What is a Health Insurance Marketplace?

Health Marketplace at a Glance

KEY TERM:

QHP – Qualified Health Plan is any medical plan that is sold on the health insurance marketplace. QHP is synonymous with Affordable Care Act (ACA).

Health Marketplace = ACA = QHP

Each state and the District of Columbia has an insurance marketplace where individuals may compare and purchase health insurance.  Hawaii is an exception, as employers in Hawaii were already required to provide health insurance to their employees prior to the Affordable Care Act through the Hawaii Prepaid Health Care Act.

• The Individual Marketplace is for individual consumers and their families.
• The SHOP is for small employers and their employees.

A Marketplace can be operated only by a state or by the federal government.  Some states choose to operate their own marketplaces. These are known as state-based marketplaces.

• State-based marketplace (SBM) – states operate their own marketplaces
• State-based marketplace on the Federal Platform (SBM-FP) – some State-based Marketplaces received approval to utilize the federal platform to perform all eligibility and enrollment functions, as well as consumer assistance, for their Individual Marketplace, the SHOP, or both, and are considered SBM-FPs.
• Federally-facilitated marketplace (FFM) – if a state does not operate a State-based Marketplace, the Department of Health & Human Services (HHS) operates an FFM and/or Federally-facilitated SHOP in that state.

You can find out  about your state from a list of the drop-down menus here.

For additional information on Affordable Care Act insurance eligibility and standards, and how it compares with Short-Term coverage, check out this article:

Affordable Care Act (ACA) vs. Short-Term Health Insurance

ACA Marketplace

Let’s take as look at the ACA marketplace. What is it’s function?

All ACA marketplace offered plans for both individual and small-employers are Qualified Health Plans (QHP).

To become certified, a QHP insurer must meet a minimum set of criteria, including:

• Coverage, at a minimum, of a comprehensive package of benefits, known as essential health benefits (EHB)
• Benefit design standards, including non-discrimination requirements and limits on cost sharing
• Network adequacy standards
  • Offer a network that is sufficient in number and types of provider
  • Make a good faith effort to provide written notice of discontinuation of a provider 30 days prior to the effective date of the change
  • Include a sufficient number of essential community providers,  to ensure reasonable and timely access to a broad range of such providers for low-income and medically underserved populations in the QHP’s service area

Small employers (generally those with 1-50 employees) may be able to enroll in SHOP plans through an insurance company or with the assistance of a SHOP-registered agent or broker. Healthcare.gov has a list of certified and licensed agents, searchable by zip code. Or you can let us know that you need insurance help.

Functions of the ACA Marketplace: 

• QHP Certification: Certifying health plans to participate in the Marketplace as Qualified Health Plans
• QHP Enrollment: Facilitating individuals’ enrollment in a Qualified Health Plan
• Medicaid/CHIP Eligibility: Determining or assessing individuals’ eligibility for enrollment in Medicaid or the Children’s Health Insurance Program
• Monitoring Issuers: Carrying out certain plan oversight functions, including monitoring QHP issuers for continuing compliance with certification requirements
• Eligibility: Determining individuals’ eligibility for enrollment in a Qualified Health Plan through the Marketplace
• Financial Assistance: Determining individuals’ eligibility for advance payments of the premium tax credit and cost-sharing reductions

ACA marketplace also offers other types of plans:

CO-OP Health Plans:

The Affordable Care Act established the Consumer Operated and Oriented Plan (CO-OP) program, which created a new type of private, nonprofit, member-run health insurer. CO-OP health plans:

• are governed by their members,
• must operate with a strong consumer focus,
• must reinvest any profits into lowering premiums, improving benefits, or otherwise improving the quality of health care delivered to their members.

CO-OPs offer health plans in some states through the Individual Marketplace and SHOP, but may also offer health plans outside of the Marketplace.

Stand-alone Dental Plans:

Since the adult dental coverage is not part of the Essential Health Benefits, it is not required to be included in the package of benefits offered by a health plan in the individual or small group market, including through the Marketplace. However, consumers can purchase a stand-alone dental plan through the FFM if they qualify for and enroll in a QHP.

Pediatric dental care is an EHB that health insurance companies must offer as part of a QHP if it is not otherwise available in the Marketplace through a Marketplace-certified stand-alone dental plan.

