Prepared by the
American Association of Colleges of Nursing
Updated August 2015
What is the Health Insurance
Marketplace?
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The Health Insurance Marketplace was created through
the Patient Protection and Affordable Care Act or ACA
[Public Law 111-148] specifically in relation to Subtitle
D—Available Coverage Choices for All Americans.
The core components of the ACA are the Individual
Mandate and the State Exchanges.
 Individual Mandate requires most individuals to
obtain health insurance or pay a penalty in the form
of a tax. In order to incentivize health insurance
acquisition, the ACA provides cost assistance
subsidies to individuals who qualify.
 State Exchanges allow for each state to decide if
they will create their own exchange, partner with
the federal government, or have a federallyfacilitated exchange for individuals to gain
coverage.
Kaiser Family Foundation (2014). State Decisions For Creating Health Insurance Marketplaces, 2014
Retrieved from http://kff.org/health-reform/state-indicator/health-insurance-exchanges
Am I Eligible?
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For an individual to be
eligible for coverage through
the Marketplace, they must
meet the following criteria:
 Live in the United States
 Be a U.S. citizen, national, or
live lawfully in the United
States
 Cannot be incarcerated
 If you have Medicare
coverage, you’re not eligible
to use the Marketplace to buy
a health or dental plan
Healthcare.gov. (2015) Am I eligible for coverage in the Marketplace, Retrieved from
https://www.healthcare.gov/am-i-eligible-for-coverage-in-the-marketplace/
How Do I Find Out What My State Is
Offering?
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Regardless of the state where you live, you can access the Marketplace to apply for
coverage, compare your options, and enroll.
https://www.healthcare.gov/screener/
What Will I Need to Enroll?
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Information about your household
Social Security Numbers (or document numbers for legal
immigrants)
Information about the professional helping you apply (if
you’re getting help)
Information on how you file your taxes
Employer and income information for every member of
your household who needs coverage (for example, from
pay stubs or W-2forms—Wage and Tax Statements)
Policy numbers for any current health insurance plans
covering members of your household
A completed Employer Coverage Tool for every jobbased plan for which you or someone in your household
is eligible
2016 income estimate
Notices from your current plan that include your plan ID,
if you had health coverage in 2015
Healthcare.gov. (2015) Marketplace Application Checklist, Retrieved from
https://marketplace.cms.gov/outreach-and-education/marketplace-applicationchecklist.pdf
How Can I Enroll: Apply on Line
Provide the following steps to help an individual or family obtain coverage:
 Create an account. Go to the Marketplace and select your state to begin. Provide
some basic information, and then choose a user name, password, and security
questions for added protection.
 https://www.healthcare.gov/marketplace/individual/
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Complete your application. Provide information about you and your family, like
income, household members, current health coverage, and more
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Pick a plan. See all the options you qualify for, including Medicaid and the Children’s
Health Insurance Program (CHIP). The system will you know if you qualify for lower
costs on private health coverage. Find out how to choose a plan that’s right for you.
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Enroll. After you choose a plan, don't forget to enroll online and contact your
insurance company to pay your first premium by the due date.
Healthcare.gov (2015). Health Insurance Marketplace Basics, Retrieved from
https://www.healthcare.gov/get-covered-a-1-page-guide-to-the-health-insurancemarketplace/.
How Can I Enroll: Other Options
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Apply by phone
 Call 1-800-318-2596, 24 hours a day, 7 days
a week (TTY: 1-855-889-4325). A customer
service representative will work with you to
complete the application and enrollment
process.
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Apply by mail
 Fill out a paper application and mail it in. Once
you get your eligibility notice, go online or
contact our call center to pick a plan and enroll.
Download the application form and instructions
to begin
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Local resources
 You may be able to apply online at a local
library or at a Community Health Center in
your area.
When Can I Enroll?
Key Dates for 2016 Open Enrollment
January 31, 2016
Open Enrollment Ends
November 1, 2015:
Open enrollment
period for 2016
plans begins
December 31, 2015:
Coverage ends for
2015 plans
January 1,2016:
First date 2016
coverage can start
During open enrollment, if your patient enrolls
Between the 1st and 15th days of the month, their
coverage starts the first day of the next month.
Between the 16th and the last day of the month,
their coverage starts the first day of the second
following month. So if they enroll on March 16,
your coverage starts on May 1.
