PY 2024 Individual Marketplace Training for New Agents and Brokers
In which of the following situations would individuals be required to input their citizenship/immigration status on the application in order to be eligible for a QHP? (Choose 2) Non-applicants on a financial assistance application Applicants on a financial assistance application Non-applicants on a non-financial assistance application Applicants on a non-financial assistance application
Applicants on a financial assistance application Applicants on a non-financial assistance application
Under the ACA, health plans that allow coverage of children as dependents must make dependent coverage available to children up to age 26.* These young adults can join or remain on a parent's plan even if they:
Are married (coverage requirement does not extend to a married child's spouse) Are not living with a parent Are not attending school Are not financially dependent on a parent Are eligible to enroll in their own employer's plan Have or adopt a child
To be eligible to obtain insurance through the Marketplace, individuals must:
Be a resident of the state where they will apply for coverage and enroll in a QHP. Be a U.S. citizen or national, or a lawfully present non-citizen, and expect to remain so for the entire period coverage is sought. Not be incarcerated, other than incarceration pending the disposition of charges.
To effectively help mixed immigration status households, you should do the following:
Be mindful that a consumer's immigration status may be a sensitive topic. Correctly identify the applicant(s) by asking consumers whether they are seeking health coverage for themselves or on behalf of someone else. Make it clear that providing an SSN is optional for non-applicants but providing one may help the consumers avoid needing to verify their income later. Marketplace applicants who have an SSN are required to provide it on their application.
What is CMS
Centers for Medicare and Medicaid Services It is a federal agency that runs the FFM, Medicare, Medicaid, and CHIP. For more information, visit CMS.gov. You will learn more about the role of CMS as it relates to Marketplace-registered agents and brokers in the Maintaining Compliance module.
What are the functions of the Marketplace?
Certifying health plans to participate in the Marketplace as QHPs* Determining or assessing individuals' eligibility for enrollment in Medicaid or CHIP Carrying out certain plan oversight functions, including monitoring QHP issuers for continuing compliance with certification requirements Determining individuals' eligibility for enrollment in a QHP through the Marketplace Determining individuals' eligibility for APTC and CSRs Facilitating individuals' enrollment in a QHP
Review ? - Are the following individuals eligible to obtain coverage through the Marketplace? U.S. citizen or national Lawfully present non-citizen Incarcerated individual pending the disposition of charges Residents of the state in which they are applying for coverage Individuals under 18 with a non-applicant parent Individuals recently experiencing hardships such as homelessness, natural disasters, or domestic violence
Eligible
Consumers who are members of federally-recognized Indian Tribes or shareholders in ANCSA Corporations can
Enroll in QHPs or change plan selections through the Marketplace throughout the year, not just during the yearly Open Enrollment Period (OEP) Qualify for APTC depending on household income and other eligibility criteria Enroll in a zero cost-sharing or limited cost-sharing plan, at any level of coverage.
ACA Health Insurance Requirements
Extension of dependent child to age 26 Expansion of guaranteed Issue - regardless of health status Prohibits limitations for preventative Prohibits exclusion for existing condition Medical Loss Ratio (MLR) ensures at least 80% of premium paid are spent on healthcare services Covers EHB (Essential Health Benefits) Prohibits annual and lifetime limits on EHB Rating variations can only vary based on age, number of covered family members, location and tobacco use Prohibits rating on health status
Assisters in the Marketplace can make specific plan recommendations to consumers. True or False
FALSE
The Marketplace determineseligibility for the TRICARE program. True or False
FALSE
All agents and brokers who wish to participate in the SHOP in the FFM and SBM-FPs must read and sign the "Agreement Between Agent or Broker and CMS for the Small Business Health Options Programs of the Federally-facilitated Exchanges and State-based Exchanges on the Federal Platform" (SHOP Privacy and Security Agreement) one time prior to assisting small employers with selecting and enrolling in SHOP coverage. You can access this Agreement via the Marketplace Learning Management System (MLMS). True or False
FALSE - Annually
In order to buy private health insurance through the Marketplace, a person must be a U.S. citizen, U.S. national, or be lawfully present in the United States. The term "lawfully present" includes immigrants who have*
"Qualified non-citizen" immigration status (e.g., Lawful Permanent Resident or Green Card holder, Conditional Entrant Granted before 1980) Humanitarian statuses or circumstances (e.g., Temporary Protected Status, Special Juvenile Status, asylum applicants, Convention Against Torture, victims of trafficking) Valid non-immigrant visas Legal status conferred by other laws (e.g., temporary resident status, Legal Immigration Family Equity Act, Family Unity individuals)
The ACA makes care more accessible by
1 - Creating the Health Insurance Marketplace 2 - Provided qualified Individuals with Financial Assistance 3. Medicaid expansion to cover household income up to or below 133% of the federal poverty level (FPL)
The Small Business Health Care Tax Credit, which may be worth up to 20% 60% 50% of the employer's contribution toward premium costs
50%
What are Agent/Broker Roles in the Marketplace?
