Prepared by the American Association of Colleges of

NursingUpdated September 22, 2014

Assisting Your Patients:Navigating The

Health Insurance Marketplace

While AACN did not take an official position on the Patient Protection and Affordable Care Act [Public Law No: 111-148], the organization supported a number of provisions that improved nursing education, research, and practice. AACN’s leadership recognizes the responsibility to educate our constituents about the law and what the Marketplace means for clinical practice, faculty, students, and patients. To review these provisions, www.aacn.nche.edu/government-affairs/HCRsupport.pdf.

What is the Health Insurance Marketplace? 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. It includes the Individual Mandate and the State

Exchange.

Individual Mandate requires most individuals to obtain health insurance or pay a penalty in the form of a tax. ○ On June 28, 2012, the United States Supreme

Court upheld this provision of the ACA as constitutional in a 5-4 decision.

State Exchanges allows for each state to decide if they will create their own exchange, partner with the federal government, or have a federally-facilitated exchange for individuals to gain coverage.Kaiser Family Foundation (2014). State Decisions For Creating Health Insurance

Marketplaces, 2014Retrieved from http://kff.org/health-reform/state-indicator/health-insurance-exchanges/

Fielding Your Patient’s Basic Questions

About The Marketplace

Am I eligible?

For an individual to be eligible for coverage through the Marketplace, they must meet the following criteria:

1. Live in the United States

2. Be a U.S. citizen, national, or live lawfully in the United States

3. Cannot be incarcerated

Healthcare.gov. (2014) Am I eligible for coverage in the Marketplace, Retrieved from https://www.healthcare.gov/am-i-eligible-for-coverage-in-the-marketplace/

What Are The Essential Health Benefits? Essential Health Benefits: A set of

health care service categories that must be covered by certain plans, starting in 2014.

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)

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.

Preventive services including counseling, screenings, vaccines, and care for managing a chronic disease.

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

These essential health benefits include at least the following items and services:

Outpatient care

Emergency room visits

Inpatient hospital treatment

Prenatal and postnatal care

Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy

Prescription drugs

Lab tests

Healthcare.gov. (2014) Glossary: Essential Health Benefits, Retrieved from https://www.healthcare.gov/glossary/essential-health-benefits/

What Will I Need to Enroll?

Social Security Numbers (or document numbers for legal immigrants)

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 job-based plan for which you or someone in your household is eligible

A Check List was created to help individuals with the enrollment process

Healthcare.gov. (2014) Marketplace Application Checklist, Retrieved from https://www.healthcare.gov/downloads/MarketplaceApp_Checklist_Generic.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/

Complete your application. Provide information about you and your family, like income, household members, current health coverage, and more. Use this checklist to gather the documents you’ll need.

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.

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 (2014). Get Covered: A one-page guide to the Health Insurance Marketplace, Retrieved from https://www.healthcare.gov/get-covered-a-1-page-guide-to-the-health-insurance-marketplace/.

How Can I Enroll: Other Options

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.

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

Local resources You may be able to apply online at a

local library or at a Community Health Center in your area.

Key Dates for 2015 Open Enrollment

November 15, 2014:

Open enrollment period for 2015

plans begins

December 15, 2014:

Deadline to enroll in plans

that start January 1, 2015.

December 31, 2014:

Coverage ends for 2014 plans

February 15, 2015Open Enrollment Ends

If your patient has not enrolled in coverage by then, they generally cannot enroll in 2015 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 2015, he or she may have to pay a penalty.

 Healthcare.gov. (2014). Key dates for the Health Insurance Marketplace. Retrieved from, https://www.healthcare.gov/blog/key-dates-for-the-health-insurance-marketplace.

During open enrollment, if your patient enrollsBetween 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.

How Do I Find Out What My State Is Offering? Regardless of the state where you live, you can access the

Marketplace to apply for coverage, compare your options, and enroll.

What Is Meant By The Tax Credit? 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.

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.

Progress Made During 2014 Open Enrollment

2014 Enrollment Summary

Over 8 million people selected a plan in the Health Insurance Marketplace before April 19, 2014. This includes some people with circumstances warranting a special enrollment period after open enrollment closed March 31, 2014. Nearly one third of these (2.2 million) were

young adults between 18 and 34 years old.

6.7 million people have had a Medicaid/CHIP Determination or Assessment through the Marketplaces, not including those applying through their state agencies.

 HHS Office of The Assistant Secretary for Planning and Evaluation. (2014). Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period. Retrieved from, http://www.aspe.hhs.gov/health/reports/2012/ACA-Research/index.cfm.

Directing Patients To Additional Resources on the Marketplace

Where Can I Direct My Patients Who Have Questions I Cannot Answer?

Online• Representatives are available to assist individuals via online chat: https://www.healthcare.gov/.

By Phone• Individuals and Families

• A hotline is available 24 hours per day, seven days per week to assist individuals who have questions about enrollment.

• 1-800-318-2596• TTY: 1-855-889-4325

In Person• Find people and organizations in your community who can help you apply, enroll, and answer your questions.

• Visit https://www.healthcare.gov/contact-us/ and enter your zip code to be connected.