The Health Insurance Marketplace
(Health Insurance Exchange)
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 “onestop-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
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.
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 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.
2. 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.
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.
4. 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.
5. Financial Management
User fees; financial integrity; support of risk adjustment, reinsurance,
and risk corridor programs.
www.healthcare.gov/marketplace
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 8. Preventive and
Benefits
wellness
1. Ambulatory
services and
patient services
chronic
2. Rehabilitative
disease
and habilitative
management
services and
9. Pediatric
devices
services,
3. Hospitalization
including oral
4. Maternity and
and vision care
newborn care 10. Emergency
5. Mental health
services
and substance
abuse use
disorder
services
6. Prescription
drugs
7. Laboratory
services
‘Actuarial Value’
Minimum levels of coverage, i.e. “actuarial
values” – coverage designed to pay X% of health
care costs associated with the plan.
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.
Iowa Benchmark Plan
• Iowa selected the largest small group plan
which 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.
Available Plans/Subsidies
1. Medicaid Expansion
1. 0-100% FPL – Medicaid plan available – no
premiums, no co-pays/deductibles (except for nonemergency use of ER)
2. 101-138% FPL – Commercial Medicaid plan
available (selected by DHS), Medicaid pays
premiums, no copays/deductibles (except for nonemergency use of ER)
2. Uninsured w/o Access to Employer Insurance
1. Commercial plans available with tax subsidies for
individuals up to 400% FPL.
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.
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
• CoOportunity Health also applied to offer statewide small group
plans.
• Two insurers applied to offer individual and small employer group
plans for smaller regional markets.
– Avera Health Plans
– Gunderson Health Plan, Inc.
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 standalone dental plans on the marketplace.
–
–
–
–
The Guardian Life Insurance Company of America,
Dentegra Insurance 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
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.
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, nonNavigator 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.
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 Marketplace.cms.gov to download the application.
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.
How are these roles funded?
Training and Certification
Healthcare.gov
Iowans will:
• apply for and purchase
private insurance
• enroll in Medicaid
• Apply for tax subsidies
through healthcare.gov
Accounts can be established
now for the Oct. 1 enrollment
period.