Health Insurance Marketplace

THE HEALTH INSURANCE MARKETPLACE, A PRODUCT OF THE AFFORDABLE CARE ACT, ALLOWS INDIVIDUALS AND FAMILIES TO FIND COVERAGE THAT BEST FITS THEIR BUDGET AND NEEDS.

How the Marketplace Works

The Marketplace offers side-by-side comparisons of local plans based on price, benefits and other features. The Marketplace application helps determine who is eligible for low-cost coverage based on income and family size, as well as who qualifies for free or low-cost coverage through Medicaid (Sooner Care). Most U.S. citizens and legal residents are now required by law (Affordable Care Act, 2010) to have qualifying health insurance coverage or pay a tax penalty.

Insurance plans in the Marketplace are offered by private companies, including CommunityCare. No plan can deny coverage or charge more because of a pre-existing illness or medical condition, and plans must cover treatments for those conditions. Health insurance plans help pay for routine health maintenance and serve to limit unexpected, high medical costs. Many preventive services are covered at no cost to the individual.

Individuals eligible for employment-based health insurance have access to health insurance that exceeds the standards required by the Affordable Care Act. In most circumstances, when an employer offers coverage, individuals are not eligible for tax credits or reduced costs through the Marketplace. However, if an individual's employment-based plan is not affordable (e.g., the employee's share of the annual premium for self-only coverage is greater than 9.5 percent of his/her annual household income), he or she may be eligible for tax credits or reduced costs through Marketplace.

Adult children can remain on their parents' plans up to age 26, including those who are full-time students, disabled or not tax dependent.

Marketplace Coverage Options

Plans in the Marketplace have a similar set of core benefits, known as “essential health benefits,” but they differ on what providers are included and how the costs of the benefits are applied. To fit different needs and budgets, plans are presented in four categories: bronze, silver, gold and platinum. This allows for selection of a plan that best fits the needs of an individual or family. One plan may be a better fit than another, depending on health needs.

Bronze

  • 60 percent coverage
  • Lower monthly payments than other plans
  • Higher cost when you receive medical care

Silver

  • 70 percent coverage
  • Higher monthly payments than a Bronze plan
  • Lower cost than a Bronze plan when you receive medical care

Gold

  • 80 percent coverage
  • Higher monthly payments than a Silver plan
  • Lower cost than a Silver plan when you receive medical care

Platinum

  • 90 percent coverage
  • Higher monthly payments than other plans
  • Lower cost than other plans when you receive medical care


Enrollment Period

Open enrollment begins Nov. 15 and ends Feb. 15. Marketplace health insurance coverage for 2014 ends Dec. 31, and coverage for 2015 can begin as early as Jan. 1. Those who enrolled in Marketplace coverage for 2014 will need to update their information and re-enroll in a plan for 2015. Plans and benefits offered in the Marketplace change from one year to the next, making it essential to carefully review plans prior to re-enrolling in a plan or selecting a new plan.

Individuals and families with special cases, such as those with a qualifying life event, may be able to sign up outside the open enrollment period. Special circumstances are listed at www.healthcare.gov (www.cuidadodesalud.gov).

Enrollment Preparation

To prepare for enrollment, you can sign up for emails and/or texts with news and reminders of important dates at www.healthcare.gov (www.cuidadodesalud.gov). Important steps include gathering income documents, finding out what you may qualify for and planning your budget. View or download St. John's Marketplace to-do list by clicking here.

How to Enroll

During open enrollment, there are several ways you can apply for coverage through the Marketplace:

  • Apply with a private insurance carrier like CommunityCare .
  • Apply with one-on-one assistance from a certified application counselor (CAC) or navigator.
  • Apply on your own via www.healthcare.gov (www.cuidadodesalud.gov) or 1-800-318-2596.
  • Apply with an insurance broker.

Carefully review and select a Marketplace plan. Many different plans will be available in the Marketplace, so make sure your desired providers and benefits are included in the one you select. St. John Health System participates in all of CommunityCare's Marketplace plans, as well some Blue Cross Blue Shield of Oklahoma plans that use the Blue Choice network.

Enrollment Assistance

St. John partners with The Midland Group to help connect consumers with a certified application counselor (CAC). CACs minimize confusion about Marketplace options and ensure desired providers and benefits are included in the selected plan. They can also assist with detailed questions about the Marketplace. St. John Medical Center has two dedicated CACs on site, available on an appointment-only basis. For free enrollment assistance, call 918-744-2664, ext. 1. General information about the Marketplace can also be provided via the St. John PulseLine at 918-744-0123.

After the Enrollment Period

Once you have health insurance, it is important to know what to expect. "From Coverage to Care: A Roadmap to Better Care and a Healthier You" ("De la Cobertura al Cuidado de Su Salud: Una Guía para Un Mejor Cuidado y Una Vida Más Saludable") by the Centers for Medicare & Medicaid Services provides key information on how health insurance coverage works and how to get the most of a plan's benefits.

Source: From Coverage to Care Roadmap. June 2014. Centers for Medicare & Medicaid Services, Baltimore, MD. http://marketplace.cms.gov/c2c

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