ACA Certification
Gold
80 % AV
Platinum
90% AV
Agents and Brokers
A "no wrong door" system that allows for paper and online eligibility determinations or eligibility assessments for insurance affordability programs A single, streamlined application that allows consumers to receive determinations for all programs they are eligible for without requiring additional application forms or multiple eligibility determinations. Applications may be filed online, in person, by mail, or by telephone
Risk
A risk is the likelihood that a threat will exploit a vulnerability. For example, a system may not have a backup power source; hence it is vulnerable to a threat such as a thunderstorm. The thunderstorm creates a risk to the system.
Threat
A threat is the potential to cause unauthorized disclosure, changes, or destruction to an asset. Impacts of a threat can include a potential breach in confidentiality, a potential breach in integrity, and the unavailability of information. There are different types of threats. Threats can be natural, environmental, and man-made.
Vulnerability
A vulnerability is any flaw or weakness that can be exploited and could result in a breach or a violation of a system's security policy.
Accountability, Including Appropriate Monitoring and Breach Reporting
Accountability is about agents and brokers knowing whether they are in compliance with the privacy and security standards — including standards set by the health insurance issuer, the Marketplace, and in accordance with applicable state reporting requirements. All agents and brokers should ensure that policies and procedures are written down and address the requirements of all governing privacy laws and regulations. Agents and brokers should clearly explain how to meet those requirements, how compliance will be enforced, and identify the penalties for noncompliance. Additionally, agents and brokers should have a plan for how they will ensure that their workforce complies with those policies and procedures. To achieve accountability, consider using such methods as: Developing an inventory of where all of the PII you are responsible for is stored Developing self-assessment checklists for use by your workforce Tracking any uses and disclosures of PII that occur outside of the Marketplace computer system Establishing an ongoing process for identifying and addressing privacy risk areas
Guaranteed Renewability
Additionally, the Affordable Care Act requires health insurance issuers to offer to renew or continue in force coverage at the option of the policyholder. This is called "guaranteed renewability."
Stand Alone Dental Plan
Adult dental is not an EHB but can be purchased as stand alone dental plan through marketplaces.
Controls
Agents and brokers can apply certain controls to protect information within the Marketplace. Controls are policies, procedures, and practices designed to manage risk and protect IT assets. Common examples of controls include: Security awareness and training programs Physical security — like guards, badges, and fences Restricting access to systems that contain sensitive information
Agents and Brokers
Agents and brokers can assist individuals, employers, and employees with enrollment in qualified health plans (QHPs) in the Federally-facilitated Marketplace. Agents and brokers may also assist qualified individuals with eligibility determinations for advance payments of the premium tax credit and cost-sharing reductions for eligible plans. Remember, the premium tax credit and cost-sharing reductions are only available to qualified individuals in the Individual Marketplace. Agents and brokers assisting consumers in the Federally-facilitated Marketplace must do so in conformance with applicable state law, including conflict of interest and confidentiality provision
Agent and Broker Compensation
Agents and brokers in the Federally-facilitated Marketplaces are compensated in accordance with their agreements with QHP issuers and any state-specific requirements. The Federally-facilitated Marketplaces do not set compensation levels. Agents and brokers receive compensation from QHP issuers in the form of commissions as a result of assisting qualified individuals in enrolling in QHPs through the Marketplace.
Applicability to Agents/Brokers
Agents and brokers must enter into agreements with the Federally-facilitated Individual Marketplace and/or the Federally-facilitated SHOP Marketplace in which they are operating. In these agreements, agents and brokers consent to comply with the Marketplace's privacy and security standards, which include requirements for special handling and data security protections, established by Centers for Medicare & Medicaid Services (CMS). .
CMS Role
Agents and brokers must enter into agreements with the Federally-facilitated Individual Marketplace and/or the Federally-facilitated SHOP Marketplace in which they will be operating. In these agreements, agents and brokers consent to comply with the Marketplaces privacy and security standards. CMS will work with the state departments of insurance to coordinate oversight activities related to agents and brokers. CMS may also provide to each state a list of the agents and brokers who have successfully registered with the Federally-facilitated Marketplace in that state.
Data Quality and Integrity
Agents and brokers must follow all Marketplace standards to ensure that PII is complete, accurate, and up-to-date, and that it has not been altered or destroyed in an unauthorized manner. Additionally, agents and brokers must establish their own standards for ensuring PII data quality and integrity.
