Understanding the Health Insurance Marketplace

Understanding the Health Insurance Marketplace
June 2014 Understanding the Health Insurance Marketplace Find health care options that meet your needs and fit your budget. “Understanding the Health Insurance Marketplace” provides a high-level overview of the Affordable Care Act and the new Health Insurance Marketplace. This training presentation was developed and approved by the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Federally-facilitated Health Insurance Marketplace. The information in this module was correct as of June To check for an updated version, visit Marketplace.cms.gov. This as an informational resource for our partners. It’s not a legal document or intended for press purposes. Members of the press should contact the CMS Media Relations Group at Official Medicare and Marketplace program legal guidance is contained in the relevant statutes, regulations, and rulings. September 2015 Health Insurance Marketplace 101

Understanding the Marketplace
Objectives June 2014 This session will help you Explain the Health Insurance Marketplace Define who might be eligible Define options for those with limited income Explain the enrollment process Explain available options for people with Medicare Locate resources This session will help you to: Explain the Health Insurance Marketplace Define who might be eligible Define options for those with limited income Explain the enrollment process Explain available options for people with Medicare Locate resources September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Session Topics Health Insurance Marketplace (Marketplace) Eligibility and enrollment Ways to lower costs Monthly premiums Out-of-pocket costs Medicaid and the Children’s Health Insurance Program (CHIP) Assistance with applying and enrolling Key points This session includes the following topics: The Health Insurance Marketplace (Marketplace) Eligibility and enrollment Ways to lower costs Monthly premiums Out-of-pocket costs Medicaid and the Children’s Health Insurance Program (CHIP) Assistance with applying and enrolling Key points September 2015 Understanding the Marketplace

What Is the Health Insurance Marketplace?
June 2014 Created by the Affordable Care Act Where qualified individuals and families can directly compare private health insurance options Known as qualified health plans (QHPs) Can directly compare on the basis of price, benefits, quality, and other factors Also known as Exchanges Small Business Health Options Program (SHOP) Marketplace for small employers Provides coverage for their employees The Health Insurance Marketplace is designed to help find and buy health insurance that fits your budget. Health insurance plans in the Marketplace offer comprehensive coverage, from doctors to medications to hospital visits. Some plans provide only dental benefits. Marketplace plans that provide medical benefits are called qualified health plans (QHPs). Marketplace plans that cover only dental services are called qualified dental plans (QDPs) or stand-alone dental plans (SADPs). You can compare all your insurance options based on price, benefits, quality, and other features that may be important to you, in plain language that makes sense. The Marketplace is sometimes referred to as Exchanges. You’ll know you’re getting a quality health plan at a reasonable price, because the coverage and benefits information, and premium rates are readily available. There’s a Marketplace for small employers too. It’s called the Small Business Health Options Program, or SHOP. We’ll briefly talk about SHOP later. This session focuses on the Individual Marketplace. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Marketplace Establishment
June 2014 Each state can decide to Create and run its own Marketplace Engage actively with the federal government in operating certain Marketplace functions Have a Marketplace established and operated by the federal government Each state has substantial flexibility in establishing a Marketplace that meets the needs of its citizens. States across the country received grants to establish Marketplaces. Some states are operating their own Marketplaces. A state may apply at any time to run its own Marketplace. A state may also decide (elect) to have the federal government operate its Marketplace. The federal government is operating a Marketplace in those states that didn’t establish their own. In states where the federal government is operating a Marketplace, the state can opt to partner with the federal government. A Partnership Marketplace allows states to make recommendations for key decisions and help tailor a Marketplace to local needs and market conditions. States may also establish and operate only a Small Business Health Options Program (SHOP), while the federal government establishes the Individual Marketplace in that state. U.S. territories can decide whether to create their own Marketplace or expand Medicaid coverage. Residents of a U.S. territory that creates a Marketplace can only enroll in plans in their territory’s Marketplace. They aren’t eligible to apply for health insurance using the Federally-facilitated or a state’s Marketplace; you must be a resident of the state in which a Marketplace is operating to be eligible to enroll in coverage through the Marketplace. Check with your territory’s government offices to learn about these options. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

How the Health Insurance Marketplace Works
June 2014 It uses one process to determine eligibility for Qualified health plans through the Marketplace Premium tax credits to lower monthly premiums Reduced cost sharing Medicaid Children’s Health Insurance Program (CHIP) It offers choice of plans and levels of coverage Insurance companies compete for business With one Marketplace application, you can learn if you can get lower costs based on your income, compare your coverage options side-by-side, and enroll. Through this one process, you can find out if you’re eligible for Qualified health plan (QHP) coverage Premium tax credits to lower what you pay for your monthly health plan premium Cost-sharing reductions to lower what you pay out-of-pocket for costs like deductibles, copayments, and coinsurance Other health coverage programs, like Medicaid (a federal/state program which covers certain people with low income and resources), and the Children’s Health Insurance Program (CHIP) (which covers certain children) The Marketplace offers competition and choice. Insurance companies are competing for business on a level and transparent playing field. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Qualified Health Plans (QHPs)
June 2014 A QHP Is offered through the Marketplace by an issuer that is licensed by the state and in good standing Covers essential health benefits Is offered by an issuer that offers at least one plan at the “Silver” and one at the “Gold” plan category of cost sharing Charges same premium whether offered through the Marketplace or outside the Marketplace A qualified health plan (QHP) is an insurance plan that is certified by the Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A QHP must be certified by each Marketplace in which it is sold. Additionally, a QHP must be offered by a health insurance issuer that Is licensed and in good standing to offer health insurance coverage in each state in which the issuer offers health insurance coverage Agrees to offer at least one QHP in the Silver level and at least one plan in the Gold level in a Marketplace Agrees to charge the same premium rate for each QHP without regard to whether the plan is offered through a Marketplace or whether the plan is offered directly from the issuer or through an agent Agrees to offer a zero cost sharing or limited cost sharing variation to American Indians and Alaska Natives in any plan category Complies with the regulations developed by the Secretary under Section 1311(d) and such other requirements as an applicable Marketplace may establish September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Qualified Health Plans Cover Essential Health Benefits
June 2014 Essential health benefits include at least these 10 categories Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care (pediatric oral services may be provided by stand-alone plan) The Affordable Care Act provides for the establishment of an Essential Health Benefit (EHB) package that generally includes coverage of EHBs (as defined by the Secretary of the Department of Health and Human Services [the Secretary]). The law directs that EHBs be equal in scope to the benefits covered by a typical employer plan and cover at least the following 10 general categories: 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 Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care (pediatric oral services may be provided by stand-alone plan) NOTE: The Marketplace only offers Qualified Health Plans, including stand-alone dental QHPs that cover pediatric dental essential health benefits. Each state has a benchmark plan that’s the basis for what services a QHP must cover as essential health benefits. If a state’s base-benchmark plan lacks pediatric dental or vision coverage it must be supplemented with the Federal Employee Dental and Vision Insurance Program’s (FEDVIP’s) pediatric vision/dental plan; or the state’s separate CHIP plan benefit if one exists. Pediatric services must be covered for individuals under 19, but states have the flexibility extend pediatric coverage beyond 19. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

How Qualified Health Plans Can Vary
June 2014 Some plans may cover additional benefits You may have to see certain providers or use certain hospitals (networks) The premiums, copayments, and coinsurance are different Quality of care data will be available The coverage level can vary within each plan Some special types of plans are structured differently Like high-deductible (catastrophic) plans Out-of-pocket costs include deductibles, copayments and coinsurance Qualified health plans in the Marketplace can vary, for instance: Some plans may cover additional benefits You may have to see certain providers or use certain hospitals (networks) The premiums, copayments, and coinsurance are different in different plans The quality of care can vary, but quality data will be made available to facilitate your shopping experience The coverage level can vary within each plan (see next slide) Some plans are structured differently, like high-deductible (catastrophic) plans Remember, all plans must cover the essential health benefits, except for pediatric dental coverage, which isn’t required if available from a stand-alone plan. The Marketplace lets you compare, choose and enroll. Out-of-pocket costs include deductibles, which is the amount you pay for your covered health care services before your plan starts to pay. You also pay copayments. For example, you may have to pay $20 each time you see your doctor. You may also have to pay coinsurance for certain services. For example, if the coinsurance is 30% and the covered service costs $100, you would pay $30 and the plan would pay $70. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Health Plan Categories
June 2014 Lowest Premiums Highest Out-of-Pocket Costs Highest Premiums Lowest Out-of-Pocket Costs Plans in the Marketplace are primarily separated into 4 health plan categories—Bronze, Silver, Gold, and Platinum—based on the percentage the plan pays of the average overall cost of providing essential health benefits to members. The plan category you choose affects the total amount you'll likely spend for essential health benefits (EHBs) during the year. The plan categories are each associated with an actuarial value, or AV, which, when looking across an entire population, can be considered a general summary measure of what portion of health costs the health plan will pay. AV represents the percentage of the total allowed costs of benefits paid by the plan, based on the provision of EHBs. For example, if a plan has an AV of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. The health plan categories are as follows: Bronze level—a health plan that has an AV of 60% Silver level—a health plan that has an AV of 70% Gold level—a health plan that has an AV of 80% Platinum level—a health plan that has an AV of 90% However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy. While premiums aren’t taken into account to calculate the AV, generally plans with a higher AV and more generous cost sharing tend to have higher premiums. 60% 70% 80% 90% Percent of Total Cost of Care Covered September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Catastrophic Health Plans
June 2014 What is catastrophic coverage? Plans with high deductibles and lower premiums You pay all medical costs up to a certain amount Includes 3 primary care visits per year and preventive services with no out-of-pocket costs Protects you from high out-of-pocket costs Who is eligible? Young adults under 30 Those who qualify for a hardship exemption Those whose plan was cancelled and believe Marketplace plans are unaffordable A catastrophic plan generally requires you to pay all of your medical costs up to a certain amount, usually several thousand dollars. Costs for essential health benefits over that amount are generally paid by the insurance company. Catastrophic plans generally have lower premiums, protect against high out-of-pocket costs, and cover 3 annual primary care visits and preventive services at no cost. They’re available only to people under 30 and to people who have received a “hardship” exemption because the Marketplace determined they couldn’t afford health coverage. Each member of a family must meet the eligibility requirements to purchase a catastrophic plan. NOTE: People who enroll in catastrophic health plans aren’t eligible for premium tax credits to lower their monthly premiums. Regardless of your income, you pay the standard price for the catastrophic plan. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Eligibility and Enrollment in the Individual Market
To be eligible for Marketplace coverage, you must Live in its state, or service area, and 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 Not be incarcerated except when pending disposition of charges Anyone can apply for Medicaid/CHIP at any time, even if incarcerated To be eligible for Marketplace coverage, you must: Live in the state served by the Marketplace, or if different, the service area of the Marketplace. Be a citizen or national of the United States, or a non-citizen who is lawfully present in the United States, and is reasonably expected to be a citizen, national, or a non-citizen who is lawfully present for the entire period for which enrollment is sought. Not be incarcerated, other than incarceration pending the disposition of charges. You can apply for Medicaid or the Children’s Health Insurance Program (CHIP) at any time, even if you’re incarcerated. Eligibility status is determined through electronic data checks with the IRS, SSA, the Department of Homeland Security, and other electronic data sources approved for eligibility verification. If you meet the eligibility requirements you’re considered a “qualified individual.” If you don’t meet the citizenship status as a national, or lawful presence requirement you can’t be a qualified individual. There’s no waiting period, such as in Medicaid, that provides eligibility after you have lived in the U.S. for a set period of time. If you have a student visa you may be eligible for coverage through the Marketplace, but not for Medicaid or CHIP. NOTE: The Affordable Care Act treats U.S. citizens living abroad as having minimum essential coverage, so they won’t have to pay the fee. September 2015 Understanding the Marketplace

