Health Reform and you
A User's Guide to Health Insurance Marketplaces

How To Use This Guide

As of October 1, 2013, consumers have access to a variety of new health insurance products and new means of securing coverage. These products will be available on exchanges within each state, also known as "Health Insurance Marketplaces", with plans designed to fit your budget and health care needs.

This guide is intended to help you better understand the Health Insurance Marketplace in your state, so that you can determine what coverage is right for you and your family.

Within this publication you will find:

  • An introduction to the concept of health insurance
  • An explanation of Health Insurance Marketplaces

  • Information on health insurance coverage and plan options

  • Affordability options available to you and your family through the Marketplace

  • And information on how to enroll in coverage

This guide also provides a list of state resources where you can find answers to questions specific to your state's individual and small business Marketplace.

Table of Contents

About the Affordable Care Act

An Introduction to Health Insurance

Understanding Health Insurance Marketplaces

Affordable Insurance and Appropriate Coverage

Special Situations

Small Business and the Marketplace

State Health Insurance Marketplace Websites

About the Affordable Care Act

In 2010, the President of the United States signed into law the Affordable Care Act (ACA) which was passed after months of debate in the US Congress and across the country. This legislation introduced sweeping reform of the US health care system, and increased coverage while implementing measures to control costs for consumers.

Key features of the law include:

  • No more pre-existing condition denials for children (For adults in 2014)
  • No more annual or lifetime dollar limits on most health insurance benefits
  • Insurance companies cannot drop your coverage because of mistakes on your insurance application
  • No more coverage denials without patients being allowed to appeal
  • 80 percent of enrollee premiums collected by insurance companies must be spent on patient care and efforts to improve the quality of patient care
  • Reduced enrollee cost-sharing for outpatient prescription drugs in Medicare Part D's "Donut Hole
  • Additional federal match to states electing to expand Medicaid coverage to childless adults with incomes up to 133 percent of the Federal Poverty Level
  • Coverage for young adults on their parent's plans up to the age of 26
  • Incentives for physicians to adopt electronic health records and capture and report certain quality measures
  • Access to certain preventive care services such as screenings and annual checkups with no enrollee cost-sharing obligations under their health plans
  • Provisions to detect waste, fraud, and abuse within the system, increase care coordination, review large premium increases by insurers, and incentivize innovation
  • Insurance tax credits for individuals with incomes between 100-400 percent of the Federal Poverty Level to help pay for health care premiums (starting in 2014)
  • Tax credits to help small businesses afford insurance for their employees
  • Penalties for individuals for failing to obtain and maintain health insurance coverage (2014)
  • Health Insurance Marketplaces, also known as exchanges (operational in 2014)

While the outcomes of many of these provisions remain to be seen, the ACA has taken important steps that increase patient access to care and control the burden of costs for patients. This informational publication provides information on one of the most significant efforts of the law: Health Insurance Marketplaces, which will be open for enrollment on October 1, 2013 with insurance coverage beginning January 1, 2014. This document is intended to introduce potential consumers to the concept of health insurance in general, Health Insurance Marketplaces, how to navigate these Marketplaces, opportunities available for support, and ultimately how to arrive at the coverage right for them.

An Introduction to Health Insurance


What is health insurance?

At some point in life, everyone is a patient. We all get sick and will eventually require assistance from the health care system. This may be in the form of a doctor's visit, a hospital visit, or an emergency situation. However, medical care is very expensive, especially for those expected to pay the whole amount on their own. This is the reason health insurance exists. Health insurance is a service in which you and/or an employer on your behalf pay a monthly sum, known as a premium, to an organization in return for a promise of partial cost coverage of an agreed upon set of medical services. Insurance companies offer different plans that cost different amounts and in return pay for different services. When you get sick or need medical attention, that organization will pay a share of any services that it has indicated will be covered under the plan you selected.


Why do I need health insurance?

Every citizen should have health insurance. There are many reasons for this:

1)  If you get sick it will help pay for medical services that you may need to be healthy.