Breaches
Agents and brokers should have documented procedures for incident handling and breach notification. These procedures should address how to: Identify incidents Determine if PII is involved in the incident Report suspected or confirmed incidents Identify and convene a core response group to determine both the risk level of an incident and the risk-based response to an incident Determine whether breach notification is required, and if so, identify the appropriate notification methods, timing, source, and contents Properly disclose information about individuals to investigators in connection with efforts to investigate and recover from an incident
Out-of-Pocket Limits
All QHPs must limit cost sharing for enrolled individuals in the following ways: Deductibles and copays cannot be applied to preventive services. Deductibles for small group plans cannot exceed $2,000 for self-only coverage or $4,000 for any other coverage (adjusted annually), except to the extent that a higher deductible is necessary to create a reasonable bronze or silver plan. Annual cost-sharing limits cannot exceed the limits for certain high deductible health plans including catastrophic plans. (For 2014 the limits are $6,350 for an individual and $12,700 for families enrolled in individual market plans.)
State Role
All agents and brokers — including web-brokers — seeking to enroll individuals through the Marketplaces must be licensed as producers by the applicable state and adhere to all applicable state laws. States will maintain their current roles overseeing licensing, marketing, and enforcement standards for the agents and brokers in their insurance markets.
10 EHB Categories
Ambulatory patient services(dr. visits) Mental health and substance abuse, including behavioral health Rehabilitative and habilative services and devices Laboratory services Emergency services maternity and newborn care Prescription drugs Pediatric services, including oral (pkg or stand alone) Preventive and wellness services and chronic disorder services
Eligibility Determinations
Application filers may request an eligibility determination enrollment in a QHP and for insurance affordability programs, which include Medicaid, CHIP, advance payment of the premium tax credit, and cost-sharing reductions. Depending on the state, the Marketplace may make an "assessment" of eligibility for Medicaid and CHIP instead of a determination. In this case, an applicant who is assessed as potentially eligible for Medicaid or CHIP by the Marketplace will be transferred to the State Medicaid or CHIP agency for a final determination.
Catastrophic Plans
Are offered in the Individual Marketplace and cover EHB. They provide affordable coverage options for young adults and people for whom coverage would otherwise be unaffordable. Catastrophic plan enrollees pay higher deductibles than enrollees in bronze, silver, gold, or platinum plans. However, catastrophic plans have several benefits: Lower premiums on average than bronze, silver, gold, or platinum plans Protection against out-of-pocket costs above $6,350 for an individual and $12,700 for a family Coverage of recommended preventive services without cost sharing Eligibility for catastrophic plans is limited to: Individuals under age 30 Individuals who otherwise do not have an affordable coverage option, or who otherwise qualify for a hardship exemption to the minimum essential coverage rule
Individual Access and Corrections
As an agent or broker assisting individuals with QHP enrollment or applying for affordability programs, it is important that you are knowledgeable of the rights that people have to access and correct their PII. Each individual whose PII is collected as part of a Marketplace function has the right to access that information in a simple and timely manner, and in a readable form and format. He or she must also be provided with a means to have information corrected, or to have a dispute documented if their request for correction is denied. Agents and brokers should be familiar with all of the methods available through the Marketplace for an individual to access and correct his or her PII, or to have a dispute documented. Additionally, agents and brokers must establish their own standards to define how an individual will be allowed to access and correct any information that the agent or broker holds as part of performing a Marketplace function, or how disputes will be documented and managed. Additional guidance on individual access and correction of PII is contained in the Federally-facilitated Marketplace Agreement you must accept before assisting with individual application and enrollment in a Federally-facilitated Marketplace.
SHOP Program Features
Be located in a SHOP's service area (generally a state) Offer coverage to all full-time employees (those working an average of 30 or more hours per week) Have at least one eligible employee on payroll Have 50 or fewer full-time equivalent (FTE) employees on payroll in 2014 This methodology includes part-time employees, but not seasonal employees (those working fewer than 120 days per year) While the Federally-facilitated SHOPs (FF-SHOP) must determine eligibility using the definitions above, State-based SHOP Marketplaces have flexibility in their counting approaches in 2014 The premium tax credits and cost-sharing reductions described earlier are not available to employers and families covered through a SHOP. However, employers meeting certain size and average wage requirements may receive a small business tax credit on their tax returns of up to 50% of the employer's contribution to the premium. This credit is only available for coverage provided through a SHOP.