Getting Help with Purchasing ACA Marketplace Health Plan

When you are trying to shop on a marketplace website, you have an option to purchase the plans on your own or you can seek assistance, to help you with navigating the system and provide advice.  You have 2 types of options:

Licensed insurance professionals – who can explain the differences between plans:

1. Health insurance agent (this can be an agent, broker, or web-broker)

Assisters – who can explain, but cannot make recommendations of specific plans:

1. Navigator – certified navigators who assist consumers in applying for and enrolling in health coverage through the Marketplace.  An insurance company representative cannot be a navigator. Navigators are usually associated  with non-profit organizations.
2. Certified application counselors (CAC) – staff members and volunteers of organizations approved by the Marketplace, such as community health centers, health care providers, and certain social service agencies.

KEY-POINT: Navigators and CACs are different from Agents because agents get paid commission on sales from the insurance companies, while Navigators and CACs are not allowed to receive compensation from any health insurance company for helping with the navigation process.

Assisters in the Marketplace cannot make specific plan recommendations to consumers.

If an assister is asked by a consumer to recommend a specific plan, the assister must remind the consumer that he or she is prohibited from making plan recommendations because federal standards require assisters to remain fair and impartial.

Once the customer asks an assister for a recommendation, the assister should refer the customer to the listings of the Marketplace-registered health insurance agents. Again, assisters must stay impartial and cannot recommend any specific agent or insurance company.

Assisters may facilitate enrollment in a Qualified Health Plan by:

• providing detailed information about the benefits and features of a plan;
• clarifying the similarities and difference between plans; and
• assisting consumers with making informed decisions in the plan selection process according to their needs.

AGENT

All agents, brokers, and web-brokers who participate in the Marketplace must comply with the standards of conduct to protect against conduct that is harmful to consumers or prevents the efficient operation of the Marketplace.

When you contact an insurance professional to help you with selecting a marketplace plan, they are legally required to:

• Show a Privacy Policy Statement  to each consumer prior to collecting his or her Personally Identifiable Information (PII)
• Get your consent to act as your assistant in navigating the marketplace

KEY-POINT: Your disclosures and consents will be stored by the agents for at least 10 years , or the life of the record – whichever is longer. 

At a minimum, in this consent you acknowledge that the agent has informed you  (the prospective buyer) of the functions and responsibilities that apply to the agent’s role in the Marketplace. In addition, the consent may include permission for the agent, broker, or web-broker to:

1) conduct an online person search,

2) assist with completing an eligibility application,

3) assist with plan selection and enrollment, and

4) assist with ongoing account/enrollment maintenance.

Marketplace insurance consent form should include:

• The individual’s, employer’s, or employee’s name;
• The date the consent was given; and
• The name of the agent(s), broker(s), or web-broker(s) to whom the consent was given.

Here are a few Resources for Agents and Brokers in the Health Insurance Marketplaces

NAVIGATOR

Navigators in the marketplace are required to disclose to consumers:

• certain relationships they may have with health insurance and stop loss insurance issuers.

Certified Application Councilor (CAC)

CAC are required to disclose to consumers:

• any potential conflicts of interest, including any relationships with issuers of QHPs or insurance affordability programs.

Marketplace-registered Agents and Assistors can be found on the Find Local Help page, searching by city and state or zip code.

Another option is to use Help on Demand service. Here the consumer sends out the request for help and the system pings the closest marketplace-certified agent according to the agent’s advertised work hours. Some agents work late, so they could respond to your sudden urge to shop for insurance at 2am. The agent has 15 minutes to confirm that they are able to help. If they don’t confirm, the system contacts the next agent on the list.  It’s kind of like Uber, but instead of the driver accepting you as a client, its an insurance agent.

Interesting point: Unlike most of the insurance industry, where the agent always pays for leads to new customers – if the consumer uses the Help on Demand search, the agent gets this client for free.

——————————————–

How are agents getting paid for helping consumers with Marketplace health plan purchase?

KEY-POINT: Using an insurance agent to help you obtain healthcare coverage through HealthCare.gov does not cost you anything extra. Their pay comes out of the insurance company’s profits.

The Marketplace does not set compensation levels.