2)  Payments from insurance companies for medical costs will help make sure you do not go broke if you get sick or injured.

3)  If you have coverage you are more likely to seek preventive care, keeping you healthy and avoiding preventable hospitalizations.

4)  Medical costs for those without health insurance are paid by the rest of society. More people with coverage should result in decreased costs for society at large.

5)  Beginning in 2014, the Affordable Care Act requires that most individuals obtain and maintain health insurance coverage or pay an annual penalty for failing to maintain coverage.


Where do I get health insurance?

Health insurance can be acquired in many ways. If you are age 65 or older, or are deemed to have a disability, you may be eligible for a federal government insurance program called Medicare. Details on this program can be found at

If you are a low-income individual you may be eligible for a government insurance program called Medicaid. Details on this program can be found at

Some may receive coverage through the military, TRICARE or the Department of Veterans Affairs. Many receive health insurance through their employer, which often requires the individual to pay some or all of the monthly premium through paycheck withholding. Others still will purchase health insurance directly from a health insurance company that is active in their state.

Started in 2014, the newest method of obtaining a health insurance plan is through the  Health Insurance Marketplace.

Understanding Health Insurance Marketplaces

What are Health Insurance Marketplaces?

A Health Insurance Marketplace, otherwise known as a health insurance 'Exchange,' is a website that acts as a virtual market for insurance where consumers can compare and contrast selected health insurance plans offered in their state. These virtual Marketplaces are comparable to websites consumers currently use to search for airline flights, such as Orbitz or Travelocity, in which an individual can compare and contrast different options at different costs. However, instead of airline flights, the products offered will be health insurance products called 'Qualified Health Plans,' or QHPs. These QHPs have been deemed qualified to be posted on each state's website, because they meet the basic requirements for coverage indicated in the Affordable Care Act. Coverage under these insurance plans will be presented in plain language, so consumers can understand the difference between plans when it comes to costs, quality, and benefits covered.

Will these plans cover what I need?

Health insurance plans within these Marketplaces must  offer  a  certain  minimum level of coverage. This minimum level of coverage consists of benefits, termed the 'Essential Health Benefits,' that include services in the following ten coverage 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 care, wellness services and chronic disease management
  • Pediatric services, including oral and vision care


Requiring coverage in these ten categories ensures that many services important to your care are covered. To determine how much is covered in each of these categories, plans in a state must offer an amount of coverage equal to a pre-approved plan in the state known as the benchmark plan. Specific services offered within these ten categories will vary from plan to plan to offer flexibility and diversity that will suit the needs of different people.


How do I determine which plan is best for me?

The selection of the appropriate health insurance plan is an important task that requires some preparation on the part of the consumer.

  • First, it will be important to evaluate your family health history and any potential health concerns you may need addressed. This will help you determine which services are important for you to have covered.

  • Second, it will be important to look at your personal finances and establish a budget for health care-related costs. Determine how much you are willing to pay each month in light of your health care needs, factoring in any eligible discounts or financial assistance (more on this later, see page 9). Also consider potential co-payments, deductibles and co-insurance you may incur when visiting physicians, hospitals and other medical facilities.

  • Finally, examine the plans on the health marketplace website. Evaluate each plan against what you have determined are important medical services to be covered, and your budget. Note any special restrictions on coverage or exclusions that a plan may have and whether they may interfere with you or your family's potential care. Research consumer and professional ratings of the insurance companies that offer your top few plans to get a better understanding of the quality of these companies. Also inquire if these plans cover services from providers close to you, and how many.

All of the insurance products offered in a Marketplace will be categorized in four 'tiers' indicated by the metals 'bronze,' 'silver,' 'gold,' and 'platinum.' While the bronze plan will be the cheapest in terms of monthly payment or 'premium' required by the consumer, it will only cover 60 percent of the medical bills up to an established out-of-pocket maximum. The silver plan will cover 70 percent of medical bills, gold will cover 80 percent of the medical bills, and platinum will cover 90 percent and above of the maximum,  with  higher  monthly  premiums  for the patient to pay as the amount of coverage increases. After you reach your plan's established out-of-pocket maximum, the plan will pay 100 percent of all covered medical care.

