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The Health Insurance Marketplace (Health Insurance Exchange)

The Health Insurance Marketplace (Health Insurance Exchange)

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The Health Insurance Marketplace (Health Insurance Exchange)

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  1. The Health Insurance Marketplace(Health Insurance Exchange)

  2. Health Insurance Marketplace • Established under the Affordable Care Act • Goal to increase competition and transparency in the insurance market as well as to provide a “one-stop-shop” for consumers. • Each state must establish a Health Insurance Marketplace to: • Facilitate the purchase of qualified health plans (QHPs) by individuals • Exchanges will serve as a gateway for an estimated 29 million people to find their insurance. • Iowa established a State/Federal Partnership

  3. Insurance Types • Individual health insurance: • Individual purchases for himself and/or his family. Individual health insurance policies are often purchased with the guidance of an insurance agent to help navigate plan choices and premium costs. • Who needs individual insurance policies? • Uninsured • Unemployed • Employed at small company not offering insurance • Employed at large company offering insurance that doesn’t meet ACA standards (min. value, min. coverage) • Group health insurance coverage is a type of health policy that is purchased by an employer and is offered to eligible employees of the company, and to eligible dependents of employees. • The majority of non-elderly Americans (56%) have group health insurance coverage through their employer, or the employer of a family member. With group health insurance, the employer selects the plan (or plans) to offer to employees. The premium cost is often split between the employer and employee, and there is a minimum percentage rate the employer must contribute. • Existing group plans will not be affected by the Marketplace, but must comply with other employer mandated regulations.

  4. Marketplaces • Marketplaces are focused in the early years on offering individual plans. • Limited/regional group plans will be offered • Small group plans to be offered on the Small Business Health Options Program “SHOP” • The SHOP will be open to the self-employed individual and the employees of firms with 100 or fewer employees. ACA allows DHS or states the authority to allow larger firms to participate in the Marketplace or SHOP in the future and/or to merge the Marketplace and SHOP into one large pool.

  5. 5 Core Functions of the Marketplace Iowa Responsibilities Under Iowa’s Partnership Model 1. Eligibility Accept applications; conduct verifications of applicant information; determine eligibility for enrollment in a Qualified Health Plan and for insurance affordability programs; connect Medicaid and CHIP-eligible applicants to Medicaid and CHIP; and conduct redeterminations and appeals. • Plan Management Plan selection approach (e.g., active purchaser or any willing plan); collection and analysis of plan rate and benefit package information; issuer monitoring and oversight; ongoing issuer account management; issuer outreach and training; and data collection and analysis for quality.

  6. Functions of the Marketplace Federal Responsibilities Under Iowa’s Partnership Model 3. Consumer Assistance Consumer support assistors, education and outreach; Navigator management; call center operations; website management; and written correspondence with consumers to support eligibility and enrollment. • Enrollment Enrollment of consumers into qualified health plans; transactions with Qualified Health Plans and transmission of information necessary to initiate advance payments of the premium tax credit and cost-sharing reductions. • Financial Management User fees; financial integrity; support of risk adjustment, reinsurance, and risk corridor programs.


  8. Qualified Health Plans • Only “Qualified Health Plans” (QHPs) can be sold through the marketplace. • QHPs must provide essential health benefits package • Minimum Benefits – statutory 10 categories Essential Health Benefits Ambulatory patient services Rehabilitative and habilitative services and devices Hospitalization Maternity and newborn care Mental health and substance abuse use disorder services Prescription drugs Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care Emergency services

  9. ‘Actuarial Value’ • Minimum levels of coverage, i.e. “actuarial values” – coverage designed to pay X% of health care costs associated with the plan.

  10. How Marketplace health plans will be priced • Prices of Marketplace plans have not been set yet. Prices will be available September 9. • All Marketplace plans must be approved by state insurance departments and certified by the Marketplace. Prices are approved by state insurance departments as required by state law. • In some states that are further ahead than Iowa, premium rates are coming in far below initial projections.

  11. Iowa Benchmark Plan • Iowa selected the largest small group planwhich is Wellmark’s Alliance Select Copayment Plus Plan which will serve as 2014 & 2015 benchmark for plans offered in the marketplace. • Benchmark serves as baseline coverage/costs for plans in the marketplace.

  12. Available Plans/Subsidies • Medicaid Expansion • 0-100% FPL – Medicaid plan available – no premiums, no co-pays/deductibles (except for non-emergency use of ER) • 101-138% FPL – Commercial Medicaid plan available (selected by DHS), Medicaid pays premiums, no copays/deductibles (except for non-emergency use of ER) • Uninsured w/o Access to Employer Insurance • Commercial plans available with tax subsidies for individuals up to 400% FPL.

