The main steps of the Marketplace eligibility and enrollment process are as follows:
By submitting a single, web-based, streamlined application, individuals will be able to receive an eligibility determination for enrollment in a QHP and access to any available financial assistance. The single, streamlined application can be submitted directly to a Marketplace or through state Medicaid and CHIP portals or call centers, and will enable individuals to find out about their eligibility for:
The online version of this application will feature a dynamic, “smart” process that will be tailored based on the applicant’s circumstances, and will ask only questions that are relevant to that applicant.
Individuals will be able to submit an application to a Marketplace through the Marketplace website, through the mail, over the phone through Federally-facilitated Marketplace toll-free call center, or through the state Medicaid or the CHIP portals or call centers. The best place to get more detailed information about the application process is at www.Healthcare.gov. This website will:
If registered agents and brokers are affiliated with certain QHP issuers, the agents and brokers may also connect to a Federally-facilitated Marketplace through the QHP issuers website to help individuals apply for eligibility determinations and, if the consumer is eligible, select and enroll in a QHP.
Prior to determining eligibility, the Marketplace will verify applicant information using data from key federal agencies.
In general, the verification process involves validating an applicant’s attestation (e.g., that he or she is a citizen) by checking available electronic data from data sources approved by the Department of Health and Human Services (HHS). In the case of inconsistencies between the applicant’s attestation and the information contained in the approved electronic sources, the application process provides a period of time for the applicant to provide satisfactory documentation or otherwise resolve the issue. At the conclusion of the eligibility verification process, the Marketplace will produce a notice that will include a list of any inconsistencies, along with instructions regarding how they can be resolved.
Depending on an individual’s specific circumstances, the Marketplace may verify the information, from the following sources, to conduct the verification process:
If the Marketplace needs additional information regarding SSN, citizenship, or immigration status, the Marketplace will establish eligibility based on the individual’s attestation in those areas for a period of 90 days, during which the individual needs to resolve the issue to continue his or her eligibility for health care coverage.
If the Marketplace needs additional information regarding a criterion of eligibility other than SSN, citizenship, or immigration status, whether the Marketplace will establish eligibility for an insurance affordability program while the inconsistency is resolved depends on whether the applicant’s income makes him or her eligible for Medicaid or CHIP, or for advance payments of the premium tax credit. The Marketplace cannot determine that the applicant is eligible for Medicaid or CHIP until the inconsistency is resolved. However, if the applicant’s income and other eligibility information are consistent with eligibility for advance payments of the premium tax credit, the Marketplace will establish eligibility based on the applicant’s attestation during the 90-day inconsistency period, as long as the applicant attests that he or she understands that advance payments of the premium tax credit are subject to tax reconciliation.
The 90-day inconsistency period may be extended if the applicant demonstrates that he or she has made a good faith effort to obtain the required documentation. After the inconsistency period expires, the Marketplace will issue a final eligibility determination.
Privacy Notice Statement
As a condition of operating in a Federally-facilitated Individual Marketplace, agents and brokers must execute the Federally-facilitated Marketplace Agreement, which includes privacy and security standards. These privacy and security standards include the requirement that agents and brokers provide individuals with a Privacy Notice Statement regarding use and disclosure of PII. This Privacy Notice Statement must be presented to individuals prior to assisting them with application and enrollment in coverage through a Federally-facilitated Individual Marketplace. You will need to review the Federally-facilitated Marketplace Agreement for more details about the Privacy Notice Statement, and when it is necessary to obtain affirmative consent.
After an idividual submits an application for coverage to a Marketplace, if no additional verification is required, the Marketplace will provide an immediate eligibility determination. If there are inconsistencies and additional verification is required, the Marketplace will provide a notice that will include information about next steps, including an identification of the inconsistencies that need to be resolved and instructions for how to resolve them.
If an individual is determined eligible for enrollment in a QHP through the Marketplace, he or she then may select a plan to initiate enrollment. If an individual is assessed as potentially eligible or determined eligible for Medicaid or CHIP, the Marketplace will provide a notification, and transfer his or her information to the state Medicaid or CHIP agency for follow-up.
If an individual disagrees with the eligibility determination, he or she may appeal the decision.
Annual Redetermination Process
Beginning January 1, 2014, the Marketplaces must annually reassess the eligibility of each qualified individual who was determined eligible for enrollment in a QHP. This eligibility reassessment will occur in advance of the open enrollment period.
Changes During the Year
A Marketplace must also re-determine a qualified individual’s eligibility if it receives and verifies new information (e.g., change of state of residence, death of a covered family member), that would affect an individual’s eligibility, either from the qualified individual or other sources, that affect an individual’s eligibility. Qualified individuals must report any changes with respect to eligibility within 30 days of that change.
Next Topic: Open Enrollment
Agents and Brokers are required to be trained to assist consumers with the application and decision making process. Using an Agent to enroll in a ObamaCare Health Plan will be the primary choice of many americans. After all agents have the inside track on companies and their promptness to handle claims and pay benefits in atimely fashion.