Agents and brokers can assist individuals with enrollment in QHPs through the Individual Marketplace, as well as assist small employers with selecting and enrolling in SHOP coverage. Agents and brokers may also assist qualified individuals with obtaining eligibility determinations for financial assistance through the Marketplace. If consumers are potentially eligible for Medicaid or CHIP, Marketplace-registered agents and brokers can help these consumers connect with the appropriate state agency to apply for this coverage.
REVIEW ? - Can assist individuals with applying for and enrolling in QHPs and refer them to Medicaid/CHIP when applicable Contact information can be found by going to Find Local Help at HealthCare.gov Must protect consumers' PII May not mislead consumers or provide them false information Only agents and brokers Only Navigators and CACs (assisters) Agents, brokers, Navigators, and CACs
Agents, brokers, Navigators, and CACs
Review ? - You meet with Manisa and Mato, members of a federally-recognized Indian Tribe who are interested in learning more about the Marketplace benefits that are offered to them as Tribal members. They are accustomed to receiving their care from an Indian healthcare provider. Which of the following is NOT an accurate statement for you to share with Manisa and Mato? Manisa and Mato's household income is 250% of the FPL. This means they're eligible for a zero cost-sharing plan with no copayments, deductibles, or coinsurance when they receive care from Indian healthcare providers or when receiving EHB through a QHP. It's February, so they can't enroll in a new plan or change their current plan selection until the next annual OEP begins. They should come back to your office in the fall to select a plan then. They may qualify for APTC through the Marketplace to help offset the cost of their premiums each month.
t's February, so they can't enroll in a new plan or change their current plan selection until the next annual OEP begins. They should come back to your office in the fall to select a plan then.
Review ? - re the following individuals eligible to obtain coverage through the Marketplace? Non-citizen who is not lawfully present Incarcerated individual (not pending disposition of charges) A household with no residents of the state in which they are applying for coverage Individuals under 18 without an adult filing the application
Ineligible
Existing Health Condition mandatory coverage went into effect
January 1, 2014
Maggie, a consumer that received a denial letter from their state Medicaid agency stating they are no longer eligible due to income changes. May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) May be Eligible for Marketplace Coverage
May be Eligible for Marketplace Coverage
Review ? - Ines, a non-pregnant adult consumer with household income over 100% of the FPL in a state that has not adopted Medicaid expansion. May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) May be Eligible for Marketplace Coverage
May be Eligible for Marketplace Coverage
Review ? - Jaime, a consumer that is only eligible for Medicaid with limited benefits. May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) May be Eligible for Marketplace Coverage
May be Eligible for Marketplace Coverage
Review ? - Diego, a 17-year-old consumer in a household with income above 133% of the FPL and below their state limit for CHIP. May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) May be Eligible for Marketplace Coverage
May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules)
Review ? - Leandro, a 35-year-old consumer with household income under 133% of the FPL in a state that has adopted Medicaid expansion. May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) May be Eligible for Marketplace Coverage
May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules)
Review ? - Mohammed, a 70-year-old consumer with income under their state's threshold. May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) May be Eligible for Marketplace Coverage
May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules)
Review ? - Naomi, a Medicare-eligible consumer with a disability in a household that otherwise qualifies for APTC. May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) May be Eligible for Marketplace Coverage
May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules)
Review ? - Nida, a consumer that received a denial letter from their state Medicaid agency stating they did not submit requested documents. May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) May be Eligible for Marketplace Coverage
May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules)
Review ? - Valentina, a pregnant consumer with income under their state's threshold. May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) May be Eligible for Marketplace Coverage
May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules)
What is Medicaid?
