Marketplace

Marketplace

Mon, 07/19/2021 - 16:43
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The Health Insurance Marketplace, also known as the Exchange, is an online site where you can shop for health insurance. It is here that tax credits can be used to purchase insurance.

Health Insurance Marketplace

Health insurance Marketplace by state

The Marketplace and state run exchanges provide information and assistance with enrollment through their websites and also by using call centers and in some areas of the country in-person help.

♦ Congressional Republicans oppose the Affordable Care Act and continue to try to turn the Marketplace lights off.

The main website is HealthCare.gov. It is usually referred to as the Marketplace since it handles the majority of the United States.

The Marketplace and the state run exchanges function the same way. To avoid confusion, we will refer to them both as the Marketplace.

Undocumented immigrants are not eligible to buy Marketplace health coverage, or receive premium tax credits and other savings on Marketplace plans. But they may apply for coverage on behalf of documented individuals.

Learn more at Immigrants & Coverage

HealthCare.gov serves as the Marketplace for the majority of the United States. 15 states including the District of Columbia maintain their own online exchanges.

→ Kentucky plans to have its own state-based exchange from the fall of 2021.

→ New Mexico plans to have their own exchange platform in the fall of 2021.

♦ Small business insurance is a little different. Some states have opted to handle that but have HealthCare.gov take care of individual policies.

It is through the Marketplace that you find out if you are eligible for a premium tax credit (subsidy) to help pay for insurance. This is the most important point for everyone who does not have access to health coverage through employment and must purchase insurance on their own.

People with low incomes can also find out if they are eligible for coverage through Medicaid and CHIP. Small businesses can purchase coverage for their employees through the Small Business Health Options Program (SHOP) Marketplace.

Most people can shop for coverage at the Marketplace.

To be eligible you must live in the state where your Marketplace (exchange) is, you must be a citizen of the U.S. or be lawfully present in the U.S., and you must not currently be incarcerated.

Marketplace Contact Information

State Name & Website Telephone TTY Number
All states not listed HealthCare.gov 1-800-318-2596 1-855-889-4325
California Covered California 1-800-300-1506 not available
Colorado Connect for Health Colorado 1-855-752-6749 1-855-346-3432
Connecticut Access Health CT 1-855-805-4325 1-855-789-2428
District of Columbia DC Health Link 1-855-532-5465 711
Hawaii Hawaii Health Connector 2017 switched to Healthcare.gov
Idaho Your Health Idaho 1-855-944-3246 not available
Kentucky Kynect 2021 switching back to Kynect
Maryland Maryland Health Connection 1-855-642-8572 711
Massachusetts Massachusetts Health Connector 1-877-623-6765 1-877-623-7773
Minnesota MNSure 1-855-366-7873 not available
Nevada Nevada Health Link 1-800-547-2927 711
New Jersey Get Covered NJ 1-800-677-1010 711
New Mexico Be Well NM 1-833-862-3935 711
New York NY State of Health 1-855-355-5777 1-800-662-1220
Oregon Oregon Healthcare 2021 switched to HealthCare.gov
Pennsylvania Pennie 1-844-844-8040 711
Rhode Island Health Source RI 1-855-840-4774 1-888-657-3173
Vermont Vermont Health Connect 1-855-899-9600 1-888-834-7898
Washington Washington Health Benefit Exchange 1-855-923-4633 1-855-627-9604

Tax Credit - Not everybody who is eligible to purchase coverage at the Marketplace will be eligible for a premium tax credit (subsidy). To qualify for a tax credit you will have to meet requirements having to do with you household income and other areas such as not having access to affordable coverage through employment.

♦ If you are not a U.S. citizen, a U.S. national, or an alien lawfully present in the U.S., you are not eligible to buy a plan on the health insurance Marketplace.

However, you can shop for health insurance outside of the Marketplace.

Insurance companies cannot turn you down based on your health status or your immigration status.

♦ If your employer provides health insurance, you can still shop for coverage at your marketplace. But you might not qualify for premium tax credits unless your employer’s health insurance is not affordable or does not meet the Affordable Care Act’s minimum value requirements.

When to enroll?

You can only enroll in a health insurance during a period referred to as Open Enrollment. This term is the same term used to refer to Medicare’s enrollment period. Do not confuse the two because the enrollment dates are considerably different.

For 2022 coverage

♦ Open Enrollment begins November 1, 2021 and runs through December 15, 2021.

CMS has proposed extending open enrollment by 30 days.  Some states have later deadlines.

Once you sign up for a plan, you are locked into that plan until the next open enrollment period.

You can still enroll outside of these dates if you have a special situation.

