- Consumers may purchase Expanded Bronze plans. Expanded Bronze plans either cover and pay for at least one major service, other than preventive services before the deductible or meet the requirements to be a high deductible health plan. Covered major services could include primary care visits, specialist visits, emergency room services, inpatient hospital services, generic drugs, preferred brand drugs or specialty drugs.
In addition, Catastrophic plans are offered and will cover the same services, but their coverage will be less generous than the Bronze level plans. A Catastrophic plan may be a less expensive option for those who are eligible: only young adults under 30 and individuals who have a hardship exemption from the individual mandate are allowed to purchase Catastrophic plans. Premium tax credits and cost-sharing reductions are not available for catastrophic plans and they cannot be used with Health Savings Accounts.
Also, stand-alone dental plans are available through the Health Insurance Marketplace.
How do the tiers (Bronze, Silver, Gold, Platinum) help consumers compare plans?
The tiers are a way to categorize plans based on actuarial value. Plans within each tier have a similar actuarial value, even if they cover benefits differently or have different cost-sharing. While all plans in a tier must cover essential health benefits, the details of their coverage (such as how many physical therapy visits are covered, or which prescription drugs are covered) may be different. Some plans may offer benefits in addition to the essential health benefits.
What is actuarial value?
Actuarial value compares how much the insurance company will pay versus how much you will pay for health care costs. The percentage the plan pays depends on the cost-sharing details – how much out-of-pocket the consumer pays for deductibles, coinsurance, and copayments and the out-of-pocket limits. The percentage is an estimate of what the plan will pay for all policyholders. Your individual benefits may be more or less.
Actuarial value only reflects differences in cost-sharing. It does not give any other information about a plan that may be important to a particular person or affect their costs. It does not tell you how broad or narrow a plan’s provider network is, the quality of the provider network, about the plan’s customer service and support, how broad or narrow the drug formulary is, or the premium levels. All of this information is important for consumers to consider when they choose a plan.
See www.healthcare.gov/choose-a-plan for additional information for consumers about actuarial value.
What insurance companies offer coverage through the Health Insurance Marketplace? How can I get a list of companies and plans available?
There are listings of the health plans available through the Health Insurance Marketplace at HealthCare.gov . People without access to the internet can call the customer service line for the Health Insurance Marketplace at 800-318-2596 or get help from an agent or another type of assistor.
How can a consumer find out the details about what a particular plan covers?
All individual and small group plans that are not grandfathered plans or otherwise renewed that are offered after January 1, 2014, cover essential health benefits.
To learn if a specific benefit is covered, and at what level, check a plan’s Summary of Benefits and Coverage (SBC). An SBC is a uniform document that includes details about what a plan does and does not cover. It also includes information about what kinds of costs a consumer can expect to pay out-of-pocket, such as copayments, coinsurance, and deductibles. An SBC comes with plans offered through the exchange and in the market outside the exchange. It gives information in the same way for every plan to make it easier to compare plans. The SBC forms are available through the Health Insurance Marketplace or from an agent for plans offered in the market outside the exchange.
The Health Insurance Marketplace website at www.healthcare.gov includes information about what each plan covers and links to the insurer’s plan brochures.
Consumers can read more about the Summary of Benefits and Coverage
here .
How can consumers compare benefits and understand what a plan covers?
Today, every insurance company and group health plan must give consumers a Summary of Benefits and Coverage (SBC) and glossary of commonly used terms both before they enroll and each year at plan renewal time. Through an SBC, consumers can compare insurance options based on covered benefits, excluded services, deductibles, and out-of-pocket costs, as well as other features that may be important to them.
An SBC is designed to help consumers compare plans and understand the benefits and coverage limits of their plan in clear and concise language.
In addition to getting an SBC, the Health Insurance Marketplace allows consumers to get information about the health plan options available online, through the Marketplace’s toll-free telephone number, 800-318-2596, or from agents, navigators or certified application counselors.
A copy of the form for an SBC can be found at https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/sample-completed-sbc.doc .
How can consumers see and compare prices for plans?
The Health Insurance Marketplace is set up to let consumers compare policies based on price, actuarial value and other factors. Consumers can get this information from the Health Insurance Marketplace website at www.healthcare.gov or the call center 800-318-2596. Also, agents, navigators, and certified application counselors should be able to help consumers compare rates.
Can an insurance company charge tobacco users more than non-tobacco users?
Yes. Under the ACA, health insurance companies can ask about tobacco use before they enroll a consumer in a plan and can then charge consumers who use tobacco products higher premium. This additional premium is not eligible for premium tax credits. Consumers in group plans may not have to pay this extra charge if they complete a tobacco cessation program.
How Health Plans Work
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Are dental or vision benefits available through the Health Insurance Marketplace?
