In 2014, individuals and employees of small businesses have access to affordable coverage through new competitive Health Insurance Marketplaces. The Marketplaces provide individuals and small businesses with a "one-stop shop" to find and compare affordable, quality private health insurance options. The Marketplaces bring new transparency to the health insurance market as Americans are now able to compare plans based on price, quality, benefits and other important features. By increasing competition between insurance companies and allowing individuals and small businesses to take advantage of combined purchasing power, the Marketplaces will help lower costs.
Consumers in every state (including the District of Columbia) are able to buy insurance from qualified health plans available through a Marketplace and about 18 million Americans may be eligible for tax credits to help pay for their health insurance.
There are three Marketplace models:
- States can choose to operate their own Marketplaces
- States can also choose to participate in a hybrid called a State Partnership Marketplace in which the state runs certain functions of a Marketplace established and operated by the federal government in that state. A Partnership Exchange allows states to make key decisions and tailor the marketplace to local needs and market conditions.
- The Federal government is operating Federally-Facilitated Marketplaces (FFMs) in states that did not choose to establish their State-based Marketplace. The FFM guidance that the Centers for Medicare & Medicaid (CMS) released can be found here.
Title X and the Health Insurance Marketplaces
Title X-funded providers have two main roles in relation to the Health Insurance Marketplaces:
Enrollment in the Health Insurance Marketplaces
- Some people may now qualify for special enrollment periods (outside of open enrollment) if they experience certain events.
- Medicaid and CHIP enrollment are ongoing.
Click here for outreach and enrollment resources
For more information on the Health Insurance Marketplaces:
Healthcare.gov is the most up-to-date source for information about the Marketplace.
Look up your state’s Marketplace here.
Get answers to Frequently Asked Questions about the Marketplace here.
The Kaiser Family Foundation offers information about the Marketplaces in each state.
Qualified Health Plans
Under the Affordable Care Act, a qualified health plan (QHP) is an insurance plan offered through the Marketplace. It must provide essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), meets other requirements and is certified by the Marketplace in which it is sold.
The law generally requires QHPs to include some essential community providers (ECPs) in their networks. ECPs are providers that serve predominantly low-income medically underserved individuals. Title X providers should contact health insurers directly if they are interested in becoming network providers for QHPs.
Essential Community Providers
All Title X providers are Essential Community Providers.
Under the Affordable Care Act, health insurance plans that offer plans on the Health Insurance Marketplace are required to include in their networks a sufficient number and geographic distribution of providers that serve predominately low-income, medically underserved individuals, referred to as essential community providers (ECPs). ECPs are defined as providers that serve predominantly low-income, medically underserved individuals including health care providers defined in 340B(a)(4) of the Public Health Service Act and providers described in section 1927(c)(1)(d)(i)(IV) of the Social Security Act.
ECPs include family planning providers receiving funds under Title X of the Public Health Service Act, federally qualified health centers, Ryan White HIV/AIDS Program providers, children’s hospitals and disproportionate share hospitals, among others. Section 1927 allows the Secretary of HHS to identify any "safety net facility or entity" that would benefit from nominal drug pricing under the Medicaid program.
The ECP designation is significant primarily for purposes of contracting with Qualified Health Plans (QHPs). A non-exhaustive database of ECPs is available here.
The Centers for Medicare & Medicaid Services which maintains the ECP data base notes the list is not exhaustive. Issuers may identify and write in other providers who meet the regulatory standard. The list is also updated periodically. The Office of Population Affairs will also continue to facilitate the inclusion of Title X providers in the ECP database.
The Family Planning National Training Centers offer trainings and other resources to help guide Title X and other safety net providers on issues relating to contracting with qualified health plans. Check their website for upcoming and archived trainings.
For more on essential community providers:
May 13, 2013 Centers for Medicare & Medicaid Services letter to Potential Essential Community Providers
Frequently Asked Questions on Essential Community Providers
Premium Tax Credits
Beginning in 2014, taxpayers with household incomes between 100% and 400% of the federal poverty level may be eligible for premium tax credits for coverage purchased through the Marketplaces for themselves and family members who do not qualify for other minimum essential coverage.
Premium tax credits are paid in advance to the health insurance provider selected by an applicant. They reduce the monthly premiums individuals or families must pay to purchase coverage. The Congressional Budget Office estimates that when the Affordable Care Act is fully phased in, individuals receiving premium tax credits will receive an average subsidy of more than $5,000/year.
Consumers who qualify may choose how much advance premium tax credit payments to apply to monthly premiums, up to a maximum amount. If the amount of advance premium tax credit payments for the year is less than the tax credit due based on the taxpayers household income, the taxpayers will get the difference as a refundable credit upon filing their federal income tax returns. If the advance payments for the year are more than the amount of the tax credit the individual is eligible for based on their household income for that year, the taxpayer will be responsible for excess tax credit advance payments when the tax return is filed.
The application process for the Marketplace will direct those who are eligible to information about premium tax credits.
For more information on premium tax credits:
The Internal Revenue Service website has information about Affordable Care Act-related tax provisions including the premium tax credit.