1 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland Center for Consumer Information & Insurance Oversight Federally-facilitated Marketplace Agent and Broker Training Outline and Summary Table of Contents 1 Affordable Care Act and Marketplace Basics... 2 Topic 3: Affordable Care Act Basics... 3 Topic 4: Marketplace Basics... 4 Topic 5: Overview of Individual and Small Business Health Options Program Marketplaces... 5 Topic 6: Registration in the Federally-facilitated Marketplaces... 6 Topic 7: Participation in the Federally-facilitated Marketplaces Privacy and Security Standards... 8 Topic 3: Privacy Standards and Implementation Specifications... 9 Topic 4: Information Security Individual Marketplace Topic 3: Review of Market Reforms Topic 4: Insurance Affordability Programs Topic 5: Eligibility Topic 6: Enrollment Small Business Health Options Program (SHOP) Marketplace Topic 3: Introduction to Health Law Changes for the Small Group Market Topic 4: Introduction to SHOP Marketplaces Topic 5: Eligibility Topic 6: Employer Application and Enrollment Topic 7: Employee Enrollment Topic 8: Enrollment and Annual Renewal... 19
2 1 Affordable Care Act and Marketplace Basics 2 Welcome to the Affordable Care Act and Marketplace Basics course for agents and brokers. This course covers basic information about the health care law the Patient Protection and Affordable Care Act of 2010, or Affordable Care Act and the Health Insurance Marketplaces that the law created. In the Affordable Care Act and associated regulations, federal and state-based Health Insurance Marketplaces are referred to as Exchanges. However, throughout this course, we will use the term Marketplace instead of Exchange because most consumer-facing materials use the term Marketplace. Research has found that the term Marketplace better describes what an Exchange does, and is more easily understood by consumers.
3 3 Topic 3: Affordable Care Act Basics Identify major health care reforms and consumer protections required under the Affordable Care Act Define the term guaranteed issue Define the term Medical Loss Ratio (MLR) Identify services included in the essential health benefits (EHB) Identify the four levels of generosity, define actuarial value (AV), and determine the AV for each level Identify limits on cost sharing Understand rating standards based on age, family composition, geographic area, and tobacco usage The primary goal of the Affordable Care Act is to help millions of Americans obtain health insurance coverage. To achieve that goal, the Affordable Care Act puts in place strong consumer protections to ensure most individuals have access to health insurance, regardless of their health status. Health insurance issuers must: o Offer all of their group and individual market policies to any eligible individual in the state (This reform is called guaranteed issue ); o Not limit or exclude coverage related to pre-existing health conditions, regardless of the age of the covered individual; o Spend at least 80 percent of premium dollars on medical care or provide a rebate to the insured individuals or policyholders; and o Offer health insurance plans that provide at least a minimum set of services (called EHB). There are four levels of generosity for health plans: Bronze, Silver, Gold, and Platinum. Each of these levels is based on an average measure of plan generosity (AV) and helps consumers, agents, brokers, and other consumer assistance entities compare and choose a health plan. In addition to the metal level plans, issuers can offer catastrophic plans to individuals under age 30 and individuals who otherwise do not have an affordable coverage option, or who otherwise qualify for a hardship exemption to the minimum essential coverage requirement. All health plans must limit cost sharing. As of January 1, 2014, all individual plans must limit out-of-pocket costs. Rates can vary by age, family composition, geographic area, and tobacco use.
4 4 Topic 4: Marketplace Basics Define the term Marketplace and identify its key functions Identify characteristics of a qualified health plan (QHP) Define Consumer Operated and Oriented Plans (CO-OP), Multi-state Plans (MSPs), and stand-alone dental plans Identify federal programs that provide health insurance coverage in addition to the Marketplaces Each state has a Health Insurance Marketplace where individuals, small business employers, and employees may purchase insurance. QHPs must be licensed and meet certain transparency requirements. To become certified, a QHP must meet a minimum set of criteria, including coverage of the EHB, benefit design standards, and network adequacy standards. The Marketplaces have certification, eligibility, enrollment, and oversight functions. Marketplaces may be State-based Marketplaces or Federally-facilitated Marketplaces. Some Federallyfacilitated Marketplaces are operated partly by the state, and these are referred to as State Partnership Marketplaces. Other types of plans may be offered through the Marketplace, including CO-OP plans, Multi-state Plans, and stand-alone dental plans. The federal government operates many other health care programs outside of the Marketplace, including Medicare, the Department of Defense TRICARE program (DoD TRICARE), the Veterans Health Administration (VA) program, and the Indian Health Service (IHS) program. People that enroll in these programs have minimum essential coverage and do not need to obtain additional coverage through the Marketplaces.
