Information and opinions presented here do not always represent the views of the American Heart Association.

Understanding the Affordable Care Act’s health insurance marketplaces

Published: 4:16 pm CDT, September 16, 2013

The Patient Protection and Affordable Care Act (ACA), which became law in 2010,  aims to make health care coverage more available, affordable, and adequate for patients with heart disease and stroke.

The law has been rolled out gradually and some provisions have already taken effect. A new phase of the law begins Oct. 1. That’s when health insurance exchanges, also called Marketplaces, will be available in all 50 states and the District of Columbia.

The American Heart Association supports the law and is working to ensure that Americans are aware of these new state-based Marketplaces, which  are easy-to-use, consumer friendly one-stop places to shop for adequate health insurance coverage with financial assistance to make premiums affordable.

With Oct. 1 just a few weeks away, here are answers to some of the most common questions about the Affordable Care Act’s Health Insurance Marketplaces:

How will the new Health Insurance Marketplaces work and who can sign up?

Through a Marketplace, you can choose the private health plan that best meets your family’s needs and budget. You’ll be able to see all of your choices in one place, know upfront what your premium, deductibles, and out-of-pocket costs will be, and make apples-to-apples comparisons of the different health insurance plans before you decide to enroll. Depending on where you live, your Marketplace could be run by your state or by the U.S. Department of Health and Human Services.

Individuals who need health insurance for themselves or their family can buy coverage through the Marketplaces, as long as they are U.S. citizens or lawfully residing in this country and are not incarcerated.  Also, small employers with 50 or fewer full-time workers can use the Marketplaces to shop for coverage for their employees. The initial open enrollment period for the new Marketplaces begins Oct. 1 and ends March 31, 2014. Coverage will begin on Jan. 1, 2014 for those who sign up this fall.

I already have health insurance. What do I need to do on Oct. 1?

Nothing. In fact, 85 percent of Americans already have health insurance coverage through their employer or through a public program. Most Americans who receive their health insurance coverage through their workplace will continue to be covered through their employer’s plan. Likewise, Americans who are covered by Medicare, Medicaid, or other governmental plans will continue to be covered through their existing plans.

What happens if I do not have health insurance by Jan. 1, 2014?

Starting Jan. 1, all individuals and their children will be required to have some type of health insurance coverage, unless there is no affordable insurance available to them. Those people who can afford coverage but choose not to obtain it will be subject to a tax penalty. In 2014, this penalty will be either 95 dollars per adult or 1 percent of their taxable income, whichever is greater.

Is there any sort of financial assistance available to help make insurance premiums affordable?

Yes. A new type of tax credit, called the Health Insurance Premium Tax Credit, will be available to individuals and families buying their health insurance coverage through the Marketplace.  The amount of this tax credit will depend on your income and family size. Those with the lowest incomes may be eligible for a health plan with no premium. What’s more, an individual who qualifies for a tax credit can choose how they want to take their credit—they can take it right away and pay a lower health insurance premium each month, or they can take the credit later and either the subtract the amount of their credit from the taxes they owe at the end of the year or get a bigger refund.

What types of benefits will be available through the plans sold by the Marketplaces? Will all of the services that heart disease and stroke patients need be covered?

Every health insurance plan sold through the Marketplaces is required to cover a core set of benefits called Essential Health Benefits. The 10 categories of essential benefits include the range of services important to heart disease and stroke patients, such as hospital care, doctors office visits, emergency services, prescription drugs, lab tests, rehabilitative care, and preventive screenings and services. The services covered are intended to be similar to the benefits provided by a typical employer plan. The American Heart Association continues to monitor the plans to make sure that the specific services heart disease and stroke patients’ needs are covered.

How will people be able to enroll in coverage through the Marketplaces?

People will be able to shop, apply for, and enroll in coverage in a variety of ways: Online through the Marketplace website, in person or by phone. Every Marketplace is required to have trained, certified counselors called Navigators available who can help consumers with the different insurance options.  In addition, licensed insurance agents and brokers can also assist consumers with the application and enrollment process.  Since 17 percent of the uninsured speak Spanish, the Marketplace website and application will also be available in that language. Individuals who need assistance in languages other than English or Spanish will be able to call the toll-free number to get help in up to 150 additional languages.

What if I miss the enrollment window between Oct. 1, 2013 and March 31, 2014?

People who are uninsured will generally have to wait until the next open enrollment period to sign up for coverage. However, in special circumstances, such as if you lose your health insurance coverage, get married, or move, you may also be eligible to enroll at that time, even if it’s not during an open enrollment period. Likewise, if you have or adopt a child, that child is immediately eligible to be signed up for coverage.  Finally, individuals who qualify for Medicaid can apply and be enrolled at any time throughout the year.

I live in a state that has opted to not participate in the Affordable Care Act, and has either refused or not yet expanded their Medicaid programs. Will there still be a Marketplace available to me?

If you live in a state that has opted not to establish its own Marketplace, then the U.S. Department of Health and Human Services will be operating the Marketplace in your state. So regardless of where you live, residents will have the new insurance options provided by the Marketplace, as well as the benefit of the new insurance protections, and the consumers in your state will need this information. For Medicaid, it currently appears that approximately half of the states will not expand their Medicaid programs for 2014. That means underprivileged Americans in some states may not be eligible for coverage they can afford. However, some of these uninsured individuals will still have the option of getting coverage through their state Marketplace. They also will qualify for financial assistance to help make both their premiums and their cost-sharing affordable.