Healthcare.gov. (2015). 2016 Open Enrollment. Retrieved from
https://www.healthcare.gov/marketplace-deadlines/2016/
If your patient has not enrolled in
coverage by then, they generally
cannot enroll in 2016 coverage until the
next open enrollment period. The
exceptions are life events such as having
a child.
If your patient does not have health
insurance coverage in 2016, he or she
may have to pay a penalty.
What Is Meant By The Tax Credit?
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When you buy health insurance coverage in the Marketplace, you may qualify to
receive a premium tax credit that lowers what you pay in monthly premiums. This
premium is dependent upon household income and size.
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To find out if you qualify for a tax premium, visit:
https://www.healthcare.gov/will-i-qualify-to-save-on-monthly-premiums/.
Here, you will be asked questions about your household which will determine if you
qualify and the premium amount.
What are the Tax Credits and
Penalties?
As of 2015:
 The average monthly premium for an individual after the advanced
premium tax credit was applied was $105
 More than 8 in 10 individuals with a Marketplace plan qualified for an
advanced premium tax credit
 The average advanced premium tax credit covers about 72 % of the
gross premium
 In 2016, anyone who does not have health insurance coverage will have to
pay the penalty of either:
 $695 for each adult and $347.40 for each child, up to $2,085 per
family, or
 2.5% of family income that is above the federal tax return filing
threshold for your filing status
 The penalty amount is capped at the cost of the national average for a
bronze level health plan available through the Marketplace in 2016.
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Health and Human Services (2015). Health Insurance Marketplace 2015: Average premiums
after advance premium tax credits through January 30 in 37 States using the healthcare.gov
platform. Retrieved from
http://aspe.hhs.gov/health/reports/2015/MarketPlaceEnrollment/APTC/ib_APTC.pdf
What Are The Essential Health Benefits?
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Essential Health Benefits: A set of health
care service categories that must be
covered by certain plans, starting in 2014.
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Insurance policies must cover these benefits
in order to be certified and offered in the
Health Insurance Marketplace.
 States expanding their Medicaid
programs must provide these benefits to
people newly eligible for Medicaid.
Healthcare.gov. (2014) Glossary: Essential Health Benefits, Retrieved from
https://www.healthcare.gov/glossary/essential-health-benefits/
What Are The Essential Health Benefits?
(continued)
These essential health benefits include
at least the following items and
services:
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Outpatient care
Emergency room visits
Inpatient hospital treatment
Prenatal and postnatal care
Mental health and substance
use disorder services:
behavioral health treatment,
counseling, and psychotherapy
Prescription drugs
Lab tests
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Services and devices that assist in
recovery if you are injured, or have a
disability or chronic condition. This
includes physical and occupational
therapy, speech-language pathology,
psychiatric rehabilitation, and more.
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Preventive services including
counseling, screenings, vaccines, and
care for managing a chronic disease.
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Pediatric services: This includes dental
care and vision care for kids
Specific health care benefits may vary by state. Even
within the same state, there can be small differences
between health insurance plans. When you fill out
your application and compare plans, you’ll see the
specific health care benefits each plan offers.1
Healthcare.gov. (2014) Glossary: Essential Health Benefits, Retrieved from
https://www.healthcare.gov/glossary/essential-health-benefits/
What Are No Cost Sharing Services?
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All Marketplace plans and many other plans must cover the following
list of preventative services without charging you a copayment or
coinsurance.
 Abdominal Aortic Aneurysm
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one time screening
Alcohol misuse screening
and counseling
Aspirin use
Blood pressure screening
Cholesterol screening
Colorectal cancer screening
Depression screening
Diabetes (type 2) screening
Healthcare.gov (2015). Preventive Health Service for Adults. Retrieved from
https://www.healthcare.gov/preventive-care-benefits/
 Diet counseling
 Hepatitis B & C screening
 HIV Screening
 HIV Screening
 Immunization vaccines
 Lung cancer screening
 Obesity screening and
counseling
 STI prevention counseling
 Syphilis screening
 Tobacco use screening
Where Can I Direct My Patients Who
Have Questions I Cannot Answer?
Online
By Phone
In Person
• Representatives are
available to assist
individuals via online
chat:
https://www.healthcare.
gov/.
• Individuals and Families
• A hotline is available 24
hours per day, seven
days per week to assist
individuals who have
questions about
enrollment.
• Find people and
organizations in your
community who can help
you apply, enroll, and
answer your questions.
• 1-800-318-2596
• TTY: 1-855-889-4325
• Visit
https://www.healthcare.
gov/contact-us/ and
enter your zip code to
be connected.