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Explore ObamaCare Coverage and Enrollment

A successful transition starts with a proper education.

Explore ObamaCare

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Explore ObamaCare Coverage and Enrollment

A successful transition starts with a propper education.

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The Care ACT

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Reform Changes

Minimum Essential Coverage

The Affordable Care Act requires individuals who are ineligible for an exemption to have minimum essential coverage for themselves and their dependents. Minimum essential coverage is the type of health care coverage an individual needs to have in order to meet the individual responsibility requirement under the Affordable Care Act.  Coverage purchased in the individual market including through a Federally-facilitated Marketplace, as well as coverage under government programs such as Medicare, Medicaid, CHIP and TRICARE, and coverage under an employer-sponsored plan, meet this requirement. 

Individuals who are ineligible for an exemption and do not have coverage by 2014 may be required to pay a fee. The fee is $95 for plan year 2014.

In most states Agents and Brokers can assist consumers in meeting this requirement by helping them receive an eligibility determination, apply for financial assistance programs, and choose and enroll in a qualified health plan (QHP). Enroll With an Agent Today

Coverage of Pre-existing Health Conditions Regardless of Age

The Affordable Care Act prohibits health insurance issuers from limiting or excluding coverage related to pre-existing health conditions, regardless of the age of the covered individual. For persons under age 19, this provision became effective for policy years beginning on or after September 23, 2010. Health insurance issuers also cannot charge an individual more because of pre-existing conditions.

Health insurance issuers are also required to re-issue a health plan to any applicant without medical underwriting, which means that health insurance issuers cannot increase premiums at renewal for existing customers because they incurred claims, or experienced worsening health during a policy year. Health insurance issuers may terminate coverage for enrollees who submitted false information on their applications and those who have not paid premiums before the end of the payment grace period.

Allowable Basis for Premium Variations

Under the Affordable Care Act, premiums can only vary based on the following factors: age, family composition, geographic area, and tobacco use.

Age:

  • Premium rates cannot vary by age for enrollees under the age of 21.
  • Premium rates cannot vary by age for enrollees age 64 or older.
  • Premium rates can vary by age for enrollees between the ages of 21 and 63, on each birthday, until a person turns 63.
  • Older enrollees cannot be charged more than 3 times the amount that younger enrollees are charged.

Family Composition:

  • Premiums may vary based on family composition. 

Geographic Area:

  • Geographic rating areas are established by each state. If a state does not choose its geographic rating areas, it will default to rating areas established by the Department of Health and Human Services (HHS).

Tobacco Use:

  • Tobacco users cannot be charged more than 1.5 times the rate of non-users.
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Health Insurance Coverage Standards

Under the Affordable Care Act, all health insurance issuers that offer QHPs (Qualified Health Plans) must:

  • Provide, at a minimum, a package of benefits, known as essential health benefits (EHB)
  • Eliminate annual dollar limits on EHB, effective for all plans beginning in 2014
  • Eliminate lifetime dollar limits on EHB, effective for all plans issued on or after September 23, 2010
  • Cover certain preventive services without requiring cost sharing
  • Cap annual out-of-pocket spending

In addition, health insurance issuers are prohibited from rescinding coverage, except in cases of fraud or intentional misrepresentation of material fact.

Next Topic: Child and Young Adult Coverage
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Child and Young Adult Coverage

Young Adult Coverage

Under the Affordable Care Act, health plans that cover children must make coverage available to children up to age 26. Young adults can join or remain on a parent’s plan even if they are:

  • Married (coverage does not extend to married child’s spouse)
  • Not living with a parent
  • Not attending school
  • Not financially dependent on a parent
  • Eligible to enroll in their employer’s plan (starting in 2014)
Next Topic: Pre-Existing Conditions
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Guaranteed Issue and Pre-Existing Conditions

The Affordable Care Act requires health insurance issuers to offer all of their individual market and group market plans to any applicant in the state. It also requires health insurance issuers to accept any individual who applies for those policies, as long as the applicant agrees to the terms and conditions of the policy, including the payment of premiums. This provision is called “guaranteed issue.”

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Coverage offered through and outside the Marketplaces may restrict guaranteed issue coverage to certain enrollment periods.

Additionally, the Affordable Care Act requires health insurance issuers to offer to renew or continue in force coverage at the option of the policyholder. This is called “guaranteed renewability.”

Effective for all health plans with plan years beginning on or after January 1, 2014, the Affordable Care Act prohibits health insurance issuers from limiting or excluding coverage related to pre-existing health conditions, regardless of the age of the covered individual. For persons under age 19, this provision became effective for policy years beginning on or after September 23, 2010.

Generally, a pre-existing condition is any health condition or illness that was present before the coverage effective date, regardless of whether medical advice or treatment was actually received or recommended.

Next Topic: Clinical Trials
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Nondiscrimination Regarding Clinical Trial Participation

The Affordable Care Act prohibits health insurance issuers from:

  • Precluding participation of qualified individuals* in an approved clinical trial
  • Denying, limiting, or placing additional conditions on the coverage of routine patient costs for items and services furnished in connection with participation in an approved clinical trial
  • Discriminating against qualified individuals on the basis of their participation in an approved clinical trial

*The Affordable Care Act defines “qualified individual,” for purposes of this provision, as an individual who is eligible to participate in an approved clinical trial according to the trial protocol with respect to the treatment of life-threatening diseases or conditions. A “qualified individual” either has a referral from a participating health care provider who has concluded that the individual’s participation is appropriate, or has provided medical and scientific information establishing that the individual’s participation in the clinical trial would be appropriate.

**When comparing plans make sure you have all your facts. Consult with a licensed Agent or Broker prior to making a decision.

Information provided by this site is subject to change.

Next Topic: Medical Loss Ratio
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Medical Loss Ratio

The Affordable Care Act helps keep costs down by limiting the proportion of premiums that a health insurance issuer can spend on things other than providing and improving the quality of the health care of their enrollees.

Medical Loss Ratio (MLR) is a basic financial measurement that shows how much of the premium dollars a health insurance issuer spends on health care expenses, as opposed to profits or administrative costs. As of 2012, a health insurance issuer that does not spend enough of its premium dollars on health care services must provide rebates to insured individuals or policyholders.

In general, if a health insurance issuer uses an average of 80 cents out of every premium dollar to pay customers’ medical claims and to conduct activities that improve the quality of care, the company has an MLR of 80%. MLR is not calculated at the individual policy level but at the state level for each issuer separately for the small group and individual markets.

An MLR of 80% indicates that the health insurance issuer is using the remaining 20 cents of each premium dollar for administrative costs and profits, including salaries and other expenses. As of 2012, a health insurance issuer is required to spend at least 80% of premium dollars on medical care.

The Affordable Care Act sets minimum MLRs for different markets, as do some state laws.

