Welcome to the Marketplace Assister Essentials course! This course includes an overview of assistance-resources/obtain-consumer-authorization.pdf.
189 KB – 104 Pages
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Contents Course Introduction . 5 Welcome .. 5 Disclaimers . 6 Definitions 8 Course Goal 9 Marketplace Overview . 10 The Health Insurance Marketplaces . 10 2021 Marketplace Information by State .. 12 How Consumers Use the Marketplaces . 13 Differences Between the Individual and SHOP Marketplaces . 15 Eligibility for QHP Coverage in the Marketplaces .. 17 Essential Health Benefits .. 18 Health Plan Categories .. 20 Knowledge Check . 22 Key Points . 23 Preparing to Apply . 24 Introduction .. 24 Consumer Consent and PII .. 26 Assess Consumers’ Needs .. 27 Discussing Individual Market FFMs With Consumers .. 28 Consumer s Applying for Medicaid or CHIP .. 29 Useful Tools to Help Consumers Get Started .. 31 Sensitivity to Consumer s Concerns . 32 Knowledge Check . 34 Key Points . 35 Account Creation and Application Completion . 36 Overview of the Account Creation Process .. 36 Ass ist Consumers with Creating a Marketplace Account 37 Helping with Identity Verification 39 Identity Verification with Experian .. 40 Identity Verification Failure 42 Upload Documents to Verify I dentity 43 Who to Include on an Application .. 44 Information Collected Du ring the Application Process . 46 Knowledge Check . 47 Application Inconsistencies .. 48 Provide Supporting Documents .. 49 Best Practices for Submitting Supporting Documents . 50 How the Marketplaces Calculate Consumers Income . 52
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Modified Adjusted Gross Income and I nsurance Affordability Programs .. . 54 Knowledge Check .. .. .. .. .. 55 Explaining Advance Payments of the Premium Tax Credit and Cost – Sharing Reductions . 56 Knowledge Check .. .. .. .. .. 58 Key Points .. .. .. .. .. 59 Interpreting Eligibility and Enrolling in Coverage .. .. 60 Eligibility Results .. .. .. .. . 60 Medicaid and the Marketplaces: Assessment Versus Determination .. . 61 Medicaid Expansion .. .. .. .. .. 63 CHIP Eligibility and the FFMs .. .. .. .. 64 Advance Payments of the Premium Tax Credit .. .. . 65 Helping Consumers Compare and Select Plans .. .. 66 Plan Compariso n .. .. .. .. 67 Side – by – side Comparison Tool .. .. .. 68 Helping Consumers Enroll .. .. .. 69 Redetermination, Re – enrollment, and Changes in Circumstances .. .. 71 Changes in Circumstances and Special Enrollment Periods .. .. .. 73 Loss of Job – based Coverage and COBRA Eligibility .. .. .. 75 Loss of Job – based Coverage and COBRA Eligibility (cont’d) .. .. .. 76 Termination of Coverage .. .. .. 77 Assisting Consumers Who Want to Switch to a Different QHP .. .. .. 78 Low – Income Consumers Who Don t Qualify for Public Coverage and Can t Afford QHP Coverage in an FFM .. .. .. .. .. . 79 Options for Consumers that Fal l into a Coverage Gap .. .. .. 80 Key Points .. .. .. .. .. 81 Exemptions and Appeals Assistance .. .. .. 82 Introduction .. .. .. .. 82 Introduction to Exemptions .. .. .. 84 Health Coverage Exemptions .. .. .. .. 85 Applying for Exemptions through the Marketplace to Purchase Catastrophic Coverage . 87 Obtaining an Exemption Certificate Number from a Marketplace to Purchase Catastrophic Coverage .. 89 Providing ECNs When Purchasing Catastrophic Coverage .. .. . 90 Tips for Helping Consumers Apply for E xemptions .. .. . 91 Assisting Consumers with Eligibility Appeals .. .. .. 93 Filing an Appeal .. .. .. .. .. 94 After Filing an Appeal .. .. .. .. 95 Appeals Process Summary .. .. .. .. 96 Legal Advice and Appeals .. .. .. . 98 Knowledge Check .. .. .. .. .. 99 Key Points .. .. .. .. 100 Conclusion .. .. .. .. 101
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Course Introduction Welcome Welcome to the Marketplace Assister Essentials course! This course includes an overview of important information that will help you provide consumers in Federally -facilitated Marketplaces (FFMs) with eligibility and enrollment assistance or support them with exemptions and appeals. For detailed information ab out topics covered in this course, we encourage you to reference the Assister’s Standard Operating Procedures (SOP) Manual . Ready? Let’s ge t started!