5 5 Topic 5: Overview of Individual and Small Business Health Options Program Marketplaces List the key eligibility requirements for the Individual Marketplaces List the key eligibility requirements for the SHOP Marketplaces Understand the insurance affordability programs available through the Individual Marketplaces Understand how the Marketplaces determine eligibility for individuals seeking health insurance coverage through a Marketplace The Affordable Care Act requires most United States citizens and legal residents to have minimum essential health coverage as of 2014, or make an individual shared responsibility payment. However, it exempts several categories of individuals from this requirement. Individuals purchasing health insurance through a Marketplace may be eligible for the premium tax credit, which reduces the cost of premiums. The premium tax credit is available to lower the cost of coverage through the Marketplaces, including on an advance basis. Premium tax credits are reconciled on an individual s federal tax return. Cost-sharing reductions limit the out-of-pocket costs for EHB covered by QHPs. There are several categories of cost-sharing reductions that are based on annual household income and family size. Each QHP issuer implements these differently, based on their specific plan design. A single, streamlined application allows consumers to receive determinations for all programs they are eligible for without requiring additional application forms or multiple eligibility determinations. The application may be filed online, in person, by mail, or by phone. In 2015, small businesses that offer coverage through a FF-SHOP may be able to offer their employees a choice of QHPs and qualified dental plans (QDPs). To qualify for a FF-SHOP, a business must be located in a FF-SHOP s service area, offer coverage to all full-time employees, have at least one eligible employee on payroll, and have 50 or fewer FTE employees on payroll. The premium tax credit and cost-sharing reductions are not available to employers, employees, and their families covered through a FF-SHOP. Employers meeting certain size and average wage requirements may receive a small business health care tax credit to assist with the cost of health insurance coverage purchased through a SHOP.
6 6 Topic 6: Registration in the Federally-facilitated Marketplaces Identify the general registration process for agents, brokers, and web-brokers in the Federally-facilitated Marketplaces Understand the circumstances for termination of an agent, broker, or web-broker s Federally-facilitated Marketplace Agreements for the 2015 Plan Year The registration requirements for agents and brokers in the Federally-facilitated Marketplaces differ depending on (1) the Marketplace in which the agent or broker wishes to participate (i.e., Individual Marketplace, SHOP Marketplace, or both) and (2) whether the agent or broker is new to the Federallyfacilitated Marketplaces or is renewing his or her registration. The Agent Broker Federally-facilitated Marketplace Agreements for the 2015 Plan Year, which agents and brokers must execute before assisting consumers in a Federally-facilitated Marketplace, contain federal regulations and Marketplace privacy and security requirements. Agents and brokers must enter their NPNs on health insurance applications in the Federally-facilitated Marketplaces in order to receive compensation from health insurance issuers. HHS may terminate an agent s, broker s, or web-broker s Federally-facilitated Marketplace Agreements for the 2015 Plan Year for cause if HHS determines that a specific finding of noncompliance or a pattern of noncompliance is sufficiently severe, or if the agent, broker, or web-broker materially breaches any term of the Agreement(s) between the agent or broker and CMS.
7 7 Topic 7: Participation in the Federally-facilitated Marketplaces Identify the roles of agents, brokers, and web-brokers in the Federally-facilitated Marketplaces Understand the roles of other assisters in the Federally-facilitated Marketplaces Describe how agents and brokers are compensated for their participation in the Federally-facilitated Marketplaces Identify the entities that are responsible for monitoring agent and broker compliance with applicable laws and standards Agents and brokers can assist individuals, employers, and employees with enrollment in QHPs in the Federally-facilitated Marketplaces. Agents and brokers may also assist qualified consumers with eligibility determinations for the premium tax credit and cost-sharing reductions for eligible plans. Web-brokers can assist consumers in selecting and enrolling in a QHP through the web-brokers own website. Web-brokers may also assist qualified consumers in the Individual Marketplaces in applying for the premium tax credit and cost-sharing reductions for eligible plans. 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. 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. QHP issuers verify that their appointed agents and brokers have a valid state license to sell health insurance products, as well as an NPN.
8 2 Privacy and Security Standards 8 Welcome to the Privacy and Security Standards course for agents and brokers. In this course, you will learn basic information on specific privacy and security standards that apply to agents and brokers operating in the Federally-facilitated Marketplaces. In the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act) and associated regulations, federal and state-based Health Insurance Marketplaces are referred to as Exchanges. However, throughout this course, we will use the term Marketplace instead of Exchange because most consumer-facing materials use the term Marketplace. Research has found that the term Marketplace better describes what an Exchange does, and is more easily understood by consumers.
