Health Insurance Marketplace
Open Enrollment begins October 1, 2013
Coverage begins January 1, 2014
Open Enrollment ends March 31, 2014
What is the Marketplace?
The Health Insurance Marketplace is part of the Affordable Care Act passed in 2010. It requires an ‘exchange’ (now called ‘Marketplace’) to be created that allows individuals and small businesses to purchase insurance coverage. While all insurance plans are offered by private companies, the Marketplace in Arizona is run by the federal government. It requires that all insurance companies participating in the exchange to provide the same essential health benefits. The ‘exchange’ has now become the Health Insurance Marketplace.
The Marketplace simplifies your search for health coverage by gathering the options available in your area in one place. You can compare plans based on price, benefits, and other features important to you before you make a choice. Plans will be presented in four categories: bronze, silver, gold, and platinum – to make comparing them easier.
In the Marketplace, information about prices and benefits will be written in simple language. You get a clear picture of what premiums you’d pay and what benefits and protections you’d get before you enroll. Compare plans based on what’s important to you, and choose the combination of price and coverage that fits your needs and budget.
Essential Health Benefits
All private health insurance plans offered in the Marketplace will offer the same set of essential health benefits. These are services all plans must cover. The essential health benefits include at least the following items and services:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (such as surgery)
- Maternity and newborn care (care before and after your baby is born)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventative and wellness services and chronic disease management
- Pediatric services
Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. You will see exactly what each plan offers when you compare them side-by-side in the Marketplace.
4 Categories of Marketplace insurance Plans
When you compare Marketplace insurance plans, they’re put into 4 categories based on how you and the plan can expect to share the costs of care:
All Marketplace insurance plan categories offer the same set of essential health benefits. The categories do not reflect the quality or amount of care the plans provide. The category you choose affects how much your premium costs each month and what portion of the bill you pay for things like hospital visits or prescription medications. It also affects your total out-of-pocket costs —the total amount you’ll spend for the year if you need lots of care.
Who is Eligible for the Insurance Marketplace?
To be eligible for health coverage through the Marketplace, you:
- must live in the United States
- must be a U.S. citizen or national (or be lawfully present)
- can’t be currently incarcerated
Do You Qualify for AHCCCS or the Insurance Marketplace?
Starting October 1, 2013 you can fill out an application for either AHCCCS or the Insurance Marketplace and it will tell you which one your qualify for and direct you appropriately. Arizona has voted to expand Medicaid. Starting in January 2014 AHCCCS will provide coverage for those individuals and/or families who earn less than 133% of the federal poverty level. Additionally, childless adults will also be covered.
How Do I Apply?
You can apply for Marketplace coverage three ways: online, by mail, or in-person with the help of a Navigator or other qualified helper. Go to ahcccs.gov or healthcare.org for more information.
Telephone help and online chat are available 1-800-318-2596, 24 hours a day, 7 days a week to help you complete your application. Help is available in English and Spanish. Downloadable and paper applications will be available October 1.
Open enrollment starts October 1, 2013. Plans and prices will be available then. Coverage starts as soon as January 1, 2014. Open enrollment ends March 31, 2014.
How To Get Ready Now
1. Sign up for Email or Text updates about the Marketplace. Go to healthcare.gov and sign up. You can get important new information about the Marketplace and timely reminders. You can also visit the Facebook page at facebook.com/healthcare.gov or follow @healthcare.gov on Twitter.
2. Learn about different types of health coverage. Through the Marketplace, you’ll be able to choose a health plan that gives you the right balance of costs and coverage. You can be better prepared if you understand the types of coverage you’ll choose from. See information below about different health plan categories.
3. Make a list of questions you have before it’s time to choose.
4. Make sure you understand how coverage works, including things like premiums, deductibles, out-of-pocket maximums,copayments, and coinsurance. You’ll want to consider these details while you’re looking for health insurance. See attached definitions.