Medicaid is a federal and state partnership to provide healthcare coverage for eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities.
You are working with two new clients who are attempting to apply for coverage on behalf of their child, John. During the application, John's parents inform you that their child is a first-generation U.S. citizen. Should you also ask the parents about their citizenship/immigration status if they are not applying for coverage themselves? Yes or No
No
Who does HHS rely on to certify QHPs to meet the Marketplace certification standards in certain areas?
States
Agents and brokers should not attempt to establish an exclusive referral relationship with Navigators and CACs. Assisters, including Navigators, are strictly forbidden from endorsing specific agents, brokers, or web-brokers or referring consumers to specific agents, brokers, and web-brokers.
TRUE
If unable to assist a consumer with, for example, applying for Medicaid through a Marketplace, the agent or broker should make sure the consumer knows that local Navigators and CACs may be available to provide assistance. They may also help direct the consumer to the appropriate state Medicaid agency, if applicable. True or False
TRUE
Navigators and CACs may not receive compensation directly or indirectly from any health insurance issuer or issuer of stop-loss insurance in connection with the enrollment of any individuals or employees in a QHP or non-QHP. True or False
TRUE
members of the federally recognized Indian Tribes or ANCSA Corporations with incomes below 100% and above 300% are required to get referrals from an Indian healthcare provider - True or False
TRUE
What is the MLR - (Medical Loss Ratio)
The ACA limits the proportion of premiums that a health insurance issuer can spend on things other than medical claims and improving the quality of the healthcare of its enrollees. MLR is a basic financial measurement that generally shows how much of the premium dollars a health insurance issuer spends on healthcare expenses, as opposed to profits or administrative costs. A health insurance issuer that does not spend enough of its premium dollars on healthcare services or quality improvement activities must provide rebates to individuals and employers.
Who is TriCare for?
Those serving Uniformed Service members, National Guard/Reserve members, survivors, retirees, and their families worldwide. Some kinds of TRICARE do not qualify as MEC.
What are EAPs?
Under a 19-month contract with CMS, EAPs employed with Cognosante will assist with the "Medicaid unwinding" efforts. They will provide outreach and impartial, free, in-person and virtual enrollment assistance to impacted consumers in specific counties within 12 FFM states: AZ, FL, IL, LA, MI, MT, NC, OK, SD, TN, TX and UT. EAPs will also collaborate with CACs in other FFM states to maximize outreach opportunities
What is Medicaid Expansion?
Under the ACA, states may expand Medicaid eligibility to cover non-elderly, non-pregnant adults ages 19-64 with a household income up to or below 133% of the FPL who are not otherwise eligible for and enrolled in Medicaid coverage and are not entitled to or enrolled in Medicare Parts A or B.
Can individuals who are not lawfully present can apply for health coverage for their household member(s) who are lawfully present without having to provide a Social Security Number (SSN) or other proof of lawful presence. Yes or No
YES - You should not ask individuals applying on behalf of others any questions about their citizenship or immigration status because the information is irrelevant to the eligibility determination for the applicant.
Based on your conversation with this family, John is eligible to enroll in a QHP as a U.S.-born citizen. How would you answer the following application questions for John? Yes; No Yes; Yes No; No No; Yes
Yes;No
What is a Grandfathered plan
a group health plan that was created, or an individual health insurance policy that was purchased on or before March 23, 2010, has not changed in certain ways, and for which the issuer disclosed to enrollees that the plan is grandfathered. Grandfathered plans are exempted from many requirements of the ACA. Plans or policies may lose their grandfathered status if they make certain significant changes that reduce benefits or increase costs to consumers.
