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. 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 with the following are considered covered and do not need to make any changes:
- Employer-sponsored coverage, including COBRA, retiree coverage and employer-sponsored coverage through a spouse/partner
- Medicaid (SoonerCare)
- Individual coverage (outside the Health Insurance Marketplace)
- TRICARE or certain types of VA coverage
Individuals eligible for employment-based health insurance have access to coverage 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 8.05 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.
- 60 percent coverage
- Lower monthly payments than other plans
- Higher cost when you receive medical care
- 70 percent coverage
- Higher monthly payments than a Bronze plan
- Lower cost than a Bronze plan when you receive medical care
- 80 percent coverage
- Higher monthly payments than a Silver plan
- Lower cost than a Silver plan when you receive medical care
- 90 percent coverage
- Higher monthly payments than other plans
- Lower cost than other plans when you receive medical care
St. John Participating Plans
UnitedHealthcare is the only health insurance carrier offering individual and family plans on the Health Insurance Marketplace that will include St. John Health System as an in-network provider for 2016. While St. John is offered in many Blue Cross and Blue Shield of Oklahoma (BCBS) Marketplace options for small business plans, BCBS is not including St. John as an in-network provider for individual and family plans on the Marketplace as they did in 2014 and 2015. CommunityCare has opted to not offer individual or family plans on the Marketplace this year, but St. John will continue to participate in CommunityCare small business plans.
Beyond the Marketplace, St. John is in network for several BCBS plans, as well as CommunityCare, Aetna, UnitedHealthcare and many other insurance plans. Before individuals seek or receive elective care from a St. John hospital or physician, they should check with their insurance provider to determine whether St. John is in network. For those whose policies do not cover St. John at the in-network level, care may still be obtained at St. John but may be subject to higher out-of-pocket costs (e.g., deductible and coinsurance).
Open enrollment is currently closed. The next open enrollment period will be Nov. 1, 2016, through Jan. 31, 2017.
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).
Individuals and families who qualify for Medicaid (SoonerCare) may enroll at any time during the year. There is no enrollment period for Medicaid. Some individuals and families may also qualify for coverage through Insure Oklahoma.
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 (here for a Spanish version).
How to Enroll
During open enrollment, there are several ways you can apply for coverage through the Marketplace:
- Apply with a private insurance carrier.
- 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. For information on Marketplace plans in which St. John participates, call the St. John PulseLine at 918-744-0123.
St. John partners with The Midland Group to help connect consumers with a certified application counselor (CAC) for enrollment assistance. 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. During the open enrollment period, St. John's CAC is available on an appointment-only basis at St. John Medical Center in Tulsa and Jane Phillips Medical Center in Bartlesville to provide free enrollment assistance.
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 health insurance plan’s benefits.
More information about St. John Health System physicians and services is available via the St. John PulseLine, 918-744-0123 or firstname.lastname@example.org.