5. Gather basic information about your household income. Most people using the Marketplace will qualify for lower costs on monthly premiums or out-of-pocket costs. To find out how much savings you’re eligible for, you’ll need income information, like the kind you get on your W-2, current pay stubs, or your tax return. Use the attached checklist to get started.
6. Set your budget. There will be different types of health plans to meet a variety of needs and budgets. You’ll need to figure out how much you want to spend on premiums each month.
7. Ask your employer if it plans to offer health insurance in 2014. If not, you may need to get insurance through the Marketplace or from other sources in 2014. If you don’t have coverage, you may have to pay a fee
Types of Healthcare Plans
Different types of health insurance plans meet different needs. When you compare options, it’s important to understand how they are structured.
Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs)
HMOs and EPOs may limit coverage to providers inside their networks. A network is a list of doctors, hospitals, and other health care providers that provide medical care to members of a specific health plan. If you use a doctor or facility that isn’t in the HMO’s network, you may have to pay the full cost of the services provided.
HMO members usually have a primary care doctor and must get referrals to see specialists. This is generally not true for EPOs.
Preferred Provider Organizations (PPOs) and Point-of-Service plans (POS)
These insurance plans give you a choice of getting care within or outside of a provider network. With PPO or POS plans, you may use out-of-network providers and facilities, but you’ll have to pay more than if you use in-network ones. If you have a PPO plan, you can visit any doctor without a referral.
If you have a POS plan, you can visit any in-network provider without a referral, but you’ll need one to visit a provider out-of-network.
High Deductible Health Plan (HDHP)
High Deductible Health Plans typically feature lower premiums and higher deductibles than traditional insurance plans. As of 2013, HDHPs are plans with a minimum deductible of $1250 per year for individual coverage and $2500 for family coverage.
Catastrophic Health Insurance Plan
A catastrophic health insurance plan covers essential health benefits but has a very high deductible. This means it provides a kind of “safety net” coverage in case you have an accident or serious illness. Catastrophic plans usually do not provide coverage for services like prescription drugs or shots. Premiums for catastrophic plans may be lower than traditional health insurance plans, but deductibles are usually much higher. This means you must pay thousands of dollars out-of-pocket before full coverage kicks in.
In the Marketplace, catastrophic plans are available only to people under 30 and to some low-income people who are exempt from paying the fee because other insurance is considered unaffordable or because they have received “hardship exemptions”. Marketplace catastrophic plans cover 3 annual primary care visits and preventive services at no cost. After the deductible is met, they cover the same set of essential health benefits that other Marketplace plans offer. People with catastrophic plans are not eligible for lower costs on their monthly premiums or out-of-pocket costs.
What Happens to Those Who Do Not Get Health Insurance?
If someone who can afford health insurance doesn’t have coverage in 2014, they may have to pay a fee. They also have to pay for all of their health care.
When the uninsured need care
When someone without health coverage gets urgent—often expensive—medical care but doesn’t pay the bill, everyone else ends up paying the price. That’s why the health care law requires all people who can afford it to take responsibility for their own health insurance by getting coverage or paying a penalty. People without health coverage will also have to pay the entire cost of all their medical care. They won’t be protected from the kind of very high medical bills that can sometimes lead to bankruptcy.
The fee in 2014 and beyond
The fee in 2014 is 1% of your yearly income or $95 per person for the year, whichever is higher. The fee increases every year. In 2016 it is 2.5% of income or $695 per person, whichever is higher. In 2014 the fee for uninsured children is $47.50 per child. The most a family would have to pay in 2014 is $285. It’s important to remember that someone who pays the fee won’t get any health insurance coverage. They still will be responsible for 100% of the cost of their medical care.
After open enrollment ends on March 31, 2014, they won’t be able to get health coverage through the Marketplace until the next annual enrollment period, unless they have a qualifying life event.