The ACA requires plans sold through the Health Insurance Marketplace to include vision coverage for children, but there is no process for offering a stand-alone vision plan through the Marketplace.
The ACA allows insurance companies to offer health plans through the Marketplace that do and do not include pediatric dental benefits. The Marketplace also offers stand-alone dental plans that include pediatric dental benefits. Stand-alone dental plans for children and adults are available.
If a consumer has minimum essential health coverage from another source, they may buy a stand-alone dental plan on the Marketplace without purchasing medical coverage.
Check the federal website www.healthcare.gov for more information about dental benefits.
What services/benefits must plans cover? What are essential health benefits?
After January 1, 2014, new plans sold in the individual and small group market, including those sold through the Health Insurance Marketplace, as well as most plans sold in the market outside the exchange, must cover, at a minimum, a comprehensive set of benefits known as essential health benefits. These essential health benefits include the following:
- Ambulatory services (doctor’s office visits and outpatient services)
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance abuse disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services, including chronic disease management
- Pediatric services, including oral and vision care
For more detailed information about essential health benefits in the Health Insurance Marketplace, visit the NAIC website at https://www.naic.org/index_health_reform_section.htm under Essential Health Benefits Data from The Center for Consumer Information and Insurance Oversight (CCIIO).
Can a person take benefits out of a plan? What if a consumer doesn’t need all of the benefits in a plan?
No, consumers cannot take benefits out of a plan. At a minimum, every health plan on the Health Insurance Marketplace must provide coverage for all of the essential health benefits the ACA requires. Even though a person may not need every benefit in a plan, plans must cover all the essential benefits to share risk across a broad pool of consumers and be sure all benefits are available for everyone. This also helps to protect people from risks they cannot always predict across their lifetimes.
Can a person’s health condition affect their coverage?
No. Under the ACA, health insurance companies can no longer limit coverage based on a person’s health condition, called “pre-existing conditions.” Nor can they charge a higher premium because of a person’s health condition. These protections apply whether a person buys coverage through the exchange or outside of the exchange.
What are preventive benefits and how are they covered?
Preventive benefits are designed to keep people healthy by providing screening for early detection of certain health conditions or to help prevent illnesses. The ACA requires that plans except grandfathered plans cover many preventive services with no out-of-pocket costs (meaning no deductibles, co-payments, and coinsurance). Some of these covered preventive services are:
- Colorectal cancer screenings, including polyp removal for individuals over age 50
- Immunizations and vaccines for adults and children
- Counseling to help adults stop smoking
- Blood pressure screening for adults
- Cholesterol and diabetes screening for certain adults
- Well-woman checkups, as well as mammograms and cervical cancer screenings
- Well-baby and well-child exams for children
Unless an insurer does not have an in-network provider to perform a particular preventive service, plans are permitted to charge for these preventive services when performed by an out-of-network provider.
For more detailed information about covered preventive service, visit the federal government’s website at https://www.healthcare.gov/coverage/preventive-care-benefits.
How does a consumer find out what drugs a plan covers?
Health insurers keep lists of which drugs are covered and which are covered at the lowest cost for each of their plans. These lists are called formularies. Drug cost-sharing is often “tiered;” that is; consumers pay less for a generic drug, more for a brand-name drug, and sometimes even more for a non-preferred brand-name drug. Consumers should review the formularies in any plan they select to be sure they meet their prescription drug needs and to know what cost-sharing is required for any given drug. For plans that use formularies, Summary of Benefits and Coverage include an internet address for obtaining information on the plan’s drug coverage, and the Health Insurance Marketplace includes links to company formularies. Consumers also can call the health insurer for help.
What are out-of-network services and do consumers have any coverage for them?
Services are considered out-of-network if they are received from a doctor, hospital, or another provider that does not have a contractual relationship with a particular health plan. Not all plans cover out-of-network services, but when they do, a consumer’s share of the cost is usually higher than an in-network service. Consumers may want to find out whether a provider is in-network before they receive services. Consumers may also want to find out if their regular health care providers are in-network before they buy a plan.
Though the ACA limits how much money a person is required to spend on his or her family’s health care, out-of-network services do not count toward these limits.
A plan’s Summary of Benefits and Coverage (SBC) will include information about coverage for out-of-network services.
How do consumers determine if their doctor or dentist is in the network?
The Health Insurance Marketplace includes links to insurance company websites that will let consumers look up whether their doctor is in a plan’s network. It is always a good idea to also check with the doctor or dentist before you schedule an appointment to learn if the information on the website is up to date.
Do consumers have access to emergency care out-of-network?
Yes, the ACA requires any health plan that provides benefits for emergency services to cover them regardless of whether the provider is in or out of the network. Under the ACA, health plans are not allowed to charge a higher co-payment or coinsurance for out of network services received in an emergency.
