states with their own health insurance marketplace

Q: Why would a business owner buy long term care insurance,
when the business could buy it for them?

Yours, with our thanks for answering 2 quick LTC questions.

imagine a health insurance marketplace where everything is half-price

Our HMA in the Health Insurance Marketplace

Ironically, but not surprisingly from a business perspective, the Affordable Care Act brought higher insurance premiums, deductibles, co-pays.  I suggest re-watching the video above and, if you haven't already, signing up for a free webinar where we will introduce you to a unique solution those rising costs.

Features and Functions of all Exchanges

To meet the goal of providing greater access to affordable coverage, exchanges are designed to:

·offer a choice of qualified health insurance plans, for both individuals and small businesses

·provide a single point of access for consumers to review, compare, and evaluate health insurance plans, and (if eligible) to secure financial assistance through premium subsidies and cost-sharing assistance

·facilitate the purchase of health care coverage

·establish rules and requirements for plan coverages and rates

A Health Insurance Marketplace is to be a "one-stop shop" for health insurance consumers. Accordingly, they can also guide consumers to Medicaid and the Children's Health Insurance Program (CHIP), if an individual or family qualifies for these programs.

Exchanges are known by various names: a health care exchange, affordable insurance exchange, health benefit exchange, and health insurance marketplace, to name a few.

The federal government and its agencies refer to these programs as "marketplaces," noting that a "health insurance marketplace" better describes what an exchange does and is more easily understood by consumers.

Those that serve individuals are formally known as a Health Benefit Exchange, Health Insurance Marketplace, or simply, individual exchanges.

Coverage offered through a health insurance marketplace plan is comprehensive and must meet all of the health insurance marketplace reforms that have been implemented by the ACA. These reforms include the following:

• ·guarantee issue of coverage
• ·elimination of preexisting condition exclusions
• ·prohibition on lifetime and annual limits for essential health benefits
• ·required coverage without cost-sharing for certain preventive services
• ·standardized plan benefit summaries to be used by all insurers
• ·the ability for children up to age 26 to remain on a parent's policy
• ·prohibition on rescission of coverage, except in cases of fraud

The Affordable Care Act created and requires all states to establish a health insurance marketplace that brings together health insurance providers, health insurance plans, and health insurance consumers, providing a single venue through which consumers can review, compare, and purchase plans that have been certified as meeting federal and state standards.

Whether state-based, federally facilitated, and partnership. exchanges are required to carry out a number of different functions. At their core—and regardless of whether the exchange model is state, federally facilitated, or partnership—every exchange is to:

·review and certify health plans as qualified health plans (QHPs)

·determine individual eligibility for enrollment in QHPs, as well as for premium tax credits and cost-sharing subsidies

·determine a small business's eligibility for access to a SHOP plan

·facilitate enrollment in the exchange's QHPs

·operate both individual and small business exchange programs

·provide consumer support for coverage decisions

·offer eligibility assessments and/or determinations for state Medicaid and CHIP assistance

Primary among health insurance marketplace functions is to review and certify health plans that are to be available through the exchange. In recognition of the diverse populations and market needs across the country, an exchange has a great deal of flexibility in defining and applying the plan certification standards it will use, as long as these standards:

·meet the final market reform requirements as outlined under the ACA and the final rules applicable to exchanges

·ensure that offering the plan is in the consumer's interest, as measured by factors such as plan service areas and marketing standards

Dominant Model: Managed Care Plans

The minimum QHP certification criteria outlined by federal law involve requirements for plan benefit packages, plan rates and rate patterns, adequacy of provider networks, and quality accreditation. Reflecting these requirements, most plans offered on an exchange are managed care plans that have networks of contracting hospitals, physicians, and other health care providers. As a general rule, managed care plans provide coverage for a period of one year, after which insureds may have to re-enroll if they want to continue coverage under the plan.

Insurer Certification

Insurers that offer exchange plans must also be certified. The certification standards for QHP insurers include the following:

·licensure and solvency—A QHP insurer must be licensed in all states in which it will provide QHPs and must meet state solvency requirements.

·benefit designs—A QHP insurer cannot use benefit designs that discourage enrollment by those with significant health needs.

·rate and benefit reporting—A QHP insurer must provide information on plan rates and benefits, and must submit justification for any rate increase.

·network adequacy—A QHP insurer must maintain provider networks that are sufficient in type and number to ensure that all services will be accessible without unreasonable delay.

