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Enroll Patients in the Marketplace

What Mandate?

Beginning in 2014, the ACA through the Internal Revenue Code requires that most individuals to have health insurance or pay a penalty for noncompliance. This is known as the Individual Mandate. Individuals will be required to have polices contain minimum essential coverage. This includes insurance purchased in the individual market, through an employer sponsored plan or a government-sponsored plan.

Enrollment Resources

Who Is Eligible for Coverage In Louisiana?

  • Potential Louisiana Residents Uninsured and Eligible for Coverage in the Marketplace: 794,805 (20%)*
    • 570,013 (72%) employed
    • 334,258 (42%) 18-35 years old
    • 377,532 (47%) White
    • 339,676 (43%) African American
    • 47,049 (6%) Latino/Hispanic
    • 423,500 (53%) (Male)
    • 723,588 (91%) have incomes below 400% of the Federal Poverty Level
    • Source: US Department of Health and Human Services 
       
  • PowerPoint from Kaiser Family Foundation, Includes Information on:
    • Nationally – What Will the Individual Exchange Members Look Like?
    • What will the new Medicaid population look like? 
    • In States That Do Not Expand Medicaid, There Will Be Large Gaps in Coverage for Low-Income Adults

Louisiana’s Federally Facilitated Marketplace

  • Louisiana has opted to have a "Federally Facilitated Marketplace” rather than have its own state run marketplace. CMS will have a tool called the Data Services Hub to verify application information and to determine eligibility for enrollment in the qualified health plans and insurance affordability programs.
     
  • Operational Functions of the Federally Facilitated Marketplace:
    • Eligibility and Enrollment - The Hub will be used with a streamlined, consumer –focused application which will be available in the fall of 2013.
    • Plan Management – All insurance plans must meet the requirements of a Qualified Health Plan (QHP)and CMS will coordinate plan management with the states who have federally facilitated marketplaces.
    • Small Business Health Options Program (SHOP) Applications – CMS will finalize the application and procedures for states (http://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10433.html)
    • Financial Management – CMS has developed the parameters for managing payment processes across entities (http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/index.html)
    • Consumer Support - CMS will provide consumer support to help purchasers of health insurance determine eligibility and apply for a plan through the Federally Facilitated Marketplace. There will be a website with chat capabilities and a 24 hour call center that consumers can use to: Identify and compare QHPs; Check eligibility for payment assistance; and Enroll in a QHP.
       
  • Qualified Health Plans approved for Louisiana will be announced in mid-September.

Help Available: Navigators, Certified Application Counselors and Agents and Brokers

  • Navigators – All exchanges must have a navigator programs. In Louisiana, four organizations have received federal grants to establish exchange programs. Navigator Program must meet federal requirements (http://www.law.cornell.edu/cfr/text/45/155.210 ). Navigators may not be:
    • a health insurance issuer,
    • a subsidiary of a health insurance issuer
    • an association that includes members of or lobbies for health insurers
    • receive any compensation from an insurance issuer.
       
  • Duties of a navigator:
    • Maintain expertise in eligibility, enrollment and program specifications and conduct public awareness of the Exchange
    • Provide information and services in a fair, accurate and impartial manner and acknowledge other health programs
    • Facilitate the selection of a QHP (for individual enrollment)
    • Provide referrals to any applicable office of a health insurance consumer assistance or any other appropriate federal, state agency for any grievance, complaint , discrimination, questions about a plan
    • Provide information that is culturally and linguistically appropriate to the needs of the individual being served by the Exchange
       
  • Navigator Resource:

Certified Application Counselors (CACs)

  • The Federally Facilitated Marketplace will designate organizations to certify staff or volunteers to perform the duties of certified application counselors according to the standards set forth in the rule. This ensures that consumers are receiving assistance from individuals who are overseen by organizations that are required to protect personally identifiable information
  • Organizations eligible to apply to the Federally Facilitated Marketplace to participate must have:
    • Processes in place to screen staff and volunteers to ensure they protect individual information
    • Engage in services that position them to help those they serve with health care coverage issues
    • Experience providing social services to the community
       
  • May also include organizations already designed as Medicaid Certified Application Counselor Organizations by state Medicaid or CHIP agency.

Agents and Brokers

 Louisiana Qualified Health Centers Designated by CMS to Assist Consumers

 Presumptive Eligibility

  • Presumptive Eligibility and You – A state policy option that allows qualified entities, like a hospital, to make on-the-spot, temporary eligibility decisions (based on an assessment of gross family income. Starting in January 2014, the ACA permits hospitals that provide Medicaid services to begin making presumptive eligibility decisions regarding Medicaid and CHIP . The ACA permits states this option whether the state has adopted presumptive eligibility as a policy or not. With the ACA in place, hospitals, not the state, make the decision about whether or not to implement presumptive eligibility. However, states will be required to develop the policies implementing presumptive eligibility and as of yet, Louisiana has not done so.
  • Find out more about presumptive eligibility from Enroll America’s The New Hospital Presumptive Eligibility Opportunity
  • Issue Brief: Implementation of the Affordable Care Act’s Hospital Presumptive Eligibility Option: Considerations for States, Shannon M. McMahon, MPA, Maia Crawford, MSc, and Christian Heiss, December 2013; Robert Wood Johnson Foundation and the Center for Health Care Strategies

 Other Resources to Help You

  • Fact Sheet: Get Ready to Enroll in the Marketplace, HHS/Marketplace.com
  • Fact Sheet: Marketplace Application Checklist, HHS/Marketplace.com
  • Fact Sheet: Things to Think About When Choosing a Health Plan, HHS/Marketplace.com
  • Fact Sheet: About the Health Insurance Marketplace, HHS/Marketplace.com
  • Fact Sheet: The Value of Health Insurance, HHS/Marketplace.com
  • Fact Sheet: Assistance Roles to Help Consumers Apply & Enroll in Health Coverage Through the Marketplace, HHS/CMS
  • Infographic: Understanding the Individual Health Insurance Tax Subsidies, Zane Benefits
  • Regulation 101- Registration and Regulation of Navigators (LAC 37:XIII.Chapter 143), pages 2095 – 2097, Louisiana Department of Insurance, Office of the Commissioner
  • Request for Comment regarding: (1) Patient Protection and Affordable Care Act; Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel; Consumer Assistance Tools and Programs of an Exchange and Certified Application Counselors, Comments due 30 days after the date of filing for public inspection at the Federal Register, August 14, 2013, HHS/CMS
  • Blog: Implementing Health Reform: Final Rule on Premium Tax Credit, Medicaid and CHIP Eligibility Determinations Part 1, Health Affairs Blog
  • Blog: Implementing Health Reform: Final Rule on Premium Tax Credit, Medicaid and CHIP Eligibility Determinations Part 2, Health Affairs Blog
  • Report: Proven Strategies For Missouri: Health Care Coverage Program Outreach and Enrollment, Enroll Missouri, American Hospital Association and Mathematica Research
  • Webinar for Journalists: Understanding Insurance Premiums Under The Affordable Care Act, Kaiser Family Foundation 
  • Premium Subsidy Scenarios Under Obamacare, JAMA
  • Issue Brief: Providing Outreach and Enrollment Assistance: Lessons Learned from Community Health Centers in Massachusetts, September 2013, Kaiser Family Foundation
  • Louisiana-specific webpage on Medicaid.gov

 

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