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Disclaimers Before we begin, you need to be aware of these training disclaimers. Assister Training Content: The information provided in this training course is not intended to take the place of the statutes, regulations, and formal policy gu idance that it is based upon. This course summarizes current policy and operations as of the date it was uploaded to the Marketplace Learning Management System. Links to certain source documents have been provided for your reference. We encourage persons t aking the course to refer to the applicable statutes, regulations, CMS assister webinars, and other interpretive materials for complete and current information. This course includes references and links to nongovernmental third -party websites. CMS offers these links for informational purposes only, and inclusion of these websites should not be construed as an endorsement of any third -party organization’s programs or activities. Coronavirus (COVID -19): This training does not address COVID -19-related guida nce or related requirements for assisters. CMS will communicate applicable information to assisters and assister organizations through separate channels. To learn more about how we’re responding to coronavirus, visit HealthCare.gov/coronavirus/ . For preventive practices and applicable state/local guidance, visit CDC.gov/coronavirus . Standards Related to Essential Health Benefits: Navigators in FFMs must be prepared to inform consumers of the essential health benefits (EHB) that qualified health plans (QHPs) must cover in the FFM(s) they service. For plan years beginning on or after January 1, 2020, states may select which benefits will be EHB in their state. All plans offered in the Marketplace must cover 10 essential health benefits , but specific services covered in each broad benefit category may vary
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Definitions In this lesson, the terms “you” and “assister” refer to the following types of assisters: Navigators in Federally -facilitated Marketplaces Certified application counselors in Federall y-facilitated Marketplaces Note: In some cases, “you” is also used to refer to a consumer, but it should be clear when this is the intended meaning. The terms “Federally -facilitated Marketplace” and “FFM,” as used in this training course, include FFMs whe re the state performs plan management functions. The terms “Marketplace” or “Marketplaces,” standing alone, often (but not always) refer to FFMs.
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Course Goal This course has important information that will help you provide consumers in FFMs with eligibility and enrollment assistance or support them with exemptions and appeals. Goal: To provide the tools and information needed to help consumers apply for health coverage through the Marketplaces. Topics: This course includes information on: Consumer consent and PII Assessing consumers’ needs Account creation process Identity verificati on and supporting documents Comparing and selecting plans Helping consumers enroll in and terminate coverage Changes in circumstances The individual shared responsibility requirement and exemptions to enroll in Catastrophic coverage for consumers who are age 30 or older Marketplace appeals
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Marketplace Overview The Health Insurance Marketplaces Consumers can apply for health coverage through the Health Insurance Marketplaces. Those who don’t have health insurance through a job, Medicare, Medicaid, the C hildren’s Health Insurance Program (CHIP), or another source that provides qualifying health coverage may qualify for financial assistance through a Marketplace. Each state has a Marketplace for individuals and families and, with the exception of Hawaii, a Small Business Health Options Program (SHOP) Marketplace for small businesses and their employees. States have the option to run their own Marketplaces or to have the Federal Government run them. This training is addressed to Navigators and CACs in states with FFMs. However, you should understand a few key differences between FFMs and State -based Marketplaces (SBMs). Different Types Generally, states are the primary regulators of health insurance companies. States are generally responsible for enforcing st atutory requirements for health insurance and provisions of the Affordable Care Act (ACA) both inside and outside of the Marketplaces. State -based Marketplaces States that manage all Marketplace functions have an SBM. Some SBMs rely on a federally -operated information technology platform to manage their eligibility and enrollment functions. These SBMs still hold primary responsibility for managing Marketplace functions. Federally -facilitated Marketplaces States that choose to have the Federal Government man age all Marketplace functions have an FFM. In some FFMs, states choose to oversee or regulate plan management functions. Some states with an individual
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market FFM operate their own SHOP Marketplace. Others have a Federally -facilitated SHOP Marketplace (FF -SHOP). Some states operate a State -based Marketplace on the Federal Platform (SBM -FP) which are like SBMs but they rely on HHS services to perform certain Marketplace functions, particularly eligibility and enrollment, while still retaining responsibility to perform certain Marketplace functions such as QHP certification and consumer outreach and assistance functions. SBM -FPs are required to operate a SHOP; however, a handful of SBM -FPs rely on the FF -SHOP on an interim basis, as they transition to full SBM s (e.g., KY, ME, and VA). Note: FF -SHOP Marketplaces and FF -SHOPs using the federal platform no longer offer employee eligibility, premium aggregation, and online enrollment functionality. Instead, qualified employers and employees can enroll in SHOP plans by working with a qualified health plan (QHP) issuer or SHOP -registered agent or broker. Small employers in states with an FF -SHOP can continue to use the SHOP website to: Learn about the benefits of SHOP, including the availability of tax credits for qualified employers; Compare available medical and dental plans side by side using the SHOP See Plans and Prices tool; and Submit SHOP employer applications and obtain eligibil ity determinations. In addition, small employers can contact the SHOP Call Center for any questions or assistance related to submitting employer applications for SHOP coverage.
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