Consumer Associations
Before assisting individuals, employers, and employees with enrollment in the Marketplaces, agents and brokers should explain that consumers may associate with only one agent or broker at a time. Consumers should terminate their current association in writing before initiating a new association.
Minimum Essential Coverage
Beginning January 1, 2014, individuals not eligible for an exemption are required to demonstrate that they maintain minimum essential coverage or make a payment when filing their federal income tax return. Coverage purchased in the individual market including a Federally-facilitated Marketplace, as well as coverage under government programs such as Medicare, Medicaid, CHIP, and TRICARE, and coverage under an employer-sponsored plan, meet the requirements.
Single Streamlined Application
By mail Online In-Person Via call center Agents and brokers are expected to assist consumers in submitting online applications.
Functions of Marketplace
Certifying health plans to participate in a Marketplace as QHPs Determining individuals' eligibility for enrollment in a QHP Determining individuals' eligibility for premium tax credits and cost-sharing reductions Determining or assessing individuals' eligibility for enrollment in Medicaid and/or the Children's Health Insurance Program (CHIP) Facilitating individuals' enrollment in a QHP Carrying out certain plan oversight functions, including monitoring QHP issuers for continuing compliance with certification requirements Facilitating employers' applications and employee enrollments in coverage through SHOP Some states will establish their own Marketplaces; however, if a state does not choose to establish its own Marketplace, HHS will establish a Federally-facilitated Marketplace.
Collection, Use, and Disclosure Limitations
Collection, use, and disclosure limitations set boundaries for any PII created, collected, used or disclosed as part of a Marketplace function, and also establish additional limitations for two special categories of PII: Eligibility PII and federal tax information (FTI). The boundaries that apply to all PII are: PII may not be created, collected, used, or disclosed unless all of the privacy and security standards set by the Marketplace are being met. Agents and brokers must also establish standards directing that PII creation, collection, use, or disclosure is limited only to the extent necessary to accomplish a specific purpose related to an authorized Marketplace function and not to discriminate inappropriately. If operating in an Individual Marketplace, it is possible that you may encounter FTI when assisting with eligibility appeals. FTI may not be disclosed to anyone without proper authorization.
3 Key Elements to Protect Information
Confidentiality: Protecting information from unauthorized disclosure to people or processes. Availability: Defending information systems and resources from malicious, unauthorized users to ensure accessibility by authorized users. Integrity: Assuring the reliability and accuracy of information and information technology (IT) resources.
Responding to Privacy Incident
Consistent with federal law, an agent or broker must report all PII incidents to the Marketplace, and make reasonable efforts to mitigate such incidents. Any incident involving the loss or suspected losses of PII should be reported in accordance with health insurance issuer requirements or state laws in which an agent or broker operates. Additionally, if the incident involves a possible improper inspection or disclosure of federal tax information (FTI), the individual making the observation or receiving information should contact the office of the appropriate Special Agent-in-Charge, Treasury Inspector General for Tax Administration (TIGTA), and the Internal Revenue Service (IRS). Agents and brokers in the Individual Marketplaces may possibly encounter FTI when assisting with an eligibility appeal. Remember, FTI may not be disclosed to anyone without proper authorization. The organization that experiences a breach must determine whether or not to provide notice to individuals whose data has been lost or breached, and will bear any costs associated with the notice or any necessary mitigation actions.
Qualified Health Plan
Coverage, at a minimum, of a comprehensive package of benefits, known as essential health benefits, or EHB Benefit design standards, including non-discrimination requirements and limits on cost-sharing Network adequacy standards
Pre-existing Conditions
Effective for all health plans with plan years beginning on or after January 1, 2014, the Affordable Care Act prohibits health insurance issuers from limiting or excluding coverage related to pre-existing health conditions, regardless of the age of the covered individual. For persons under age 19, this provision became effective for policy years beginning on or after September 23, 2010. Generally, a pre-existing condition is any health condition or illness that was present before the coverage effective date, regardless of whether medical advice or treatment was actually received or recommended.