Such "sufficiency" must be reflected in the insurer's QHPs.

·essential community providers—A QHP insurer must have in its provider networks essential community providers that serve low income and medically underserved areas.

·service area—A QHP insurer cannot create service areas that are discriminatory; such areas must be established without regard to demographic or health factors.

·accredited procedures—A QHP insurer entering a new year of exchange participation must attest that its QHP administrative policies and procedures have been reviewed and approved by a recognized accrediting entity.

The federal government has stressed that states will retain their regulatory authority over insurance companies and insurance plans; therefore, insurers that offer plans through an exchange must continue to meet state requirements as well as QHP certification standards.

QHP Recertification and Decertification

In addition to certifying QHPs, a health insurance marketplace must also establish procedures for recertifying and decertifying their plans. Currently, the law requires an exchange to conduct an annual review of all plans and complete its recertification process in the fall of each year. Similarly, an exchange must develop and maintain a process for decertifying any plan at any time if it fails to meet certification requirements. A decertification process must include:

·provisions for an appeal of the decertification

·notice of decertification to all parties (the QHP issuer, plan enrollees, HHS, and the state's insurance department)

Enrollees of a decertified health insurance marketplace plan must be given a chance to enroll in other coverage.

Eligibility for Enrollment in a QHP (Qualified health Plan)

The ACA intends that health care be available to virtually all U.S. citizens; therefore, eligibility for a QHP through an exchange is based only on the following criteria:

1.The applicant is a citizen, a national, or a noncitizen who is lawfully in the United States.

2.The applicant is not incarcerated.

3.The applicant is a resident of the state in which the exchange operates.

This information is provided by the applicant on the eligibility determination form. Upon its submission, the exchange will check and review the information, using the federal Data Services Hub. Designed by HHS and CMS, the hub provides connection to common federal data sources, including the Social Security Administration, the 1RS, and the Department of Homeland Security. In turn, these sources can check and verify information necessary to determine eligibility for exchange enrollment in a qualified health plan: employment, income and tax information, family size, demographic data, etc. The hub will not store information but will securely transmit data between state and federal systems to verify consumer application information.⁴

Eligibility for Premium Tax Credits and Cost- Sharing Subsidies

As specified by the ACA, financial assistance with paying for health insurance is available to qualified individuals who purchase QHPs through an individual exchange. This assistance comes in the form of premium tax credits and cost-sharing subsidies (lower deductibles and co-payments). Consequently, a health insurance marketplace must determine an applicant's eligibility for such financial assistance.

Using the information an applicant supplies on the eligibility determination form, the exchange will identify individuals who meet the financial assistance criteria, which is based primarily on income. Generally speaking, premium tax credits and cost-sharing reductions are reserved for low- to moderate-income wage earners.

Verification and Redetermination

If the information submitted by the consumer on the eligibility determination form is verified without inconsistencies and the exchange determines the consumer meets the requirements, the consumer will receive notice that he or she is eligible for enrollment in a QHP through the exchange. At the same time, the individual will also be notified whether he or she qualifies for premium tax credits and cost-sharing reductions. At that point, the applicant will be able to review the available QHPs and select a plan. This initiates the plan enrollment process.

Once an individual has been determined eligible for a health insurance marketplace plan (and he or she does, in fact, enroll in an exchange plan), his or her status is subject to redetermination every year. Any change that might affect an exchange participant's eligibility-such as a move to another state-must be reported to the exchange within 30 days of the change. At certain points during the year, a participant may be contacted by the exchange and asked to verify his or her information (or to authorize the exchange to receive updated information from various federal agencies, such as the 1RS).

Eligibility for Medicaid/CHIP

Because exchanges are intended to operate as a "one-stop shop" under a "no wrong door" policy, they can also help individuals who might be eligible for Medicaid and/or CHIP. However, due to the variations and intricacies of these programs from state to state, each state has been given the right to decide separately whether its health insurance marketplace will determine and approve individual eligibility for Medicaid or CHIP or simply assess eligibility. In either case, the process starts with the single eligibility determination form. If the review of the form indicates the individual may be eligible for Medicaid and/or CHIP, the exchange will either:

·forward the information to the state Medicaid or CHIP agency to make a final eligibility determination or

·make the final eligibility determination, notify and help the individual enroll in Medicaid or CHIP