If consumers know how much they are able to spend each month on health insurance, they can compare the different plan coverage options within the category that is most appropriate for their budget. In addition, consumers with lower annual incomes, up to 250 percent of the Federal Poverty Level, may qualify for additional cost-sharing assistance.

Plan Reimbursement of Medical costs

Platinum 90%+

Gold 80%

Silver 70%

Bronze 60%


What if I still cannot decide on the best plan for me?

Recognizing that selecting a health insurance plan can be overwhelming, the Affordable Care Act called for the creation of the 'navigator program,' in which individuals or organizations (Navigators) are trained to help you search for the health plan that is best for you. These Navigators will inform you of coverage options (but not select one for you), help facilitate enrollment in a plan, and help you understand your rights and responsibilities. They will also assist with troubleshooting, highlight financial assistance opportunities, make sure you are put in touch with someone that can accommodate your cultural and language needs, and help direct you to the appropriate office to express a complaint.

Navigators are intended to  be  completely  unbiased.  These specialists are not to be associated with any insurance company or plan and cannot receive payment for recommending one plan over another. Navigators exist as an advocate for you to make the appropriate choice. If you are in need of assistance from a Navigator, you can locate one through your state's Marketplace website or by going to

When and how do I enroll?

There will be a period of time each year, termed an 'annual open enrollment period' in which you can enroll in a health plan for the first time or change health plans through a Marketplace. In October 2013, consumers will be able to view information about the different plans available through the Marketplace in their state. The initial open enrollment period will last from the beginning of October 2013 through March 2014. Starting in the fall of 2014 and for all subsequent years, open enrollment will last from October 15 until December 7.

Enrollment can be performed through a single streamlined application that will determine eligibility not only for QHPs, but state Medicaid and Children's Health Insurance Programs (CHIP), financial assistance with cost-sharing and a premium tax credit as well. All of this information will be available on your state's Marketplace website, which you will find here. In addition to being able to access this information and apply directly through the Marketplace website, there is also a national toll-free hotline available for enrollment and questions at (800) 318-2596.

What if I need help with the application process?

If you need assistance with the application process, you may use a Navigator, as outlined above. In addition, Marketplaces may have 'certified application counselors' that  can provide you with direct assistance online, by phone or in person. These counselors will be trained to help you in your application process and maintain confidentiality.

Who runs these marketplaces and does it matter?

The Affordable Care Act gave each state the option of setting up a Marketplace itself, allowing the Federal Government to set up a Marketplace in the state, or partnering with the Federal Government. For 2014, 16 states and the District of Columbia plan to run state- based Marketplaces, 8 states plan to run a partnership Marketplace, and the remaining 26 states will allow the Federal government to run their Marketplace. Each Marketplace will have a wide variety of insurance options available regardless of who is running it.

What's the difference between a plan on the Marketplace and other commercial plans?

Starting in 2014, no matter how you buy your health insurance - through the Marketplace in your state or directly from an insurance company - all plans sold in the individual and small group markets must offer the consumer rights and protections provided under the health care law. In addition, all plans sold in the individual and small group markets (except for certain grandfathered plans) may not charge or refuse to cover you if you have a pre- existing condition, and must cover Essential Health Benefits (see page 4).

However, the only way you may receive federal assistance such as tax credits or subsidies to get lower costs for your premium based on income is by purchasing your insurance through the Marketplace. Premium Insurance Tax Credits (PITC) are available to individuals between 100-400 percent of the Federal Poverty Level. PITC is based on your household income and size. Your eligibility for and assistance from Premium Insurance Tax Credits is determined during the enrollment process within the Marketplace.

Can I keep my current doctor?

