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Questions and Answers about Patient Enrollment in Health Insurance Marketplaces

  1. Why should physicians help patients enroll? Iím a doctor, not a social worker.

  2. Where can I direct patients who have detailed questions about health insurance enrollment?

  3. My patients are very low-income. Will they be able to find coverage?/a>

  4. I have a lot of patients who speak a language other than English. Are there resources to help them to enroll in coverage?

  5. What is the deadline to enroll in coverage? Can my patients still enroll if they miss it?

  6. What if my patients do not enroll in coverage in time or canít afford it? Will they have to pay a fine?

  7. What are some other resources I can use to help answer my patientís enrollment questions?
1. Why should physicians help patients enroll? Iím a doctor, not a social worker.

Prior to implementation of the Affordable Care Act, about 50 million Americans were uninsured, and millions more had insufficient insurance. Adults without health insurance are less likely to receive clinical preventive services that can reduce the likelihood of developing serious illness. Those with chronic disease are more likely than the insured to forego necessary therapies. Uninsured adults are also more likely to die from serious acute conditions than those with insurance. Lack of health insurance also takes a financial toll, as 60% of all bankruptcies are connected to the cost of medical care.

You want the best for your patients. Learn the basics about how the health reform law can help patients get coverage and let your patients know what is coming. Once itís time for them to enroll, consumer assistance resources will be able to help them.

2. Where can I direct patients who have detailed questions about health insurance enrollment?

Choosing a health insurance plan is an important decision and patients may need assistance to pick a plan that fits their needs and budget. Consumer assistance organizations, called Navigators or in-person assisters, are on hand to raise awareness about coverage options; help your patients fill out application forms; determine if your patients are qualified for financial assistance; provide impartial advice on choosing a plan; and refer your patients to the state Medicaid agency, ombudsmen or other assistance organizations as needed. Other entities called certified application counselors may include staff from community health centers, hospitals, and other health care providers, trained to educate consumers about their coverage options and help them complete applications. Provider organizations can apply and train to become certified application counselors. Chain drug stores and web-based health insurance brokers, may also provide insurance information and assistance. Marketplaces will also establish call centers to answer patient inquiries and ultimately help patients with their insurance applications and health plan selection. The center for the 36 federally-operated marketplaces is staffed with personnel to answer questions in 150 different languages. The call center number is 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325) If your patient has a question about health insurance enrollment, refer them to the appropriate consumer assistance organization.

More information can be found here:

Contact information for health insurance Navigator programs can be found at https://localhelp.healthcare.gov/ or your stateís marketplace website.

Also check the State information page for patient enrollment guides.

What information should patients have to help them make an informed decision on selecting the health plans thatís right for them?

To apply for coverage, patients will need their Social Security number (or other information that proves legal residency) and their gross income. They should also collect information about providers they want in their network, medications requirements, and other relevant benefits. Patients should also review plan benefit packages and educate themselves about insurance terms, such as deductibles and copayments. Marketplace-based plans are required to provide a provider directory, so patients will be able to know if their preferred physician is in the planís network. Navigators and other consumer assistance organizations can assist with necessary information.

3. My patients are very low-income. Will they be able to find coverage?

The ACA mandated that all states expand Medicaid coverage to all individuals with incomes up to about $15,800 (in 2013 dollars). However, the Supreme Courtís struck down this provision but gave states the option to expand. As of February 2014, 26 states and the District of Columbia are expanding their Medicaid programs and 25 states are not expanding. This means that in states that have not expanded Medicaid, the poorest residents (those with incomes up to about $11,500) will have no other way to get coverage, resulting in poorer health outcomes for them, more uncompensated care for the hospitals and physicians who take care of them, more cost-shifting for us, and ultimately, higher cost to the state. Medicaid-eligible individuals in non-expansion states will not be subject to the individual mandate penalty.

ACP strongly supports the Medicaid expansion. If your state has decided against expansion or remains undecided, contact your ACP state chapter and become involved in ACPís Medicaid expansion advocacy campaign. If your state has decided to expand, your patients can sign up for coverage through their stateís marketplace or traditional channels such as your stateís department of social services.

4. I have a lot of patients who speak a language other than English. Are there resources to help them to enroll in coverage?