FOR ASPIRING INSURANCE AGENTS:

If you become a health insurance agent, what will you get paid for assisting clients with the marketplace health plan?

Licensed insurance professionals who participate in the Marketplace are paid according to:

• their agreements with the Qualified Health Plan providers and
• according to any applicable state-specific requirements

When an agent wants to be listed on the Marketplace’s help website, first they must get connected to all the insurance companies that they want to represent.  The agent must be appointed by the insurance company. If there is no appointment , the agent cannot sell their product. During the signup (appointment) process, the agent finds out how commission will be calculated.

In some cases, the agent may get paid a flat, fixed fee per plan sold: $5-10 per month, depending on if it’s an individual or a family plan. In other cases, the agent might not get paid at all. It is all up to the insurance companies. and greatly varies per state. This type of fee structure can work great for agent who help write a lot of ACA plans every month. Helping 500 customers per month can net $2,500-$5,000 in pay.

The majority of health agents usually operate through an agency, and they must share their profits with them.  At first the agency gets their full commission directly from the insurer.  Then it deducts it’s cut and gives the agent the rest.  The cut to the agency is called an Override.

KEY-POINT: On average, the standard Marketplace plan commission pays 5-8% of your monthly premium to the AGENCY that the agent is working for. Then the agency pays the WRITING AGENT 50-75% of that.  The difference that the agency keeps is called Override (or Overwrite), depending on who you talk to.

This is how this method breaks down:

• Let’s say, you are an agent who helps a client to obtain insurance coverage with monthly premium of $500 (the full premium, before applying any Advance Premium Tax Credits).

Using the average commission of 6% of the $500 premium, the $30 commission goes to your agency. Then the agency pays you 50-75% of that $30.  So, in this type of setup, you – the agent get paid $15-$22 per month, while your client keeps the plan.

Whenever your client renews their annual HealthCare.gov insurance, the agency receives a 1-3% annual commission. This number can vary drastically between states. Truth be told, some agencies have been known to completely keep this commission to themselves, stiffing their agents in the process.

What are the penalties for agents who break marketplace rules?

• Agent’s marketplace account may be suspended for up to 90 days
• Agent’s marketplace account may be terminated
• Denial of future listing on the marketplace
• Fine of up to $28,906* per application, for failure to provide correct information
• Maximum fine of up to $289,906* for each application, for willingly providing false information in the application
• Maximum fine of up to $28,906 for willful disclosure of Personally Identifiable Information

*stats as of 2019

Health Marketplace – Steps to Coverage

The main steps of the Marketplace eligibility and enrollment process are as follows:

1. Individual submits an application to the marketplace ( https://www.healthcare.gov/ )
2. Marketplace verifies information needed to determine eligibility
3. Marketplace determines eligibility and notifies the applicant
4. Eligible individual compares health plans and completes the enrollment
5. If needed, individual submits documentation to resolve a data matching issues

To be eligible to get insurance through the marketplace, an individual must:

• Be a resident of the state where they will apply for coverage and enroll
• Be a United States (U.S.) citizen or national, lawfully present non-citizen , and mixed immigration households (including valid non-immigrant visa holders).

  • Important Point: Individuals who are not lawfully present can apply for health coverage for their household member(s) who are lawfully present without having to provide their own Social Security number (SSN) or other proof of lawful presence. As long as they are not the ones who are getting the coverage.

    EXAMPLE: Not-lawfully present parents may apply for coverage for a child, without having to provide their own personally identifiable information.

• Not be incarcerated, other than incarceration pending the disposition of charges

Eligibility for Insurance Affordability Programs

APTC / CSR / Medicaid / CHIP

There are several programs that can help families and individuals obtain access to affordable health coverage. The Patient Protection and Affordable Care Act (ACA) provide opportunities for eligible individuals to reduce:

1. Cost of health coverage through the advance premium tax credit (APTC)

The premium tax credit helps eligible individuals and families afford health insurance coverage purchased through the marketplace.  After you submit an application to the marketplace, you may be determined eligible to receive Premium Tax Credit. APTC is the amount that the government pays monthly to your insurance company, to reduce the amount you must otherwise pay each month for coverage in a qualified health plan (QHP). You can find out more about APTC eligibility here: How to reconcile your premium tax credit and here: Affordable Care Act (ACA) Tax Provisions

1. Out-of-pocket expenses for covered health benefits through cost-sharing reductions (CSRs).

CSRs are subsidies that reduce out-of-pocket costs, such as deductibles, coinsurance, and copayments.  CSRs do not apply to balance billing, such as from an out-of-network provider or for non-covered services. Eligibility for income-based CSRs is based on household income and generally requires the individual or family to enroll in a Silver plan category and be eligible for APTC.