Minimum essential coverage
To avoid the fee in 2014 you need insurance that qualifies as minimum essential coverage. If you’re covered by any of the following in 2014, you’re considered covered and don’t have to pay a penalty.
- Any Marketplace plan, or any individual insurance plan you already have
- Any employer plan (including COBRA), with or without “grandfathered” status. This includes retiree plans
- The Children’s Health Insurance Program (CHIP)
- TRICARE (for current service members and military retirees, their families, and survivors)
- Veterans health care programs (including the Veterans Health Care Program, VA Civilian Health and Medical Program (CHAMPVA), and Spina Bifida Health Care Benefits Program)
- Peace Corps Volunteer plans
Other plans may also qualify. Ask your health coverage provider.
Who doesn’t have to pay the fee
Uninsured people won’t have to pay a fee if they:
- are uninsured for less than 3 months of the year
- are determined to have very low income and coverage is considered unaffordable
- are not required to file a tax return because their income is too low
- are a member of a federally recognized Indian tribe
- participate in a health care sharing ministry
- are a member of a recognized religious sect with religious objections to health insurance
If you don’t qualify for these situations, you can apply for an exemption asking not to pay a fee. You do this in the Marketplace.
What kinds of health insurance don’t qualify as coverage?
Health plans that don’t meet minimum essential coverage don’t qualify as coverage in 2014. If you have only these types of coverage, you may have to pay the fee. Examples include:
- coverage only for vision care or dental care
- workers’ compensation
- coverage only for a specific disease or condition
- plans that offer only discounts on medical services
Navigator Sites Approved in Arizona
Arizona Association of Community Health Centers Anticipated grant amount: $1,344,096 The Arizona Association of Community Health Centers has served as Arizona’s Primary Care Association since 1985 and continuously strives to fulfill its mission of promoting the development and delivery of affordable and accessible healthcare. The Arizona Association of Community Health Centers Navigators will coordinate outreach opportunities throughout Arizona.
Arizona Board of Regents, University of Arizona Anticipated grant amount: $190,268 The Center for Rural Health at the University of Arizona aims to reduce the numbers of Asian American and Pacific Islander uninsured in Pima County, and implement a comprehensive outreach strategy. They intend to use the Southern Arizona Asian & Islander Health Coalition to reach out to these populations and inform them of new coverage options.
Greater Phoenix Urban League, Inc. Anticipated grant amount: $523,773 The Greater Phoenix Urban League aims to equip the disadvantaged with tools to achieve economic and social equality, including through improving their health and well-being. Greater Phoenix Urban League’s Navigators will provide a comprehensive, statewide, public awareness campaign aimed at identifying and assisting uninsured individuals across Arizona to access and navigate the Health Exchange Marketplace.
Campesinos Sin Fronteras, Inc. Anticipated grant amount: $71,386 Campesinos Sin Fronteras is a Hispanic serving agency, providing services to farm workers and low-income Hispanics, while serving the general population as well. The Campesinos Navigator program will provide enrollment assistance to uninsured individuals in Yuma County, Arizona.
Lower Premium Costs with the Marketplace?
Who Qualifies for Lower Premium Costs? When you get health insurance coverage in the Marketplace, you may be able to get lower costs on monthly premiums. This depends on your income and family size.
Pay lower costs for premiums each month In the Health Insurance Marketplace you may be able to lower the costs of your health insurance coverage by paying lower monthly premiums. You’ll see the amount of savings you’re eligible for when you fill out your Marketplace application after October 1, 2013. Prices shown for insurance plans will reflect the lower costs.
Savings depends on income and family size The amount you save depends on your family size and how much money your family earns. In general, if your income falls within the following ranges you’ll qualify to save money on your premiums in 2014. The lower your income within these ranges, the more you’ll save. (The amounts below are based on 2013 numbers and are likely to be slightly higher in 2014.)