• Note: states that are running their own exchanges have the option to extend the enrollment period.

For 2022 coverage year, the states listed below all extended open enrollment.

At this time, only 3 states have confirmed plans for 2022 enrollment.

States with extended enrollment

(Coverage year 2022)
• California — Nov. 1 to Jan. 31
• Colorado — Nov. 1 to Jan. 15
• Massachusetts — undecided
• Minnesota — undecided
• Nevada — undecided
• New Jersey — undecided
• New York — undecided
• Pennsylvania — undecided
• Rhode Island — undecided
• Washington, D.C. — Nov. 1 to Jan. 31

If you fail to sign up for a plan, once the Open Enrollment period is over, you will not be able to enroll in a Marketplace health plan until the next Open Enrollment period.

There is an allowance for people with special situations which may permit you to enroll outside of the Open Enrollment period. There is a separate page devoted to this topic because there are many special situations. Please take a look at Special Enrollment Period.

If you want to enroll in a plan off-exchange, you will have the same restrictions. You can only enroll in coverage during Open Enrollment periods and special enrollment situations.

Exception: American Indians and Alaska Natives can enroll in coverage throughout the year, not just during Open Enrollment.

Note: You can enroll in Medicaid or CHIP at any time during the year. You do not have to wait for the Open Enrollment Period.

What can I buy?

All health insurance plans offered through the Marketplace must meet requirements set forth in the Affordable Care Act. They must all be what is referred to as “qualified health plans.”

This means they will cover essential health benefits, have certain limits on the amount of cost sharing you are responsible for (deductibles, co-pays and coinsurance), and they must provide consumer protections required under the law.

Health insurance plans will vary somewhat in the benefits provided. The plans will also vary based on the level of cost sharing required. The Marketplace has assigned labels to four levels of coverage based upon how much they are expected pay for coverage healthcare expenses.

The levels are referred to as metal levels.

• Bronze: pays 60%

• Silver: pays 70%

• Gold: pays 80%

• Platinum: pays 90%

Bronze plans will have the highest deductibles and other cost sharing, while Platinum plans will have the lowest. Bronze plans will have the lowest premium cost and Platinum plans will have the highest premium cost.

It is important to understand that if you qualify for cost-sharing reductions you must select a Silver plan to obtain the greatest savings. With cost-sharing reductions it is possible to get a plan with benefits similar to a Gold or even a Platinum plan at the cost of a Silver plan.

Cost-sharing reductions is a confusing subject but one everyone should try to learn a little about.

Networks

Insurance companies rely upon networks of hospitals and doctors. Not all hospitals and not all doctors will welcome every insurance company or plan.

♦ Most plans at the Marketplace will be HMO plans. They will be more restrictive than PPO plans so you must be sure to confirm if your preferred doctors and closest hospital accept the plan.

♦ Using an out-of-network provider can be very expensive. If you would like to become familiar with differences between an HMO and a PPO plan please review Types of Health Insurance.

♦ All Marketplace plans are required to cover ten categories of essential health benefits. However, insurers in many states have the flexibility to modify coverage some. In addition, some states may require extra benefits.

♦ All plans must provide a Summary of Benefits and Coverage (SBC). This is a brief description of what a plan covers and how it works.

The SBC will make it easier for you to compare differences in each plans’ benefits, especially what they expect you to pay for cost sharing (deductible, copay, and coinsurance). Insurance companies are always working to find more ways to shift healthcare costs to the patient so read the SBC carefully.

Emergency Room

♦ The recent trend has been to move emergency room expenses to the patient by changing from a set copay amount for an ER visit to requiring that the deductible first be met.

A late night trip to the ER for your baby’s high fever can easily end up costing thousands of dollars if your plan has a high deductible. Read the SBC carefully.

The SBC will not tell you which doctors or hospitals accept the plan. You will need to contact the insurance company directly or go through their website. Unfortunately, insurers do not always have accurate lists of who is going to be accepting their plans the next year.

♦ The Affordable Care Act has a provision to penalize insurers for giving out incorrect info. So far, this provision has not been enforced.

It would be best to double check what you learn from the insurance company by calling the doctor or hospital you are interested in using. Be sure to tell them the exact name of the plan because many providers will accept a well know company like BlueCross BlueShield but not take all the plans they offer.

This is especially true for HMO plans.

Dental Coverage

Health insurance has traditionally only provided emergency dental benefits. It is possible to find a few companies selling separate dental insurance. The premiums will be high and the benefits a bit skimpy.

• Note: There is no penalty for NOT having pediatric dental. The penalty often referred to is for not having health insurance, not dental insurance.

