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The Marketplace

The Affordable Care Act (ACA) affects Pennsylvania’s 
health insurance market by creating an additional path
to obtaining health insurance.  An individual 
or small business
may choose to purchase health
insurance in the Private Market or Federally-Facilitated                    Marketplace (sometimes called an Exchange). 

Here’s a quick overview of the marketplace under the ACA
-- or learn more by clicking Private Market or
Federally-Facilitated Marketplace.

The FFM is a new path for purchasing health insurance. The private health insurance market will continue to serve Pennsylvanians along with the FFM.

Below are answers to frequently asked questions about the marketplace under the ACA

 

How does the ACA affect my current coverage?

 

Large Employer Coverage

If you work for a large employer (currently 51 or more employees) and currently have health care coverage through your work, your coverage will likely stay the same, with some exceptions for certain services and additional protections.Your employer may also modify your options, as it has been able to do in the past.

 

Small Employer Coverage

If you work for a small employer (currently 50 or fewer employees) and have health care coverage through your work, you may experience some changes to your coverage. These changes may provide coverage for additional services, and may also increase your out-of-pocket deductibles, co-pays and other cost-sharing obligations.

 

Individual Market

In the individual market (that is, health insurance coverage offered to individuals or families directly, rather than through a group), your premiums may vary according to your age, where you live, how many are in your family and whether anyone in the family uses tobacco products, but may not vary based on your health or any other factors.

The cost of insurance may be offset by financial assistance from the federal government, depending on an individual's income. This assistance may be in the form of a tax credit against premiums and, for certain lower income individuals, additional reductions in cost-sharing. To get the tax credits or cost-sharing reductions, you need to purchase your health coverage through the FFM and provide income information with your application.

The ACA requires everyone to have health coverage, whether through insurance or a government program.  If you do not have health coverage (and do not meet one of the exceptions), you will be submect to paying a tax. If you think you meet one of the exceptions, you will need to apply for an exemption at www.healthcare.gov.

 

What do I do if my policy has been terminated?

Some consumers have received notices from their insurance companies that their individual or small group policies have been terminated because they no longer meet minimum standards under the ACA.  There are some exceptions, but most policies must now meet those ACA minimum standards.  Read more about what to do in the Q&A below.

Q. Why can’t I keep my policy?

A. Policies that start coverage in 2014 have to meet all the standards of the federal health law.  There are a few exceptions:   If you purchased a policy before March 2010 and renewed it each year, and neither you nor the insurer has made anything other than a minimal change to the policy, then it is "grandfathered." Essentially, your plan had to be frozen in time without any changes to your coverage or rate. If either you or the insurer made even a simple modification to a benefit or to your cost-sharing (i.e., deductible or co-pay), that plan is not grandfathered. Also, a few plans that are not grandfathered were extended into 2014 to help smoot the transition into the health insurance marketplace as it has changed under the ACA. Contact your insurance company to learn more.

Q. Why did I get a notice saying my policy is being cancelled?

A. Insurers are discontinuing, or cancelling, products that do not satisfy the standards of the federal health law.  When an insurer discontinues a product, this means the insurer is not selling that product any longer to anyone:  an insurer may not discontinue a product for some of its policyholders and not for others. 

Q. I got a letter from my insurer that says I can keep my 2013 planfor another year.  Can I do that even if my current plan doesn’t meet the standards of the federal health law?

A.  Yes, under certain conditions. If your policy provides limited coverage, however, you may want to confirm with your insurer that your policy will satisfy the tax requirement that you have health insurance.   

Q. If my policy is cancelled, can I get a new policy for the same premium?

A. That depends. Some people, if they purchase a policy on the federal exchange, or FFM, will be eligible for subsidies that will lower the total cost of their policies, but many others will find that the new policy will cost more than their old policy.  When calculating the cost of a new policy, you should consider not just the premium, but also the cost-sharing (i.e., deductibles, co-pays and co-insurance).  Also, when looking at your options for a new policy, don’t forget to look at whether your doctors and hospital are in the provider network for the new plan, and whether your prescription drugs are on the plan’s formulary. 

Q. Where can I go for assistance?

A.  If you think you qualify for premium assistance -- ask if your current insurance company has any plans for sale on the “Health Insurance Marketplace,” or explore other options at the www.Healthcare.gov website.  Help is also available 24 hours a day, 7 days a week by calling the federal call center:

1-800-318-2596 if you are an individual/family

1-800-706-7893 if you are a small employer needing help

  • Remember you can always check coverage options directly on health insurance company sites. If you are not eligible for or do not want subsidies, insurers are able to directly enroll you in a plan in the private market.
  • Seek the advice of a licensed agent/broker.  Agent licensing can be checked at the Pennsylvania Insurance Department website, www.insurance.pa.gov under “On-Line Resources” tab on the homepage. 
  • Seek in-person assistance in your community or a Navigator.  Information regarding these resources may be obtained by visiting https://localhelp.healthcare.gov.

 

How does the Private Market compare to the Federal Marketplace

Below is a chart that compares the Private Market with the Federally-Facilitated Marketplace. Click the links below to go directly to either Marketplace option and to read more details.

 

OPTIONS

PRIVATE MARKET

FEDERALLY-FACILITATED MARKETPLACE

Tax subsidies/premium assistance

No

Yes

Government verification of personal information

No

Yes

Essential health benefits

Yes

Yes

Deny insurance coverage for pre-existing conditions

No

No

Cover preventive services with no cost-sharing

Yes

Yes

Apply online

Yes, through insurer websites

Yes, through the FFM website

Determine if eligible for government programs

Insurer may be able to assist

Yes

Small employers can purchase

Yes

Yes

Large employers can purchase

Yes

No

Can apply now

Yes

Yes

Compare Benefits with Summary of Benefits and Coverage (SBC)

Yes

Yes

 

Related Documents
PAGE LAST UPDATED » 3/25/2014