Next Topic: Network Standards
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Network Adequacy Standards

Network Adequacy Standards

Questions answered

For QHP (Qualified Health Plan) certification, a plan must have an adequate provider network available to its enrollees. A QHP must:

  • Offer a network with a sufficient number of providers, including mental health and substance abuse providers, to ensure access to all services without unreasonable delay; and
  • In addition to the overall network adequacy requirement, a QHP’s network must include a sufficient number and geographic distribution of essential community providers to ensure reasonable and timely access to care for low-income and medically-underserved populations in the QHP’s service area.
Next Topic: Rate Reviews and Oversite
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Rate Reviews

The Affordable Care Act brings an increased level of scrutiny and transparency to health insurance rate increases. The Affordable Care Act ensures that, in any state, proposed rate increases will be evaluated by experts to make sure they are based on reasonable cost assumptions and solid evidence. This analysis is expected to help moderate premium hikes and provide those who buy insurance with greater value for their premium dollar. Additionally, health insurance issuers must provide easy to understand information to their customers about their reasons for rate increases, as well as publicly justify and post on their websites any rate increases determined to be unreasonable. These steps will allow consumers to better understand the basis for the rates they are paying.

Rates for qualified health plans (QHPs) in the Individual Marketplace or SHOP will be reviewed for reasonableness, as well as compliance with market rating reforms under the Affordable Care Act.

Many states have been classified as having an Effective Rate Review Program for all or some markets. In other states or markets without an Effective Rate Review Program the review will be accomplished by the Centers for Medicare & Medicaid Services (CMS). This is good news for agents, brokers, and consumers because rates (and rate increases) for QHPs will be reviewed by independent experts. In this topic, you will learn about reviewing health plan premiums and the variances in those rates.

Under the Affordable Care Act, most increases in health plan premiums are subject to monitoring. Health insurance issuers must tell consumers when they want to increase insurance rates for individual or small group policies. This process, together with review of rates as part of the qualification process for health plans to be offered by Marketplaces, will enhance consumer protection through increased transparency. The rate reviews of increase requests, called effective rate reviews, will be conducted by independent state or federal experts.

Effective Rate Review

The Department of Health and Human Services (HHS) (through CMS) works with states to ensure that all proposed rate increases in the individual and small group markets are thoroughly reviewed. The Affordable Care Act sets minimum standards for the review of these proposed increases, called effective rate review standards. If a state lacks the resources or authority to meet these standards and conduct the needed reviews, HHS conducts the rate review while continuing to make resources available to states to strengthen their rate review process.

Next Topic: Rate Variation Calculations
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Rate Variations

Age Rating Standards

  • Health insurance issuers are not allowed to charge an older adult more than three times the rate of a 21-year old.
  • States can establish age curve or default to federal age curve
  • Federal age bands:
    • 0-20
    • One-year bands between 21-63
    • 64 and older
Next Topic: The Marketplace
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The MarketPlace

Are You Ready For ObamaCare and "The Market Place"

Open Enrollment Begins Oct 1, 2013. You may keep your current coverage if you are already insured and your plan meets the mandated core benefit requirements. Compare health insurance rates today so you may have an idea of what your savings are when you compare rates on the Exchange, Marketplace or SHOP.

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State Exchanges

State MarketPlace information

ObamaCare MarketPlace by state

Beginning October of 2013, consumers can apply and enroll in coverage through the Marketplaces in every state and the District of Columbia. Some states will establish their own Marketplaces, known as State-based Marketplaces. If a state chooses not to establish its own Marketplace, the Department of Health and Human Services (HHS) will either establish a Federally-facilitated Marketplace in that state, or will operate the Marketplace in partnership with the state. (These are called State Partnership Marketplaces, and they are one type of Federally-facilitated Marketplace.)

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Next Topic: Functions of the Exchange

States using the Federal Exchange use:
The Health insurance MarketPlace

State
Federal Exchange
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Alabama
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Next Topic: Functions of the Exchange
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Functions of the Exchange or Marketplace

Obamacare Questions Answered

The Major Functions of a Marketplace Include:

  • Certifying health plans to participate in a Marketplace as QHPs (Qualified Health Plans)
  • Determining individuals’ eligibility for enrollment in a QHP
  • Determining individuals’ eligibility for premium tax credits and cost-sharing reductions
  • Determining or assessing individuals’ eligibility for enrollment in Medicaid and/or the Children's Health Insurance Program (CHIP)
  • Facilitating individuals’ enrollment in a QHP
  • Carrying out certain plan oversight functions, including monitoring QHP issuers for continuing compliance with certification requirements
  • Facilitating employers’ applications and employee enrollments in coverage through SHOP
Next Topic: ObamaCare Health Plans
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ObamaCare Health Plans

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Qualified Health Plans

QHP's Questions answered

Marketplaces will offer only health insurance plans that are certified as qualified health plans, or QHPs. These QHPs must be licensed and accredited, and must meet certain requirements for transparency. To become certified, a QHP must meet a minimum set of criteria, including the following: 

  • Coverage, at a minimum, of a comprehensive package of benefits, known as essential health benefits, or EHB
  • Benefit design standards, including non-discrimination requirements and limits on cost-sharing and out-of-pocket costs
  • Network adequacy standards

Essential Health Benefits

The Affordable Care Act requires that health plans offered in the individual and small group markets, both inside and outside of the Marketplaces, offer a comprehensive package of services, known as essential health benefits, or EHB. EHB include items and services within 10 benefit categories that are highlighted on the next page. The Affordable Care Act requires that EHB:

  • Reflect appropriate balance among the 10 EHB categories
  • Do not discriminate based on age, disability or expected length of life
  • Take into account the health care needs of diverse segments of the population

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For plan years 2014 and 2015, each state was asked by HHS to select a specific health plan’s set of benefits as its “EHB-benchmark plan,” equivalent to a typical employer health plan. If the state did not choose a plan, the EHB-benchmark plan was determined by HHS. The EHB in each state will be measured against the state’s EHB-benchmark plan. Because states elected their EHB-benchmark plans from existing state plans that included state-specific benefits, the EHB package will vary from state to state. Starting in 2014, QHP issuers will need to ensure that every QHP offered in the Marketplace is substantially equal to the EHB-benchmark plan in the state where the QHP is offered.

Essential Health Benefit Categories

  • Ambulatory Services such as Doctor Visits
  • Hospitalization
  • Mental Health and Substance Use Disorder Services, Including Behavioral Health
  • Rehabilitative and Habilitative Services and Devices
  • Laboratory Services
  • Emergency Services
  • Maternity and Newborn Care
  • Presciption Drugs
  • Preventative and Wellness Services and Chronic Disease Management
  • Pediatric Services, including oral care, offered as part of a QHP package or as a stan-alone plan

Next Topic: Levels of Coverage
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Levels of Coverage

Questions answered

The five levels of coverage are called Catastrophic, Bronze, Silver, Gold, and Platinum. These levels, sometimes referred to as “metal levels” provide several benefits:

  • Help consumers, and the agents and brokers who assist those consumers, in comparing coverage options to determine which plans best fit the consumers’ needs
  • Help consumers understand their benefits and the cost of services once they enroll
  • Facilitate consumer choice based on specific value comparisons

QHP issuers do not have to offer plans in all five levels. However, each QHP issuer must offer a silver and a gold QHP in a Marketplace. These requirements begin on January 1, 2014.