What is a “grandfathered” health plan?
A grandfathered health plan is a plan that has existed continuously since before March 23, 2010, without significant changes in the plan. Grandfathered plans are not subject to many of the requirements of the ACA, such as the requirement that plans cover essential health benefits.
Grandfathered plans that make certain changes, such as significant increases in their cost-sharing, (such as coinsurance, deductibles, co-payments), or eliminating benefits to diagnose or treat a particular condition may lose grandfathered status and then would have to follow the ACA. Employer-sponsored plans that substantially raise the employee share of the premium also could lose grandfathered status.
A plan must indicate in the plan material if it is a grandfathered plan. Also, consumers can check with their insurance company or employer.
My plan is not grandfathered, but it does not comply with the ACA’s requirements. Can I still keep it?
In November 2013, the Obama Administration announced a transitional policy that would permit certain policyholders to keep their 2013 coverage if the plan did not comply with certain ACA reforms. On March 23, 2022, CMS/CCIIO extended this transitional policy to allow the renewal of these plans for policy years and will remain in effect until CMS announces that all such coverage must come into compliance with the specified requirements. These transitional plans may not be sold as new plans.
Do consumers have to re-enroll annually?
Eligibility for premium assistance and enrollment in a health plan is decided annually using updated income, family size, and tax information (when authorized). Each year, before the open enrollment period, the Health Insurance Marketplace will check income data and send a notice to consumers who are enrolled through the Marketplace. This notice explains the consumer’s eligibility for the upcoming year and tells the consumer to let the Marketplace know of any changes. Insurance companies are also required to send notice providing information including premium cost for the new year. After this, there will be an annual open enrollment period for consumers to change plans or insurance companies if they want to. For 2025, consumers enrolled through the Marketplace will be auto-renewed in their current plan, if still available. Exceptions will be consumers who failed to give the Marketplace authority to re-check their income or if their income is found to be much higher than previously declared, in which case they will be auto-renewed without subsidies.
During the year consumers must report any changes in circumstances to the Health Insurance Marketplace within 30 days of experiencing the change. Changes include changes in income from a new job. Consumers who have not requested financial assistance do not need to report changes related to financial assistance eligibility. The Marketplace will review available data sources or individuals who become eligible for Medicare, Medicaid or CHIP.
Under what circumstances can consumers enroll if they didn’t when enrollment was first available?
If consumers did not enroll during the open enrollment period they may be eligible to enroll during a special enrollment period under certain circumstances. A few examples of special enrollment periods are when an individual or dependent loses health insurance coverage, an individual gains a dependent or becomes a dependent through marriage, birth or adoption, or an individual moves into a new exchange service area.
What is the individual mandate, and does that mean consumers must buy coverage through the Health Insurance Marketplace?
Under the ACA, starting January 1, 2014, consumers and their dependent children were required to have “minimum essential coverage” or pay a penalty unless they fit within an exemption. This requirement is commonly known as the “individual mandate”. The penalty for not having minimum essential coverage will remain set to $0 for the 2025 plan year.
Consumers may buy a plan through the Health Insurance Marketplace but they can also buy coverage outside of the Marketplace. Other forms of health coverage include most employer-sponsored plans, union plans and enrollment in a government program such as Medicare, Medicaid, TRICARE or CHIP. Consumers can continue to use agents to buy insurance available in the market outside the exchange.
Some examples of health plans that do not meet the requirement of minimum essential coverage are plans that cover only specific or ancillary services (for example, hearing, chiropractic, etc.).
Enrolling in Health Care Coverage: Where Can I Get Help?
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Where do consumers go for help to choose and enroll in a plan?
Consumers should make a list of questions before they shop for a health plan. Consumers should gather information about household income and set a budget for health insurance. Consumers should find out if they can stay with their current doctors and pharmacy, and understand how insurance works – including an understanding of deductibles, out-of-pocket maximums and co-payments.
The Kansas Department of Insurance offers resources on their website at insurance.kansas.gov. There are a number of other resources from the Kaiser Family Foundation, the National Association of Insurance Commissioners, and the U.S. Department of Health and Human Services and the Department of Labor to help consumers understand how insurance works, the different insurance options, and what to consider when you buy coverage.
The Summary of Benefits and Coverage (SBC), and the companion Uniform Glossary that includes a set of uniform definitions, are also available for all health insurance plans. This information can help consumers compare different insurance options. Consumers can receive the form and definitions through the Health Insurance Marketplace or ask the company for it.
If a consumer is eligible to buy coverage through the Health Insurance Marketplace, he or she can enroll through the Marketplace website at HealthCare.gov, by phone at 800-318-2596, or in-person through agents, navigators or certified application counselors.
There are three types of individuals trained to help consumers make decisions about health coverage.