Federally recognized tribes or shareholders in the Alaska Native Claims Settlement Act (ANCSA) Corporations may receive CSRs if they enroll in a plan in any plan category, and those who qualify for a limited cost-sharing plan do not have to be eligible for APTC.

Note: Medicaid and the Children’s Health Insurance Program (CHIP) are two other programs that provide affordable health coverage to eligible individuals and families. These programs provide safety net coverage for the country’s lowest-income populations and vary greatly by state. An individual who is eligible for Medicaid or CHIP that qualifies as minimum essential coverage* is not eligible for APTC or income-based CSRs to help pay for Marketplace coverage.

• Medicaid is a federal and state partnership to provide coverage for:
  • people with lower incomes,
  • older people,
  • people with disabilities,
  • and some families and children.

To qualify for Medicaid, the applicant must be part of a covered group:

• children,
• pregnant women,
• parents or caretaker relatives,
• the elderly,
• the disabled,
• other non-elderly adults who are not eligible for or enrolled in Medicare – and must meet financial eligibility requirements.

To be eligible for Medicaid, individuals usually need to meet federal and state requirements for:

• residency;
• citizenship or immigration status;
• household income; and,
• in some cases, financial resources.

Medicaid is jointly funded with federal and state dollars, but is administered at the state level.

State-based Medicaid programs often have different names in each state. For example, Oklahoma has “SoonerCare”, while Massachusetts has “MassHealth”.

States expanding their Medicaid programs must provide the 10 categories of Essential Health Benefits (EHB) to people newly eligible for Medicaid. All states are required to provide EHB to certain other groups of people eligible for Medicaid.

If you decide to work with an insurance agent, to help you navigate the insurance marketplace, it is important that the agent knows and understand your local states requirements.  The agent must be licensed in your state.

Children’s Health Insurance Program (CHIP)

CHIP provides no-cost or low-cost health insurance coverage to children under the age of 19 in families where the qualifying income is too high to qualify for Medicaid coverage. In some states, CHIP also covers pregnant women.

Like Medicaid, the costs for CHIP are shared by the federal government and state governments, but the program is administered at the state level. CHIP programs operate under different names in each state, such as “Washington Apple Health for Kids” in the state of Washington and “BadgerCare” in Wisconsin.

CHIP provides comprehensive benefits, often through insurance companies.

To find CHIP information by state, visit InsureKidsNow.gov.

When an individual indicates on their marketplace application that they are interested in help paying for health insurance, the marketplace conducts an eligibility assessment or determination, depending on the state, for Medicaid and CHIP for each household member indicated as needing health coverage.

Individuals determined eligible for minimum essential coverage Medicaid or CHIP can enroll in Marketplace coverage if otherwise eligible, but will have to pay full cost for their share of the marketplace plan premium and covered services, as they are ineligible for APTC and for income-based CSRs, if applicable.

KEY-POINT: Certain household members may qualify for Medicaid or CHIP, even if other household members do not.

Medicaid and CHIP Eligibility Determination

For households applying through the marketplace for health coverage and help paying for it, the marketplace evaluates each applicant’s eligibility for Medicaid and CHIP.

There are two types of states: Determination states and Assessment states.

In Determination states, the marketplace is able to process the full eligibility by itself,  consistent with Medicaid and CHIP regulations and state-specific policies.

In Assessment states, the marketplace makes preliminary assessments of eligibility for Medicaid and CHIP coverage; while the state Medicaid/CHIP agencies make the final eligibility determinations, consistent with Medicaid and CHIP regulations and state-specific policies.

In assessment states, there is a possibility that the marketplace will assess an individual potentially eligible for Medicaid/CHIP, and then the state Medicaid/CHIP agency may determine the individual ineligible for Medicaid/CHIP. In this case, the state agency will notify the individual of the determination, and send the updated application information to the Marketplace via a secure transaction.