Percentage of Benefits paid

  • Up to 90% for Platinum Plans
  • Up to 80% for Gold Plans
  • Up to 70% for Silver Plans
  • Up to 60% for Bronze Plans
  • Catastrophic
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Next Topic: Catastrophic Plans
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Catastrophic Plans

Catastophic Plans

Questions answered

Catastrophic plans are offered in the Individual Marketplace and cover EHB. They provide affordable coverage options for young adults and people for whom coverage would otherwise be unaffordable.  

Check Catastrophic Plan Rates

Catastrophic plan enrollees pay higher deductibles than enrollees in bronze, silver, gold, or platinum plans.  However, catastrophic plans have several benefits:

  • Lower premiums on average than bronze, silver, gold, or platinum plans
  • Protection against out-of-pocket costs above $6,350 for an individual and $12,700 for a family
  • Coverage of recommended preventive services without cost sharing

Eligibility for catastrophic plans is limited to:

  • Individuals under age 30
  • Individuals who otherwise do not have an affordable coverage option, or who otherwise qualify for a hardship exemption to the minimum essential coverage rule
  • Premium Advanced Tax Credits and Cost sharing is not available with this plan.
Next Topic: Out-of-Pocket-Limits
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Out of-Pocket Limits

Out of Pocket Limits

Questions answered

The Affordable Care Act requires QHPs (Qualified Health Plans) to provide certain recommended preventive health services without cost sharing or deductible requirements.

All QHPs must limit cost sharing for enrolled individuals in the following ways:

  • Deductibles and copays cannot be applied to preventive services.
  • Deductibles for small group plans cannot exceed $2,000 for self-only coverage or $4,000 for any other coverage (adjusted annually), except to the extent that a higher deductible is necessary to create a reasonable bronze or silver plan.
  • Annual cost-sharing limits cannot exceed the limits for certain high deductible health plans including catastrophic plans. (For 2014 the limits are $6,350 for an individual and $12,700 for families.)

No annual or lifetime dollar limits are allowed on EHB beginning January 1, 2014. 

Next Topic: ObamaCare Plan Costs
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ObamaCare Plan Costs

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Affordability Programs

Affordability Programs Questions answered

Under the Affordable Care Act, millions of Americans will be eligible to purchase affordable health coverage through Marketplaces. Enrollments will start in October 2013 with an effective date of January 1, 2014.

The Affordable Care Act also provides opportunities for many individuals to reduce the cost of health insurance coverage through premium tax credits and cost-sharing reductions for eligible enrollees. The tax credits may be paid directly to insurance companies on behalf of individuals and families.

The application process that Marketplaces will use as a result of the Affordable Care Act will make it easy for individuals, and the agents and brokers who assist them, to determine if they are eligible for the premium tax credit or cost-sharing reductions.

Overview of Eligibility for Affordability Programs

Some individuals who are eligible to enroll in a QHP will be eligible for financial support to make their health insurance coverage more affordable. As part of the application process, the Marketplace will assess eligibility for premium tax credits and cost-sharing reductions based on household income relative to the Federal Poverty Level (FPL). The 2013 FPL is $11,490 for an individual and $23,550 for a family of four.

Consumers must apply through the exchange to determine what affordability programs they qualify for.

See What You Are Eligible For

Advance Payment of the Premium Tax Credit

The premium tax credit is a new income tax provision to help individuals and families afford health insurance coverage purchased through a Marketplace.

An individual may choose to apply some or all of the tax credit towards QHP premiums costs on an advance basis – with reconciliation at the end of the year – or to receive the credit on his or her federal tax return filed for the coverage year.  

Advance payments of the premium tax credit are paid directly to the insurance company offering the QHP on a monthly basis. The income tax return for the coverage year will reconcile any advance payments of the premium tax credit with the premium tax credit allowed on the return. The Marketplace will provide documentation to the tax filer and to the IRS that will support the reconciliation process in the same way that an employer or bank provides a Form W-2 or Form 1099.

Individuals eligible for a premium tax credit who do not receive an advance payment of the premium tax credit may claim the credit on their income tax return filed for the coverage year.

Eligibility for the Advance Payment of the Premium Tax Credit

Eligibility criteria for advance payment of the premium tax credit are the following:

  • Meets the eligibility criteria for enrollment in a QHP (and ultimately enrolls in a QHP offered through the Marketplace)
  • Has an annual household income between 100% and 400% of the FPL (or lower if a lawfully present non-citizen who is ineligible for Medicaid by reason of immigration status)
  • Be a part of a tax household that will file a tax return and, if the tax household includes a married couple, that will file a joint return
  • Is not eligible for minimum essential coverage (including employer-sponsored coverage, Medicaid, CHIP, Medicare, and other forms of coverage), other than through the Individual Marketplace, unless their employer-sponsored coverage is unaffordable or does not provide minimum value

Advance payment of the premium tax credit are not available for the purchase of catastrophic coverage.

Cost-sharing Reductions

Cost-sharing reductions are subsidies that reduce the amount of out-of-pocket expenses, such as deductibles or coinsurance, an individual is responsible for as part of their coverage under a QHP. 

Some individuals who are eligible for tax credits are also eligible for cost-sharing reductions, depending on income, as determined by their modified adjusted gross income (MAGI). 

Eligibility for Cost-sharing Reductions

Eligibility criteria for cost-sharing reductions are the following:

  • Meets the eligibility criteria for enrollment in a QHP and for advance payment of the premium tax credit
  • Has an annual household income at or below 250% of the FPL, OR an annual household income at or below 300% of the FPL for American Indians and Alaska Natives
  • Is enrolled in a silver level plan through a Marketplace

Summary of Benefits and Coverage and Cost-sharing Reductions

A consumer’s summary of benefits and coverage will summarize the health plan’s benefits that apply to the QHP before taking into account financial assistance the enrollee may receive in the form of cost-sharing reductions. If a consumer is eligible for cost-sharing reductions, the cost sharing (for example, deductibles, coinsurance, or copayments) may be lower than what the consumer sees on his or her summary of benefits and coverage. Consumers who are eligible for cost-sharing reductions can review the cost-sharing information available on the Federally-facilitated Marketplace website or in their health plan’s plan documents to see what their cost sharing might be.

