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Health Insurance Marketplace: 10 Things Providers Need to Know

Posted Aug 29 2013 2:17pm

By AIDS.gov Cross-posted from CMS Resources

Editor’s note: For more information about the Affordable Care Act and HIV/AIDS, please visit  http://aids.gov/federal-resources/policies/health-care-reform/index.html .

A primary goal of the Affordable Care Act is to help the 16% uninsured and eligible Americans gain access to quality, affordable health care. Central to this goal is the creation of the Health Insurance Marketplace. Through the Marketplace, eligible Americans will be able to enroll in a health plan to get coverage that starts as soon as
January 2014.

As a trusted source for health information, your patients may look to you for help navigating the Marketplace. Here are 10 things you should know:

  1. The Marketplace is a new way to shop for health coverage. A single, online source will let consumers get information about their health coverage options in a way that makes it easy to make side-by-side comparisons of private insurance plans’ benefits, quality, and price, and find out if they’re eligible for assistance with the costs of health coverage.
  2. Each state will have a Marketplace, run either by the state, through a state-federal partnership, or by the federal government.
  3. Open Enrollment begins on October 1, 2013, and ends on March 31, 2014. Coverage can begin as soon as January 1, 2014.
  4. Health plans offered in a Marketplace will generally offer comprehensive coverage, including a set of “essential health benefits” with at least these items and services • Ambulatory patient services
    • Emergency services
    • Hospitalization
    • Maternity and newborn care
    • Mental health and substance use disorder services, including behavioral health treatment (which includes counseling and psychotherapy)
    • 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
  5. Individuals can buy insurance through a Marketplace if they live in the United States, are U.S. citizens or U.S. nationals (or are lawfully present), and aren’t currently incarcerated.
  6. Nobody can be turned away or charged more because of their gender or a pre-existing condition.
  7. Depending on household income and family size, many individuals may qualify for tax credits to help lower their share of monthly premiums, or help that reduces deductible, copayment or other cost-sharing amounts.
  8. Individuals will be able to choose a Marketplace plan by health plan category (bronze, silver, gold, or platinum). The differences among the categories will be based on the average percentage of the costs the plan will cover. This system makes it easier to compare similar plans based on price and coverage. Catastrophic plans and stand-alone dental plans also may be available.
  9. Using a single application on HealthCare.gov, consumers can find out if they and/or their family members are eligible for Medicaid, the Children’s Health Insurance Program (CHIP), or for financial help paying for a private health insurance plan offered in the Marketplace.
  10. Resources are available now.
    Marketplace.cms.gov: Where organizations and individuals looking to help can get the latest resources and learn more about the Marketplace
    HealthCare.gov: Where individuals can learn about the Marketplace and the upcoming benefits (including where they can find local assistance), or be connected to appropriate resources in states that are running their own Marketplace.
    Health Insurance Marketplace Call Center: If you have questions, call 1-800‑318‑2596. TTY users should call 1-855-889-4325.
Help your patients get ready

Consumers can learn more through local community groups and special events. Trained assisters and navigators will be available in communities nationwide to help consumers understand their choices and apply for coverage. Starting October 1, consumers can apply for health coverage on HealthCare.gov or by calling the Marketplace Call Center at 1-800-318-2596.

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