Family Rating Standard
Family premiums are based on the premiums for each family member including each family member's age and tobacco use. Only the premium for the 1st 3 children under 21 contribute towards total family premium. Family rates include per-member rates for members 21 plus
Specific Privacy Standards for Agents/Brokers
In practice, key privacy and security responsibilities and restrictions for agents and brokers will include: Using and disclosing the information only for purposes of assisting with obtaining eligibility determinations and assisting with or enrolling consumer(s) in a Marketplace, and not in a discriminatory or other unauthorized manner (to the extent that they collect PII) Establishing and following appropriate privacy and security standards to safeguard the PII, including preventing unauthorized or inappropriate access, use, or disclosure Providing consumer(s) with guidance on where they can learn more about the privacy policies and practices of the Marketplace Ensuring that consumer(s) can access their own PII, correct any errors, and make informed decisions about its use Taking reasonable steps to ensure the PII is complete, accurate, and up-to-date for the consumer's intended purpose Ensuring that PII is securely destroyed or disposed of in an appropriate or reasonable manner
Premium Tax Credits
Individuals eligible for a premium tax credit who do not receive an advance payment of the premium tax credit may claim the credit on their income tax return filed for the coverage year. Individuals who are married at the end of the coverage year are required to file a joint return to receive a premium tax credit. if the premium tax credit allowed on the return is more than the amount of the advance payment of the premium tax credit, the individual may receive the excess amount as a tax return. On the other hand, if the premium tax credit allowed on the return is less than the amount of the advance payment of the premium tax credit, the individual will repay the excess amount via the tax return, subject to statutory caps. The Marketplaces will provide documentation to the tax filer and to the IRS that will support the reconciliation process, in the same way that an employer or bank provides a Form W-2 or Form 1099.
Information Security
Information security refers to the protection of information and information systems from unauthorized access, use, disclosure, disruption, modification, or destruction in order to provide confidentiality, integrity, and availability. Information security is achieved through implementing technical, management, and operational measures designed to protect the confidentiality, integrity, and availability of information. The goal of an information security program is to understand, manage, and reduce the risk to information under the control of the organization. In today's work environment, many information systems are electronic; however the Department of Health and Human Services (HHS) has a media neutral policy towards information. This means that any data must be protected — whether it is in electronic, paper, or oral format.
Other State and Federal Laws
Insurance claim form and glasses.
Age Rating Standards
Insurance companies are not allowed to charge an older adult more than 3x the rate of a 21 yr old. States can establish an age curve or default to federal age curve: 0-20, 1 yr bands between 21-63, 4 & older
Tobacco Rating Standards
Insurance companies cannot charge an individual who smokes more than 1.5x the non-smoker rate. Tobacco rating can vary based on age. For small employers - covered individuals will be able to avoid tobacco surcharge by participating in a wellness program
Medical Loss Ratio
Is a basic financial measurement that shows how much of the premium dollars a health insurance issuer spends on health care expenses, as opposed to profits or administrative costs. As of 2012, a health insurance issuer that does not spend enough of its premium dollars on health care services must provide rebates to insured individuals or policyholders.
Actuarial Value
Is a measure of EHB coverage established to be paid by the QHP issuer for a standard population expressed in percentages. The higher the AV the more the enrollee will pay in premium costs and less in out of pocket limit.
Threats To Computer
It is essential that computers used to conduct business in the Federally-facilitated Marketplaces are protected from harmful computer programs, applications, and malware. As an agent or broker, it is your responsibility to ensure that the computer you use to access a Federally-facilitated Marketplace is regularly updated with the latest security software to protect against any cyber-related security threats. Malware, short for malicious software, is software designed to harm or secretly access a computer system without the owner's informed consent. It is a generic term used by computer professionals to mean a variety of forms of hostile, intrusive, or annoying software or program code. Malware is also known as pestware. Types of malware include (click on each for more information): Virus Trojan Horse Worms Spyware Adware Rootkits Crimeware Scareware
Obligating Business Partners to Follow same Standards
Just as when agents and brokers enter in to a relationship with a Marketplace, business partners of agents and brokers are also obligated to comply with or exceed the Marketplace's privacy and security standards. If an agent or broker has a business partner that assists in performing Marketplace functions involving PII, then the agent or broker must legally obligate the business partner or associate to meet or exceed the same set of standards. By law, agents and brokers may not enter into business partner agreements that authorize access to federal tax information (FTI) except in accordance with the Internal Revenue Code and Internal Revenue Service (IRS) approval. Beyond the requirement to meet or exceed standards, you may also want to consider addressing topics like these within legal agreements with business partners: Privacy and security training requirements How compliance will be assessed Incident response Validation steps for PII handoffs to ensure data quality and integrity
Security Incidents
Loss of data through theft Device misplacement Loss or misplacement of hardcopy documents Misrouting of mail Violation, or an imminent threat of violation, of an explicit or implied security policy
Verification: Assurance of Correct Data
Marketplace data verification for individuals seeking coverage through the Marketplace: Social Security Number (if applicant has SSN) Citizenship or lawful presence Incarceration status American Indian/Alaskan-Native status (if applicable) Verification for individuals seeking eligibility for insurance affordability programs: Current monthly household income (Medicaid/CHIP); annual household income (advance payment of the premium tax credit/cost-sharing reduction) Access to minimum essential coverage (premium tax credit/cost-sharing reduction)
Medicaid and CHIP Eligibility
Medicaid and CHIP provide free or low-cost health insurance coverage. Medicaid is administered by states to provide health coverage for low-income people, families and children, the elderly and people with disabilities. Beginning in 2014, individuals with incomes of about $15,000 or less will qualify for Medicaid in about half of all states. The Medicaid program is designed to be very affordable for every participant and cost sharing is extremely limited. CHIP is administered by states to provide no-cost or low-cost health insurance coverage for children in families who earn too much to qualify for Medicaid coverage but cannot afford to purchase private health insurance. CHIP also covers pregnant women in some states.