9 9 Topic 3: Privacy Standards and Implementation Specifications Describe the difference between privacy, security and confidentiality Define PII Explain the Agreement Between Agent or Broker and the Centers for Medicare & Medicaid Services (CMS) for the Federally-facilitated Exchange Individual or Small Business Health Options Program (SHOP) Market Explain how individuals may access their PII Describe the requirements regarding the Privacy Notice Statement Identify the extent to which PII may be used and disclosed Explain how individuals may correct their PII Identify types of privacy incidents Describe the procedures required for incident handling and breach notification Explain record retention policies Understand when a civil money penalty may be imposed Explain requirements for business partners Describe the relationship between state and federal laws In helping consumers obtain eligibility determinations, compare plans, and enroll in QHPs through the Federally-facilitated Marketplaces, agents and brokers may gain access to PII. PII is information that can be used to distinguish or trace an individual s identity, alone, or when combined with other personal or identifying information that is linked or linkable to a specific individual. An agent or broker may only use or disclose PII as needed to carry out required functions. Before assisting consumers in a Federally-facilitated Individual Marketplace or FF-SHOP, agents and brokers must accept the Agreement Between Agent or Broker and CMS for the Federally-facilitated Exchange Individual or SHOP Market, which includes privacy and security standards for use and disclosure of PII. Tax information is confidential and special rules apply to its access and disclosure. A privacy incident occurs any time people have access or potential access to PII when they are not authorized to, or for a purpose they are not authorized to do. A privacy incident can arise from any number of causes. An agent or broker must report all PII incidents and breaches to the CMS IT Service Desk.
10 10 Topic 4: Information Security Define the term information security Identify three key elements to protecting information Identify the differences between threats, vulnerabilities, and risks to information Identify certain controls that agents and brokers can take to protect information within the Marketplaces List steps that agents and brokers can take to help promote information security in the Marketplaces Information security is the protection of information and information systems from unauthorized access, use, disclosure, disruption, modification, or destruction to provide confidentiality, integrity, and availability. The goal of an information security program is to understand, manage, and reduce the risk to information. There are three key elements to protecting 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 IT resources. A threat is the potential to cause unauthorized disclosure, changes, or destruction to an asset. Threats can be natural, environmental, and man-made. 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. A risk is the likelihood that a threat will exploit a vulnerability. Agents and brokers can apply certain controls policies, procedures, and practices that manage risk and protect IT assets to protect information within the Marketplaces. There are steps agents and brokers can take to help promote information security in the Marketplaces. Most importantly, NEVER share your password.
11 3 Individual Marketplace 11 Welcome to the Individual Marketplace course for agents and brokers. This course provides more information about the health care law the Patient Protection and Affordable Care Act of 2010, or Affordable Care Act and the new Individual Marketplaces where individuals and families can shop for private insurance plans as of October 1, In the Affordable Care Act and associated regulations, federal and state-based Health Insurance Marketplaces are referred to as Exchanges. However, throughout this course, we will use the term Marketplace instead of Exchange because most consumer-facing materials use the term Marketplace. Research has found that the term Marketplace better describes what an Exchange does, and is more easily understood by consumers.
12 12 Topic 3: Review of Market Reforms Outline minimum essential coverage Describe market reforms under the Affordable Care Act Minimum essential coverage is the type of health care coverage an individual needs in order to meet the individual shared responsibility requirement. An individual who is ineligible for an exemption and does not have coverage in 2014 is required to make an individual shared responsibility payment on his or her 2014 tax return filed in In certain circumstances that affect an individual s ability to purchase health insurance coverage, an individual may qualify for a hardship exemption, which enables him or her to buy catastrophic coverage through the Marketplace. Health insurance issuers must: Not limit or exclude coverage related to pre-existing health conditions, regardless of the age of the covered individual Limit premium variations to age, family composition, geographic area, and tobacco use Offer health insurance plans that: o Provide, at a minimum, a package of benefits, known as essential health benefits (EHB) o Eliminate annual dollar limits on EHB, effective for all plans as of 2014 o Eliminate lifetime dollar limits on EHB, effective for all plans issued on or after September 23, 2010 o Cover certain preventive services without requiring cost sharing o Cap annual out-of-pocket spending (for individual market plans)
13 13 Topic 4: Insurance Affordability Programs Describe the premium tax credit, including the option for consumers to obtain the credit in advance Describe cost-sharing reductions Describe Medicaid and CHIP The premium tax credit is an income tax provision to help individuals and families afford health insurance coverage purchased through a Marketplace. Advance payments of the premium tax credit are paid on a monthly basis directly to the insurance company offering the QHP. An individual may choose to apply some or all of the tax credit towards QHP premiums costs on an advance basis with reconciliation at the end of the year or to receive the credit on his or her federal tax return filed for the plan year. Cost-sharing reductions are subsidies that reduce the amount of out-of-pocket expenses, such as deductibles or coinsurance, that an individual is responsible for as part of his or her QHP coverage. Medicaid and CHIP are federal and state partnership programs designed to provide coverage to lower income adults and children up to age 19. A person eligible to receive Medicaid or CHIP may purchase QHP coverage through a Marketplace, but is not eligible for the premium tax credit or cost-sharing reductions. Family members may be covered by different health plans; certain family members may qualify for coverage through Medicaid or CHIP, while others may purchase QHPs through the Marketplaces.
