Healthcare Reform

What is the Marketplace?

The Affordable Care Act gave states the option to create their own website for comparing and buying insurance policies, or using the federal system. The State of Florida has selected to use the federal system, which is called the Federally-Facilitated Marketplace (FFM), otherwise known as the "Marketplace" or "Exchange". To participate with the Marketplace, insurance companies must be a Qualified Health Plan (QHP) approved by the US Department of Health & Human Services (HHS).

If you're looking for coverage for yourself or your family (also called an "Individual" plan), you can visit the Federal Marketplace for Florida website at to see what health plans are available in your area, find out if you're eligible for financial assistance to help pay for your plan, get quotes for the cost of each plan, and apply for an insurance policy. Enrollment for Individual plans is open from November 15, 2014 through February 15, 2015.

The Marketplace also allow small businesses the opportunity to compare and choose coverage through the Small Business Health Options Program (SHOP). For 2015, small business have two options:

  1. The employer can select a carrier and plan, and enroll their employees in that plan, or
  2. The employer can select a "metal level" (for example, Platinum, Gold, Silver, or Bronze), and their employees can enroll in the plan of their choice in the same metal level.

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How do I choose and buy a plan?

To choose and buy an individual/family policy, you can:

  • work with your current insurance agent or broker
  • buy directly from an insurance company like Health First, or
  • go online to view plans on the Federal Marketplace for Florida

You can also ask a "Navigator" for help understanding your options. Navigators may be employed by the federal government or an agency that has received grants or funds to help people learn more about healthcare reform and understand their coverage options. In Florida, Navigators are not licensed to sell insurance policies-they can only help you understand the benefits and the trade-offs of the coverage being offered.

Also, since some employers may drop group health coverage from their employee benefits package, they may offer educational sessions to help employees transition to individual/family coverage.

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Who can enroll?

While healthcare reform has brought new requirements (or a "mandate") for all American citizens and legal residents to have health insurance, it also makes it easier for more people to get coverage, regardless of their medical history.

As of January 1, 2014, anyone (children and adults) with pre-existing conditions cannot be denied coverage, or charged higher premiums because of their medical history. You also cannot be charged more because of your gender. Premiums will only be based on these four factors:

  • Age of each person covered on the policy
  • Tobacco use
  • Number of family members covered on the policy
  • Zip code of where each person covered on the policy lives

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What benefits are covered?

As of January 1, 2014, all individual/family health plans and those sold to small businesses must include a complete package of "essential health benefits":

  • Emergency services
  • Hospitalizations
  • Laboratory services
  • Maternity care
  • Mental health and substance abuse treatment
  • Outpatient, or ambulatory, care
  • Pediatric care
  • Prescription drugs
  • Preventive care
  • Rehabilitative and habilitative (helping maintain daily functioning) services
  • Vision and dental care for children

Also, preventive services are covered 100% with no cost share (you don't have to pay any copay, coinsurance, or meet a deductible before the service is covered). These benefits include:

  • Services recommended by the United States Preventive Services Task Force (USPSTF) with a current rating of A or B.
  • Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) for routine use in children, adolescents, and adults.
  • Preventive care and screenings for women, infants, children, and adolescents that are provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).

Lifetime coverage limits were eliminated in 2012, and in 2014 annual dollar limits went away.

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What plans are available?

To help people do an "apples-to-apples" comparison and choose their coverage more easily, policies sold through the Marketplace now have standardized plan names, essential benefits (listed above), and coverage levels:

  • Platinum??pays 90 percent of covered benefits (you pay 10%)
  • Gold??pays 80 percent of covered benefits (you pay 20%)
  • Silver??pays 70 percent of covered benefits (you pay 30%)
  • Bronze??pays 60 percent of covered benefits (you pay 40%)

Catastrophic plans with limited coverage are also available for individuals aged 21-30 who can prove financial hardship.

Some insurance companies, including Health First, may also add extra benefits above and beyond what is required.

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When may I enroll?

Most people can choose a new plan during the annual Open Enrollment Period (OEP), which is from November 15, 2014 through February 15, 2015. If you enroll from November 15 to December 15, 2014, coverage can begin on January 1, 2015. If you enroll between January 1 and February 15, 2015, and your coverage would begin the first or second month after you enrollment information is submitted and approved.

If you currently have coverage, that coverage may affect when you can enroll in a new plan. Most policies are in effect for one year, so if you have coverage that began sometime during 2013 and want to keep it until it ends, you can. If you don't want to keep it, you can review the plans on the Federal Marketplace for Florida and select a plan that starts on January 1, 2015. If you choose to stay enrolled in your current plan you will be eligible to enroll in a new plan on the anniversary of your coverage renewal. Whatever you decide, your future coverage will renew and be updated effective on January 1 of each year based on choices you are able to make during the annual open enrollment period.

There are also other special circumstances that may allow you to enroll other times during the year, for example:

  • Losing coverage through your employer plan or another policy
  • Gaining or becoming a dependent through marriage, birth, or adoption
  • Becoming a citizen
  • Moving out of the service area
  • Gaining or losing eligibility for financial assistance

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Is financial assistance available?

Most people want to have health insurance, but simply can't afford it. And they worry about paying a penalty if they don't buy insurance next year.

One of the biggest parts of healthcare reform is financial assistance to help make insurance more affordable for people who earn up to 400% of the Federal Poverty Level (FPL).

  • That means if you don't have coverage through your employer and you're an individual earning between $11,670 and $46,680 a year, or a family of four earning from $23,850 to $95,400 a year, you can qualify for a tax credit to help pay for part of your premium, or maybe even pay for your whole premium.
  • And if you earn between $11,670 and $29,175 for an individual or $23,850 and $59,625 for a family of four, you also can get help to pay out-of-pocket costs, such as deductibles and copayments.

You may also qualify for tax credits if you have an employer-sponsored plan and the cost for employee-only coverage exceeds 9.5 percent of your income.

The discount that helps cover the cost of premiums is called the Advance Payments of the Premium Tax Credit (APTC), and the Cost Sharing Reduction (CSR) helps reduce out-of-pocket costs.

Remember: You must use the Marketplace to see if you qualify for financial assistance, and if you do qualify, you must buy your policy through the Marketplace.

People eligible for public health coverage or Medicaid are not eligible for APTCs.

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