Cost-sharing Reductions
Meet the eligibility requirements for enrollment in a QHP Meet the criteria for eligibility for a premium tax credit Have annual household income at or below 250% of FPL, except for members of federally-recognized Indian tribes, who have special standards Be enrolled in a silver-level QHP, except for members of federally-recognized Indian tribes who have special standards
Eligibility for Premium Tax Credit
Not be eligible for minimum essential coverage — including employer-sponsored coverage, Medicaid, CHIP, Medicare, and other forms of coverage — other than through the individual insurance market, unless their employer-sponsored coverage is not affordable or does not provide minimum value Have an annual household income that is between 100% and 400% of the Federal Poverty Level (FPL) (or below 100% of FPL for lawfully present non-citizens who are ineligible for Medicaid by reason of immigration status) Be a part of a tax household that will file a tax return for the coverage year and, if the tax household includes a married couple, that files a joint return Be eligible for coverage through a QHP
Network Adequacy Standards
Offer a network with a sufficient number of providers, including mental health and substance abuse providers, to ensure access to all services without unreasonable delay; and In addition to the overall network adequacy requirement, a QHP's network must include a sufficient number and geographic distribution of essential community providers to ensure reasonable and timely access to care for low-income and medically-underserved populations in the QHP's service area.
Catastrophic
Offers a level of coverage that doesn't meet specific AV but must comply with maximum out of pocket limit
Registration Part 1 (Agent/broker)
Part I. Register on MLN, complete assigned training and exams, and execute Federally-facilitated Marketplace Agreements. (All agents and brokers in the Federally-facilitated Marketplaces are required to register on the MLN website. This applies to all agents and brokers, regardless of which insurance market they wish to serve in the Federally-facilitated Marketplaces.)
Patching
Patches are updates issued by the vendor that fix a particular problem or vulnerability within a software program. Patch management is a critical business function for effective data risk management. To mitigate the impact of any potential attacks, agents and brokers should ensure the operating systems and applications on their computers remain patched with the latest security updates from their vendors. In addition to the security consequences of not installing the most recent patches to your system, recovery from attacks and infections can be expensive and prolonged. To limit risk and vulnerability, pay attention to security alerts and conduct patch management systematically. Schedule patching activities as a regular part of your business routine, and allow flexibility for emergencies.
Marketplace-specific rules PII
Per the Affordable Care Act, a Marketplace must also establish and comply with privacy and security standards that are consistent with these seven principles: Collection, use, and disclosure limitations Individual access and corrections Policy transparency and informed decision-making Data quality and integrity Operational safeguards to prevent unauthorized access, use, or disclosure Accountability, including appropriate monitoring and breach reporting Obligating business partners to follow the same or more stringent standards
Geographic Rating Standards
Premiums may reflect geographic rating areas in the state. Rating area is: home address for individual and employer's primary place of business for small group coverage
Privacy Notice Standards for the Federally-facilitated Marketplaces
Privacy Notice Statement Standards for the Federally-facilitated Marketplaces Before assisting individuals with application and enrollment in coverage through a Federally-facilitated Individual Marketplace, agents and brokers must successfully complete training and execute the Federally-facilitated Marketplace Agreement. Agents and brokers assisting employers and employees with enrollment in SHOP coverage must also execute the Federally-facilitated Marketplace Agreement, and are encouraged (but not required) to complete training. The Federally-facilitated Marketplace Agreement contains privacy and security standards, which include the requirement that agents and brokers provide consumers with a Privacy Notice Statement regarding use and disclosure of PII. This Privacy Notice must be presented to consumers prior to assisting them with application and enrollment through a Marketplace. You will need to review the Federally-facilitated Marketplace Agreement for more details about the Privacy Notice and when it is necessary to obtain affirmative consent.