Next Topic: Premium Tax Credits
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Premium Tax Credits

Eligibility for Tax Credits

Questions answered

Individuals enrolling in a QHP (Qualified Health Plan) through an Individual Marketplace may be eligible for premium tax credits which reduce the cost of premiums for themselves and for any tax dependents. An individual may choose to apply the tax credit towards QHP premium costs on an advance basis – with reconciliation at the end of the year – or to receive the credit on his or her federal tax return filed for the coverage year. Advance payments are paid directly to QHP issuers on a monthly basis. 

See if You Qualify

Individuals eligible for a premium tax credit who do not receive an advance payment of the premium tax credit may claim the credit on their income tax return filed for the coverage year. Individuals who are married at the end of the coverage year are required to file a joint return to receive a premium tax credit.

A tax filer on whose behalf advance payments are made is required to file a tax return for the coverage year to reconcile any advance payments of the premium tax credit with the premium tax credit allowed on the return. Thus, if the premium tax credit allowed on the return is more than the amount of the advance payment of the premium tax credit, the individual may receive the excess amount as a tax return. On the other hand, if the premium tax credit allowed on the return is less than the amount of the advance payment of the premium tax credit, the individual will repay the excess amount via the tax return, subject to statutory caps. 

The Marketplaces will provide documentation to the tax filer and to the IRS that will support the reconciliation process, in the same way that an employer or bank provides a Form W-2 or Form 1099.

Next Topic: Eligibility
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Tax Credit Eligibility

Eligibility for Tax Credits

Questions answered

Eligibility for the premium tax credit is based on the household income and access to minimum essential coverage. The following summarizes the key eligibility standards for premium tax credits (tax credits that reduce the cost of insurance premiums).

Individuals must meet the following eligibility criteria to be eligible for a premium tax credit:

  • Not be eligible for minimum essential coverage — including employer-sponsored coverage, Medicaid, CHIP, Medicare, and other forms of coverage — other than through the individual insurance market, unless their employer-sponsored coverage is not affordable or does not provide minimum value
  • Have an annual household income that is between 100% and 400% of the Federal Poverty Level (FPL) (or below 100% of FPL for lawfully present non-citizens who are ineligible for Medicaid by reason of immigration status)
  • Be a part of a tax household that will file a tax return for the coverage year and, if the tax household includes a married couple, that files a joint return
  • Be eligible for coverage through a QHP
Check Your Eligibility

Overview of Eligibility

Some individuals who are eligible to enroll in a QHP will be eligible for financial support to make their health insurance coverage more affordable. As part of the application process, the Marketplace will assess eligibility for premium tax credits and cost-sharing reductions based on household income relative to the Federal Poverty Level (FPL). The 2013 FPL is $11,490 for an individual and $23,550 for a family of four.

Advance Payment of the Premium Tax Credit

Eligibility criteria for advance payment of the premium tax credit are the following:

  • Meets the eligibility criteria for enrollment in a QHP (and ultimately enrolls in a QHP offered through the Marketplace)
  • Has an annual household income between 100% and 400% of the FPL (or lower if a lawfully present non-citizen who is ineligible for Medicaid by reason of immigration status)
  • Be a part of a tax household that will file a tax return and, if the tax household includes a married couple, that will file a joint return
  • Is not eligible for minimum essential coverage (including employer-sponsored coverage, Medicaid, CHIP, Medicare, and other forms of coverage), other than through the Individual Marketplace, unless their employer-sponsored coverage is unaffordable or does not provide minimum value

Advance payment of the premium tax credit are not available for the purchase of catastrophic coverage.

Next Topic: Cost Sharing Reduction
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Cost Sharing Reduction

Cost Sharing Reductions

Questions answered

Cost-sharing reductions limit the out-of-pocket costs for EHB (Essential Health Benefits) covered by QHPs (Qualified Health Plans) such as deductibles or coinsurance, an individual is responsible for as part of their coverage under a QHP. 

To be eligible for cost-sharing reductions, individuals must:

  • Meet the eligibility requirements for enrollment in a QHP
  • Meet the criteria for eligibility for a premium tax credit
  • Have annual household income at or below 250% of FPL, except for members of federally-recognized Indian tribes, who have special standards
  • Be enrolled in a silver-level QHP, except for members of federally-recognized Indian tribes who have special standards

There are several categories of cost-sharing reductions that are based on annual household income and family size. Each QHP issuer will implement these differently, based on their specific plan design. When an individual is determined eligible for a category of cost-sharing reduction, the plan comparison pages will reflect adjusted cost-sharing requirements of each plan. See the plan details for the cost sharing adjustments.

Summary of Benefits and Coverage and Cost-sharing Reductions

A consumer’s summary of benefits and coverage will summarize the health plan’s benefits that apply to the QHP before taking into account financial assistance the enrollee may receive in the form of cost-sharing reductions. If a consumer is eligible for cost-sharing reductions, the cost sharing (for example, deductibles, coinsurance, or copayments) may be lower than what the consumer sees on his or her summary of benefits and coverage. Consumers who are eligible for cost-sharing reductions can review the cost-sharing information available on the Federally-facilitated Marketplace website or in their health plan’s plan documents to see what their cost sharing might be.

Next Topic: Medicaid and Chip
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Medicaid and Chip

Medicaid and the Children's Health Insurance Program

Questions answered

Medicaid and CHIP

Medicaid and CHIP are federal and state partnership programs designed to provide coverage to lower income individuals and children. These programs provide safety net coverage for the country’s lowest income populations. Like Marketplaces, these programs vary by state. A person who is eligible for Medicaid or CHIP is also eligible to enroll in a qualified health plan (QHP), but such coverage cannot be supported with advance payments of the premium tax credit or cost-sharing reductions. This is because Medicaid eligibility will affect an individual’s eligibility to receive advance payments of the premium tax credit and cost-sharing reductions for coverage purchased through the Individual Marketplace. 

The single streamlined application required by the Affordable Care Act will streamline eligibility determinations for:

  • Enrollment in a QHP through the Marketplace
  • Insurance affordability programs

Medicaid

Medicaid is a federal and state partnership to provide coverage for some people with lower incomes, older people, people with disabilities, and some families and children. To qualify for Medicaid, an individual must be part of a covered group – children, pregnant women, parents or caretaker relatives, the elderly, the disabled, or other non-elderly adults who are not eligible for or enrolled in Medicare – and must meet financial eligibility requirements. To be eligible for Medicaid, individuals need to satisfy federal and state requirements regarding residency, citizenship or immigration status, and household income.

Medicaid is jointly funded through federal and state dollars, but administered at the state level. State-based Medicaid programs often have different names in each state, like “MassHealth” in Massachusetts, and “SoonerCare” in Oklahoma. It is important to be familiar with the program in any state in which you operate. The Affordable Care Act significantly streamlines the eligibility standards and enrollment processes for Medicaid.

