Bronze (plan pays 60%), Silver (plan pays 70%), Gold (plan pays 80%) and Platinum (plan pays 90%). 

metalicchart

What are Premium Tax Credits?

Last, but certainly not least, massive tax credits will be available for households earning up to 400% of the Federal Poverty Line (FPL)... the majority of Americans. A key fact is that individuals can only access the premium tax credits through the individual health insurance marketplace. Here are the 2014 FPL guidelines by household size, and the premium range after federal tax credits:

tax_credit_eligibility

 Source: Affordable Care Act 101 Guide