What is the Federally-facilitated SHOP Marketplace?
The Small Business Health Options Program = SHOP Part of the Health Insurance Marketplace created by the Affordable Care Act (ACA) Offers small employers a choice of qualified health and dental plans and tools for making informed choices Gives otherwise eligible qualified small employers access to the Small Business Health Care Tax Credit—worth up to 50% of employer’s premium contributions Works with new insurance reforms to spur competition based on price and quality The Small Business Health Options Program (SHOP), is part of the new Health Insurance Marketplace—sometimes called an Exchange—and is available in every state. It was created to make it easier for small employers to find and purchase health insurance for their employees. Some states are running their own SHOP Marketplaces, while others are participating in the Federally-facilitated SHOP Marketplace. This presentation is focused on the Federally-facilitated SHOP Marketplace, also known as the FF-SHOP Marketplace. The SHOP is open to employers with 1-50 employees—including non-profit and religious organizations. The FF-SHOP Marketplace offers a choice of health and dental plans, and tools to help customers make informed purchasing decisions. Employers and their employees can submit initial group enrollments for SHOP coverage at any time throughout the year. After the initial group enrollment is submitted and coverage goes into effect, SHOP enrollments are limited to an annual enrollment period for employees, special enrollment periods, and enrollment periods for newly eligible employees. In addition, if employers offer their employees coverage through the SHOP, and meet other eligibility requirements, small employers may be able to claim a Small Business Health Care Tax Credit worth up to 50% percent of their premium contributions. Together, new insurance reforms and the SHOP will help curb premium growth, and spur competition based on price and quality. The SHOP Marketplace now lets small businesses find and enroll in 2015 coverage online through HealthCare.gov. And, in 14 of the 33 states using the FF-SHOP, small employers now have the option to offer their employees a choice of health plans, much like large employers do. Small employers with fewer than 50 full-time-equivalent employees, aren’t required to offer their employees health insurance, and there’s no penalty if they choose not to. September 2015 Understanding the Marketplace

What is the Federally-facilitated SHOP Marketplace? Continued
For coverage starting in 2015: Offers online purchase and enrollment in health and dental coverage through HealthCare.gov Offers small employers in 14 states the option to give employees a choice of plans In 2016 small employers in all states and DC will have the option to give employees a choice of SHOP Marketplace plans The SHOP Marketplace now lets small businesses find and enroll in 2015 coverage online through HealthCare.gov. And, in 14 of the 33 states using the FF-SHOP, small employers now have the option to offer their employees a choice of health plans, much like large employers do. Small employers with fewer than 50 full-time-equivalent employees, aren’t required to offer their employees health insurance, and there’s no penalty if they choose not to. Note: Employers with fewer than 50 full-time-equivalent employees, aren’t required to offer health insurance, and there’s no penalty if they choose not to September 2015 Understanding the Marketplace

Who Can Purchase SHOP Marketplace Coverage and When?
Small employers: With 1-50 full-time equivalent employees (increases to as of 2016) With at least one employee who is not a co-owner or spouse Including tax-exempt and religious employers Who offer coverage to all full-time employees FTE in the FF-SHOP employees working on average 30 or more hours/week Visit the SHOP FTE Calculator HealthCare.gov/shop-calculators-fte/ The FF-SHOP is open to small employers with 1 to 50 full-time equivalent employees (FTEs) Part-time workers, whose combined hours total at least 30 hours per week, are also included when determining FF-SHOP eligibility. Employers must have at least one employee on payroll, who is not a business partner or spouse, to be eligible for FF-SHOP coverage. To participate in the FF-SHOP employers must offer coverage to all employees who work an average of 30 or more hours per week. HealthCare.gov now offers an online tool, the SHOP FTE Calculator, that can help employers count how many full-time equivalent employees they have, to help determine if they might be eligible for the Federally-facilitated SHOP. Full-time equivalent employees generally include those who work at least 30 hours per week. The FTE Calculator is based on the counting method used by the FF-SHOP which, until 2016, may differ from the method used by states running their own SHOP. Employers in a state with a state-based SHOP should contact the SHOP in their state to learn more. September 2015 Understanding the Marketplace

Who Can Purchase SHOP Marketplace Coverage and When? Continued
Enroll in FF-SHOP coverage: Initial group enrollment can occur anytime during the year—no limited Open Enrollment period Before 15th of month for coverage starting next month After 15th of month for coverage starting 2nd following month Small employers can offer employees health coverage through a FF-SHOP now, or at any time during the year. In the FF‐SHOP, if an employer’s initial group enrollment is completed between the 1st and 15th day of the month, coverage could begin as soon as the first day of the next month. For example, if initial group enrollment is completed on October 10, group coverage could begin as soon as November 1. For initial group enrollments completed after the 15th of the month, coverage could begin as soon as the first day of the second following month. So, for enrollment completed on October 18, group coverage could begin as soon as December 1. September 2015 Understanding the Marketplace

How the SHOP Marketplace Works Moving Towards Employee Choice
A key goal of the SHOP: Options for small employers and their employees In 2015: Employers in 14 states using the FF-SHOP Marketplace can offer employees a choice of plans In 2016: The SHOP Marketplace will offer small employers an Employee Choice option in all states and DC The ultimate goal of SHOP is to give small employers more options for their employees—including the option to offer employees a choice among health plans at in one plan category. In 2014, small employers in states with a Federally-facilitated SHOP generally had a choice of health plans and dental plans in different plan categories, from various health insurance companies. Employers could select to offer employees only one SHOP Qualified Health Plan —and, if applicable, a single SHOP Qualified Dental Plan. Some states running their own SHOP Marketplace gave employers the option to offer employees a choice of plans. Plans taking effect in 2015, employers in 14 states using the Federally-facilitated SHOP will be able to offer employee choice. This means that an employer selects a plan category, and then the employee can enroll in any plan available within that category. Many states running their own SHOP Marketplace offer an employee choice options, which may differ from the employee choice option offered by the FF-SHOP Marketplace. In 2016, all states are expected to offer small employers a choice between offering employees a single SHOP plan, or letting employees select among multiple SHOP plans. September 2015 Understanding the Marketplace

The Small Business Health Care Tax Credit
Certain small employers that meet certain requirements, may qualify for the Health Care Tax Credit: Those with fewer than 25 “full-time equivalent” employees (FTEs) Whose employees’ wages average less than $50,000 per year, adjusted for inflation beginning in 2014 Employers whose employees’ wages average less than $51,000 in 2015 Who contribute at least 50% of employees’ premium costs The Small Business Health Care tax credit was created to help small employers of low-to-moderate-wage workers defray the costs of providing coverage. One important reason for employers to consider offering employees SHOP coverage is that, as of the year 2014, the credit is generally only available to those who have employees enrolled in SHOP coverage. Employers may be eligible for the credit if they have fewer than 25 full-time-equivalent employees and those employees have average wages of less than $50,000 a year. The average salary limit is adjusted for inflation beginning in For practical purposes, that means that an employer whose employees’ wages average less than $51,000 may qualify for the credit in tax year 2015. The limit on employer size applies to “full-time-equivalent” employees. That means that employers that have more than 25 lower-to-moderate wage part-time employees may still be eligible for the credit. For example, two half-time employees might equal one full-time-equivalent employee. Full-time equivalent employees are calculated differently for purposes of the tax credit than for determining whether an employer can use the SHOP Marketplace. The tax credit bases full-time equivalent employees off a 40 hour work week. To be eligible for the credit, employers must also pay at least 50% of employees’ self-only health insurance premiums. The value of the tax credit increased significantly starting with tax year 2014, and is now worth up to 50% of the employer’s premium contribution (up to 35% for tax-exempt employers). Employers who offered employees health insurance during any of the years from 2010 to 2013, may still be able to claim the credit for those years, and should consult a tax advisor for more information. However, for tax years 2010 through 2013, the credit was worth up to 35% of the employer’s contribution (25% for tax exempt employers.) September 2015 Understanding the Marketplace

The Small Business Health Care Tax Credit Continued
Available only to employers with employees enrolled in a Qualified Health Plan through the SHOP Worth up to 50% of employer’s premium contribution to SHOP health and dental plans (up to 35% for tax exempt employers) Can be claimed for 2 consecutive years Visit the SHOP Tax Credit Estimator HealthCare.gov/shop-calculators-taxcredit/ Starting with tax year 2014, the enhanced tax credit is available for two consecutive years—even for employers that have already claimed the credit one or more times before 2014. Since the Small Business Health Care Tax Credit became available in 2010, small employers have received more than $1.5 billion in tax credits for contributions to employee premium costs. To help employers learn if they might be eligible for the tax credit, and how much that credit might be worth, HealthCare.gov offers a tool, called the SHOP Tax Credit Estimator, available at the web address listed here. September 2015 Understanding the Marketplace