CHIP

CHIP provides no-cost or low-cost health insurance coverage to children in families that have too much income to qualify for Medicaid coverage, but that cannot afford to purchase private health insurance. It also covers pregnant women in some states. Like Medicaid, the costs for CHIP are shared by the federal government and state governments but the program is administered at the state level. CHIP programs operate under different names in each state, such as “BadgerCare” in Wisconsin and “Washington Apple Health for Kids” in Washington State.

To find CHIP information by state, visit InsureKidsNow.gov

Medicaid Eligibility Expansion

The Affordable Care Act, through Medicaid expansion, provides new opportunities for adults in some states to be covered by Medicaid. The Affordable Care Act specifies that, as of January 1, 2014, Medicaid will cover all non-elderly individuals who are ineligible for Medicare and have household income at or below 138% of the Federal Poverty Level (FPL), which for 2013 is $11,490. That translates into an annual income of approximately $15,856 for an individual and $32,499 for a family of four, in 2013.

However, some states have chosen not to expand Medicaid eligibility to these income levels. Regardless of whether a state chooses to expand its Medicaid eligibility, effective January 1, 2014, all state Medicaid programs will:

  • Use a new income methodology for the majority of applicants, called modified adjusted gross income (MAGI), which we will discuss on the next page
  • Not consider assets in determining eligibility for individuals whose financial eligibility is based on MAGI
  • Streamline income-based rules, systems, and verification procedures

A Simplified Calculation of Income

The Affordable Care Act requires all states to determine eligibility for Medicaid and CHIP for the majority of individuals (essentially, all non-disabled, non-elderly individuals) based on their modified adjusted gross income (MAGI). The MAGI calculation equals adjusted gross income as defined by the Internal Revenue Service (IRS), plus any foreign income, tax-exempt interest, and non-taxable Social Security benefits. Assets will not be considered in determining eligibility. This is the same income methodology that will be used for determining eligibility for the premium tax credit and cost-sharing reductions, with the following exceptions:

  • In limited cases, the set of individuals whose income is counted in determining eligibility for Medicaid and CHIP may be slightly different from the set of individuals counted for premium tax credits and cost-sharing reductions.
  • Medicaid and CHIP disregard certain rare types of income.
  • Medicaid and CHIP eligibility is primarily based on current monthly income, while eligibility for premium tax credits and cost-sharing reductions is based on projected annual household income.

Eligibility for Medicaid and CHIP

Medicaid eligibility determinations are made at the state level. The level of Medicaid assistance available is also determined at the state level. 

When individuals go to the Marketplace for coverage or financial assistance, the Marketplace will first assess their eligibility for Medicaid or CHIP. Individuals who are eligible for Medicaid may also enroll in a QHP available through a Marketplace. However, this approach would not normally be in the person’s financial best interests, since they would not be eligible to receive either the premium tax credit or cost-sharing reductions and would be required to pay full premiums.

Marketplace QHPs are generally not intended for individuals who are eligible for or enrolled in other types of minimum essential coverage outside of the Marketplace—such as employer-based coverage, Medicare, Medicaid, CHIP, TRICARE, and certain other types of coverage.

Medicaid and CHIP Eligibility Determinations

As is the case for health insurance programs under the Marketplace, agents and brokers cannot make Medicaid or CHIP eligibility determinations.

In some states, the Marketplace makes final eligibility determinations for Medicaid and CHIP.

In other states, the Marketplace may conduct assessments of eligibility for Medicaid and CHIP and the state Medicaid and CHIP agencies make the final Medicaid and CHIP eligibility determinations, consistent with Medicaid and CHIP regulations and state-specific policies. In these states, there is a possibility that the Medicaid agency will disagree with the Marketplace’s assessment, in which case the application will be returned to the Marketplace for further processing.

State Differences in Medicaid and CHIP Eligibility

Assessments will be made based on each state’s applicable Medicaid MAGI-based income standards, other eligibility requirements, citizenship and immigration status, and verification rules and procedures, consistent with federal regulations.

As Medicaid programs vary by state, you should familiarize yourself with the Medicaid program for the state(s) in which you reside. Additional information is available through your state Medicaid office; or to learn more about a state Medicaid program and other available options, use the insurance and coverage finder on Healthcare.gov or visit Medicaid.gov. For state-specific CHIP program information, visit Medicaid.gov or InsureKidsNow.gov

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Application

ObamaCare Application and Verification

Questions answered

The main steps of the Marketplace eligibility and enrollment process are as follows:

  • Individual submits the single, streamlined application
  • Marketplace verifies information needed to determine eligibility
  • Marketplace determines eligibility and notifies individual
  • Eligible individual completes the plan comparison, selection, and enrollment process

By submitting a single, web-based, streamlined application, individuals will be able to receive an eligibility determination for enrollment in a QHP and access to any available financial assistance. The single, streamlined application can be submitted directly to a Marketplace or through state Medicaid and CHIP portals or call centers, and will enable individuals to find out about their eligibility for:

  • Enrollment in a QHP through a Marketplace
  • Advance payments of the premium tax credit
  • Cost-sharing reductions
  • Medicaid
  • CHIP
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The online version of this application will feature a dynamic, “smart” process that will be tailored based on the applicant’s circumstances, and will ask only questions that are relevant to that applicant.

Individuals will be able to submit an application to a Marketplace through the Marketplace website, through the mail, over the phone through Federally-facilitated Marketplace toll-free call center, or through the state Medicaid or the CHIP portals or call centers. The best place to get more detailed information about the application process is at www.Healthcare.gov. This website will:

  • Guide individuals directly to the online application for their state
  • Provide clear information about how to complete the application online, apply by phone, or access individual support
  • Provide a checklist for the information an applicant needs, depending on their circumstances

If registered agents and brokers are affiliated with certain QHP issuers, the agents and brokers may also connect to a Federally-facilitated Marketplace through the QHP issuers website to help individuals apply for eligibility determinations and, if the consumer is eligible, select and enroll in a QHP.

Verification

Prior to determining eligibility, the Marketplace will verify applicant information using data from key federal agencies.

In general, the verification process involves validating an applicant’s attestation (e.g., that he or she is a citizen) by checking available electronic data from data sources approved by the Department of Health and Human Services (HHS). In the case of inconsistencies between the applicant’s attestation and the information contained in the approved electronic sources, the application process provides a period of time for the applicant to provide satisfactory documentation or otherwise resolve the issue. At the conclusion of the eligibility verification process, the Marketplace will produce a notice that will include a list of any inconsistencies, along with instructions regarding how they can be resolved.