14 14 Topic 5: Eligibility Identify the eligibility criteria for enrolling in a qualified health plan (QHP) Outline the required method for calculating income used for the Medicaid program and the Children s Health Insurance Program (CHIP), the premium tax credit, and cost-sharing reductions as of 2014 Identify the eligibility criteria for qualifying for advance payments of the premium tax credit and costsharing reductions Describe the process and responsibilities for determining eligibility for Medicaid and CHIP Identify methods of applying for health insurance coverage through a Marketplace and steps in the application process When a consumer applies for coverage in a Marketplace, he or she needs to provide some information about his or her household, including income, any insurance he or she currently has, and some additional items. Mixed immigration status families can apply for Medicaid and CHIP coverage, as well as advance payments of the premium tax credit and cost-sharing reductions for private insurance for any family members who are eligible for coverage in the Marketplace. The Marketplaces use MAGI to determine a consumer s eligibility for advance payments of the premium tax credit and cost-sharing reductions. The MAGI calculation equals adjusted gross income as defined by the IRS, plus any excluded foreign income, tax-exempt interest received or accrued during the taxable year, and non-taxable Social Security benefits. Assets are not considered in determining eligibility. This income methodology is the same for determining eligibility for advance payments of the premium tax credit and cost-sharing reductions, and determining eligibility for Medicaid and CHIP, with a few exceptions. In order to determine eligibility, the Marketplace verifies applicant information using data from key federal agencies. After an individual submits an application for coverage to a Marketplace, the Marketplace provides an immediate eligibility determination. If an individual completes an application by visiting HealthCare.gov and learns that he or she is eligible for a government-sponsored coverage such as Medicaid or the CHIP, you can help guide them through next steps.
15 15 Topic 6: Enrollment Identify enrollment rules, including the available enrollment periods Identify circumstances that permit enrollment or plan changes outside of an open enrollment period Describe the enrollment process Enrollment is the process of signing up for a QHP. Before enrolling in a QHP, individuals must obtain eligibility determinations from a Marketplace. After their eligibility has been determined, individuals may enroll in a QHP during two timeframes throughout the year: the open enrollment period and SEPs. The date that an individual s QHP health insurance coverage takes effect is based on the date a Marketplace receives his/her enrollment selection, and SEP eligibility SEPs are based on certain triggering events, which include gaining or becoming a dependent through marriage, birth, adoption, placement for adoption, or placement in foster care; loss of minimum essential coverage; or other exceptional circumstances. After successfully completing registration, agents and brokers are able to assist consumers in the Federally-facilitated Marketplaces in two ways: the Direct Enrollment Pathway and the Marketplace Pathway. When a Marketplace receives a QHP selection from an eligible individual, it promptly notifies the applicable QHP issuer of the requested enrollment and transmits the needed eligibility and enrollment information to the issuer. If a qualified individual makes a QHP selection but later selects a new QHP before the coverage effective date, without making application changes, the initial QHP selection can be automatically terminated by the Marketplace as part of the transmission of updated enrollment information to QHP issuers. Enrollees may terminate QHP coverage on their own accord at any time of the year, including as the result of obtaining other minimum essential coverage, after giving appropriate notice to the Marketplace.
