Frequently Asked Questions about the Health Insurance Marketplace

Starting October 1, 2013, consumers will be able to visit http://www.healthcare.gov/ to get all the information they need about the Health Insurance Marketplace. Whether you are uninsured, or just want to explore new options, the marketplace will give you more selection and control over your health insurance choices.

Q: What is the Health Insurance Marketplace?
The marketplace is a competitive marketplace where people and small businesses can shop for and buy private health insurance. With one application, you can find out if you qualify for health plans in the marketplace, and other programs like Medicaid, and the Children’s Health Insurance Program (CHIP), tax credits, and cost-sharing reductions.

Q: What is the difference between the marketplace and the traditional insurance market?
A: The marketplace is designed to enhance and improve today’s insurance markets for consumers and small businesses. It will achieve this by:

  • More Choice – You will have a choice of health plans to fit your needs.
  • More Competition – The marketplace will make it easier for you to compare plans on the basis of price, quality, and benefits. This gives insurance companies incentives to offer better products at lower prices than their competitors.
  • More Clout – The marketplace will give 25 million individuals and small businesses the same purchasing power as big businesses by bringing people and businesses together, lowering costs by spreading the cost of insurance across a larger group of people and allowing insurance companies to reduce prices.

Q: What does the marketplace mean for consumers?
A: The marketplace is a single place where consumers can apply for and enroll in health insurance coverage that’s right for them and their families. Consumers can compare health plans with similar coverage levels and learn if they qualify for help paying for health care costs through tax credits and cost-sharing reductions. The marketplace makes it easier for consumers to keep their coverage, even if income and employment changes make them ineligible for other programs like employer-sponsored insurance, private insurance tax credits, Medicaid, or the Children’s Health Insurance Program (CHIP).

Q: When will I know my health insurance options?
A: Starting November 1, 2016, consumers will be able to shop for plans on http://www.healthcare.gov/ or enroll with Certified Application Counselors (CAC) or Navigators, or call a toll-free call center.

Q: What if I can’t afford insurance?
A: When you fill out a marketplace health insurance application, you’ll find out if you can get lower costs on monthly premiums or out-of-pocket costs, or get free or low-cost coverage. Most people who apply will qualify for lower costs of some kind. You can save money in the marketplace in three ways, depending on your income and family size:

  • You may be able to lower costs on your monthly premiums when you enroll in a private health insurance plan.
  • You may qualify for lower out-of-pocket costs for copayments, coinsurance, and deductibles.
  • You or your child may get free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP).

Q: What if I have a pre-existing condition?
A: Being sick won’t keep you from getting health coverage. An insurance company can’t turn you down or charge you more because of your condition. You can apply for marketplace insurance when open enrollment starts on November 1, 2016, and coverage starts as soon as January 1, 2017.

Q: What types of benefits will marketplace plans offer?
A: Health plans in the marketplace will generally offer comprehensive coverage, including 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

Q: Will there be different prices for plans on the marketplace?
A: 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.

Q: Which plans are in-network for Methodist Health System?
A: Methodist does not offer its own plan, but is in-network in the Blue Cross Blue Shield, Aetna, and Cigna plans on the exchange.

Q: I’m young and healthy. Can I buy a “catastrophic” plan?
A: Yes, people under 30 and some people with limited incomes may buy a “catastrophic” health plan. 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 are generally paid by the insurance company. These policies usually have lower premiums than a comprehensive plan, but cover you only if you need a lot of care. In the marketplace, catastrophic policies cover three primary care visits per year at no cost, and also cover free preventive benefits. If you have a catastrophic plan in the marketplace, you can’t get lower costs on you monthly premiums or on out-of-pocket costs. When you fill out a marketplace application, you’ll see catastrophic plans listed as options if you qualify for them.

Q: Can I keep my own doctor?
A: Depending on the plan you choose in the marketplace, you may be able to keep your current doctor. When comparing plans in the marketplace, you will see a link to a list of providers in each plan’s network. If staying with your current doctor(s) is important to you, check to see if they are included before choosing a plan.

Q: What do American Indians and Alaska Natives need to know about the marketplace?
A: Members of a federally recognized tribe have certain protections in the marketplace starting in 2014.

  • You don’t have to pay a fee if you don’t have health coverage.
  • You more easily qualify for lower out-of-pocket costs for deductibles, copayments, and coinsurance.
  • You get monthly special enrollment periods allowing you to get insurance outside the yearly open enrollment period.
  • You have special cost and eligibility rules for Medicaid and the Children’s Health Insurance Program (CHIP).
  • For more information, visit www.HealthCare.gov/tribal

Applying and Enrolling in Coverage

Q: How do I apply for coverage and enroll in a health plan through the marketplace?
A: Starting November 1, 2016, you will be able to file a marketplace application online, by phone (through a toll-free call center), by mail, or in person (with accommodations for people with disabilities). Coverage starts as soon as January 1, 2017. The marketplace will automatically tell you if you qualify for discounts or qualify to participate in state programs based on your income. Then you can choose the health plan that’s right for you through the online plan comparison tool.

