State of Delaware Office of Management and Budget, Statewide Benefits Office

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1 State of Delaware Office of Management and Budget, Statewide Benefits Office Patient Protection and Affordable Care Act (ACA) Notice of Coverage Options and Health Insurance Marketplace Frequently Asked Questions (FAQs) 1. Why did I receive a notice entitled New Health Insurance Marketplace Coverage Options and Your Health Coverage? The ACA requires each American to have health insurance by March 31, 2014, which is known as the individual mandate. Employers are required to provide this notice to all of their employees by October 1, 2013 notifying them of this requirement and the Health Insurance Marketplace. 2. What is a Health Insurance Marketplace or Exchange? A Health Insurance Marketplace is a place where people can go to buy individual health insurance. Each state will have its own marketplace, either set up by the state, the federal government or a partnership between the two. 3. If I am a state employee or retiree who is enrolled in the State s Group Health Insurance Program, what do I need to do? You do not need to take any action. The State s eligibility rules and plan coverage are not changing. Your coverage meets the individual mandate and is expected to be a better value than the Marketplace coverage. 4. What if I like a plan offered through the Marketplace better than what s offered by the State s Group Health Insurance Program, can I still choose coverage through the Marketplace? Yes, but since the State s plan meets the minimum value standard, you and your eligible family members would not qualify for a premium assistance tax credit to buy coverage through the Marketplace unless the Plan s required contribution for self-only coverage made the coverage unaffordable. 5. Can I drop my coverage for myself under the State s Group Health Insurance Program as I wish to enroll in coverage through the Marketplace? Yes, you can drop coverage for yourself to enroll in coverage through the Marketplace. You must put your request in writing to disenroll from your State health plan, note the effective date of the Marketplace coverage and give to your Benefits representative in your agency or school within 30 days of the effective date of the Marketplace coverage.

2 6. I am not currently enrolled in the State s Group Health Insurance Plan and wish to enroll to satisfy the Individual Insurance Mandate. Employees must wait to enroll in the State s Group Health Insurance Plan until open enrollment in May 2014 for an effective date of July 1, Employees whose employers have a mid-year plan are given relief from the individual mandate penalty provided they enroll in the employer plan when enrollment is available mid-year. 7. Would an employee be subject to the individual mandate penalty during the first three months of employment if he/she chooses to waive coverage during that time instead of paying the full share of the premium? The employee would be subject to the penalty for each month that he/she does not have coverage. However, the employee may be exempt under the following circumstances: (1) not having affordable coverage; (2) having a hardship; and (3) having a 'short coverage gap.' A short coverage gap is defined as a continuous period of less than three months in which the employee does not have coverage. An employee can only have one short coverage gap per calendar year. In order to ensure that the employee is not subject to the penalty, it is recommended that the employee elect coverage upon employment and pay the full share, if not yet eligible for State share, until State share begins or seek assistance from a Marketplace Guide to enroll in coverage through the Marketplace for the first three months. Please visit the Need Help section of 8. If I choose to waive coverage during the first two months of employment, can I apply for coverage through the Marketplace and receive a subsidy? Yes, you can apply for coverage if the two months coincides with the open enrollment period for the Marketplace or if you just lost coverage and therefore are eligible to enroll outside of the open enrollment period. Receipt of a subsidy depends on your individual financial situation. 9. I recently lost my health care coverage. Can I enroll in the State s Group Health Insurance Plan? Yes, you can enroll yourself and/or your dependent(s) in the State s Plan due to loss of coverage (e.g. spouse s employer is terminating employer health coverage) provided the request is made within 30 days of loss of coverage. If you are enrolling a spouse, please complete the Spousal Coordination of Benefits Form. 10. If I am a state employee or non-medicare eligible retiree eligible for, but not participating in the State s Group Health Insurance Program, what do I need to do? The ACA requires everyone to have health insurance by March 31, If you are not a participant of the State s Plan but are covered under another plan, then you may meet the individual mandate. If you are not covered under any health plan then you may want to