- $11,490 to $45,960 for individuals
- $15,510 to $62,040 for a family of 2
- $19,530 to $78,120 for a family of 3
- $23,550 to $94,200 for a family of 4
- $27,570 to $110,280 for a family of 5
- $31,590 to $126,360 for a family of 6
- $35,610 to $142,440 for a family of 7
- $39,630 to $158,520 for a family of 8
If your income falls below the amounts shown, you may qualify for coverage under AHCCCS, Arizona’s Medicaid program.
How to estimate your income When you apply for lower costs in the Marketplace, you’ll need to estimate your household income for 2014.For most people, you can use your household’s adjusted gross income for this estimate. If you know your 2013 adjusted gross income, use that and take into account any changes you expect in 2014.
Another way to estimate your income is to add up the following items for all the people in your household, based on what you think they’ll receive in 2014:
- Net income from any self-employment or business
- Unemployment compensation
- Social Security payments
Other kinds of income to include when estimating your 2014 income are: rental income, interest, dividends, capital gains, annuities, alimony, and some retirement and pensions.
Modified adjusted gross income When you fill out the Marketplace application, a number called “modified adjusted gross income” (MAGI) will be used. Modified adjusted gross income is generally your household’s adjusted gross income plus any tax-exempt Social Security, interest, and foreign income you have. It’s used to determine your eligibility for lower costs on Marketplace coverage, and for Medicaid and the Children’s Health Insurance Program (CHIP). You don’t have to figure out this income yourself. The math will be done for you when you apply through the Marketplace or your state agency.For Medicaid, it also matters if you’ve had a change in household income since your last tax return. When you apply you’ll need to tell us your household income now and also estimate the amount for 2014, taking into account changes that you know about.
Deductibles: The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Out of Pocket Maximums: The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. In Medicaid and CHIP, the limit includes premiums.
Co-Payment: A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
Co-Insurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Qualifying Life Event: A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby).
A Guide to the New Exchanges for Health Insurance
By Tara Siegel Bernard
Given all of the rhetoric about the Obama administration’s health care law, it’s not surprising that many consumers are confused about how the new insurance exchanges will actually work. Some states that oppose the law have gone as far as intentionally limiting the information that trickles out to its residents.
But after much anticipation, the curtain will finally rise on the exchanges next week, providing millions of consumers with an online marketplace to compare health insurance plans and then buy the coverage on the spot.
The exchanges are likely to be most attractive to people who qualify for subsidized coverage. Individuals with low and moderate incomes may be eligible for a tax credit, which can be used right away, like a gift card, to reduce their monthly premiums. People with pre-existing conditions will no longer be denied coverage or charged more (this applies to most plans outside the exchanges, too). And all of the plans on the exchanges will be required to cover a list of essential services, from maternity care to mental health care.
“In today’s individual market, it’s like Swiss cheese coverage,” said Sarah Dash, a research fellow at the Health Policy Institute at Georgetown University. “Consumers should have an easier time figuring out what they are getting for their money.”
But it’s still going to take some time to analyze the plans and their costs, which are expected to vary widely across the states. And the coverage may still pinch many families’ budgets. Fortunately, there’s a six-month window, from now to March 31, for people to figure it all out.
Here’s some information to get you started:
Q. Where can I apply or get more information on the exchanges?
A. To avoid fraud artists, enter through the front door: Healthcare.gov. From there, you can find links to the exchange offered in your state. There may be technical glitches as the program gets started, so alternatively, you can call 1-800-318-2596.
Q . When does coverage go into effect?
A. You can apply as early as Oct. 1, but coverage won’t begin until Jan. 1. The enrollment period for coverage in 2014 closes on March 31, 2014. After that, you can enroll only if you have a major life event like a job loss, birth, marriage or divorce.
Q. What sort of coverage will be offered?
A. All plans will have to provide the same set of essential benefits, including prescriptions, preventive care, doctor visits, emergency services and hospitalization (this also applies to most individual and small-employer group plans sold outside of the exchanges). But plans can offer additional benefits, or different numbers of services like physical therapy, so you’ll need to do a side-by-side comparison to see what fits your needs — or at least the needs you can anticipate.