Upon receiving the application information from the state agency, the marketplace starts the marketplace application, and will notify the applicant via a notice (see sample notice here) if something needs to be confirmed or clarified.

KEY-POINT: Assessments and determinations for Medicaid and CHIP eligibility are made based on each state’s applicable Medicaid MAGI-based income standards; other eligibility requirements, like rules regarding citizenship and immigration status; and verification rules and procedures, consistent with federal regulations.

Medicare Periodic Data Matching (PDM)

The marketplace also does a quick screening of anyone listed on a marketplace application for coverage and who requests help paying for coverage to assess whether the individual might be eligible for Medicaid based on factors other than MAGI, such as being age 65 or older, disabled, or in need of long-term care services.

If the periodic check done by the marketplace – raises a red flag of someone having double coverage, the individual receives an initial warning notice. The notice includes the list of steps that must be taken immediately, to get it resolved.

The Marketplace sends a final notice (see sample at Marketplace.CMS.gov) to the household contact for consumers who do not respond by the date specified in the initial warning notice, letting the individual know that he or she is still enrolled in a marketplace plan but will no longer receive financial help for that coverage.

*If a consumer still wants a Marketplace plan after having been determined eligible for Medicaid or CHIP (that counts as qualifying coverage), they will have to pay full cost for their share of the marketplace plan premium and covered services, without APTC or income-based CSRs, if otherwise eligible.

Similarly, if the marketplace identifies a consumer who may be dually enrolled in minimum essential coverage Medicare and a marketplace plan – it will send a letter in the mail or it will post a notice in the consumer’s marketplace account, stating that the consumer is not eligible to receive financial assistance to help pay for marketplace plan premiums or other covered services. The notice will contain instructions on how to end Marketplace coverage with financial assistance.

Use the How to Take Action When You Have Both Marketplace and Medicare Coverage resource for help, when you receive a Medicare PDM notice.

What is Medicaid Expansion?

What is Modified Adjusted Gross Income (MAGI)?

Determining Eligibility for Insurance Affordability Programs

The Department of Health & Human Services (HHS) issues annual poverty guidelines that are also referred to as the “Federal Poverty Level” (FPL). The Marketplace uses these guidelines when making calculations for advance payments of the premium tax credit (APTC) and income-based CSRs.

Your will need to determine your MAGI either as an individual or as a family.

What is Modified Adjusted Gross Income (MAGI)?

MAGI  is your:

1. adjusted gross income from the federal income tax return, plus
2. any excluded foreign-earned income, plus
3. tax-exempt interest received or accrued during the taxable year, plus
4. non-taxable Social Security benefits

Your MAGI indicates if you qualify for any assistance through the marketplace and also determines your eligibility for Medicaid and CHIP.

KEY-POINT: Eligibility for Medicaid and CHIP is primarily based on current monthly income, while eligibility for APTC and income-based CSRs is based on projected annual household income, projected family size, and other eligibility criteria for the coverage year.

Multi-Tax Households

Currently, the marketplace does not support people from different tax households enrolling in a QHP together on one application, if the applicants are applying for financial assistance. Individuals in different tax households who are applying for a QHP with financial assistance must file separate marketplace applications for each tax household.

KEY-POINT: The Marketplace uses MAGI to determine a consumer’s eligibility for APTC and income-based CSRs and for assessing or determining eligibility for Medicaid and CHIP. It also screens for potential eligibility for Medicaid on other bases.

Hot to calculate Advance Premium Tax Credit – APTC

KEY-TERM:

Benchmark Plan Premium is usually the second lowest cost Silver plan (SLCSP) available to the applicant

Monthly Contribution Amount is 1/12 of applicant’s projected annual household income multiplied by an applicable percentage available in the instructions for Form 8962

The maximum APTC a tax filer is allowed for each month is the lesser of 2 amounts:

1. The monthly premium for the plan in which the tax filer’s tax family enrolled; and
2. The adjusted monthly premium for the tax filer’s applicable benchmark plan premium minus the tax filer’s monthly contribution amount.

If the monthly contribution amount is equal to or more than the benchmark plan premium for the month, the maximum APTC for the month is zero.