Depending on an individual’s specific circumstances, the Marketplace may verify the information, from the following sources, to conduct the verification process:

  • Social Security Number (SSN) (Social Security Administration [SSA]) (An individual does not have to provide an SSN if he or she does not have one.)
  • Residency data
  • Citizenship status (SSA and Department of Homeland Security [DHS])
  • Immigration status (DHS)
  • American Indian or Alaska Native status
  • Household size (IRS)
  • Household income (IRS, SSA, Equifax, potentially other sources)
  • Access to other coverage (Medicaid, CHIP, Medicare, TRICARE, Department of Veterans Affairs, Peace Corps, other Marketplaces, the SHOP, and potentially other sources)

Additional Information

If the Marketplace needs additional information regarding SSN, citizenship, or immigration status, the Marketplace will establish eligibility based on the individual’s attestation in those areas for a period of 90 days, during which the individual needs to resolve the issue to continue his or her eligibility for health care coverage.

If the Marketplace needs additional information regarding a criterion of eligibility other than SSN, citizenship, or immigration status, whether the Marketplace will establish eligibility for an insurance affordability program while the inconsistency is resolved depends on whether the applicant’s income makes him or her eligible for Medicaid or CHIP, or for advance payments of the premium tax credit. The Marketplace cannot determine that the applicant is eligible for Medicaid or CHIP until the inconsistency is resolved. However, if the applicant’s income and other eligibility information are consistent with eligibility for advance payments of the premium tax credit, the Marketplace will establish eligibility based on the applicant’s attestation during the 90-day inconsistency period, as long as the applicant attests that he or she understands that advance payments of the premium tax credit are subject to tax reconciliation.

The 90-day inconsistency period may be extended if the applicant demonstrates that he or she has made a good faith effort to obtain the required documentation. After the inconsistency period expires, the Marketplace will issue a final eligibility determination.

Privacy Notice Statement

As a condition of operating in a Federally-facilitated Individual Marketplace, agents and brokers must execute the Federally-facilitated Marketplace Agreement, which includes privacy and security standards. These privacy and security standards include the requirement that agents and brokers provide individuals with a Privacy Notice Statement regarding use and disclosure of PII. This Privacy Notice Statement must be presented to individuals prior to assisting them with application and enrollment in coverage through a Federally-facilitated Individual Marketplace. You will need to review the Federally-facilitated Marketplace Agreement for more details about the Privacy Notice Statement, and when it is necessary to obtain affirmative consent.

After the Application Submission

After an idividual submits an application for coverage to a Marketplace, if no additional verification is required, the Marketplace will provide an immediate eligibility determination. If there are inconsistencies and additional verification is required, the Marketplace will provide a notice that will include information about next steps, including an identification of the inconsistencies that need to be resolved and instructions for how to resolve them.

  • Electronically-submitted applications generally will be processed in real time.
  • Mailed applications will take longer to process.

If an individual is determined eligible for enrollment in a QHP through the Marketplace, he or she then may select a plan to initiate enrollment. If an individual is assessed as potentially eligible or determined eligible for Medicaid or CHIP, the Marketplace will provide a notification, and transfer his or her information to the state Medicaid or CHIP agency for follow-up.

If an individual disagrees with the eligibility determination, he or she may appeal the decision.

Eligibility Recertification

Annual Redetermination Process

Beginning January 1, 2014, the Marketplaces must annually reassess the eligibility of each qualified individual who was determined eligible for enrollment in a QHP. This eligibility reassessment will occur in advance of the open enrollment period.

Changes During the Year

A Marketplace must also re-determine a qualified individual’s eligibility if it receives and verifies new information (e.g., change of state of residence, death of a covered family member), that would affect an individual’s eligibility, either from the qualified individual or other sources, that affect an individual’s eligibility. Qualified individuals must report any changes with respect to eligibility within 30 days of that change.

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Open-Enrollment

Open Enrollment

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Open Enrollment starts Oct 1 2013.

After their eligibility has been determined, individuals may enroll in a QHP during various timeframes throughout the year. The three timeframes are the initial open enrollment period, the annual open enrollment period, and special enrollment periods (SEP).

  • The initial open enrollment period begins October 1, 2013 (before the Marketplaces first make coverage available on January 1, 2014), and continues through March 31, 2014.
  • The annual open enrollment period is between October 15 and December 7 each year, beginning in 2014.
  • SEPs occur throughout the year, based on individuals’ special circumstances.
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Beginning in 2014, the Marketplaces will send an annual open enrollment notice to each enrollee, between September 1 and September 30, to ensure enrollees are aware of the upcoming annual open enrollment period.

When Enrollments Take Effect During the Initial Open Enrollment Period

The date that an individual’s QHP health insurance coverage takes effect is based on the date the Marketplace receives their enrollment selection. The effectuation standards for the initial open enrollment period are as follows:

Enollment Selection received By Coverage Begins
Dec 15, 2013 Jan 1, 2014
Dec 16, 2013 to Jan 15, 2014 Feb 1, 2014
Jan 16, 2013 to Feb 15, 2014 March 1, 2014
Feb 16, 2014 to March 15, 2014 April 1, 2014
March 16th March 31, 2014 May 1,2014

 

When Enrollments Take Effect After the Initial Open Enrollment Periods

As described above, an annual open enrollment period will take place each year from October 15 to December 7 of each year, beginning in 2014. All enrollment selections made during that period will take effect on January 1 of the following year.

For enrollment selections made outside of the annual open enrollment period, during the SEP, the date that an individual’s QHP health insurance coverage takes effect is based on the date the Marketplace receives the enrollment selection. The effectuation standards for enrollment selections made after the initial open enrollment periods are:

Enollment Selection received By Coverage Begins
Oct 15, 2014 to Dec 7, 2014 Jan 1, 2015
1st-15th calendar day of month 1st Day of Following Month
16th-31st calenday day of month 1st Day of second Following Month

Note: Medicaid and Chip do not limit periods of time which an individual can enroll.

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Special Enrollment Periods (SEP)


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Special Enrollment Periods

Under certain circumstances, individuals may change QHPs outside of the annual open enrollment period. These SEPs are based on certain triggering events* or exceptional circumstances.

Events that permit a SEP include, but are not limited to:

  • Gaining or becoming a dependent
  • Gaining status as a citizen, national, or lawfully present individual
  • Loss of minimum essential coverage (e.g., loss of Medicaid eligibility, termination of a QHP), except if enrollment is terminated based on failure to pay premiums
  • Loss of affordable employer-sponsored coverage
  • Determination that an individual is newly eligible or ineligible for premium tax credits or a change in eligibility for cost-sharing reductions
  • Permanent move to an area where different QHPs are available
  • Other exceptional circumstances identified by the Marketplace
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In most cases, SEPs will extend for 60 days from the date of the triggering event. Under certain circumstances, such as the pending loss of minimum essential coverage due to the termination of a QHP, a SEP may begin before the triggering event takes place.

*Trigering Events:
A number of triggering events allow people to enroll in or switch their Marketplace coverage during a SEP outside the annual open enrollment period.