Q. Are the plans sold on the exchange more comprehensive than plans outside?
A. There are four plan levels, each named for a precious metal. They all generally offer the same essential benefits, but their cost structures vary. The lower the premium, the higher the out-of-pocket costs.
The bronze level plan, for instance, has the lowest premiums, but will require consumers to shoulder more costs out of pocket. They generally cover 60 percent of a typical population’s out-of-pocket costs, and include deductibles, co-payments and coinsurance. The silver plans cover 70 percent; gold, 80 percent; while platinum covers 90 percent (and therefore carries the highest premiums).
If you buy a plan on an exchange, your annual out-of-pocket costs cannot exceed $6,350 for individuals and $12,700 for a family of two or more in 2014. Catastrophic plans are also available to people under age 30 or those suffering a financial hardship. These carry high deductibles (equivalent to the out-of-pocket maximum, or $6,350 for a single person, in 2014). You cannot apply tax credits to these plans, either.
Premiums will vary across the states because of a variety of factors, like market competition, the underlying cost of care and the negotiating power of the exchanges, according to Kaiser research.
Q. If the costs with plan levels are similar, how will plans differ within the metal levels?
A. Networks of doctors and hospitals will differ, and cost-sharing structures may also vary. One plan might have lower deductibles and higher co-pays, whereas another plan might have a separate deductible for prescriptions. Various medications may also be covered differently. “If you are someone who is taking medicines, make sure you know what your drugs will cost in the various plans being offered,” said Cheryl Fish-Parcham, deputy director of health policy at Families USA, a Washington consumer advocacy group.
Q. Will I be eligible for a premium tax credit (subsidized coverage)?
A. People with income between 100 percent of the poverty line (or about $23,550 for a family of four) and 400 percent of poverty ($94,200 for a family of four) are eligible for a tax credit to defray premium costs. (All income eligibility is based on your modified adjusted gross income; the online version of this column links to a guide explaining how that is calculated).
The tax credits are set up so that consumers will not have to pay more than a certain percentage of their income, ranging from 2 percent for those with incomes of up to 133 percent of the poverty level ($15,282 for a single and $31,322 for a family of four) to 9.5 percent for those with income of 300 to 400 percent of the poverty level, according to the Center on Budget and Policy Priorities. The dollar amounts of the credits are calculated based on the costs of the second-to-lowest-cost silver plan available to you.
Kaiser has a calculator that can give you an idea of your eligibility.
Q. Can I get help with my out-of-pocket expenses, like deductibles?
A. People with incomes between 100 percent of the federal poverty line ($23,550 for a family of four) and 250 percent ($58,875 for a family of four) are also eligible for cost-sharing reductions, which means you’ll pay less for items including deductibles and co-payments, and you’ll have lower out-of-pocket maximums.
There is a big caveat: you can qualify for the reductions only if you buy a silver plan. When choosing a silver plan — and compare them closely, because they will differ — the exchange Web site will automatically show what you will pay, with the cost-sharing reductions included, according to the Center on Budget and Policy Priorities.
Even if you’re tempted by the bronze plans’ lower premiums, remember you’ll probably end up paying more for out-of-pocket costs. For people who qualify for both premium and cost-sharing subsidies, the silver plan will usually be the better deal, Ms. Fish-Parcham said.
Q. Should I use all of my subsidy at once? How can I avoid owing taxes?
A. The premium subsidies are delivered in the form of a refundable tax credit, which can be used immediately to reduce your monthly premiums.
You can use it all right away, or you can use part of it, or none at all. If you expect your income to remain the same, you might use the entire credit. But if your income is likely to rise, it may pay to use only a portion of the subsidy. That way, you’ll avoid owing money to the I.R.S. at tax time.