Marketplace dental — Each Marketplace can decide whether to require all insurers to cover pediatric dental benefits or whether to allow the sale of stand-alone dental policies. Often times if stand-alone dental policies are allowed, health insurers in the Marketplace might not be required to cover pediatric dental benefits.

If your health plan covers dental benefits, you will pay one premium for everything. If you get dental benefits through a stand-alone plan, you will have to pay a separate premium for the dental benefits.

♦ Many plans which included pediatric dental care are not very useful. Read the SBC carefully. Most plans at HealthCare.gov specify that the deductible must first be met before they pay anything for pediatric care.

If you have a large deductible this makes it quite costly to depend upon these plans for pediatric care. You may want to consider a separate dental plan.

Review all dental plan SBC carefully. Just like health insurance, dental plans can have restrictions that limit you to only certain dentists or are skimpy as to what they cover and pay. You may want to consider an off-exchange dental plan.

♦ Any subsidy you receive is for health insurance so it does not affect your subsidy if you enroll in a better dental plan off-exchange.

Information needed to apply

Information about your household size. Who in your household will be applying for coverage? Household = Tax filer + spouse + tax dependents

Include your spouse and tax dependents even if they don’t need health coverage.

Documentation — You may need to prove you are legally eligible to apply for coverage. If you recently became a citizen, a Certificate of Citizenship would suffice. If you have legal immigrant status a Green Card would be the most familiar proof.

However, depending upon your situation you may be able to use other immigrant documents.

You can access the list of acceptable documents along with descriptions by visiting HealthCare.gov page: Immigration Document Types

Income — You will need to estimate what your household income is likely to be for the year. This an estimate, not what your income was the year before. What you enter here will be used to determine if you qualify for a premium tax credit. Later, this number will be compared to your income filing for the year.

If you over estimate and you qualify for a premium tax credit you may be entitled to additional tax credit once you file your taxes. If you underestimate you might have to return some tax credits.

Read more ... Income - What counts?

Household income — This part of the application process has people worried the most. The online application form will walk you through most of this.

Be aware, when you calculate your household income it is usually the tax filer, their spouse and any dependents (even if the dependents don’t need coverage you still have to count their income).

You count everyone you claim on your taxes as a dependent. Read more about Households

Child's income — you count your child's income if it is enough earnings to require him or her to file taxes.

♦ A child who has only earned income must file a return only if the total is greater than the standard deduction.

For 2021 income, the threshold is $12,550 for earned income.

• Unearned income must be greater than $1,100. Unearned income comes from interest, dividends, capital gains, etc.

Other coverage — If anyone in your household has coverage through an employer, a plan they bought themselves, a public program like Medicaid, CHIP, or Medicare, or another source, you still need to include them and their income on your application.

MAGI — The Marketplace uses an income number called Modified Adjusted Gross Income (MAGI) to determine eligibility for a premium tax credit and other savings.

• For most people, this number will be close to their Adjusted Gross Income (AGI) which is on line 11 of Form 1040 or 1040-SR — 2020 and 2021 tax years.

The MAGI takes the AGI and adds back some deductions. Many of these deductions are rare, so it's possible your AGI and MAGI can be identical.

Examples of deductions added back to AGI to come up with MAGI:

  • Student loan interest
  • One-half of self-employment tax
  • Qualified tuition expenses
  • Tuition and fees deduction
  • Passive loss or passive income
  • IRA contributions, taxable social security payments
  • The exclusion for income from U.S. savings bonds
  • The exclusion under 137 for adoption expenses
  • Rental losses
  • Any overall loss from a publicly traded partnership

The majority of people applying at the Marketplace make their best effort to estimate their income based off their prior tax year. The Marketplace will also be comparing what you estimate with what your reported the last year.

You usually won't be questioned, unless there is a large discrepancy from a prior year (usually $6,000 or more). The Marketplace may ask for some documents to help support your estimate. Don’t get overly worried, this is quite rare.

Can I get a subsidy?

Your MAGI must be between 100 – 400 % of the Federal Poverty Level to qualify for a premium tax credit (subsidy). Below 100% and you are expected to seek assistance through Medicaid.

♦ If the state you live in did not expand Medicaid you are not likely to be able to receive much assistant through Medicaid.

Above 400% you can purchase coverage at the Marketplace but you will not qualify for a premium tax credit because you have too much income.

The page Tax Credits has a section devoted to Income Levels — Income needed to qualify for a subsidy for coverage is based upon FPL.

• For coverage in 2022, income will be compared to 2021 FPL.

Here you will will also find a subsidy calculator and be able to get a good estimate of what you may be able to receive.

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