- Insurance Agents – Health insurance agents sell insurance coverage on behalf of one or more insurance companies. Health insurance agents are licensed in Kansas and receive continuing education related to their job. They can help educate consumers about health insurance policies, help consumers apply for coverage, and advise consumers about the type of health insurance coverage that best suits them and their families. Agents can sell consumers’ insurance plans in the market outside the exchange, as they always have. Agents who want to sell policies through the Health Insurance Marketplace will have had extra training from the U.S. Department of Health and Human Services (HHS). They will have passed a test at the end of their training to sell insurance policies through the Health Insurance Marketplace. Consumers may wish to talk with more than one agent before making a decision on which plan to buy.
- Navigators – Individuals trained to help consumers understand the insurance policies available through the Health Insurance Marketplace and answer consumer questions about the Marketplace as well as insurance affordability programs, including Medicaid and CHIP. Navigators also can help educate consumers about their health insurance policy options and help them apply for coverage. Navigators get grants from the federal government and receive training on how to assist consumers. After training, they must pass a test and be certified by the federal government.
- Certified Application Counselors – Provide enrollment assistance to consumers. Certified application counselors receive and successfully complete comprehensive training. They, too, can help educate consumers about health insurance plans and help them complete an application for coverage. Examples of application counselors include staff at local community health centers, hospitals or other consumer non-profit organizations.
How are people who help consumers make decisions about health coverage paid?
Insurance agents may have an agreement with one or more insurance companies that will pay them if they enroll consumers in a health insurance policy consistent with state law. Other agents may work directly for an insurance company and be paid a salary by the company.
In Kansas, navigator organizations receive funding from the federal government. Individual navigators may be volunteers or in some cases, staff paid by the organization. They do not receive enrollment-based reimbursement from insurance companies and are not allowed to charge a fee.
Certified application counselors may be paid staff of the organization for which they work but will not be paid through the Health Insurance Marketplace. They do not receive enrollment based reimbursement from insurance companies and are not allowed to charge a fee. They may, however, receive federal funding through other grant programs or Medicaid, or from another source.
Where should consumers go with a problem enrolling in a plan through the Health Insurance Marketplace?
The Health Insurance Marketplace should be able to help consumers with enrollment problems. In particular, the Marketplace operates a call center to help answer consumer questions. The number for the call center is 800-318-2596. Insurance agents, navigators and certified application counselors should also be able to help.
How can a navigator help consumers with enrollment through the Health Insurance Marketplace?
In Kansas, navigators can help consumers log-on to the Health Insurance Marketplace. Consumers will log into their own Marketplace account. The navigator can help consumers as needed to complete the application. Consumers will be asked to enter the navigator’s Marketplace user identification on the application to show that the navigator helped them.
The navigator can help consumers to compare qualified health plans and answer questions about health insurance policies in general. The navigator can answer questions from consumers about the differences in health plans and what they might mean for them, but the navigator cannot recommend or suggest which health plan would be best for consumers and their families. Navigators are not permitted to collect premium payments on behalf of an insurer or the Health Insurance Marketplace.
Navigators cannot sell, solicit, or negotiate a qualified health plan through the Marketplace. They cannot suggest that one health plan would be better for the individual than another.
Must consumers share their personal information, including their tax return with an agent, navigator, or certified application counselor?
No, a consumer is not required to share personal information, including tax returns with an agent, navigator, or certified application counselor. If a consumer is completing the application on the Health Insurance Marketplace website with the help of an agent, navigator or counselor, the consumer should be able to fill out and submit their eligibility application without the agent, navigator or counselor in direct view of the application. Income figures obtained from the IRS are not displayed during the application process, whether or not the consumer gets help filling out the application or does it independently. After training, agents, navigators, and certified application counselors must complete a privacy and security agreement before the use of the Health Insurance Marketplace.
Do consumers have to share their account username and password with an insurance agent, navigator, or certified application counselor?
No. Agents, navigators, and certified application counselors should not ask for a consumer’s account username and password. If a consumer is asked to share a username or password, he or she should contact the Kansas Department of Insurance at 800-432-2484 and discuss this with a consumer assistance representative.
What help should an insurance agent, navigator or certified application counselor give consumers if they or their dependents are eligible for Medicaid or CHIP?
An agent, navigator, or certified application counselor working with consumers eligible for Medicaid or CHIP is expected to refer consumers to KanCare, the state Medicaid and CHIP program. Agent, navigator, and certified application counselor training will include information about where to direct Medicaid or CHIP-eligible consumers.
Can small employers use navigators to buy health insurance?
Navigators, by law, are not allowed to sell health insurance unless they have an agent license. They are available to help small employers view plan options. Navigators can explain the plans offered but cannot legally offer advice as to which plan is a better fit for the small employer. Only a licensed agent is qualified and allowed to offer this service.