CO-OP Health Plan (Consumer operated & oriented plan)
Private nonprofit health insurer directed by their customers and designed to offer individual and small business more affordable, consumer-friendly and high quality health insurance options.
QHP Issuer Role
QHP issuers will verify that their appointed agents and brokers have a valid state license to sell health insurance products, as well as an NPN. As part of issuer onboarding, agents and brokers will have to send their MLN training certificates to QHP issuers. It's very important that you keep your training certificates, for this reason. Agents and brokers must also comply with any policies of the QHP issuers with which they are affiliated, and must adhere to the federal privacy and security standards which are discussed in this training course.
Bronze
QHP pays on average 60% AV
Silver
QHP pays on average 70%
Essential Health Benefits
Reflect appropriate balance among the 10 EHB categories Do not discriminate based on age, disability or expected length of life Take into account the health care needs of diverse segments of the population
SHOP Marketplace
SHOP collects and verifies eligibility information from employers and employees, determines their eligibility for enrollment in a QHP, and facilitates enrollment. After an employer has entered basic information about their business and employees, SHOP will generate information on the range of premiums for all plans available. SHOP also facilitates enrollment for employees' dependents if offered coverage by their employer. Eligibility for the small business tax credit is determined when an employer files his or her taxes each year. Please visit http://www.irs.gov (keyword: ACA) for more information.
Clinical Trials
The Affordable Care Act prohibits health insurance issuers from: Precluding participation of qualified individuals in an approved clinical trial Denying, limiting, or placing additional conditions on the coverage of routine patient costs for items and services furnished in connection with participation in an approved clinical trial Discriminating against qualified individuals on the basis of their participation in an approved clinical trial
Guaranteed Issue
The Affordable Care Act requires health insurance issuers to offer all of their individual market and group market plans to any applicant in the state. It also requires health insurance issuers to accept any individual who applies for those policies, as long as the applicant agrees to the terms and conditions of the policy, including the payment of premiums. This provision is called "guaranteed issue."
Effective rate Review
The Department of Health and Human Services (HHS) (through CMS) works with states to ensure that all proposed rate increases in the individual and small group markets are thoroughly reviewed. The Affordable Care Act sets minimum standards for the review of these proposed increases, called effective rate review standards. If a state lacks the resources or authority to meet these standards and conduct the needed reviews, HHS conducts the rate review while continuing to make resources available to states to strengthen their rate review process.
Individual Marketplace
The Individual Marketplace collects and verifies eligibility information from individuals, determines their eligibility for a QHP, and facilitates enrollment. The streamlined application process will assist in determining an individual's eligibility to enroll in Medicaid and CHIP, and in determining whether an individual is eligible for advance payments of the premium tax credit and cost-sharing reductions. The eligibility determination will use information provided by the applicant on citizenship, incarceration, income, and residency status through a streamlined system that allows the Marketplace to verify an applicant's information through the Social Security Administration (SSA), the Internal Revenue Service (IRS) (IRS) and the Department of Homeland Security (DHS).
Two Types of Martketplaces (exchanges)
The Individual Marketplaces for individual consumers and their families such as Kate, the self-employed interior decorator The SHOP Marketplaces for small business owners such as Tony, the owner of the small Italian restaurant
Marketplace Notification Requirements:
The Marketplace must provide applicant timely written notice of eligibility determination. Notification occurs immediately if the application was submitted electronically, and will indicate if additional information is needed. Notices will include information regarding the right to appeal eligibility findings. The Marketplace must transfer any applicant assessed or determined eligible for Medicaid or CHIP to the applicable State Medicaid or CHIP agency, which will follow up for plan/delivery system selection.
Calculating Premium Tax Credit
The amount of the premium tax credit depends on the plan that the individual or family selects. If the premium for the selected plan is greater than the maximum premium tax credit, the individual or family may elect to receive the maximum premium tax credit in advance, and pay the difference in a monthly premium cost. If the premium for the selected plan is less than the maximum payment, the individual or family may elect to receive the maximum premium tax credit in advance, and have no additional premium cost.