For example, people who lose employer-sponsored insurance, or lose Medicaid coverage because of an increase in income can enroll in a Marketplace plan. Other triggering events include marriage, divorce, and the birth or adoption of a child.

Special Enrollment Period for Marriage

As mentioned in triggering events, a SEP exists for marriage. This means that, if a qualified individual gets married, he or she has the chance to either enroll in a QHP for the first time, or add a spouse to the plan without waiting for the annual open enrollment period.

  • If a marriage occurs and the Individual Marketplace is notified before the last day of the month when the marriage occurred, coverage will begin the 1st of the following month.
  • If a marriage occurs and the Individual Marketplace is notified after the end of the month when the marriage occurred, coverage will begin the 1st of the month following the notification.

The Individual Marketplace would need to be notified within 60 days of a marriage for a spouse to be covered. If the 60-day deadline is missed, the spouse cannot enroll until the plan's annual open enrollment period

Special Enrollment Period for Birth or Adoption

Another important SEP exists for the birth or adoption of a child.

The effective date of coverage can be the date of the birth or the official date of adoption as long as the Individual Marketplace is notified in a timely manner.

The Individual Marketplace would need to be notified within 60 days of a birth or adoption for dependents to be covered. If the 60-day deadline is missed, the dependents cannot be enrolled until the plan's annual open enrollment period.

Premiums would be pro-rated for the month, based on when the child was added to the policy.

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Enrollment And Termination

Questions answered

Enrollment

When a Marketplace receives a health care plan selection from an eligible individual, it will promptly notify the applicable QHP issuer of the requested enrollment and transmit the needed eligibility and enrollment information.

The QHP issuer will then provide the enrollee with an enrollment information package.

If an individual contacts a QHP issuer to initiate an enrollment, the issuer will direct the individual to either:

  • Submit an enrollment application to a Marketplace
  • Fill out and submit the single, streamlined Marketplace application if the individual has not yet received an eligibility determination

If a qualified individual makes a QHP selection but later selects a new QHP before the coverage effective date, the initial QHP selection could be automatically cancelled by the Marketplace as part of the transmission of updated enrollment information to QHP issuers. If any premiums were paid to the initial QHP, the QHP issuer would be responsible for refunding the premium. In some instances, such as when cancellation requests are received immediately before the coverage effective date, the process might result in a retroactive cancellation and QHP issuers should ensure their systems can accommodate such transactions.

Enrollment Termination

Enrollees may terminate QHP coverage on their own accord at any time of the year, including as the result of obtaining other minimum essential coverage (e.g., Medicaid, employer-sponsored insurance coverage), after giving appropriate notice to the Marketplace.

Marketplaces and QHPs may terminate an enrollee’s coverage if the individual:

  • Is no longer eligible for coverage in a QHP through the Marketplace
  • Fails to pay premiums, consistent with the three-month minimum grace period requirement
  • Is enrolled in a QHP that is being terminated or decertified and does not select a different QHP during an applicable enrollment period
  • Has obtained coverage based on fraud or an intentional misrepresentation of material fact

When an individual selects a different QHP during an applicable enrollment period, coverage under the previous QHP will end automatically on the date that coverage under the new QHP takes effect.

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Agent Certification

Agents and Brokers Registration

Questions answered

Registration Process

Agents and brokers operating in the Individual Marketplace must complete the steps below before they may assist individuals with an application, plan selection, and enrollment through a Federally-facilitated Marketplace.

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Note that the registration steps occur on two different websites —

  1. The Medicare Learning Network (MLN)® Portal: http://medicarelearningnetworklms.com
  2. The CMS Enterprise Portal: https://portal.cms.gov/

Agents and brokers who ONLY operate in the Federally-facilitated SHOP are only required to complete the applicable steps in Part I.

Part I.  Register on MLN, complete assigned training and exams, and execute Federally-facilitated Marketplace Agreements. (All agents and brokers in the Federally-facilitated Marketplaces are required to register on the MLN website. This applies to all agents and brokers, regardless of which insurance market they wish to serve in the Federally-facilitated Marketplaces.)

Step 1. Enter basic identifying information, including your NPN, as prompted. You will also be prompted to create an MLN user ID. It is vital that you enter your NPN correctly, and that you remember your MLN user ID. 
Step 2. When prompted during the MLN registration,
a. Select your user type: “agent/broker/web-broker”
b. Select your role, based on which insurance market(s) you wish to serve. 

The role choices are: “Individual Marketplace,” “SHOP Marketplace,” or “Individual Marketplace and SHOP Marketplace.” Your role selection will determine the courses and agreements you complete. Your progress in completing those items will be tracked, based on your role selection.

Step 3. Depending on the role you select, you must complete the following steps, as prompted, in order to receive training completion certificates.

a. If you select the Individual Marketplace role, you must —

i. Take the “Affordable Care Act and Marketplace Basics” course and pass the exam. (required)
ii. Take the “Individual Marketplace” course and pass the exam. (required)
iii. Read and accept the Federally-facilitated Marketplace Agreement for the Individual Marketplace. (required)

b. If you select the SHOP Marketplace role, you will be prompted to —

i. Take the “Affordable Care Act and Marketplace Basics” course and pass the exam. (highly recommended)
ii. Take the “Small Business Health Options Program Marketplace (SHOP)” course and pass the exam. (highly recommended)
iii. Read and accept the SHOP Marketplace Agreement for the Federally-facilitated SHOP. (required)

c. If you select the Individual Marketplace and SHOP Marketplace role, you will be prompted to —

i. Take the “Affordable Care Act and Marketplace Basics” course and pass the exam. (required.)
ii. Take the “Individual Marketplace” course and pass the exam. (required)
iii. Take the “Small Business Health Options Program Marketplace (SHOP)” course and pass the exam. (highly recommended)
iv. Read and accept the Individual Marketplace Agreement for the Federally-facilitated Marketplace. (required)
v. Read and accept the SHOP Agreement for the Federally-facilitated SHOP. (required)

Step 4. Keep the training completion certificates you receive. You will need to provide copies of these certificates to the issuers and web-brokers with which you are affiliated. You will receive a certificate for each curriculum you complete. 

a. The Individual Marketplace curriculum consists of: Affordable Care Act and Marketplace Basics exam; Individual Marketplace exam; Federally-facilitated Marketplace Agreement for the Individual Marketplace

b. The SHOP Marketplace curriculum consists of: Affordable Care Act and Marketplace Basics exam (if completed); SHOP Marketplace exam (if completed); SHOP Marketplace Agreement for the Federally-facilitated SHOP

c. The Individual Marketplace and SHOP Marketplace curriculum consists of: Affordable Care Act and Marketplace Basics exam; Individual Marketplace exam; SHOP Marketplace exam (if SHOP training is completed); Individual Marketplace Agreement for the Federally-facilitated Marketplace; SHOP Marketplace Agreement for the Federally-facilitated SHOP

Remember to keep these certificates for your records. You will need to provide copies to the issuers and web-brokers with which you are affiliated.