If your income does change, report it to the exchange. If your income drops, you may be eligible for a larger credit. Changes in family size should also be reported. “It will all get reconciled on your taxes in the spring of 2015,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation.
Q. How can I find out if my doctor accepts exchange-based insurance?
A. Many of the insurance providers’ networks of doctors and hospitals will be narrower than are typically found in commercial insurance, as my colleague reported this week. So just because your doctor accepts, say, a Blue Cross plan provided by your employer, that doesn’t necessarily mean the doctor will take the same carrier’s plan offered on the exchange.
The plans will be required to provide a directory that lists their network’s providers, Ms. Pollitz said, so inspect them carefully.
Q. How will I know if my drugs are covered by the plans?
A. The exchanges must include a summary of benefits and coverage for each plan. That includes information about what your co-payments would be for generic, brand name and specialty drugs. It should also provide a Web link to the plan’s list of covered drugs and how they are categorized by a particular plan, said Ms. Fish-Parcham.
Q. If I have employer-based coverage, can I go to the exchange for coverage?
A. You can, but you probably won’t want to. Your employer’s plan is usually a better deal. Many employers heavily subsidize your premiums and you can pay for your coverage using pretax dollars, something you can’t do if you buy coverage on the exchange.
“Plus, employer plans are typically fairly generous,” said Lynn Quincy, a senior policy analyst at Consumers Union.
Besides, if your employer offers you coverage, you probably won’t qualify for a tax credit unless your share of the premium (for the lowest-cost plan for individual coverage offered by your employer) is more than 9.5 percent of your modified adjusted gross income, Ms. Quincy explained.
If your employer’s insurance plan doesn’t cover 60 percent of medical costs, on average (what’s known as “minimum value”) you may also qualify for subsidized coverage. Your employer is supposed to let you know where the plan falls in terms of minimum costs. “If you are spending huge amounts out of pocket each year and you have a high deductible, it’s worth looking at what your possibilities are,” said Sara R. Collins, vice president of the health care coverage and access program at the Commonwealth Fund.
Q. Am I eligible for Medicaid?
A. The health care law aimed to expand Medicaid so that everyone under age 65 would qualify if they earned up to 138 percent of the federal poverty level (that’s about $16,000 for an individual and $32,500 for a family of four in 2014). But the Supreme Court ruled in June that the decision to expand Medicaid is up to the states — and only 26 states have decided to move forward, according to Kaiser.
Q. So if I’m poor but not eligible for Medicaid, can I get insurance on the exchange?
A. Yes, but unfortunately, many people in this situation won’t be able to afford it. People who don’t qualify for their state’s Medicaid program but earn too little to qualify for subsidies on the exchange will have to pay full price for the coverage offered on the exchanges. So if you can’t get Medicaid and your income is below 100 percent of the poverty level, you will not be eligible for subsidized coverage on the exchange.
Q. What if I’m self-employed or own a small business?
A. If you’re self-employed with no employees, you can shop for coverage on the exchange.
If you have fewer than 50 employees, you can get coverage for yourself and your workers though the Small Business Health Options program, known as the SHOP Marketplace. “Small employers have always wanted to have the buying clout of a large employer and the SHOP exchanges offer them just that,” said Kevin Lucia, project director at Georgetown University’s Health Policy Institute.
Q. What are the penalties for not having coverage? Are there any exceptions?
A. Most people will be required to have insurance, with some exceptions. You are not required to buy insurance if: the cost of insurance premiums would exceed 8 percent of your income, your income is below the threshold for filing taxes, you have a certified hardship, or you would have qualified for Medicaid but live in a state that did not expand the program. Illegal immigrants, the incarcerated, members of Indian tribes and those who qualify for certain religious reasons are also exempt.
Everyone else will pay a penalty. In 2014, it will cost you $95 or approximately 1 percent of your income, whichever is greater. The penalties will rise each year.
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