Q: What items do I need to have before enrolling?
A: Before beginning the enrollment process, you should have:

  • Social Security number (SSN)
  • Document number (if you’re an eligible immigrant who wants health coverage)
  • Birth date
  • Paystubs, W-2 forms, or other information about your income
  • Policy/member numbers for any current health coverage

Q: How do I use http://www.healthcare.gov/ to apply for marketplace coverage?
A: You can enroll in health coverage in just four steps using http://www.healthcare.gov/.

  1. Set up an account. You’ll provide some basic information to get started, like your name, address, and email address.
  2. Fill out the online application. You’ll provide information about you and your family, like household income, household size, current health coverage information, and more. This will help the marketplace find options that meet your needs.
  3. Compare your options. You’ll be able to see all the options you qualify for, including private insurance plans and free and low-cost coverage through Medicaid and the Children’s Health Insurance Program (CHIP). The marketplace will tell you whether you qualify for lower costs on your monthly premiums and out-of-pocket costs on deductibles, copayments, and coinsurance. You’ll see details on costs and benefits before you choose a plan.
  4. Enroll. After you choose a plan, you can enroll online and decide how you pay your premiums to your insurance company. If you or a member of your family qualifies for Medicaid or CHIP, a representative will contact you to enroll.

Q: What if I don’t have access to a computer so that I can visit http://www.healthcare.gov/?
A: There will be people in local communities who can give you personal help with your choices. You can also call a toll-free number, 1-800-318-2596, and talk to a trained customer service representative in 150 languages about the marketplace.

Q: How do I get help enrolling in the marketplace?
A: The marketplace will offer several kinds of assistance to help you apply for coverage and choose the plan that’s right for you, including online questions and answers, online chat, a toll-free call center, as well as people in your community who are trained and certified to help you apply and enroll (starting October 1, 2013).

In keeping with its mission to improve and save lives through compassionate quality health care, Methodist Health System offers free assistance to anyone wanting to enroll for coverage through the national health insurance exchange program.

Methodist has 10 Certified Application Counselors (CAC) who are available by appointment to meet with individuals to discuss options, answer questions, and help navigate the enrollment process. CAC assistance is available at Methodist Charlton Medical Center, Methodist Mansfield Medical Center, and two locations at Methodist Richardson Medical Center. Call the numbers below to request an appointment. Methodist has also created a new insurance marketplace web page to provide further assistance: www.methodisthealthsystem.org/insurance-marketplace.

Coverage for Employees, Self-Employers, and Small Businesses

Q: I have insurance through my employer. What does the health care law mean for me?
A: If you have health insurance through your employer, nothing will change. However, if you’re uninsured, purchase insurance on your own, or want to explore new options, the marketplace will make it easier for you to shop for plans and see if you are eligible for savings that lower your monthly premiums.

Q: What if I’m losing job-based insurance?
A: If you lose your job and with it your job-based health insurance coverage, you may buy an individual plan through the marketplace. You may also have the option of keeping your health insurance for a limited time through a program called COBRA continuing coverage. COBRA is a federal law that may let you pay to keep you and your family on your employee health insurance for a limited time (usually 18 months) after your employment ends or you otherwise lose coverage.

Q: What if I’m self-employed?
A: If you’re self-employed with no employees, you’re not considered an employer. You can use the individual marketplace to find coverage that meets your needs. You can compare important features of several plans side-by-side, all of them offering a full package of essential health benefits. You can see what your premium, deductible, and out-of-pocket costs will be before you decide to enroll. If you currently have individual insurance – a plan you bought yourself, not the kind you get through an employer – you may be able to change to a marketplace plan.

Q: What do health insurance marketplaces mean for small businesses?
A: A Small Business Health Options Program (SHOP) marketplace is available in each state. SHOP gives small employers and their employees some of the advantages large employers have today, including choices among high quality health plans to meet every budget. Employers who qualify for SHOP must have fewer than 100 employees (states may limit eligibility to employers with 50 or fewer employees for the first two years). Employers must also have an office within the service area of the SHOP, and prove that they’re offering full-time employees SHOP coverage.

Q: Do I have to insure my employees?
A: No employer has to offer coverage. Some large businesses that don’t offer coverage meeting certain standards may have to make a shared responsibility payment.

  • If you have fewer than 50 full-time equivalent (FTE) employees, you are not subject to the Employer Shared Responsibility parts of the law. You may use SHOP to offer coverage for your employees
  • If you have 50 or more FTEs, you may have to make an Employer Shared Responsibility Payment if at least one of your full-time employees gets lower costs on their monthly premiums when buying insurance in the marketplace.

Q: Will my business get tax credits?
A: You may qualify for employer health care tax credits if you have fewer than 25 full-time equivalent (FTE) employees making an average of about $50,000 a year of less. To qualify for the Small Business Health Care Tax Credit, you must pay at least 50 percent of your full-time employee’s premium costs. The credit is available only if you get coverage through the SHOP marketplace. You don’t have to wait until open enrollment to find out if you qualify for the Small Business Health Care Tax Credit. You can find out now by visiting http://www.irs.gov/.