SHOP Marketplace on HealthCare.gov Benefits for Small Employers
convenience: Find, and compare all available SHOP health and dental plans in the area Complete the entire enrollment process online for coverage beginning in 2015 Access to tax credits Worth up to 50% of contributions to employee premiums, for eligible employers who buy SHOP coverage Useful online information, tools and links The SHOP Marketplace offers a simpler way to find, and compare health insurance and dental insurance options for small employers and employees. New online features put the whole enrollment process online at HealthCare.gov for coverage beginning as early as January 1, 2015. Beginning in tax year 2014, small employers may qualify for a tax credit worth as much as 50% of their contribution to employee premiums when they buy coverage through the SHOP Marketplace and meet other eligibility requirements. HealthCare.gov offers straightforward information, useful links to information about how the ACA affects small business and helpful tools, like the SHOP FTE Calculator, SHOP Tax Credit Estimator, and the Premium Estimate Tool Employers get a choice of health plans from multiple insurance companies, and in different plan categories. Help is available and easy to find, through the HealthCare.gov “Find local help” tool, the SHOP Call Center, and through the searchable online list of FF-SHOP-registered agent or brokers. September 2015 Understanding the Marketplace

SHOP Marketplace on HealthCare.gov Benefits for Small Employers Continued A choice of plans For employers, and For employees in the 14 Employee Choice states Many ways to get help Toll-free call center “Find Local Help” on Healthcare.gov where employers can search for FF-SHOP-registered agents and brokers The SHOP Marketplace offers a simpler way to find, and compare health insurance and dental insurance options for small employers and employees. New online features put the whole enrollment process online at HealthCare.gov for coverage beginning as early as January 1, 2015. Small employers may qualify for a tax credit worth as much as 50% of their contribution to employee premiums when they buy coverage through the SHOP Marketplace and meet other eligibility requirements. HealthCare.gov offers straightforward information, useful links to information about how the ACA affects small business and helpful tools, like the SHOP FTE Calculator, SHOP Tax Credit Estimator, and the Premium Estimate Tool Employers get a choice of health plans from multiple insurance companies, and in different plan categories. Help is available and easy to find, through the HealthCare.gov “Find local help” tool, the SHOP Call Center, and through the searchable online list of FF-SHOP- registered agent or brokers. September 2015 Understanding the Marketplace

Lower Premium Costs June 2014 The premium tax credit may be taken as advance payments to lower monthly premium costs, or as a refundable credit on the tax return you file Eligibility is based on Household income and family size Household income between 100% to 400% FPL $23,850 – $95,400 for a family of 4 in 2015 Obtaining health insurance through the Marketplace Ineligibility for government-sponsored coverage, affordable employer-sponsored insurance, or certain other minimum essential coverage When you use the Marketplace you may be eligible to receive advance premium tax credits that may be used to lower your monthly premiums, and cost-sharing reductions that lower your out-of-pocket costs. The premium tax credit is generally available to individuals and families with household incomes between 100% and 400% of the federal poverty level, $23,850 – $95,400 for a family of 4 in 2015, who don’t have access to certain other types of minimum essential coverage. This makes coverage much more affordable for the middle class. Remember, minimum essential coverage includes government-sponsored coverage (like Medicare, Medicaid, CHIP, some VA coverage, and TRICARE), affordable employer-sponsored insurance (meaning the cost for the employed individual is no more than 9.5% of their income), and certain other coverage. 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 payment 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 credit. On the other hand, if the amount of the premium tax credit on the tax return, determined based on annual household income and family size, is less than the amount of the advance payment of the premium tax credit, the individual will be responsible for repayment of the excess amount via the tax return, subject to a statutory cap. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

How Much Is the Premium Tax Credit?
Amount of the premium tax credit depends on Actual household income as a percentage of the federal poverty level (FPL) and family size Sliding scale that increases your contribution toward the premium as income as percentage of FPL increases The premium for the second lowest cost Silver- level qualified health plan (QHP) adjusted for age May apply premium tax credit to QHP in any health plan category (i.e., Bronze, Silver, Gold, or Platinum) The amount of the premium tax credit can vary based on the following: The amount of your household income as a percentage of the federal poverty level (FPL) and family size. The higher the household income, the higher your contribution to your monthly premium. The amount of the premium for the second lowest cost Silver-level qualified health plan (QHP) in your Marketplace, adjusted for age. The amount of the premium tax credit is based on your actual household income as reported on your income tax returns. You may apply the premium tax credit to a QHP in any health plan category, including Bronze, Silver, Gold, or Platinum. Premium tax credits may not be used to lower the cost of catastrophic health plan premiums. September 2015 Understanding the Marketplace

Ways to Use a Premium Tax Credit
June 2014 Choose to Get It Now: Advance Payments of the Premium Tax Credit All or some of the premium tax credit is paid directly to your plan on a monthly basis You pay the difference between the monthly premium and advance payment You reconcile when you file a tax return for the coverage year* Choose to Get It Later Don’t request any advance payments You pay the entire monthly plan premium Claim the full amount on the tax return filed for the coverage year If you enroll through an Individual Marketplace you may be eligible to receive premium tax credits which can be used to reduce the cost of monthly premiums for yourself and for any tax dependents. You can choose to receive a portion of the credit each month as an advance payment of the premium tax credit—with reconciliation at the end of the year—or to receive the tax credit on your federal tax return filed for the coverage year. Advance payments are paid directly to Qualified Health Plan issuers on a monthly basis. Individuals eligible for a premium tax credit who don’t 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 credit. On the other hand, if the amount of the premium tax credit determined based on annual household income and family size on the tax return is less than the amount of the advance payment of the premium tax credit, the individual will be responsible for repayment of the excess amount via the tax return, subject to statutory caps. 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 You should report all changes to the information in your application (such as marriage, divorce, birth, eligibility for affordable employer coverage, and increases and decreases in household income) as soon as possible to avoid owing money after reconciliation on your tax return. *You should report all changes in the information you provided on your application to avoid owing money after reconciliation on your tax return. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Who’s Eligible for Cost-Sharing Reductions?
June 2014 Lower costs on deductibles, copayments, and coinsurance To be eligible, you must Have income at or below 250% FPL $59,625 annually for a family of 4 in 2015 Receive the premium tax credit Enroll in a Marketplace Silver-level plan Members of federally recognized Indian tribes Don’t have to pay cost-sharing if household income is at or below 300% of the federal poverty level (FPL) Up to around $71,550 for a family of 4 ($89,460 in Alaska) in 2015 Cost sharing means any expenditure required by or on behalf of an enrollee with respect to essential health benefits (EHB), including deductibles, coinsurance, copayments, or similar charges. Cost sharing excludes premiums, balance billing amounts for non-network providers, and spending for non-covered services. Cost-sharing reductions are available to help reduce your out-of-pocket expenses, including deductibles, copayments, and coinsurance. To be eligible for a cost-sharing reduction, you must have a household income that is less than or equal to 250% of the federal poverty level (FPL) which is $59,625 annually for a family of 4 in 2015); meet the requirements to enroll in a qualified health plan through the Marketplace; receive the premium tax credit; and enroll in a Silver-level plan through the Marketplace. There are 3 levels of cost-sharing reductions: If your income is between 100% and 150% FPL ($23,850-$35,775* for a family of 4 in 2015, the actuarial value (AV) of your Silver-level plan is approximately 94% (you pay 6% for covered services). If your income is between 150% and 200% FPL ($35,775-$47,700* for a family of 4 in 2015), the AV of your Silver-level plan is approximately 87% (you pay 13% for covered services). If your income is between 200% and 250% FPL ($47,700-$59,655* for a family of 4 in 2015), the AV of your Silver-level plan is approximately 73% (you pay 27% for covered services). Members of federally recognized tribes, shareholders of Alaska Native regional and village corporations, California Indians, and persons of Indian descent who are eligible for services from the Indian Health Service, tribal programs, or urban Indian health programs, who purchase health insurance through the Marketplace (regardless of plan category like Bronze or Silver) don’t pay premiums and cost-sharing if their income is under 300% FPL, which is roughly $70,650 for a family of 4 ($88,320 in Alaska), or $71,550 for a family of 4 ($89,460 in Alaska and $82,290 in Hawaii). *Higher in Hawaii and Alaska. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Medicaid Eligibility Eligibility tied to groups specified under the federal Medicaid law Pregnant women Children People with disabilities Seniors States must cover certain groups, such as children and pregnant women, and have the option to cover other groups Financial and non-financial requirements To qualify for Medicaid, you must belong to one of the eligibility groups specified under the federal Medicaid law. To be eligible for federal funds, states must cover people in certain groups up to federally defined income thresholds. However, many states have expanded Medicaid beyond these thresholds and have extended coverage to other optional groups. There are financial and non-financial requirements that must be met. Non-financial requirements include residency and citizenship requirements. Because of the Affordable Care Act, states now have options to cover additional groups, which we’ll discuss next. September 2015 Understanding the Marketplace

Eligibility—Medicaid Expansion
Affordable Care Act’s Eligibility Groups (state option) effective 1/1/2014 Adult group 19–64 with income below 133% of Federal Poverty Level (FPL) Former foster care group Under 26 and enrolled in Medicaid while in foster care at 18 or “aged out” of foster care Optional eligibility group for individuals with income above 133% of FPL Under 65 with income above 133% of FPL Starting January 1, 2014, the Affordable Care Act established 3 new Medicaid eligibility groups that made health insurance available to millions of people who weren’t previously eligible: The New Adult Group covers individuals 19–64 with income below 133% of the Federal Poverty Level (FPL), including 19- and 20-year-old children. Children under 19 aren’t included in this group because they’re covered under other mandatory eligibility groups. To be eligible for the New Adult Group, individuals may not be entitled to or enrolled in Medicare, they can’t be eligible for any other mandatory Medicaid eligibility group, and they may not be pregnant at the time of enrollment. This group is a mandatory eligibility group that states can elect to cover. A second eligibility group created under the Affordable Care Act established Medicaid coverage for individuals under 26 who were enrolled in Medicaid while they were either in foster care at 18 or when they “aged out” of foster care. There is no income or resource test for this eligibility group. States have the option to cover individuals who were in foster care and in Medicaid in another state. The third group is similar to the New Adult Group. Individuals in this group must be under 65, with income above 133% of the FPL, and can’t otherwise be eligible for another Medicaid group. Unlike the eligibility requirements for the New Adult Group, individuals in this optional group may be pregnant or may be eligible for Medicare. In addition, this group covers both children and adults who aren’t otherwise eligible. If a state is expanding Medicaid, individuals will probably qualify if they make up to about $16,100 a year for 1 person ($32,900 for a family of 4). Coverage started as early as January 1, 2014. NOTE: The Medicaid expansion up to 133% of the FPL resulted in a number of states needing to transition children 6–18 between % of the FPL that were previously covered in separate Children’s Health Insurance Programs to Medicaid. September 2015 Understanding the Marketplace