16 4 Small Business Health Options Program (SHOP) Marketplace 16 Welcome to the Small Business Health Options Program (SHOP) Marketplace course for agents and brokers. This course provides information about the Federally-facilitated SHOP Marketplaces. In the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act) and associated regulations, Health Insurance Marketplaces are referred to as Exchanges. However, throughout this course, we will use the term Marketplace instead of Exchange because consumer-facing materials use the term Marketplace. Research has found that the term Marketplace better describes what an Exchange does, and is more easily understood by consumers. Please note that these courses are intended for agents and brokers operating in the Federally-facilitated Health Insurance Marketplaces, and certain content is not applicable to the Health Insurance Marketplaces that are operated by states. Topic 3: Introduction to Health Law Changes for the Small Group Market Describe Affordable Care Act health law changes Describe how premium rates are allowed to vary Health insurance issuers can no longer impose pre-existing condition exclusion periods or charge employers more because of the health status of their employees. Premiums in the small group market are built differently than prior to the enactment of the Affordable Care Act. There are limitations on how premium rates may vary. Participation in tobacco-related wellness programs eliminates the surcharge added to premiums for enrollees who legally use tobacco.
17 17 Topic 4: Introduction to SHOP Marketplaces Describe the advantages of the FF-SHOP Marketplaces Describe how premiums are built in the FF-SHOP Marketplaces Describe how employee contributions to the premium are calculated The SHOP Marketplace may offer small employers several advantages, including: o The ability to offer a single QHP and QDP, or a choice of QHPs and QDPs to all employees o Choice of percentage contribution toward the health insurance premium of each employee o Less financial uncertainty related to premium cost increases at plan renewal o A SHOP website with anonymous shopping tools o The Small Business Health Care Tax Credit All health plans offered in a SHOP must be QHPs. Topic 5: Eligibility Identify who is eligible for SHOP Identify who qualifies for the Small Business Health Care Tax Credit Identify how a Small Business Health Care Tax Credit is determined Employers are eligible for an FF-SHOP if: o Their business is located in an FF-SHOP s service area o They have 50 or fewer FTE employees o They offer coverage to all full-time employees Employers are eligible for the Small Business Health Care Tax Credit if: o They have fewer than 25 FTE employees o Employee wages are on average below $50,000 o They pay at least 50% of the cost of single health care coverage for each of their employees The Small Business Health Care Tax Credit is generally available only for coverage purchased through SHOP beginning in Health care tax credit amounts depend on the number of employees and average employee wages.
18 18 Topic 6: Employer Application and Enrollment Identify agent and broker privacy and security requirements Describe the online employer application process Describe how to make changes after initial enrollment There are eight steps for agents and brokers to help employers with FF-SHOP application and enrollment: 1. Import basic information about the employer s business on the SHOP website or through the SHOP Agent Broker Portal 2. Create an employee roster with basic information about each employee 3. Employer reads information about each plan on the SHOP website 4. Employer determines whether to offer employees a single health plan or a choice of health plans within a given metal level or issuer beginning plan year Employer chooses a defined percentage of the reference plan to contribute for each employee (and if applicable, for dental coverage and for each dependent) 6. Employer reviews summary of choices 7. Agents and brokers help employees enroll in SHOP 8. Employer reviews completed group enrollment An employer must submit the first month s premium after employees enroll. Employers pay an aggregated premium payment to SHOP directly beginning plan year 2015.
19 19 Topic 7: Employee Enrollment Describe the process for an employee to complete an FF-SHOP application Describe how dependents are enrolled in an FF-SHOP Describe how to add a newly-hired employee in an FF-SHOP Agents and brokers can help employees and their dependents complete an application and enroll in a SHOP qualified health plan (and if applicable a qualified dental plan); employees can also register and enroll themselves and their dependents using an online portal. Employees that choose to accept the offer of SHOP coverage must establish a Health Insurance Marketplace account, enter their personal information, select a plan, and decide whether to enroll their dependents if dependent coverage is offered. Employees may enroll and make changes during an open enrollment period or, if eligible, during an SEP. Employers need to add new employees to their rosters for them to be eligible to enroll in a SHOP. If authorized by the employer, an agent or broker may also manage the employee roster through the SHOP Agent Broker Portal. Topic 8: Enrollment and Annual Renewal Identify the timelines for initial enrollment Identify parameters for special enrollment periods (SEP) Describe the annual renewal process Agents and brokers can help employees enroll in a SHOP plan; employees can also enter enrollment information online. There are SEPs for certain triggering events, such as when an individual loses minimum essential coverage, when an individual moves, marriage, and birth or adoption of a child. SEPs generally last for 30 days. Employers may renew 2014 plan year QHPs as early as November 15, 2014 for coverage to be effective as early as January 1, Thereafter, employers may renew plans online using the FF-SHOP portal when the 2014 and 2015 plans end.
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The July 2013 The Problem Insurance companies could turn away the 129 million Americans with pre-existing conditions Premiums had more than doubled over the last decade, while insurance company profits