Here’s an example of the calculation, as shown by the Wisconsin Office of the Commissioner of Insurance.

KEY-POINT: APTC is a “Use it or Lose It” type of credit.  Use the allowable credit to get the best affordable coverage for your needs, but make sure not to overstate your qualifications. Otherwise you will have to pay the credit back.

APTC Example – SINGLE

Bill is a single recent college graduate, who wants to get an qualified health plan from the marketplace.  It’s his first time purchasing insurance on his own, since moving out of his parent’s house.  Bill asks an insurance agent to help him navigate the plan options. The agent checks the marketplace and finds out that Bill qualifies for a maximum monthly APTC of $400.  Now Bill can decide to either get a plan for less than $400 and (in a way) have free insurance coverage OR Bill can choose a higher premium plan and pay the price difference from his pocket.

Bill ultimately decides on the plan for $340 a month, making sure that it’s covered by his APTC.

NOTE: The $60 difference does not get paid out to Bill. Since Bill didn’t use it, he loses it.

APTC Example:  MARRIED

Jim and his wife Jill would like to get health coverage through the marketplace, but the cost seems too high for them to afford on their modest salary.  Jim has been recently laid off, and Jill is the only one working. Jill’s small-business employer does not offer health insurance, and neither Jim nor Jill qualify for Medicare or Medicaid.  Jim and Jill want to check if they can qualify for Advance Premium Tax Credit.

After Jim and Jill plug in the numbers, the marketplace makes a determination based on: projected household income, family size of two, where they reside, and their SLCSP premium. Let’s says that they receive qualification for a maximum of $800 in APTC each month. So now, they can select a plan closest in price to their APTC. If they choose a plan for $900, it will cost them just $100. The remaining $800 gets covered by their APTC.

How to reconcile Advance Premium Tax Credit against the Allowed Premium Tax Credit?

At the end of the year, everyone who had any APTC paid on their behalf during the year, must file the IRS Form 8962. In this form you must compare two numbers against each other:

• The amount of APTC paid on your and your family’s behalf, and
• The actual premium tax credit amount you are eligible for based on actual household income and other eligibility information for the plan year for which APTC was paid.

Any difference between the two numbers will affect the amount of the tax refund or amount owed.

• If the amount of the allowed premium tax credit is more than the APTC – the difference will increase your refund or reduce the tax liability.
• If your APTC is more than the allowed premium tax credit, excess APTC was paid on your behalf and you will be required to repay all or a portion of the excess APTC when filing the tax return. The excess APTC repayment amount results in a decrease in your refund or an increase in your tax liability.

Each year marketplace mails out an  IRS Form 1095-A to all insured, who get premium tax credits. So, keep an eye out for an envelope arriving in the spring, with a label “Important Tax or Health Coverage Information Inside,”. The form is designed to provide you the most important information, to assist with filling out Form 8962.

So, if you don’t want a headache come tax time, make sure that your Allowable PTC is equal to the Advance PTC that you are getting. To ensure that this happens, you want to:

• Report changes in circumstances to the Health marketplace as they happen. This allows the marketplace to update the information they used previously to determine your eligibility. If the amount needs to be adjusted, its better to do it fast – 0r risk having to repay the benefits at the end of the year.

The common types of changes that should be reported for advance premium tax credit adjustment:

• • increases or decreases in household income,
  • marriage or divorce,
  • birth or adoption of a child and other changes in household composition,
  • gaining or losing eligibility for government-sponsored programs or employer-sponsored health care coverage,
  • change of address.

KEY-POINTS:

– You may choose to apply some or all of the APTC you are determined eligible to receive towards Marketplace QHP premiums.

– You must reconcile the APTC at the end of the year to reflect on your federal tax return

Cost Sharing Reduction – CSR

CSRs are subsidies that reduce the amount of certain out-of-pocket expenses, such as deductibles or coinsurance, that an individual is responsible for as part of his or her Marketplace QHP coverage.

Eligibility for Cost Sharing Reductions (CSRs)

Are you eligible for CSR?

Additional Resources:

CMS.gov:  FPL: Cost-sharing Reduction Calculations and Federal Poverty Line – Guidelines Chart

CMS.gov:  Essential Health Benefits

How does health marketplace verify eligibility?