Medicaid Expansion in 2015: 31 States and the District of Columbia
As of July 2015, the following states and the District of Columbia elected to expand Medicaid coverage, including Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, Washington, and West Virginia. Adoption is under discussion in Utah. The remaining states have not expanded their Medicaid programs to date, but could expand Medicaid in the future. Under the law, the federal government will pay states all of the costs for newly eligible people for the first 3 years. It will pay no less than 90% of the costs in the future. States are continuing to make coverage decisions. States may also drop their Medicaid expansion coverage at a later time without a federal penalty. This graphic can be accessed at the-medicaid-expansion-decision/. September 2015 Understanding the Marketplace

Affordable Insurance Programs Without Expansion
For non-elderly, non-disabled individuals, based on current median state eligibility 133% FPL Medicaid/CHIP Children 241% FPL 400% FPL Children Varies by state 100% FPL 63% FPL 37% FPL Marketplace Subsidies Jobless Parents Working Pregnant Women This chart shows Medicaid coverage gaps in states that don’t expand coverage. While the adult group is a mandatory group, the Supreme Court ruled that there can be no penalty for states that don’t adopt the new group. Medicaid and Children’s Health Insurance Programs (CHIP) vary by state, with eligibility ranging from 0% to 241% of the federal poverty level (FPL). Under the Affordable Care Act’s Maintenance of Effort provision, states aren’t permitted to use standards, procedures, or methodologies that reduce eligibility for children in either CHIP or Medicaid until after September 30, 2019. In states that don't expand, the groups potentially continuing without Medicaid coverage or eligibility for Marketplace subsidies include childless adults from 0% to 100% of the FPL, jobless parents from 37% to 100% of the FPL, and working parents from 63% to 100% of the FPL. NOTE: This doesn’t display the state option for the Basic Health Plan (BHP) for uninsured individuals with incomes between 133% and 200% of the FPL who would otherwise be eligible to receive premium subsidies in the Health Insurance Marketplace. Individuals with incomes between 133% and 200% of the FPL in states creating BHPs aren’t eligible for subsidies in the Marketplace. Currently, both Minnesota and New York are developing a Basic Health Plan (BHP). September 2015 Understanding the Marketplace

A Seamless System of Coverage With Expansion
Medicaid/CHIP Children 133% FPL 241% FPL 400% FPL Marketplace Subsidies Adults Children Medicaid Adults Varies by state This chart is a visual display for coverage in states that expand coverage. Currently, 28 states and the District of Columbia have adopted the new adult group. Four states are participating through an alternative expansion model: Marketplace subsidies for individuals from 138% to 400% of the federal poverty level (FPL). The New Adult Group (displayed with the red square above)— Medicaid for adults from 0% to 138% of the FPL (allows for 5% disregard) For children, Medicaid and the Children’s Health Insurance Program (CHIP) vary by state, up to 241% of the FPL. Marketplace subsidies are available above the applicable state limit up to 400%. For more information on Medicaid and the Affordable Care Act, visit Medicaid.gov/affordablecareact/affordable-care-act.html. September 2015 Understanding the Marketplace

States Not Expanding Medicaid
If you live in a state that’s NOT expanding Medicaid you may Have fewer coverage options Not qualify for either Medicaid or reduced costs on a private insurance plan in the Marketplace Be able to get a hardship exemption and won’t have to pay a fee if you don’t have minimum essential health coverage Some states haven’t expanded their Medicaid programs. In these states, some people with limited incomes may have fewer coverage options. If you live in a state that isn’t expanding Medicaid, you may not qualify for either Medicaid or reduced costs on a private insurance plan in the Marketplace; it depends on where your income falls. If your income is more than 100% of the federal poverty level (FPL)—about $11,670 a year as a single person, or about $23,850 for a family of 4, you can buy a private health insurance plan in the Marketplace and may get lower costs based on your household size and income. If you make less than about $11,670 a year as a single person or about $23,850 for a family of 4, you may not qualify for lower costs for private insurance based on your income. However, you may be eligible for Medicaid, even without the expansion, based on your state’s existing rules. Many adults in those states (that aren’t expanding Medicaid) with incomes below 100% of the FPL fall into a gap. Their incomes may be too high to get Medicaid under their state’s current rules, but their incomes are too low to qualify for help buying coverage in the Marketplace. However, these individuals can apply for a hardship exemption so they don’t have to pay a fee if they don’t get health coverage. These individuals may also have the option to purchase a catastrophic plan in the Marketplace. For more information on Medicaid expansion, visit HealthCare.gov/medicaid-chip/medicaid- expansion-and-you/. September 2015 Understanding the Marketplace

Streamlined Application
One application for all programs Application can lead seamlessly from comparing Qualified Health Plans in the Marketplace to enrollment May be able to enroll immediately once eligibility determination is complete Depending on the program for which the applicant is eligible The Federally-facilitated Marketplace and states use a streamlined application for coverage through the Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP). The application may lead seamlessly from eligibility, to plan selection, and enrollment. Individuals can submit one application for all programs. Online applications are available in every state, along with traditional paper applications that may be sent by mail; people continue to have the option to apply in person or over the phone. Through the single streamlined application, individuals and families receive eligibility determinations for the following: Medicaid and CHIP Enrollment in Qualified Health Plans in the Marketplace Advance premium tax credits Cost-sharing reductions Once the eligibility determination is complete, applicants may be able to enroll in affordable coverage immediately, depending on the programs for which they’re eligible and the model established in their state. September 2015 Understanding the Marketplace

Application and Enrollment Process
Application process Relies primarily on electronic data Reduces need for paper documentation Apply online, by phone, by mail, or in person 12-month eligibility period for most Adults Parents Children Medicaid and Children’s Health Insurance Program (CHIP) application, enrollment, and renewal processes have been simplified in the following ways: Eligibility verification procedures rely primarily on electronic data sources. States have flexibility to determine the usefulness of available data before requesting additional information from applicants. Renewals are limited (for people enrolled through the simplified, income-based rules) to once every 12 months, unless you report a change or the agency has information to prompt a reassessment. Movement toward real-time eligibility determinations. September 2015 Understanding the Marketplace

Verification Primary reliance on electronic data sources Supported by Federal Data Services Hub Social Security Internal Revenue Service U.S. Department of Homeland Security Decreased reliance on documentation Increased reliance on self-attestation For those who apply online, verifications for eligibility may occur in real or near real time. Supported, in part, by the federally managed Marketplace Data Services Hub, real-time verification of information is available through Social Security, the Internal Revenue Service, and the U.S. Department of Homeland Security. With increased use of electronic data sources, paper documentation may not be necessary for most applicants. States may also rely on self-attestation for many factors of eligibility. September 2015 Understanding the Marketplace

State Options for Coordinated Eligibility Determinations With the Marketplace Marketplace makes Medicaid/Children’s Health Insurance Program (CHIP) Modified Adjusted Gross Income eligibility determinations using state Medicaid/CHIP eligibility rules and standards Must be a governmental entity Marketplace makes initial assessment of Medicaid/CHIP eligibility; state Medicaid and CHIP agencies make the final eligibility determination States have options for coordinating eligibility determinations with the Marketplace. For example, the state can delegate eligibility determination to the Marketplace, but only to a government agency that maintains personnel standards on a merit basis, and subject to safeguards. Under this option, the Marketplace makes final eligibility determinations for Medicaid/Children’s Health Insurance Program (CHIP) in accordance with the state’s eligibility policies and rules using a standard set of verification procedures accepted by the state. To ensure a seamless, accurate, and timely eligibility determination, the state Medicaid/CHIP agency accepts the electronic account through a secure electronic interface and follows the Medicaid/CHIP enrollment procedures to the same extent as if the application had been submitted to the Medicaid/CHIP agency. Under the assessment option, the Marketplace makes an initial assessment of Medicaid/CHIP eligibility. State Medicaid and CHIP agencies make the final eligibility determination. Assessments are made using the applicable Medicaid/CHIP income standards, and other non-financial criteria such as citizenship and immigration status, using verification rules and procedures consistent with Medicaid and CHIP regulations. The Marketplace and Medicaid/CHIP agencies enter into agreements outlining the responsibilities of each entity to ensure a seamless and coordinated process. September 2015 Understanding the Marketplace

Everyone Must: June 2014 1. Have minimum essential coverage They’re already covered and don’t need to do anything. 2. Have an exemption from the shared responsibility payment (fee) They don’t have to get coverage and won’t have to pay a fee for not having coverage. Pay a fee (shared responsibility payment) They should consider getting coverage. If they don’t, they’ll pay a fee. OR OR 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 fee (shared responsibility payment). Everyone must have minimum essential coverage, have an exemption from the shared responsibility payment (fee), or pay a fee. If you have minimum essential coverage, you don’t have to do anything. You’re already covered. If you qualify for an exemption, you won’t have to pay the fee even if you don’t have coverage. But, if you don’t have coverage and don’t qualify for an exemption, you have to pay a fee. Let’s look at what all this means. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

1. What is Minimum Essential Coverage?
June 2014 If you have coverage from any of the following, you are covered and don’t have to do anything Employer-sponsored coverage, including COBRA and retiree Individual coverage (outside the Marketplace) Marketplace coverage Medicare (Part A) and Medicare Advantage Plans Most Medicaid coverage Children’s Health Insurance Program (CHIP) Certain Veterans health coverage (from the VA) Minimum essential coverage is coverage that meets a standard that provides essential health benefits. The following provides minimum essential coverage. If you have it you don’t have to do anything. Employer-sponsored coverage, including self-insured plans, COBRA coverage and retiree coverage Coverage purchased in the individual market, including a qualified health plan offered by the Health Insurance Marketplace Medicare (Part A) coverage and Medicare Advantage Plans Most Medicaid coverage Children’s Health Insurance Program (CHIP) coverage Certain types of Veterans health coverage administered by the Department of Veterans Affairs About 85% of Americans already have minimum essential coverage. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