What is a A health insurance issuer, or issuer
an insurance company, insurance service, or insurance organization (including a health maintenance organization) that is required to be licensed to engage in the business of insurance in a state and that is subject to state law that regulates insurance (within the meaning of Section 514(b)(2) of the Employee Retirement Income Security Act of 1974 [ERISA]). This term does not include a group health plan.
What is a existing health condition
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.
What is Guaranteed issue?
Carrier must offer all plans (not grandfathered) to all individuals
Review ? - An individual with a primary home in the state in which they are applying for coverage Resident of the state, eligible to apply for coverage Residency may be established in more than one state if there is a primary residence for part of the year Residency is not established if there is no intent to have a primary residence
Resident of the state, eligible to apply for coverage
Review ? - An unhoused individual with no home address, who is staying with a friend, in a shelter, or outdoors in the state in which they are applying for coverage Resident of the state, eligible to apply for coverage Residency may be established in more than one state if there is a primary residence for part of the year Residency is not established if there is no intent to have a primary residence
Resident of the state, eligible to apply for coverage
Who can assist individuals on the marketplace besides Brokers
CAC's Navigators EAPS - limited contract
What is CHIP
CHIP provides no-cost or low-cost health insurance coverage to uninsured children under age 19 in families with qualifying incomes that are too high to qualify for Medicaid coverage.
Review Question: Last December, you helped Amari enroll in Marketplace coverage. It's now OE again, and Amari tells you he's worried he won't be able to sign up for the same plan again because he had cancer this year and had high utilization of his policy. You tell Amari he doesn't need to worry, because Marketplace plans don't take your healthcare spending or health status into consideration when considering eligibility. What is this policy called? Guaranteed issue Guaranteed renewability Grandfathered plan
Guaranteed Renewability
Hardship Exemptions - catastrophic coverage. Only individuals under age 30 or individuals of any age with hardship or affordability exemptions may purchase a catastrophic coverage plan. Catastrophic plans typically have high deductibles, and mainly protect individuals with very high medical costs. To make the determination, the Marketplace considers whether an individual has experienced a qualifying hardship.
Homeless Eviction./Foreclosure Utilities shut off Domestic Violence Family Member - death Disaster Bankruptcy Medical Expense Family Care expenses Dependent Child - Denied CHIP & Medicaid Non-Medicaid Eligibility State Eligibility Appeal Other - No Marketplace plans available
Review ? - Cannot make specific QHP recommendations to consumers Must conduct public outreach and education activities to raise awareness about the Marketplace May not receive compensation directly or indirectly from any health insurance issuer May not assist in SHOP enrollment Only agents and brokers Only Navigators and CACs (assisters) Agents, brokers, Navigators, and CACs
Only Navigators and CACs (assisters)
Review ? - Can make specific plan recommendations to consumers May assist small employers with selecting and enrolling in SHOP coverage May receive compensation from a health insurance issuer Only agents and brokers Only Navigators and CACs (assisters) Agents, brokers, Navigators, and CACs
Only agents and brokers
What are Navigators?
Organizations that are approved by and receive grants from CMS have certified Navigators who, among other required duties, must assist consumers in applying for and enrolling in health coverage through the Marketplace free of charge
What is the primary goal of the ACA
Provides a premium tax credit (PTC) to help subsidize coverage. Gives consumers tools to make informed choices about their healthcare coverage. Puts in place strong consumer protections
Review ? - An individual planning to visit another state temporarily during the year Resident of the state, eligible to apply for coverage Residency may be established in more than one state if there is a primary residence for part of the year Residency is not established if there is no intent to have a primary residence
Residency is not established if there is no intent to have a primary residence
Review ? - An individual with two primary homes in different states in which they are applying for coverage Resident of the state, eligible to apply for coverage Residency may be established in more than one state if there is a primary residence for part of the year Residency is not established if there is no intent to have a primary residence
Residency may be established in more than one state if there is a primary residence for part of the year
What are CACs?
community health centers, healthcare providers, and certain social service agencies. Marketplace CACs are certified directly by those CDOs. Participation as a CDO is voluntary and not funded by the Marketplace.
