Health Insurance Marketplace

Eligibility

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.

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 you 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.

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, deductiblesout-of-pocket maximums,copayments, and coinsuranceYou’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.

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.

If you have an HDHP, you can use a health savings account or a health reimbursement arrangement to pay for qualified out-of-pocketmedical costs. This can lower the amount of federal tax you owe.

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. Starting with the 2019 plan year (for which you’ll file taxes in April 2020), the fee no longer applies.

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.

After open enrollment ends, 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.

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.

If your income falls below the amounts shown, you may qualify for coverage under AHCCCS, Arizona’s Medicaid program.

Helpful Resources for Healthcare:

www.HealthCare.gov – The HealthCare.gov site has a comprehensive list of resources regarding the marketplace (information on who can help assist, answers to questions on premium costs, etc.)

www.HealthEArizonaPlus.gov – Consumers interested in applying for health insurance are urged to start by first applying for AHCCCS, which they can find at this website. They should only move on to applying for the Marketplace if they are certain they are not eligible for AHCCCS.

www.Keoghhealth.org – Consumers who want help applying for AHCCCS and/or consumers who aren’t part of the bleeding disorder community and would like to apply for the Marketplace can go here for help. Their information is:
Phone: 602-266-0397
Email: cmaldonado@keoghhealth.org
Mail: 3620 N. 4th Ave., Suite 2-2, Phoenix, AZ 85013

www.coveraz.org – More resources for consumers wanting information on the Marketplace in AZ.

http://coveraz.org/navigators-and-assisters/ – This link helps consumers find a comprehensive list of organizations in AZ that can assist them with their application for coverage in the Marketplace.

Glossary


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).