What is Minimum Essential Coverage? Continued
June 2014 If you have coverage from any of the following, you are covered and don’t have to do anything related to the Marketplace Most types of TRICARE coverage Coverage provided to Peace Corp volunteers Coverage under the Nonappropriated Fund Health Benefit Program Refugee Medical Assistance (ACF) Self-funded health coverage offered to students by universities State high risk pools Other coverage recognized by the Secretary of HHS Minimum essential coverage is coverage that meets a standard that provides essential health benefits. The following provides minimum essential coverage. If you have it you don’t have to do anything. Most types of TRICARE coverage under chapter 55 of Title 10 of the United States Code Coverage provided to Peace Corps volunteers Coverage under the Nonappropriated Fund Health Benefit Program Refugee Medical Assistance supported by the Administration for Children and Families Self-funded health coverage offered to students by universities for plan or policy years that begin on or before December 31, 2014 (check with your university to see if your plan qualifies as minimum essential coverage) State high risk pools for plan or policy years that begin on or before December 31, 2014 (check with your state’s high risk pool plan to see if the plan qualifies as minimum essential coverage) Other coverage recognized by the Secretary of HHS as minimum essential coverage Minimum essential coverage doesn’t include coverage providing only limited benefits, such as coverage only for vision care or dental care; and Medicaid covering only certain benefits such as family planning; workers' compensation; or disability policies. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

2. Who is Eligible for an Exemption?
June 2014 You may get a coverage exemption if you Are a member of a recognized religious sect with religious objections to insurance Are a member of a recognized health care sharing ministry Are a member of a federally recognized tribe or eligible for services through an Indian Health Services provider Don’t make the minimum income required to file taxes If you don’t have minimum essential coverage, you may have to pay a fee. We will discuss that next. You may be exempted from the fee for one of these reasons: religious conscience; membership in a recognized health care sharing ministry; membership in a federally recognized tribe or eligible for services through an Indian Health Services provider; you have no tax filing requirement (household income below minimum threshold ―Continued on next slide September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Who is Eligible for an Exemption? Continued
June 2014 You may get a coverage exemption if you Had a short coverage gap (less than 3 consecutive months) Suffered a hardship (that affects his or her ability to purchase health insurance coverage) Didn’t have access to affordable coverage (cost of available coverage greater than 8% of household income) Were incarcerated (unless pending disposition of charges) Weren’t lawfully present in the U.S. Had your health insurance cancelled and the Marketplace plans weren’t affordable Continued by previous slide―you have a short coverage gap* (<3 consecutive months); you suffered a hardship (a circumstance that affects your ability to purchase health insurance coverage, like being homeless, or recently experiencing domestic violence); you have unaffordable coverage options (minimum amount you must pay for premiums is more than 8% of your household income), you’re incarcerated; or you’re not lawfully present (neither a U.S. citizen, a U.S. national, nor an alien lawfully present in the U.S.), or your health plan was cancelled and there is no affordable coverage option in the Marketplace. To apply for an exemption based on coverage being unaffordable; membership in a health care sharing ministry; an Indian, as defined by section 4(d) of the Indian Self-Determination and Education Assistance Act, with membership in a federally-recognized tribe, including shareholders of Alaska Native regional or village corporations; or being incarcerated, you have 2 options—you can claim these exemptions when you fill out your 2015 federal tax return, which is due in April 2016, or you can apply for the exemptions in the Marketplace. To apply for an exemption based on membership in a recognized religious sect whose members object to insurance; are a member of a federally recognized Indian tribe or you’re eligible for services through an Indian health care provider; or one of the hardships described above, you fill out an exemption application in the Marketplace. If your income is low enough that you’re not required to file taxes, you don’t need to apply for an exemption. This is true even if you file a return to get a refund of money withheld from your paycheck. You won’t have to make the shared responsibility payment. For more information visit IRS.gov/pub/irs-pdf/p501.pdf. If you have a gap in coverage of less than 3 months, or you’re not lawfully present in the U.S., you don’t need to apply for an exemption. This will be handled when you file your taxes. If you have 2 short gaps in coverage during a year, the 3-month gap exemption only applies to the first gap. Visit HealthCare.gov/fees-exemptions/fees-exemptions-overview/ for more information. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

3. You May Pay a Fee (Shared Responsibility Payment)
June 2014 You may pay a fee when you file your 2015 federal tax return in 2016 (and thereafter) If you don’t have minimum essential coverage, and Don’t qualify for an exemption Paying the fee doesn’t provide health coverage When an uninsured person requires 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 fee (shared responsibility payment). People who choose not to get 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. Open Enrollment for 2015 coverage ended February 15, 2015. You generally can’t enroll in a private health plan through the Marketplace for the rest of 2015, unless you have a qualifying life event that provides for a Special Enrollment Period. You can apply for Medicaid or CHIP at any time. If you enrolled in a Marketplace plan for 2015 coverage during open enrollment, and pay the premiums, you won’t have to pay a fee for a gap in coverage for For more information visit IRS.gov/Affordable-Care-Act/Employers/Questions-and-Answers-on- Employer-Shared-Responsibility-Provisions-Under-the-Affordable-Care-Act. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

How much is the fee? June 2014 You pay the Greater Amount of Percent of Annual Household Income A Flat Dollar Amount For 2015 2% or $325 per adult, and $ per child under 18 For 2016* 2.5% $695 per adult, and $ per child under 18 The fee (penalty) in 2015 is calculated one of two ways. You’ll pay whichever of these amounts is higher: 2% of your yearly household income. The maximum penalty is the national average yearly premium for a bronze plan. $325 per person for the year ($ per child under 18). The maximum penalty per family using this method is $975 It’s important to remember that someone who pays the fee won’t get any health insurance coverage. The IRS routinely works with taxpayers who owe amounts they can’t afford to pay. The law prohibits the IRS from using liens or levies to collect any payment you owe related to the individual responsibility requirement (also known as the individual shared responsibility payment), if you, your spouse or a dependent included on your tax return doesn’t have minimum essential coverage. Any penalty that taxpayers are required to pay for themselves or their dependents must be included in their return for the taxable year. Those individuals who file joint returns are jointly liable for the penalty. *After Plus an increase based on cost of living. Penalty for noncompliance can’t exceed the national average premium for a Bronze level Marketplace QHP (for the relevant family size). September 2015 Understanding the Marketplace Health Insurance Marketplace 101

When You Can Enroll in Coverage
July 2015 During the Annual Open Enrollment Period (OEP) The OEP for coverage in 2015 ended February 15 For coverage in 2016, the OEP will be November 1, January 31, 2016 During a Special Enrollment Period (SEP), if eligible Once per month if member of federally recognized Indian tribe or Alaska native shareholder Anytime you’re eligible for Medicaid or the Children’s Health Insurance Program You can only enroll in or change a Marketplace plan during the annual Open Enrollment Period (OEP), or during a Special Enrollment Period (SEP) if you qualify. The OEP for coverage in 2015 ended February 15. The OEP for 2016 coverage will be November 1, January 31, If you experience certain qualifying life events or other qualifying changes in circumstance (like moving, getting married, a change in income, or getting citizenship), you can qualify for an SEP. If you’re eligible for Medicaid or the Children’s Health Insurance Program (CHIP), you may enroll at any time during the year. If you're a member of a federally recognized Indian tribe or an Alaska native shareholder, you can sign up for or change plans once per month throughout the year. This training focuses on SEPs. September 2015 Understanding the Marketplace

Special Enrollment Periods (SEPs)
May 2015 You can enroll if you’re eligible for an SEP because you have A qualifying life event, or Another qualifying circumstance Most SEPs last 60 days from the date of the qualifying event 30 days in the Small Business Health Options Program (SHOP) Marketplace Outside of the Open Enrollment Period, you can enroll in Marketplace coverage only if you experience certain qualifying life events or other qualifying changes in circumstance that make you eligible for a Special Enrollment Period (SEP). Most SEPs last 60 days from the date of the qualifying life event in the Individual Marketplace and 30 days in the Small Business Health Options Program (SHOP) Marketplace. If you don’t enroll within this period, you may have to wait until the next annual Open Enrollment Period. September 2015 Understanding the Marketplace

Qualifying Life Events
July 2015 Lose minimum essential coverage not including Voluntary termination Failure to pay premiums on a timely basis Including COBRA premiums prior to expiration of COBRA coverage Situations allowing for a rescission Enrolled in any non-calendar year group health plan or individual health insurance coverage Lose pregnancy-related coverage Lose medically needy coverage Only once per calendar year The Marketplace must allow a qualified individual or enrollee, and his or her dependent, to enroll in or change from one Qualified Health Plan to another if one of the following triggering events occur: Loss of minimum essential coverage, not including voluntary termination, failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage, and situations allowing for a rescission (ending the contract), such as when an individual (or a person seeking coverage on behalf of the individual) performs an act, practice, or omission that constitutes fraud, or the individual makes an intentional misrepresentation of material fact, as prohibited by the terms of the plan or coverage. The end of the plan or policy year for the non-calendar year group health plan or individual health insurance coverage, even if the qualified individual or his or her dependent has the option to renew such coverage. The date of the loss of coverage is the last day of the plan or policy year. Loss of pregnancy-related coverage described under section 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Social Security Act. The date of the loss of coverage is the last day the consumer would have pregnancy-related coverage. Loss of medically needy coverage as described under section 1902(a)(10)(C) of the Social Security Act only once per calendar year. The date of the loss of coverage is the last day the consumer would have medically needy coverage. September 2015 Understanding the Marketplace