Five Levels of Coverage
The five levels of generosity are called catastrophic, bronze, silver, gold, and platinum in ascending order of generosity. These levels, sometimes referred to as "metal levels" provide several benefits: Help consumers, and the agents and brokers who assist those consumers, in comparing coverage options to determine which plans best fit the consumers' needs Help consumers understand their benefits and the cost of services once they enroll Facilitate consumer choice based on specific value comparisons QHP issuers do not have to offer plans in all five levels. However, each QHP issuer must offer a silver and a gold QHP in a Marketplace. These requirements begin on January 1, 2014.
Policy Transparency and Informed Decision Making
The purpose of policy transparency is to ensure that individuals have the information needed PRIOR to making a decision about whether to share his or her PII. Individuals should understand the following: What information is being collected? What will happen to it? How it is being protected? How long it will be kept? Who it is shared with? How will it be destroyed? Agents and brokers should be familiar with all of the Marketplace resources available for individuals. Typically, multiple methods are used to provide transparency. Additionally, agents and brokers must establish their own standards about how they will achieve policy transparency about their information handling practices.
Safeguards to Prevent Unauthorized Access, Use, or Disclosure
Two hands; one hand is giving the other hand a set of keys All guidance for operational, technical, administrative, and physical safeguards is found within a suite of documents called the Minimum Acceptable Risk Standards for Exchanges (MARS-E). (Remember, Marketplaces are typically referred to as Exchanges in the Affordable Care Act and associated regulations.) To view the MARS-E document, go to: http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Catalog-of-MinAcceptable-Risk-Controls-for-Exchanges-ERA-Supp-v-1-0-08012012-a.pdf
Young Adult Coverage
Under the Affordable Care Act, health plans that cover children must make coverage available to children up to age 26. Young adults can join or remain on a parent's plan even if they are: Married (coverage does not extend to married child's spouse) Not living with a parent Not attending school Not financially dependent on a parent Eligible to enroll in their employer's plan (starting in 2014)
Web-Broker
Web-brokers can also assist consumers in selecting and enrolling in a QHP through the web-brokers' own websites. Web-brokers may also assist qualified consumers in the Individual Marketplace in applying for advance payments of the premium tax credit and cost-sharing reductions for eligible plans. Web-brokers must comply with additional regulatory requirements.
Multi State Plans MSPs
Will be available to families or small business that reside or operate in more than one state and will be available in all states 2014
CLAS
is an acronym that stands for culturally and linguistically appropriate services, which are services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs. When working with consumers, agents and brokers are encouraged to take CLAS into consideration to make education, enrollment, and outreach efforts more effective. CLAS will enable you to communicate better and build the trusting relationships necessary to work successfully with individuals, employers and employees.
Eligibility PII
is created or collected for determining eligibility for enrollment in a QHP, other insurance affordability programs, or exemptions from the individual shared responsibility payment. includes both information collected from applicants and information received from electronic databases, which may include state and federal databases and electronic sources. may only be used or disclosed to carry out a very specific list of Marketplace functions, and not for any other purpose. Agents and brokers will have access to eligibility PII through the Individual Marketplace as well as the SHOP Marketplace. Agents and brokers may only use this information for the purposes of enrolling individuals in a QHP, or assisting individuals in applying for premium tax credits and cost-sharing reductions for QHPs. Any person or entity that knowingly and willfully improperly uses or discloses eligibility PII associated with individual market health insurance coverage is subject to a civil penalty of up to $25,000 per use or disclosure.
PII Personally Identifiable Information
is information which can be used to distinguish or trace an individual's identity, alone, or when combined with other personal or identifying information which is linked or linkable to a specific individual.
Media Protection
n addition to protecting your computer and related systems, it is critical that you protect various media forms as well. Click on each of the following to read more: Protect Sensitive Unclassified Information Protect Your Equipment Protect Your Area Printing, Faxing, and Postal Mailing Protect E-mail and Conversations
SHOP Benefits
some cases, the employer may be eligible for small business tax credits of up to 50% of the employer's share of the insurance coverage for up to two years. This tax credit is ONLY available through the SHOPs beginning in 2014. The small business tax credit applies to small businesses with up to 25 FTE employees that pay employees an average annual wage below $50,000 and that contributes 50% or more towards employees' health insurance premiums