  13. Tax Credits • Federal tax credits will help low-middle income individuals pay for coverage • Credits are advanceable, meaning tax filers need not wait until the end of the tax year in order to benefit (payments go directly to the issuer). • Premium credits will be available for qualified individuals if they: • Are lawfully in a state in the United States, unless their presence in the US is only for a specified period. • Are not enrolled under a Marketplace plan as an employee or their dependent (through an employer who purchases coverage through the Marketplace for their employees). • Have a modified adjusted gross income (MAGI) of less than 400% of the federal poverty level (FPL) ($43,000 for an individual or $88,000 for a family of four, 2010 HHS Poverty Guidelines). • Are not eligible for Medicaid. • Are not enrolled in an employer's qualified health benefit plan, a grandfathered plan (group or non-group), Medicare, Medicaid, military or veterans' coverage or other coverage recognized by the commissioner. • Are not a full-time employee in a firm where the employer offers health insurance and makes the required contribution toward that coverage.

  14. Iowa • Iowa’s filing deadline for participation in Iowa’s health insurance marketplace as provided for in the Affordable Care Act closed June 30. • In all, six companies have elected to apply to offer health plans that must meet the criteria as Qualified Health Plans. • Two of the companies are expected to offer statewide coverage for individuals. • Coventry Health Care of Iowa, Inc. • CoOportunity Health • CoOportunityHealth also applied to offer statewide small group plans. • Two insurers applied to offer individual and small employer group plans for smaller regional markets. • AveraHealth Plans • Gunderson Health Plan, Inc. 

  15. Iowa • Two companies, Sanford Health and Health Alliance Midwest, Inc., have applied to offer small group plans only. • In addition, four companies have applied to offer stand-alone dental plans on the marketplace. • The Guardian Life Insurance Company of America, • DentegraInsurance Company, • Delta Dental Plan of Iowa • BEST Life and Health Insurance Company. • Wellmark Blue Cross and Blue Shield has announced it will not participate in the exchange and will not increase premiums in 2014. • Open enrollment begins Oct. 1

  16. Outreach and Education Navigators: Navigators will have a vital role in helping consumers prepare electronic and paper applications to establish eligibility and enroll in coverage through the Marketplace. • This includes steps to help consumers find out if they qualify for insurance affordability programs (including a premium tax credit, cost sharing reductions, Medicaid and the Children’s Health Insurance Program), and if they’re eligible, to get enrolled. • Navigators will also provide outreach and education to consumers to raise awareness about the Marketplace, and will refer consumers to ombudsmen and other consumer assistance programs when necessary. • Navigators can play a role in all types of marketplaces. They’ll be funded through state and federal grant programs, and must complete comprehensive training.

  17. Outreach and Education Non-Navigator assistance personnel: Non-Navigator assistance personnel (also known as in-person assistance personnel) will perform generally the same functions as Navigators but will exist in either a State-based Marketplace or a State Partnership Marketplace. • Non-Navigator assistance personnel will serve as a part of an optional program that the state can set up before its Marketplace is economically self-sustaining, and before its Navigator program is fully functional. • Though they perform the same functions as Navigators, non-Navigator assistance personnel will be funded through separate grants or contracts administered by a state. They must also complete comprehensive training. • No word yet as to whether Iowa intends to establish.

  18. Outreach and Education Certified application counselors: • The Federally-facilitated Marketplace will designate organizations to certify application counselors who perform many of the same functions as Navigators and non-Navigator assistance personnel—including educating consumers and helping them complete an application for coverage. • An online application is available for organizations who want to become Marketplace-designated organizations that can certify application counselors. • These groups might include community health centers or other health care providers, hospitals, or social service agencies. • Visit to download the application.

  19. Outreach and Education Agents and Brokers: To the extent permitted by a state and if all Marketplace requirements are met, licensed health insurance agents and brokers may enroll individuals, small employers, and employees in coverage through the Marketplace. • Agents and brokers will be compensated by the issuer or by the consumer to the extent permitted under state law. • Federal and state training and certification requirements will apply to agents and brokers who enroll or assist consumers in the Marketplace.

  20. How are these roles funded?

  21. Training and Certification

  22. • Iowans will: • apply for and purchase private insurance • enroll in Medicaid • Apply for tax subsidies • through • Accounts can be established now for the Oct. 1 enrollment period.