Registration process Part 2

Part II.  Create a User Account and complete identity verification through the CMS Enterprise Portal.
(Required only for agents and brokers who wish to enroll individuals in a Federally-facilitated Individual Marketplace.)

Step 1. Go to the CMS Enterprise Portal at https://portal.cms.gov/ and select “New User Registration.” Note: To allow time for your training results from the MLN site to be transmitted to the CMS Enterprise Portal, you must generally wait at least two business days after completing your registration, training and exams, and Marketplace agreement(s) on the MLN website. During the initial 2013 launch of the agent/broker registration process, the transmission of training results may sometimes take longer than two business days.
Step 2. As a result of selected "New User Registration", the CMS Enterprise Identity Management (EIDM) system on the CMS Enterprise Portal will prompt you to agree to the EIDM terms and conditions, and then enter basic identifying information. Be sure to enter your legal name rather than a nickname.
Step 3. The EIDM system will prompt you to create a Federally-facilitated Marketplace user account (your FFM user ID, password, and challenge questions). 
  • Agents and brokers operating in the Individual Marketplace will use this ID to enroll individuals in the FFM.
  • The challenge questions may be used later to retrieve your password or make profile updates.
  • Note that this FFM user ID will not be fully activated until all steps below are completed.
Step 4. After the completion of Step 3, the EIDM system will acknowledge the creation of the account and redirect you to the CMS Enterprise Portal home page for you to log back in with your new FFM user ID and password.
Step 5: On the CMS Enterprise Portal home page, select "login to CMS Secure Portal" and log in with the FFM user ID and password you created in Step 3. This returns you to the EIDM system.

Step 6: Select “Request Access Now”.  On the “My Access” page, select “Request New Application Access”.

Step 7: Select “FFM” from the Application Description dropdown menu.
Step 8: Select your role: “Agent/Broker.”
Step 9: Before granting you the Agent/Broker role, the EIDM system will automatically begin a secure identity proofing process. The EIDM system receives the questions from an external application, and does not control the content of the questions. You will be asked questions that only you can answer, so-called “out of wallet” questions — because the answers are usually not found in your wallet or purse. 

Step 10: Once the identity proofing process is successfully completed, you will be returned to the “My Access” page.

Step 11: Enter your NPN and MLN User ID. (It is absolutely vital that you enter both of these items accurately, or the system will not be able to match your training records.) 

Step 12: When identity proofing has been successfully completed, your FFM user ID will be activated, and you will be granted the Agent/Broker role. Your FFM user ID and NPN must be entered on Federally-facilitated Marketplace applications in order to receive compensation from health insurance issuers.

Note that in some cases, identity proofing will not be feasible on-line. In this case, EIDM will display a phone number for you to call that is staffed by appropriate personnel. If you are unsuccessful in completing identity proofing with that individual phone assistance, you may also contact the Agent/Broker Email Help Desk.

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Small Business Health Options (SHOP)

Questions answered

Under the Affordable Care Act, during the first year of operation, small businesses that qualify for coverage through a SHOP will be able to offer their employees a single QHP (Qualified Health Plan) option. SHOPs will offer qualified small groups access to QHPs in each state, and will provide flexibility in the amount that members of the small group contribute towards the total premium.

To qualify for SHOP coverage, a business must:

  • Be located in a SHOP's service area (generally a state)
  • Offer coverage to all full-time employees (those working an average of 30 or more hours per week)
  • Have at least one eligible employee on payroll
  • Have 50 or fewer full-time equivalent (FTE) employees on payroll in 2014
    • This methodology includes part-time employees, but not seasonal employees (those working fewer than 120 days per year)
    • While the Federally-facilitated SHOPs (FF-SHOP) must determine eligibility using the definitions above, State-based SHOP Marketplaces have flexibility in their counting approaches in 2014
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Premium tax credits and cost-sharing reductions are not available to employers and families covered through a SHOP. However, employers meeting certain size and average wage requirements may receive a small business tax credit on their tax returns of up to 50% of the employer’s contribution to the premium. This credit is only available for coverage provided through a SHOP.

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SHOP Benefits

Questions answered

The SHOP Marketplace provides consumers, both employers and employees, with many benefits. Only QHPs (Qualified Health Plans) will be offered through the Marketplaces. 

Consumers will be assured that the available plans meet network adequacy and benefit design standards of the SHOP.

Premiums for the employers and employees will not be based on their health or medical history, but can only vary based on age, family composition, geographic area, and tobacco use.

A SHOP provides unbiased information and comparison tools for consumers. The tools available through the Marketplaces will help agents provide consumers with “apples to apples” comparisons among health plans.

In some cases, the employer may be eligible for Small Business Tax Credits.(Only available in 2014)

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Small Business Tax Credit

Questions answered

In some cases, the employer may be eligible for small business tax credits of up to 50% of the employer’s share of the insurance coverage for up to two years. This tax credit is ONLY available through the SHOPs beginning in 2014. 

The small business tax credit applies to small businesses with up to 25 FTE employees that pay employees an average annual wage below $50,000 and that contributes 50% or more towards employees’ health insurance premiums.

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AT ExploreObamacare.com we hope this resource of information will help enable you to gain the knowledge needed for your family or small business during this time of transition.

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ExploreObamacare.com is not affiliated with any government agency. All information provided is for informational purposes only and no guarantee of the accuracy is hereby implied. The information was the product of researching the Affordable Care Act Bill and is subject to change.
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Prescription COST Assistance

Prescription Drug Cost Reduction

Paid Programs are available that offer consumer assistance by helping consumers find free or significantly reduced prescription drugs.

If you are struggling to meet the out-of-pocket expenses associated with your medication(s) there are organizations and independent foundations which may help reduce this cost.

Spend Over $150 a month on scripts?

If you spend over $150 a month for prescription drugs you may benefit from signing up with a paid service which helps you find out if you qualify for FREE brand name medications or significantly reduced cost prescriptions, making your name brand medication more affordable.

How does it Work?

This is not a government or federal drug assistance program however there are paid services that help people find free and reduced cost prescription fulfilment.

Find out how much you can save

  • Complete a Consultation Request
  • Provide confidential list of medications and current fulfillment costs
  • Find out how much you can save.
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Dental Plans and ObamaCare

Dental plans will be available on State and Federal Exchanges in most states. With health plan costs being subsidized this leaves consumers with more options concerning their dental needs.

Why Dental Insurance

Maintaining the health of your teeth and gums is important to your overall health. Having dental insurance will help to minimize your out-of-pocket expenses as most policies will cover an array of dental services.

People with Dental Insurance are more likely to go for annual cleanings and check ups.

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