In order to determine eligibility, the marketplace verifies your information using data from federal agencies and other trusted data sources:

• Social Security Number (SSN) (if applicant has an SSN) is verified through the Social Security Administration (SSA).
• Citizenship or immigration status is verified through SSA and the Department of Homeland Security (DHS).
• Identity is verified through an external identity verification provider.
• Incarceration status is verified through the consumer’s attestation on the eligibility application.

Additionally, for individuals seeking eligibility for insurance affordability programs, the marketplace verifies the following data:

• Income is verified through the Internal Revenue Service (IRS), SSA, and consumer reporting agencies.
• Confirmation that an applicant has Minimum Essential Coverage (MEC) is verified through:
  • State Medicaid agency
  • State Children’s Health Insurance Program (CHIP) agency
  • Center for Medicare and Medicaid Services (CMS)
  • Department of Defense’ TRICARE
  • Veteran’s Health Administration Health Care Program
  • Peace Corps
  • Office of Personnel Management (OPM)
  • and other sources.

 KEY-POINT: Eligibility requirement does not include Health Status. This is because marketplace plans do not care about pre-existing conditions.

What is a temporary eligibility notice?

What is a data matching issue?

If some information gets flagged during the verification as “Inconsistent”, the marketplace puts the account in a sort of a temporary eligibility mode.

The applicant receives a notice, in which he is given 90 days (95 for citizenship and immigration issues) to provide a response to each issue that got identified in the data matching process.

During this time the applicant can apply for coverage and start using their insurance.

If you get such temporary notice during your application, make sure to resolve all the questions before your temporary period ends. Otherwise your coverage might get cancelled.

The most common types of data matching issues are related to:

• annual household income
• citizenship
• immigration status

Tips for Resolving Data Matching Issues and Expediting the Process

• Carefully read the notice. If you don’t understand everything clearly, ask for assistance.
• Submit requested information as soon as possible
• Make digital copies and upload the requested documents through your HealthCare.gov account. ( How to upload documents to HealthCare.gov )
• If you have an insurance professional helping you out, they may be able to use the Enhanced Direct Enrollment Pathway to upload your documents to resolve data matching issues and to view the status of those issues.
• If you decide to mail the requested documents:
  • Never mail original documents
  • Include the page from the original notice that includes a barcode unique to application.
  • If you do not have the page with the barcode, include your state, full legal name, and application ID number on the mailed documents.
  • Don’t forget, you are on the clock. Don’t miss your deadline.

At the end of the 90-95 day period you get an Eligibility Determination Notice. If you disagree with the decision, you may appeal it according to what is stated in your Eligibility Determination Notice.

How to File an Appeal of an Eligibility Determination

You can file an appeal of a marketplace eligibility determination online, by mail, and by fax.

• Online: Visit HealthCare.gov/marketplace-appeals/appeal-forms and select the applicable state.

Submit the appeal request online or download and print the request form and submit it separately.

• Mail or fax: Make sure to send a completed letter requesting an appeal. Include your name, address, and the reason for the appeal. Fax the form to (877) 369-0130 or mail the paper form to the marketplace for review at: Health Insurance Marketplace, ATTN: Appeals, 465 Industrial Blvd, London, KY 40750-0061. If you send documents, send copies only. Keep the originals.

• Consumers may retroactively apply an eligibility appeal decision to obtain a full or partial refund of Marketplace plan premiums paid if the appeal results in a new eligibility determination that reinstates the consumer’s eligibility for a larger premium tax credit.
• Consumers may request eligibility pending appeal that will continue the level of eligibility the consumer had immediately before the determination.
• Some appeal types require consumers to maintain an active enrollment in order to implement their favorable appeal decision, and eligibility pending appeal may help these consumers maintain their enrollment.

For more in-depth information on Marketplace Appeals:

• The Marketplace Appeals page at HealthCare.gov
• Appealing Eligibility Decisions in the Health Insurance Marketplace 
• Appoint an authorized representative for your appeal

How to Qualify for Hardship Exemptions

What is a Catastrophic health coverage?

In certain cases that affect an individual’s ability to purchase health insurance coverage, an individual may qualify for a hardship exemption, which also enables them to buy catastrophic coverage.

