Health reform and you

What is the health insurance Marketplace?

The Marketplace, also called the Exchange, is a way to find health coverage that fits your budget and meets your needs. With one application, you can see all your options and enroll. When you use the Marketplace, you’ll fill out an application and find out if you can get lower costs on your monthly premiums for private insurance plans. You’ll find out if you qualify for lower out-of-pocket costs. The Marketplace will also tell you if you qualify for free or low-cost coverage available through Medicaid or the Children’s Health Insurance Program (CHIP).

The Marketplace simplifies getting health coverage

The Marketplace simplifies your search for health coverage by gathering the options available in your area in one place. With one application, you can compare plans based on price, benefits, quality and other features important to you before you make a choice. You can also get help online, by phone, by chat or in person.

Find a plan that fits your needs and budget

In the Marketplace, information about prices and benefits is written in simple language. You get a clear picture of the premiums you’d pay and what benefits and protections you’d get before you enroll. Compare plans based on what’s important to you, and choose the combination of price and coverage that fits your needs and budget.

There are two types of public exchanges 1) the American Health Benefit Exchange (AHBE), which is a Marketplace for individuals purchasing insurance; and 2) the SHOP exchange (Small Business Health Options Program), an exchange for insurance purchased by small businesses (such employer employs an average of at least 1 but not more than 50 employees on the first day of the plan year). * MercyCare Health Plans will no longer offer new SHOP plans effective January 1, 2017.

What are essential health benefits and how do they affect me?

The Affordable Care Act ensures Americans have access to quality, affordable health care. To achieve this goal the law is requiring health plans offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services for these 10 categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management, and
  • Pediatric services, including oral and vision care

Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. You will see exactly what each plan offers when you compare them side-by-side in the Marketplace.

For a full list of covered preventive services, click here: US Preventive Services Task Force-Covered Services

How do I apply for Marketplace Coverage?

  • You can apply for health coverage, compare all your options, and enroll in a plan in one streamlined application through the Marketplace.
  • When open enrollment begins on October 1, you can go to the Marketplace (https://www.healthcare.gov/marketplace/individual#state=wisconsin) and see the health coverage options available to you. Then you can compare plans side-by-side and choose a plan that meets your needs and fits your budget.
  • Get health coverage in four steps:
    • Set up an account. You’ll provide some basic information to get started, like your name, address, and email address. Sign up for Marketplace emails now and we’ll let you know when you can set up a Marketplace account. We’ll also keep you up-to-date on other key information.
    • Fill out the online application. You’ll provide information about you and your family, like income, household size, current health coverage information, and more. This will help the Marketplace find options that meet your needs.
    • Compare your options. You’ll be able to see all the options you qualify for, including private insurance plans and free and low-cost coverage through Medicaid and the Children’s Health Insurance Program (CHIP). The Marketplace will tell you if you qualify for lower costs on your monthly premiums and out-of-pocket costs on deductibles, copayments, and coinsurance. You’ll see details on costs and benefits before you choose a plan.
    • Enroll. After you choose a plan, you can enroll online and decide how you pay your premiums to your insurance company. If you or a member of your family qualify for Medicaid or CHIP, a representative will contact you to enroll. If you have any questions, there’s plenty of live and online help along the way.

What’s the difference between Marketplace health plans and other private plans?

No matter how you buy your health insurance—through the Marketplace, directly from an insurance company or with the help of an agent or broker–all plans for individuals and small groups must cover the same set of essential health benefits.

Plans will not be able to charge you more or refuse to cover you if you have a preexisting condition. Most plans also must offer the consumer rights and protections provided under the health care law.

Can I keep my doctor?

Depending on the plan you choose in the Marketplace, you may be able to keep your current doctor.

Different plans have different networks and providers. Most health insurance plans offered in the Marketplace have networks of hospitals, doctors, specialists, pharmacies and other health care providers.

Networks include health care providers that the plan contracts with to take care of the plan’s members. Depending on the type of policy you buy, care may be covered only when you get it from a network provider.

When comparing plans in the Marketplace, you will see a link to a list of providers in each plan’s network. If staying with your current doctors is important to you, check to see if they are included before choosing a plan.

What if I choose not to buy insurance?

  • If you’re not exempt and you don’t have employer or government-provided insurance you will be charged a fine with your income taxes in April. Here are the fines:
    • In 2015, the penalty is the larger of 2 percent of taxable income, or $325 for every adult and $162.50 for every child.
    • In 2016 and beyond, the penalty is $695 per adults and $347.50 per child (up to $2,085 for a family), or 2.5 percent of family income, whichever is greater.

More information can be found at Healthcare.gov.