Qualifying Life Events—Continued
July 2015 Gain a dependent or becomes a dependent Marriage, birth, adoption, placement for adoption, or placement in foster care, or through a child support order or other court order Enrollee loses a dependent or is no longer considered a dependent Divorce or legal separation, or death The qualified individual, or dependent, who wasn’t previously a citizen, national, or lawfully present individual gains such status The Marketplace must allow a qualified individual or enrollee, and his or her dependent, to enroll in or change from one Qualified Health Plan to another if one of the following triggering events occur (continued): The qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption, placement for adoption, or placement in foster care, or through a child support order or other court order. At the option of the Marketplace or effective January 1, 2017, the enrollee loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by state law in the state in which the divorce or legal separation occurs, or if the enrollee, or his or her dependent, dies. The qualified individual, or his or her dependent, who wasn’t previously a citizen, national, or lawfully present individual gains such status. September 2015 Understanding the Marketplace

Qualifying Life Events—Continued 2
July 2015 The qualified individual's or dependent's enrollment or non-enrollment in a Qualified Health Plan (QHP) is unintentional, inadvertent, or erroneous QHP substantially violated a material provision of its contract in relation to the enrollee The Marketplace must allow a qualified individual or enrollee, and his or her dependent, to enroll in or change from one Qualified Health Plan (QHP) to another if one of the following triggering events occur (continued): The qualified individual's or his or her dependent's, enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the Marketplace or HHS, its instrumentalities (an organization that serves a public purpose and is closely tied to federal and/or state government, but is not a government agency), or a non-Marketplace entity providing enrollment assistance or conducting enrollment activities. For purposes of this provision, misconduct includes the failure to comply with applicable standards under prescribed regulations, or other applicable Federal or State laws, as determined by the Marketplace. The enrollee or, his or her dependent, adequately demonstrates to the Marketplace that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee. September 2015 Understanding the Marketplace

July 2015 The enrollee (or the enrollee's dependent enrolled in the same Qualified Health Plan) is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions A qualified individual or dependent who’s enrolled in an eligible employer-sponsored plan is determined newly eligible for APTC The Marketplace must allow a qualified individual or enrollee, and his or her dependent, to enroll in or change from one Qualified Health Plan (QHP) to another if one of the following triggering events occur (continued): The enrollee (or the enrollee's dependent enrolled in the same Qualified Health Plan) is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions A qualified individual or his or her dependent who is enrolled in an eligible employer- sponsored plan is determined newly eligible for advance payments of the premium tax credit based in part on a finding that such individual is ineligible for qualifying coverage in an eligible-employer sponsored plan in accordance with 26 CFR 1.36B-2(c)(3), including as a result of his or her employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage. September 2015 Understanding the Marketplace

July 2015 Consumers living in a non-Medicaid expansion state becoming newly eligible for advanced payment of your premium tax credit Gaining access to new Qualified Health Plans (QHPs) as a result of a permanent move Gaining or continuing status as a member of an Indian tribe or an Alaska Native shareholder May enroll in a QHP or change from one QHP to another one time per month The Marketplace must allow a qualified individual or enrollee, and his or her dependent, to enroll in or change from one Qualified Health Plan (QHP) to another if one of the following triggering events occur (continued): A qualified individual in a non-Medicaid expansion State who was previously ineligible for advance payments of the premium tax credit solely because of a household income below 100% of the Federal Poverty Level, who was ineligible for Medicaid during that same timeframe, and who has experienced a change in household income that makes the qualified individual newly eligible for advance payments of the premium tax credit. The qualified individual or enrollee, or his or her dependent, gains access to new QHPs as a result of a permanent move. The qualified individual who is an Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month. September 2015 Understanding the Marketplace

July 2015 Exceptional circumstances Enrollment errors Survivors of domestic violence, domestic abuse or spousal abandonment Members of AmeriCorps, VISTA, and NCCC programs The Marketplace must allow a qualified individual or enrollee, and his or her dependent, to enroll in or change from one Qualified Health Plan (QHP) to another if one of the following triggering events occur (continued): The qualified individual or enrollee, or his or her dependent, demonstrates to the Marketplace, that the individual meets other exceptional circumstances. Exceptional circumstances include serious situations that prevent you from enrolling in a plan by the appropriate deadline, like a serious medical emergency, such as an unexpected hospitalization or a temporary cognitive disability that caused you to be incapacitated. Natural disasters that prevented you from enrolling, such as an earthquake, massive flooding, or hurricane. System outages around plan selection deadlines (for example, a Social Security outage). Enrollment errors occur when a qualified individual choses a plan by the appropriate deadline, but the enrollment wasn’t processed by the Marketplace, the insurance company says it doesn’t have the enrollment, or you were enrolled in the wrong plan. For example, you enrolled through the Marketplace, but the insurance company didn’t get your information due to technical issues; the insurance company got your information and it may have been processed, but the enrollment file contained defective or missing data which made the insurance company unable to enroll you in coverage; your application may have been rejected by the insurance company’s system because of errors in reading the data. Please note that this isn't an exhaustive list of errors that could create an SEP. Survivors of domestic violence, domestic abuse or spousal abandonment. This SEP is available to survivors of domestic violence, survivors of domestic abuse or spousal abandonment. Spousal abandonment, sometimes referred to as desertion, refers to when an individual can’t locate his or her spouse after making a reasonable attempt to find the spouse. To access this SEP, eligible consumers should call the Marketplace Call Center at to explain that they’re a survivor of domestic violence, victim of domestic abuse, or survivor or victim of spousal abandonment. When completing their Marketplace application, consumers should indicate that they aren’t married on the application. Upon qualifying for the SEP, consumers will have 60 days to select and enroll in a QHP. They will receive regular, prospective coverage effective date following the 15th of the month rule. Members of AmeriCorps, Volunteers in Service to America (VISTA), and National Civilian Community Corps (NCCC) may be eligible for a Special Enrollment Period (SEP) if not provided health insurance options or are provided short-term limited- duration coverage or self-funded coverage not considered minimum essential coverage (MEC). You and your dependents in the Federally-facilitated Marketplace are eligible to enroll in Marketplace coverage on the date you begin your service term, or on the date you lose any coverage offered through your program when your service term ends. September 2015 Understanding the Marketplace

Plan Selection for Other Circumstances Special Enrollment Periods (SEPs) July 2015 Generally you have 60 days to select a plan From date you’re granted Other Circumstances SEP Plan selection timeframe starts when You get a letter telling you you’re eligible for an SEP You contact the Call Center and are found eligible A CMS caseworker finds you eligible If you experienced any of these other qualifying circumstances prior to the end of Open Enrollment, you may be able to complete your enrollment for the first time. If you’ve already enrolled in coverage and then receive a Special Enrollment Period (SEP), you have the option to change plans or stay in your current plan. In most cases, you have 60 days to select a plan from the date you’re granted the Other Circumstance SEP, which could be one of the following triggering events: The date you get a letter telling you you’re eligible for an SEP The date you contact the Call Center and are found eligible for an SEP The date a CMS caseworker finds you eligible for an SEP NOTE: If you choose to switch plans during an SEP, any deductibles or out-of-pocket costs you paid under the first plan won’t count toward the new plan’s deductible or out-of-pocket maximum. September 2015 Understanding the Marketplace

How to Use a Special Enrollment Period for a Life Change
July 2015 If you have a qualifying life change, you can contact the Marketplace Online at HealthCare.gov Log into your account and click on Report a life change By phone Call the Marketplace Call Center at TTY If you have a qualifying life change, you can use your Special Enrollment Period (SEP) online or by phone. You can login to your account on HealthCare.gov and click on the “Report a Life Change” button to start the SEP process. You can also call the Marketplace Call Center to request an SEP at TTY users should call Remember, most SEPs last 60 days from the date of the qualifying life change in the Individual Marketplace and 30 days in the Small Business Health Options Program (SHOP) Marketplace. If you have a qualifying life change and apply for new health coverage, you’ll see a reminder message on your “Enroll-To-Do” list in your account on HealthCare.gov to let you know you’re eligible for an SEP. If you already have Marketplace coverage and report a qualifying life change, you’ll see a reminder message on your “Enroll-To-Do” list letting you know you’re eligible for an SEP. You’ll have the option to remain enrolled in your current plan or choose a new plan during your SEP timeframe. September 2015 Understanding the Marketplace

Online at HealthCare.gov/screener
July 2015 Use the screening tool to see if you qualify for a Special Enrollment Period Maricopa County You can find out if you’re eligible to get 2015 health coverage using the screening tool located at HealthCare.gov/screener. September 2015 Understanding the Marketplace

Answer a Few Questions about Life Changes
July 2015 Simply click yes or no to the questions about life changes. Then click to see if you qualify for a Special Enrollment Period. September 2015 Understanding the Marketplace

Start or Update an Application
July 2015 If it looks like you may qualify, update your old application if you have one, or start a new one if you don’t. If it looks like you may qualify for a Special Enrollment Period, what you do next depends on whether you already have an application on file in the Marketplace. If you have an application in the Marketplace, you will go in and update it based on your new information. If you don’t have an application in the Marketplace, you will start one. September 2015 Understanding the Marketplace

Gather Important Information
July 2015 Download or print this checklist so you know what information may be needed to apply for coverage marketplace.cms.gov/outreach-and-education/apply-for-or-renew-coverage.pdf If you apply for coverage during a Special Enrollment Period, it may be helpful to have important household information ready. CMS Product No is available at marketplace.cms.gov/outreach-and-education/apply-for-or-renew-coverage.pdf. The information needed may include but not be limited to the following: Household size Home and/or mailing address for everyone applying for coverage Information about everyone applying for coverage Social Security Numbers for everyone on the application Immigration document information (for legal immigrants) Tax filing information Employer and income information for everyone in your household Best estimate of household income for 2015 Policy numbers for anyone in your household currently covered by a health plan September 2015 Understanding the Marketplace