3 explore coverage options through the marketplace. You may enroll in the State s health plan during open enrollment in May 2014 for coverage effective July 1, I am a casual seasonal employee or substitute not eligible for coverage in the State s Group Health Insurance Program. Am I now eligible to enroll in the State s health plan due to the ACA? No, the State s eligibility rules have not changed. Casual seasonal and substitutes employees are not eligible for coverage under the State s Group Health Insurance Program. 12. If I am not eligible for coverage under the State s Group Health Insurance Program, what do I need to do to satisfy the individual mandate? If you are covered under another plan (e.g. under your spouse s or parent s plan), then you may meet the individual mandate. If you are not covered under any health plan then you may want to explore coverage options through the marketplace at If I am a State of Delaware pensioner are there any changes to my eligibility and coverage for the State of Delaware s Group Health Insurance Program due to the Health Insurance Marketplace? No, your health coverage through the State of Delaware Office of Pensions has not changed. No action is required on your part to continue your health coverage if you are currently enrolled. 14. Can I drop my coverage for myself or my spouse or dependent children covered by the State Group Health Insurance program as they wish to enroll in coverage through the Marketplace? Yes, you can drop coverage for yourself, your spouse or dependent children covered by the State Group Health Insurance program to enroll in coverage through the Marketplace. You must put your request in writing to disenroll from your State health plan, note the effective date of the coverage and give to your Benefits representative in your agency or school within 30 days of the effective date of the Marketplace coverage. 15. Can I drop coverage from my individual Marketplace plan outside of the open enrollment period? Individuals may drop Marketplace coverage if they have a qualifying event (e.g. they get coverage through their employer or family). Insurers will drop coverage if the individual does not pay their premiums for 90 days. Dropping coverage for any other reason outside of open enrollment is subject to the rules of the individual policy and/or insurer. Individuals should seek guidance from their insurer.

4 16. I cover my spouse under the State s Group Health Insurance Program as secondary as he had employer health coverage. His employer has directed its employees to the Small Business Health Options Program (SHOP). What is Small Business Health Options Program (SHOP)? SHOP is group coverage currently offered to small businesses with fewer than 25 fulltime employees and the average annual wages of the employees are less than $50,000. SHOP coverage will be available through the Marketplace in Is my spouse required to enroll in his/her employer s plan through the SHOP or can they be covered under the State s Group Health Insurance Program? Yes, your spouse is required to enroll through the SHOP unless the share of the premium for the lowest priced plan offered is more than 50% of the total cost of the coverage. You can also cover your spouse through the State s plan, however the state s plan will pay as secondary. If your spouse is required to pay more than 50% of the total cost of the lowest plan offered, your spouse can choose to not enroll in the SHOP and enroll in coverage through you and your spouse will be covered as primary. Enrollment must be completed within 30 days of your spouse s loss of employer coverage. 18. If my spouse has coverage through the SHOP, what if anything do I need to do? Coverage in SHOP constitutes employer coverage and if you are covering your spouse under the State s Group Health Plan, you need to complete an updated Spousal Coordination of Benefits form. 19. I cover my spouse under the State s Group Health Insurance Program as secondary as he had employer health coverage. His employer is dropping health care coverage entirely. Can my spouse now be covered as primary under the State s Group Health Insurance Program? Yes, if your spouse s employer is dropping health care coverage entirely, please complete an updated Spousal Coordination of Benefits Form within 30 days of the loss of employer coverage indicating the date your spouse lost coverage in order to update your spouse s State coverage from secondary to primary. 20. I currently do not cover my spouse under the State s Group Health Insurance Program as he had employer health coverage. His employer is dropping health care coverage entirely. Can my spouse now be enrolled in the State s Group Health Insurance Program? Yes, if your spouse s employer is dropping health care coverage entirely, please contact your HR/Benefits representative within 30 days of the loss of coverage if you wish to enroll your spouse in the State s Group Health Insurance Program. You must also complete a Spousal Coordination of Benefits Form upon enrolling your spouse in the State s plan.

5 21. Will the State of Delaware notify the federal government if an employee is not insured through the State Group Health Program as either an employee or pensioner? Beginning in 2016, employers must report to the IRS about group health plans they offer, covered persons and employee full-time status. The IRS will use this information to enforce the individual mandate penalty. 22. How will an individual be required to notify the federal government if they have health care coverage and have satisfied the individual mandate? When you file your 2014 tax return you will have to enter information about your coverage (or your exemption) on your return. You may get a notice from your insurance provider by January 31, 2015 describing your coverage status during the previous year. There is an Internal Revenue Service requirement that requires applicable large employers (those with more than 50 fill-time employees) to furnish statements to fulltime employees so that employees may use the statements to help determine whether, for each month of the calendar year, they can claim a premium tax credit on their tax returns. These statements will be required by employers beginning in 2016 for the 2015 tax year. 23. How do I get information on the coverage options available through the Marketplace and the rates? The coverage options and rates will be available on the State s Marketplacewww.choosehealthde.com beginning on October 1, How do I enroll in the Marketplace? Enrollment though the Marketplace for 2014 begins October 1, 2013 and runs through March 31, Visit to enroll. In order to have coverage by January 1, 2014, you must enroll before December 23, Enrollment for subsequent years begins on November 15 and runs through February I am still confused. Is there someone I can talk to? Yes, you can call the federal government at or meet with one of the State s Marketplace Guides (MPGs). To schedule a meeting with a MPG, call March 28, 2014