The new Health Insurance Marketplace: what individuals and small businesses need to know.
January 1, 2014, the health insurance marketplace (or exchange) will become a new way for individuals and employees of small businesses to obtain health insurance coverage. Enrollment began on October 1, 2013.
The marketplace is intended as an easy way to shop for health insurance —it will have all options available in one place and a comparison of price, benefits, quality and other factors. In 2014, the U.S. Department of Health and Human Services (HHS) expects that 25 million Americans will have access to quality health insurance. In addition, up to 20 million people, including families, may qualify for assistance to make coverage more affordable. In 2016, the marketplace will be available to those working for businesses with 100 full-time employees and full-time equivalents, and in 2017 each state has the option to expand the marketplace to employers with more than 100 workers.
By law, the marketplace includes provisions to determine eligibility for premium tax credits or cost-sharing subsidies toward individual or family health insurance based on an individual’s prior year tax return. An individual cannot get marketplace cost-sharing subsidies if he or she is eligible for employer-sponsored coverage that is deemed affordable and meets minimum value. Although there is no requirement to purchase health insurance through the marketplace, to receive premium tax credits or cost-sharing subsidies, an individual or small employer must purchase coverage through the marketplace (not in the outside market).
Essential Health Benefits
While private companies offer insurance plans, the marketplace will be run by either the federal government (federally-based exchange) or by your state (state-based exchange). The insurance plans offered in the marketplace will cover the same core set of benefits, called the “essential health benefits.”
In addition, a plan may not turn someone away or charge more due to an illness or medical condition, or charge women more than men for the same plan. Florida is operating the marketplace from HealthCare.gov. Specific plans and prices are available now.
Small Business Marketplace Enrollment
October 1, 2013, small businesses were able to begin enrolling in the marketplace and purchase employee coverage that will begin January 1, 2014. The marketplace for small businesses is referred to as the Small Business Health Options Program, or the “SHOP Exchange.” This is a streamlined way for small employers and small tax-exempt entities to shop for health insurance coverage. Small businesses may enroll directly through the SHOP Exchange or through a broker registered with the SHOP.
Small employers using the SHOP Exchange may be eligible to receive the tax credits available under the Affordable Care Act (ACA).
Individual Marketplace Enrollment
Individuals who want to participate in the marketplace must live in its service area, be a U.S. citizen or national, or be a non-citizen who is lawfully present in the U. S. for the entire period for which enrollment is sought, and is not incarcerated.
The marketplace lists all of the health plans available in your area, including the monthly premium costs for private insurance plans. It will explain if you qualify for premium tax credits, cost-sharing subsidies, Medicaid or the Children’s Health Insurance Program (CHIP).
Navigators
The ACA includes a community-based navigator program, where individuals trained on the regulations will provide outreach, education, and enrollment resources for individuals. You can apply for marketplace insurance in-person with the help of a navigator or other qualified helper. You can also apply online or by mail. HHS is working with local libraries and community colleges to assist those who do not have computer or web access. Application help is available 24/7 at 800.318.2596 and online.
Health Insurance Exchange Employee Notice
All employers were required to provide their current employees with the Health Insurance Exchange Notice no later than October 1, 2013, regardless if they do or do not offer coverage. This notice informs employees of the existence of the exchange, the services offered and contact information. For employees hired after October 1, 2013, the notice must be provided upon hire. Model notice language is available on the Department of Labor website for employers who offer a health plan as well as employers who do not.
Planning for open enrollment
Individuals and businesses can stay informed about open enrollment by:
- Signing up at healthcare.gov to receive email or text updates about the marketplace
- Finding out which marketplace will serve you
- Learning about the different types of health coverage available through the marketplace
- Determining if you will have employer-sponsored coverage in 2014, and if not, how to obtain insurance through the marketplace or other sources
- Starting the marketplace application process to find out if you are eligible for premium tax credits or cost-sharing subsidies.
Editor’s note: Kelly Davis is an employee benefit plans manager for CliftonLarsonAllen, one of the nation’s top 10 certified public accounting and consulting firms. [cliftonlarsonallen.com]