General Process for Other Circumstances Special Enrollment Periods (SEPs) July 2015 Call the Marketplace Call Center to request an SEP at (TTY ) Call Center asks questions to determine if you’re eligible If granted, the Call Center activates the SEP You can enroll online or through the Call Center If your SEP request is denied, you can appeal Other qualifying circumstance Special Enrollment Periods (SEPs) are handled through a special process and aren’t initiated through the life change reporting process. In general, if you want to request an SEP based on other qualifying circumstances, you must call the Marketplace call center to request an SEP at TTY users should call The call center asks a variety of questions to determine if you’re eligible for an SEP. The call center forwards cases that need additional review to CMS caseworkers to determine whether to grant an SEP. If an SEP is granted, the call center activates the SEP and allows you to complete the enrollment. If the SEP is approved by a caseworker, you should call the call center to “activate” the SEP. You can enroll online or through the call center. If your SEP request is denied, you can appeal the decision. See slide 20 for details on how to file an appeal. There are some circumstances in which the Marketplace, insurance company, or state Medicaid or Children’s Health Insurance Program agency may be able to identify some consumers who are eligible for another qualifying circumstance SEP. In these cases, the Marketplace or insurance company may reach out to you to tell you about your potential SEP (for example, for plan benefit display errors). If you’re enrolling through your state’s Marketplace and want to request an SEP, you should contact your state. Visit HealthCare.gov/how-can-i-get-consumer-help-if-i-have-insurance to get information for state-based Marketplaces. September 2015 Understanding the Marketplace

4 Ways to Get Marketplace Coverage
June 2014 You can apply for coverage in the Marketplace by phone, online, in person, or by mail. The number for the National Health Insurance Marketplace call center is TTY users should call Customer service representatives are available 24 hours a day, 7 days a week, including New Year's Day. The call center is closed on Thanksgiving, Christmas, Labor Day, Memorial Day, and the Fourth of July. The call center provides objective information in English and in Spanish. It uses language lines for 150 additional languages. The customer service representatives help you go through the eligibility and enrollment process, and refer you to local in-person help. When you call, you are asked what state you live in. If you live in a state operating a State-Based Marketplace, you are provided with the number to that state’s Marketplace call center. HealthCare.gov can help you identify your options for health insurance. The website is also available in Spanish at CuidadoDeSalud.gov. This website is also accessible for those with visual disabilities. If your state is running its’ own Marketplace (state-based Marketplace), you’ll be referred to its’ website. If you click on “See Plan A Prices” you can see what plans are available in your area and their full cost. If you qualify for a tax credit or cost sharing reduction, you would save on these costs. Visit HealthCare.gov/find-premium- estimates/. In-person help is also available. You can find trained and certified help to apply and enroll by visiting Localhelp.HealthCare.gov, or call the Marketplace call center. The paper application is available for download and printing on Marketplace.cms.gov/applications-and- forms/marketplace-application-for-family.pdf. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

How the Marketplace Works
May apply or change plan during Special Enrollment Period due to certain life changing events. There are four steps to using the Marketplace when enrolling or renewing coverage during open enrollment. Create an account. First provide some basic information. Then choose a user name, password, and security questions for added protection. Apply. Next you’ll enter information about you and your family, including your income, household size, other coverage you’re eligible for, and more. Visit HealthCare.gov to get a checklist to help you gather the information you’ll need. Pick a plan. Next you’ll see the plans and programs you’re eligible for and compare them side-by-side. You’ll also find out if you can get lower costs on monthly premiums and out-of-pocket costs. Enroll. Choose a plan that meets your needs and enroll. If you have any questions, there’s plenty of live and online help along the way. Applying for affordability programs is optional. However, your eligibility information will still be verified against data sources even if you don’t apply for lower premiums. September 2015 Understanding the Marketplace

Application and Eligibility
Enroll Medicaid/CHIP Premium tax credit Cost-sharing reduction Enroll in Marketplace qualified health plan Eligible for qualified health plan, Medicaid, or CHIP Supported by Data Services Hub Online By phone By mail In person Pay first monthly premium NO YES Submit streamlined application to the Marketplace Verify and determine eligibility The first step in the application and eligibility process is to submit a streamlined application to the Marketplace. You can apply online, by phone, by mail, or in person. When you complete the application, information will be verified including: residency; that you live in the service area of that Marketplace; your incarceration status; American-Indian/Alaska Native status; household income; household size; and eligibility for other essential coverage including employer coverage or government programs like Medicare, Medicaid, CHIP, VA, and TRICARE. This information is checked electronically against the data of Social Security, the Internal Revenue Service, Department of Defense, Department of Homeland Security, and other approved electronic data sources for verification. Anyone who submits an incomplete application to the federally facilitated Marketplace will receive a notice and have 90 days to provide the needed information. State Marketplaces could have fewer days. You may be determined eligible to purchase and enroll in a qualified health plan through the Marketplace, or enroll in Medicaid or the Children’s Health Insurance Program (CHIP). If you’re eligible to enroll in a qualified health plan in the Marketplace, you also find out if you’re eligible for a premium tax credit and cost-sharing reduction. Then, you enroll in the program for which you’re eligible. NOTE: If you don’t have a street address for your home, indicate “no fixed address” and you will be able to include a mailing address such as a P.O. Box number. September 2015 Understanding the Marketplace

The Coverage Application
Available electronically and on paper in English and Spanish Federally-facilitated Marketplace Application form Dynamic online version asks only relevant questions based on your responses Streamlined paper version State-based Marketplaces may have own version Help is available to complete application You can apply for Marketplace coverage online, by phone, in person, or by mail. The Marketplace application is available electronically and on paper, in both English and Spanish. The online version of the Federally-facilitated Marketplace application is dynamic and asks only relevant questions based on your prior responses. If your state is operating its own Marketplace, you’ll be directed to your state’s application or website, as applicable. The federal streamlined paper application can be downloaded from marketplace.cms.gov/applications-and-forms/individual-short-form.pdf. The Spanish version of the application can be found at State-based Marketplaces may have their own versions of the application. For helpful tips on applying for and enrolling in Marketplace coverage, visit: HealthCare.gov/how- to-have-the-best-experience-with-healthcare-gov. For application job aids that aren’t fillable or processed in other languages, go to marketplace.cms.gov/outreach-and-education/other-languages.html. You can also review plan options and estimated prices before you apply and without creating an account using the Premium Estimator Tool: HealthCare.gov/find-premium-estimates. September 2015 Understanding the Marketplace

Premium Payment You must pay the first month’s premium by the insurer’s deadline Issuers must accept at least these payment methods Paper check Cashier’s check Money order Electronic fund transfer (EFT) Pre-paid debit card Some issuers may also accept online, credit card, or debit card payments (check with the plan) Once you select a plan and enroll, you must pay your first premium directly to the insurance company – not to the Health Insurance Marketplace. You’ll receive a link to the issuer’s payment site, if the issuer provided one. QHP issuers may, but aren’t required to, accept payment online at the time of enrollment. If there is no link, or if you complete plan selection via the call center, contact the QHP issuer directly to inquire about other options to make premium payments. You must pay your first month’s premium by the insurer’s deadline to get coverage. CMS requires issuers to accept a variety of payment methods, including paper checks, money orders, cashier's checks, electronic fund transfers (EFT), and pre-paid debit cards. They don’t have to accept credit card or debit card payments unless states make that a requirement, although many insurers currently accept all of these forms of payment. Therefore, it may vary from state to state and between insurers. Each insurer sets its own payment deadline. Some insurers may accept your first payment after your coverage has become effective or pay for your care retroactively. Contact your insurer to find out when you need to make your payment and what flexibility they’re able to give you. If you don’t pay your premiums, your enrollment may be terminated by your issuer. The effective termination date must be consistent with state law. There’s a 3 month grace period for you if you’re receiving an advanced payment of the premium tax credit, as long as you paid at least one full month’s premium. The exact length will vary depending on state law. You’re free to end your enrollment in a QHP at any time – no Special Enrollment Period is required. You must terminate your Federally-facilitated Marketplace enrollment through the Marketplace and may specify the effective date of termination as long as it is at least 14 days in advance. However, if you go for more than 3 months without minimum essential coverage and don’t qualify for an exemption, you may have to pay a fee. To terminate enrollment, log into your “MyAccount” on the FFM and navigate to the “My plans & programs” tab. Then select the red button labeled “End (Terminate) All Coverage.” This will terminate the entire enrollment group. In short, this process will apply if you’re single (enrollment group of 1), or request termination of the entire enrollment group (you and everyone else on your application). If you would like to terminate less than a full enrollment group, your enrollment group must use the “report a life change” functionality. September 2015 Understanding the Marketplace

Enrollment Assistance
Help is available in the Marketplace Marketplace Call Center SHOP Call Center for employers Marketplace in-person help is available If you have questions or need help applying for coverage, there are resources that are available, including a toll-free call center and website with plan comparison tools. There are also Marketplace in-person help is available through several programs to help you with the process of enrolling and using health insurance, including the Navigator program. Use the Find Local Help tool at LocalHelp.HealthCare.gov to find local, personal help applying for health coverage. September 2015 Understanding the Marketplace

Marketplace Call Center
Services consumers in Federally-facilitated and State Partnership Marketplaces (TTY ) Customer service representatives available 24/7 Help with eligibility, enrollment, and referrals Assistance in English and Spanish Language line for 240+ additional languages State-based Marketplaces have own call centers There’s a National Marketplace Call Center for consumers who live in states operating Federally-facilitated and State Partnership Marketplaces. When you call, you’ll be asked what state you live in. If you live in a state operating a State-Based Marketplace, you’ll be provided with the number to that state’s Marketplace call center. The number for the Marketplace Call Center is TTY users should call Customer service representatives are available 24 hours a day, 7 days a week, including New Year's Day. The call center is closed on Memorial Day, the Fourth of July, Labor Day, Thanksgiving, and Christmas. Customer service representatives can help you complete the entire application and enrollment process from beginning to end with information you provide over the phone, including reviewing your options and helping you enroll in a plan. They can also answer questions as you fill out an online or paper application and refer you to local help resources in your community. The call center provides objective information in English and in Spanish. It also uses a language line to provide assistance for more than 240 additional languages. NOTE: You may be referred if you live in a state with a state-based Marketplace or SHOP to your state’s call center. September 2015 Understanding the Marketplace

SHOP Call Center For questions about SHOP for small employers with 50 or fewer employees (TTY 711) Customer service representatives available Monday – Friday from 9 a.m. to 7 p.m. EST Small business employees with SHOP questions can also call the SHOP Call Center There’s a SHOP Call Center where you can get your SHOP and small business questions answered by a customer service representative at or (TTY 711). The call center is open Monday through Friday, 9 a.m. to 7 p.m. ET. Agents and brokers may also use this number. Small business employees with SHOP questions can also use the SHOP Call Center. If your state has its own SHOP, you may be referred to its SHOP call center. September 2015 Understanding the Marketplace