QHP Plan Information

Once a consumer elects to enroll in a QHP, he or she must be given information about the plan. This information takes the form of a written summary of benefits and coverage, which includes:

·definitions of medical and health coverage terms

·a description of the participant's coverage, including costsharing requirements (such as deductibles, coinsurance, and co-payments)

information about any coverage limits or exceptions

·network provider and contact information

Consumer Assistance and Support

Each health insurance marketplace must provide consumer assistance and support to help individuals review and enroll in a qualified plan and inform them of any financial assistance for which they might qualify. The following are among the most important exchange responsibilities with regard to consumer assistance and support:⁵

·Maintain a website that provides standardized comparative information on each QHP available through the exchange and allows qualified individuals to select a QHP in which to enroll.

·Provide a toll-free telephone hotline to help individuals who request assistance.

·Establish a navigator program, staffed by eligible entities and individuals, to help consumers understand the exchange, compare and select QHPs, interact with QHP carriers, and enroll in a QHP.

·Conduct education and outreach programs to inform consumers about the exchange and encourage participation.

·Consult regularly with stakeholders—enrollees, community service organizations, small businesses, public health experts, and QHP issuers—as to the exchange's accessibility and administration.

·Inform consumers about available support services, including those offered by navigators and, if applicable, licensed insurance agents and brokers.

Enrollment in a QHP (Qualified Health Plan)

Upon receiving notice from the exchange that he or she is eligible for enrollment and, if applicable, financial assistance, the applicant can review and compare the QHPs offered through the exchange and select one for enrollment. Depending on the exchange, assistance with plan review and selection may be available through navigators, certified application counselors, and licensed insurance agents and brokers. Once the exchange receives notice of a QHP selection from an eligible individual, it will inform the QHP carrier and forward the necessary eligibility and enrollment information.

The QHP insurer will then provide the consumer with the appropriate plan enrollment forms and information.

Alternatively, a consumer can work directly with a QHP insurer: through the insurer (or one of its producers), the consumer's eligibility determination information is forwarded to the exchange for verification; if eligible for a QHP, the consumer can then shop among the insurer's QHP plans and select one for enrollment. The insurer directly enrolls the consumer but shares the enrollment information with the exchange.

Through either enrollment path-with the exchange or directly with the insurer—QHP-eligible applicants are assured they will be accepted into the plan they select; the insurer cannot deny their applications or refuse to provide coverage.

In 2010, the Affordable Care Act, or ACA, was passed into law. Its primary goal - to ensure all Americans can access, obtain, and maintain affordable health insurance coverage. To meet this goal, ACA effected many changes.  Among the most notable are these:

• It put in place private insurance consumer protection measures to guarantee most individuals have access to quality health insurance, regardless of their health status.
• It created public health insurance exchanges, or marketplaces, as a way consumers can access and purchase health coverage they may not otherwise have been able to obtain, or afford.

Consumer protection measures steadily came into effect over a number of years. Currently, all of the following are in place and apply to all non-grandfathered health insurance plans:

• prohibition on the rescission of coverage due to illness
• prohibition on the denial of claims or the rescission of coverage due to technical mistakes on an insurance application 
• elimination of annual and lifetime limits on essential health benefits coverage
• elimination of preexisting condition exclusions and prohibition on denial of coverage due to preexisting conditions
• the requirement to allow young adults to remain on their parents’ plan until the age of 26
• prohibition on the denial of coverage to children under the age of 19
• the requirement to cover certain preventive care services without cost to the insured
• the right to appeal coverage decisions and claims that are denied by the insurer

 Few would dispute that the . . .

health Insurance Marketplace is the cornerstone of ACA.

"Affordable coverage" is defined by numerous rules and requirements in the ACA, and insurance offered through exchanges is underwritten and issued according to these rules. These exchanges are public-- offered by the government. Your state will be one of three health insurance marketplace models:

My state has its own exchange

My state uses the Federal exchange

My state partners with the Federal government

Disclaimer Regarding Medicare Advantage Plans 

We are multi-state licensed, and headquartered in Minnesota.  Here, in MN, we represent 7 organizations which offer 45 Medicare Advantage products. You can always contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

Disclaimer Regarding Medicare Supplements 

We are multi-state licensed, and headquartered in Minnesota. we do not offer every Medicare supplement available in Every area. Currently we represent 10 out of 13 organizations which offer Medicare supplements in MN.  Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

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