Catastrophic plans usually have high deductibles, and mostly protect individuals with very high medical costs. To make the determination, the marketplace considers whether an individual has experienced a qualifying event, that will enable them to get this coverage:

• If the individual:
  • becomes homeless
  • has been evicted, or is facing eviction or foreclosure
  • has received a shut-off notice from a gas, water, or electric company
  • recently experienced domestic violence
  • recently experienced the death of a close family member
  • experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member.
  • recently experienced a fire, flood, or other natural or human-caused disaster resulting in substantial damage to individual property.
  • filed for bankruptcy.
  • incurred medical expenses that resulted in substantial debt.
  • expects to claim a child as a tax dependent who has been denied coverage in Medicaid and CHIP, and another person is required by court order to give medical support to the child.
  • was determined ineligible for Medicaid because his or her state did not expand eligibility for Medicaid under the Patient Protection and Affordable Care Act.
  • experiences some other hardship in obtaining health insurance.
• As a result of an eligibility appeals decision, the individual is determined eligible for enrollment in a QHP through the Marketplace, APTC, and/or CSRs for a period of time during which he or she was not enrolled in a QHP through the Marketplace.

MUST-KNOW INFORMATION FOR MARKETPLACE PLANS

• Insurance issuers cannot refuse to sell a policy to consumers or charge them more just because they have a pre-existing condition.
• Insurance issuers cannot charge higher premiums based on gender.
• The marketplace offers same-sex spouses the same coverage and eligibility that are available to opposite-sex spouses.
• Insurance seekers may reject health coverage, even after an agent or an assistant explains how health coverage can benefit them.
• Household members may be covered by different health plans; certain household members may qualify for coverage through Medicaid or CHIP, while others may obtain health insurance through the Marketplace.
• Consumers need to make sure that they understand all of the information BEFORE agreeing to the plan. If any acronyms or technical language are not clear – ask an agent or an assistant to explain.
• Individuals receiving employer-sponsored coverage may purchase a QHP through the Marketplace as long as they meet the eligibility criteria. The person:
  • is a resident of the state in which he/she applies for and enrolls in a QHP;
  • is a United States citizen or national or lawfully present non-citizen; and is not incarcerated, other than incarceration pending the disposition of charges).

However, individuals who are enrolled in employer-sponsored coverage, or are eligible for employer-sponsored coverage that is affordable and meets the minimum value standard, are NOT eligible for APTC and income-based CSRs.

If an individual has access to affordable and minimum value employer-sponsored coverage, he or she likely does not need to obtain health insurance coverage through a QHP.

• The Marketplace sends periodic data matching notices to consumers who are enrolled in a Marketplace QHP with APTC or income-based CSRs and who are also enrolled in Medicare, Medicaid, or CHIP that qualifies as minimum essential coverage. Notices inform and instruct those dually enrolled how to end their Marketplace coverage with APTC/CSRs, or update their Marketplace applications to reflect that they are not enrolled in Medicare, Medicaid, or CHIP.
• If you complete an application and find out that you are eligible for government-sponsored programs (Medicaid/CHIP, Medicare, or Tricare), the assisting individual or agent can also help you with that type of enrollment.
  • If Medicaid eligibility is discovered, the applicant’s information is automatically forwarded to their state’s Medicaid enrollment office ( https://www.medicaid.gov ) .
  • Individuals who are determined to be eligible for minimum essential coverage Medicaid can enroll in Marketplace coverage, if otherwise eligible; however, they will have to pay the full cost for their share of the Marketplace plan premium and covered services, as they are ineligible for APTC, and for income-based CSRs.
  • Marketplace application system will not prevent the individual from enrolling if the consumer indicates he or she is eligible for or enrolled in Medicare. If the marketplace applicant already has Medicare coverage,  it is the assistant’s (agent’s) responsibility to make sure that there is no duplication of coverage.

*It is illegal to sell or issue a Qualified Health Plan to a Medicare beneficiary with the knowledge that the QHP duplicates the beneficiary’s Medicare benefits.

For additional information on Medicare costs, please refer to  https://www.medicare.gov, and the Medicare and You resource.

If you have questions about the Marketplace, please contact your trusted health insurance agent or call the ACA Marketplace Center for help at (800) 318-2596