In-Person Assistance Marketplace in-person help is available
June 2014 Marketplace in-person help is available Navigators Non-Navigator assistance personnel Certified application counselors Issuer application assisters Enrollment assistance contractor Agents and brokers To find help in your area, go to Localhelp.HealthCare.gov There are several programs to help you through the process of applying for, enrolling in, and using health insurance, including the Navigator program, non-Navigator assistance personnel, issuer application assisters, enrollment assistance contractors, agents and brokers, and certified application counselors. These programs play a large role in helping people apply for health insurance coverage. It’s important to note that some of the assistance resources (Marketplace call centers and websites, and Navigators) are required to provide unbiased and impartial advice, while others (such as agents and brokers and issuer web sites and call centers) aren’t. Organizations that don’t meet the requirements to become Marketplace-approved assisters are invited to become a “Champion for Coverage.” They can help educate the public about the Marketplace and refer them to resources where they can find assistance. Visit Marketplace.cms.gov/technical-assistance-resources/assister- programs/champion.html for more information. If you have questions, send an to Visit Marketplace.cms.gov for information on your organization becoming a Champion for Coverage September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Marketplace and People with Medicare
June 2014 Medicare isn’t part of the Marketplace If you have Medicare you don’t need to do anything related to the Marketplace Your benefits don’t change because of the Marketplace No one can sell you a Marketplace plan Except an employer through the Small Business Health Options Program (SHOP) if you are an active worker or dependent of an active worker The SHOP employer coverage may pay first No late enrollment penalty if you delay Medicare Doesn’t include COBRA coverage Medicare isn’t a part of the Health Insurance Marketplace. Medicare Part A provides minimum essential coverage. If you have Medicare, you don’t have to do anything related to the Marketplace. The Marketplace doesn’t change your Medicare plan choices or your benefits. Medicare plans and supplement (Medigap) policies aren’t available in the Marketplace. It’s against the law for someone who knows that you have Medicare to sell or issue you a Marketplace policy. This is true even if you have only Medicare Part A or only Part B. The exception is coverage from your employer through the Small Business Health Options Program. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

If You Have a Marketplace Plan First and Then Get Medicare Coverage
June 2014 You lose eligibility for any premium tax credits and/or reduced cost sharing for your Marketplace plan If you choose to drop your Marketplace plan, wait until you’re covered by Medicare to avoid a gap in coverage Depending on your income and resources, you may be eligible for help paying your Medicare Part B and Part D premiums and for some reduced cost sharing for Medicare Part D coinsurance/copayments You may also be able to buy a Medigap (Medicare Supplement Insurance) policy or join a Medicare Advantage Plan (like an HMO or PPO) You can get a Marketplace plan to cover you before your Medicare begins. You can then cancel the Marketplace plan once your Medicare coverage starts. However, it is important that you time the end of your Marketplace plan so that it doesn’t end before your Medicare coverage begins, or you could have a gap in coverage. Once you’re eligible for Medicare, you’ll have an initial enrollment period to sign up. In most cases it’s to your advantage to sign up when you’re first eligible because once you’re getting Medicare, you won’t be able to get lower costs for a Marketplace plan based on your income like premium tax credits and reduced cost-sharing (except if you only have Part B). If you have limited income and resources, you may be eligible for help paying your Medicare Part B and Part D premiums and for some reduced cost sharing for Medicare Part D coinsurance/copayments. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Marketplace/Medicare Enrollment Considerations
June 2014 If you don’t enroll in Medicare when you’re first eligible (Initial Enrollment Period) A late enrollment penalty may apply (lifetime) You generally can’t enroll until the Medicare General Enrollment Period (January 1 to March 31) and coverage won’t start until July 1 If your Marketplace plan isn’t through your employer And you must pay a premium for Part A, you would need to drop Part A and Part B to be eligible to get a Marketplace plan However, if you are also receiving Social Security benefits, you would have to drop your Social Security if you drop Medicare There are a few situations where you can choose a Marketplace private health plan instead of Medicare. 1. If you’re paying a premium for Part A. In this case you can drop your Part A and Part B coverage and get a Marketplace plan instead. In the rare instance that you only have Part B, you also could drop it and get coverage in the marketplace. If you’re eligible for Medicare but haven’t enrolled in it, this could be because: You’d have to pay a premium You have a medical condition that qualifies you for Medicare, like End-Stage Renal Disease (ESRD), but haven’t applied for Medicare coverage You’re not collecting Social Security retirement or disability benefits before you’re eligible for Medicare 2. If you’re getting Social Security retirement or disability benefits before you’re eligible for Medicare, you’ll automatically be enrolled in Medicare once you’re eligible. Before choosing a Marketplace plan over Medicare, there are two important points to consider: If you enroll in Medicare after your initial enrollment period ends, you may have to pay a late enrollment penalty for as long as you have Medicare. Your monthly premium may go up 10%. You'll have to pay the higher premium for twice the number of years you could have had Part A, but didn't sign up (Note: If you are already receiving Social Security benefits prior to becoming eligible then you will be automatically enrolled in Part A; no penalty would be applicable here) If you don’t enroll in Part B when first eligible, you may have to pay a late enrollment penalty for as long as you have Medicare. You may owe a Part D late enrollment penalty if, at any time after your initial enrollment period is over, there's a period of 63 or more days in a row when you don't have Part D or other creditable prescription drug coverage. Marketplace plans are not required to provide creditable coverage. You may have to pay this penalty as long as you have Part D coverage. Generally, if you miss your IEP, you can enroll in Medicare only during the Medicare general enrollment period (from January 1 to March 31 each year). Your coverage won’t start until July. This may cause a gap in your coverage. Employer coverage offered through the Small Business Health Options Program (SHOP) is treated like any other employer coverage. Medicare Secondary Payer rules apply. For more information, view the publication Medicare & the Health Insurance Marketplace, CMS Product No at Medicare.gov/Pubs/pdf/11694.pdf. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Written materials and videos available in English and Spanish
From Coverage to Care June 2014 Written materials and videos available in English and Spanish Marketplace.cms.gov/c2c From Coverage to Care is an initiative to help people with new health care coverage understand their benefits and connect to primary care and the preventive services that are right for them, so they can live a long and healthy life. We encourage you to share these resources with consumers, and help them on their journey from coverage to care. We also hope you share information about local resources during your conversations, to help individuals know where and how to access care in your community. Print resources now include the full Roadmap booklet, Discussion Guide, and individual steps. Sign up for our Minority Health listserv for notification when Spanish translations and other new resources are posted by entering your at public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_610. Order From Coverage to Care materials! Instructions are on Marketplace.cms.gov/c2c. Print your own booklets by selecting a file and changing your printer to “booklet” setting before printing. Files will print on standard 8.5x11” paper. The Roadmap to Health is a guide to understanding how to use health insurance. Related products are available at marketplace.cms.gov/technical-assistance-resources/c2c.html. The materials are available in both English and Spanish. There are companion videos as well. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Marketplace Appeals June 2014 If you don’t agree with a decision made by the Health Insurance Marketplace, you may be able to file an appeal. You can appeal the following kinds of Marketplace decisions Whether you’re eligible to buy a Marketplace plan Whether you can enroll in a Marketplace plan outside the regular open enrollment period Whether you’re eligible for lower costs based on their income The amount of savings you’re eligible for Whether you’re eligible for Medicaid or the Children’s Health Insurance Program (CHIP) Whether you’re eligible for an exemption from the individual responsibility requirement If you don’t agree with a decision made by the Health Insurance Marketplace, you may be able to file an appeal. You can appeal the following kinds of Marketplace decisions Whether you’re eligible to buy a Marketplace plan Whether you can enroll in a Marketplace plan outside the regular open enrollment period Whether you’re eligible for lower costs based on your income The amount of savings you’re eligible for Whether you’re eligible for Medicaid or the Children’s Health Insurance Program (CHIP) Whether you are eligible for an exemption from the individual responsibility requirement September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Key Points to Remember June 2014 The Marketplace is a way for qualified individuals and families to find and buy health insurance You may enroll or change plans during a Special Enrollment Period if you have certain life changing events Small employers can cover their employees through the SHOP States have flexibility to establish their own Marketplace Individuals and families may be eligible for lower costs on their monthly premiums and out-of-pocket costs There is help available If a you don’t agree with a decision made by the Marketplace, you may be able to file an appeal Here are some key points to remember: The Marketplace is a way for qualified individuals and families to find and buy health insurance You may enroll or change plans during a Special Enrollment Period if you have certain life changing events. However, you may enroll in Medicaid and CHIP at any time you’re eligible. Small employers can cover their employees through the SHOP States have flexibility to establish their own Marketplace Individuals and families may be eligible for lower costs on their monthly premiums and out-of-pocket costs There is assistance available to help you get the best coverage for your needs If you don’t agree with a decision made by the Health Insurance Marketplace, you may be able to file an appeal. Decisions you may appeal include eligibility for the Marketplace, Medicaid, or CHIP coverage, whether you qualify for a Special Enrollment Period, lower costs, or fee exemption. Appeal request forms are available at HealthCare.gov/marketplace-appeals/. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Marketplace.cms.gov June 2014 Get the latest resources to help people apply, enroll, and get coverage You can get up-to-date information to help you counsel people who may benefit from the Heath Insurance Marketplace at Marketplace.cms.gov. There is access to consumer materials, training materials (including videos), research and more. You can sign up for updates as well. This is also where organizations can apply to become Certified Application Counselors and Champions for Coverage. September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Want More Information about the Marketplace?
June 2014 Stay connected Sign up to get and text alerts at HealthCare.gov/subscribe CuidadoDeSalud.gov for Spanish Updates and resources for organizations are available at Marketplace.cms.gov Facebook.com/HealthCare.gov Need more information about the Health Insurance Marketplace? Sign up to get and text alerts at HealthCare.gov/subscribe/. CuidadoDeSalud.gov/es/ provides the HealthCare.gov information in Spanish. Updates and resources for partner and stakeholder organizations are available at Marketplace.cms.gov. Like us on Facebook and follow us on Twitter! September 2015 Understanding the Marketplace Health Insurance Marketplace 101

Understanding the Health Insurance Marketplace

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