The ACA requires that marketplaces provider services and resources for people with limited English proficiency. The federal government has created numerous resources for non-English speaking patients. Among them, a Spanish language version of healthcare.gov (www.cuidadodesalud.gov/es/) and resources in other languages (https://www.healthcare.gov/language-resource).

Marketplace.cms.gov has fact sheets, posters, brochures and other materials in many languages, from Arabic to Creole.

A call center (1-800-318-2596) will be staffed to answer questions in 150 languages.

5. What is the deadline to enroll in coverage? Can my patients still enroll if they miss it?

Generally, the open enrollment period for the health insurance marketplace begins in the fall season and ends in the spring. For the 2015 plan year, open enrollment begins on November 15, 2014. Some of your patients may be able to enroll in coverage outside of open enrollment:

  • A special enrollment period may be granted to people who experience a ďqualifying life eventĒ such as marriage, the birth of a child, or losing health coverage because of a change in employment status.
  • People who were unable to enroll because of an exceptional circumstance, such as marketplace website technical problems or enrollment errors, an unexpected hospitalization or temporary cognitive disability, a natural disaster, or circumstance related to domestic abuse, may also be able to enroll in coverage outside of open enrollment.
  • People who are eligible for Medicaid or the Childrenís Health Insurance Program can enroll at any time during the year.
  • Small business owners shopping for employee health insurance can also purchase coverage throughout the year.
  • Finally, people can buy private insurance outside of the marketplace, through insurance agents and brokers, outside of open enrollment. However, they will not be able to receive premium tax credits or cost-sharing assistance unless they purchase coverage through the health insurance marketplace.
  • More information on getting coverage outside of the open enrollment period can be found here.
6. What if my patients do not enroll in coverage in time or canít afford it? Will they have to pay a fine?

As of 2014, most individuals and their dependents are required to enroll in minimum essential coverage or pay a penalty.

The following types of insurance count as minimum essential coverage:

  • Medicare;
  • Medicaid or Childrenís Health Insurance Program;
  • TRICARE (for service members, retirees, their families);
  • The veteranís health program (i.e., the VA);
  • Peace Corps Volunteer plans;
  • Health insurance offered by an employer;
  • Insurance purchased by the individual that meets at least the Bronze level (i.e., 60% actuarial value); and,
  • A grandfathered plan that was in existence before the Affordable Care Act was signed into law.

In 2014, the penalty amount is the greater of 1% of a personís annual household income above the tax filing threshold of $10,150 or $95 per person ($45 per child) up to a total of $285 per family. For example, ďa single adult with household income below $19,650 would pay the $95 flat rate. A single adult with household income above $19,650 would pay an amount based on the 1% rate. (If income is below $10,150, no penalty is owed.)Ē The penalty amount grows each year; in 2015, itís the greater of $325 per person or 2% of household income and in 2016 and beyond, the penalty is 2.5% of income or $695 per person. In later years the penalty will be adjusted for inflation. A partial penalty will be assessed for people who are uninsured for part of the year, unless theyíre uninsured for less than 3 months.

However, there are a number of exemptions to the penalty. If your patient meets one of these requirements, they will not have to pay the penalty:

  • Person belongs to a religious group that is opposed to acceptance of benefits from a health insurance policy;
  • Person is an undocumented immigrant;
  • Person is incarcerated;
  • Person is a member of an Indian tribe;
  • Person does not have to file a tax return because their income is too low;
  • The lowest-priced insurance available exceeds 8% of their annual household income;
  • The person is uninsured for less than 3 months of the year.

Additionally, there are a number of ďhardship exemptionsĒ to the individual responsibility penalty. If any of the following affected a personís ability to purchase insurance, they do not have to pay the penalty. A partial list of hardship exemptions follows; a complete list can be found here.

  • Person was homeless;
  • Person was evicted in the past 6 months or was facing eviction or foreclosure;
  • Person received a shut-off notice from a utility company;
  • Person experienced domestic violence;
  • Person filed for bankruptcy in past 6 months.

This page has instructions on how to claim an exemption from the penalty.

7. What are some other resources I can use to help answer my patientís enrollment questions?

The Kaiser Family Foundation has created an exhaustive list of frequently asked questions regarding ACA enrollment.

The Washington Post website also has a FAQ.

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