Most health insurance plans have a network that includes a specific set of hospitals, doctors, specialists, pharmacies, and other health care providers that they contract with to provide services to patients enrolled in their plans. You will need to research the network that is outlined within the plan options during your selection process to ensure that you choose a plan that covers your current doctor.

When comparing plans in the Marketplace, you will have the opportunity to view a list of providers in each plan's network. You may also work with a Navigator or certified application counselor to make sure your doctor is covered in the network of the plans you are considering. If staying with your current doctors is important to you, you should check to see if they are included before you choose a plan.


Can I get dental coverage?

In the Health Insurance Marketplace, you may get dental coverage as part of a health plan or by itself through a separate, stand-alone dental plan.

Dental coverage is available two ways:

  • Health plans that include dental coverage. In the Marketplace, dental coverage will be included in some of the health plans available. You'll be able to see which plans include dental coverage when you compare them. You'll also see explanation of the specific dental benefits within each plan. If a health plan includes dental coverage, the premium shown for the plan includes both health and dental coverage.
  • Separate, stand-alone dental plans. In some cases separate, stand-alone plans will be offered. You may want to choose this option if the health coverage you plan to enroll in doesn't include dental coverage or if you want different dental coverage. If you choose a separate dental plan, you'll pay a separate, additional premium for the dental plan.

Under the Affordable Care Act, dental insurance is treated differently for adults and children 18 and under. Dental coverage for children is an Essential Health Benefit, and thus must be made available in either stand-alone plans or included within plans that cover children.

However, dental coverage is not considered an Essential Health Benefit for adults, and thus is an optional benefit that adults may select if they desire. Insurance companies do not have to offer adult dental coverage, however you are likely to see plans in your Marketplace that do offer dental plans for adults either included or as stand-alone policies. Included dental benefits, if any, will be identified in the coverage summary for each plan.

What about vision coverage?

At this time, any separate vision plans available on the Marketplace would be at the discretion of the insurance company offering coverage. If you are seeking additional coverage related to your eye health (commonly including eye exams, contacts, eyeglasses, etc), we encourage you to look specifically at the Marketplace within your state to find out what is available, or ask your current eye care provider for information on the vision networks in your area. As with dental coverage, the Affordable Care Act treats vision coverage differently for adults and children 18 and under.  Vision coverage for children is an Essential Health Benefit, so it must be made available in either stand-alone plans or included within plans that cover children.

What do I need to have to start an enrollment application?

Consumers can research and review available plan details at their Marketplace website before committing to enroll, and enrollment applications will be available beginning October 1, 2013. When ready to begin an enrollment application you may need to gather the following information in order to accurately answer questions along the way.

Required information needed to finalize a Marketplace application:

  • Social Security Numbers (or document numbers for legal immigrants) for individuals seeking insurance
  • If you are employed, you will need your employer contact information & wage information for each household member. You will also need to include information about any additional sources of income you may have, if any.
  • Information about any current health insurance you may have.
  • Information about your children or other family members who will be covered

After you complete the enrollment application, you will receive information about your eligibility for tax credits and subsidies, and can work with a Navigator or certified application counselor to find an insurance plan that is right for you.

Am I buying government health insurance through the Marketplace?

Every health insurance plan purchased through a Marketplace is provided by a private insurance company - not the government. The premiums will be paid directly to the insurance company that issues the plan. If you are eligible, the federal government may provide you with financial assistance to pay these premiums, in the form of Premium Insurance Tax Credits for people who qualify based on their household income and size.

Affordable Insurance and Appropriate Coverage

How will Health Insurance Marketplaces help me save money?

The theory behind Health Insurance Marketplaces is that presenting   the   coverage   available   from   each   health insurance plan through an easy-to-understand summary of costs and benefits in a centralized location will allow for consumer comparison.  This simplified comparison will encourage increased competition between insurance companies, resulting in better benefits and lower costs to attract consumers to their plans. That is, health insurance companies will be competing over you.

What if I still cannot afford coverage?

Navigators will be able to inform you of any financial assistance available to help reduce your medical costs. One example of such financial assistance will be the Premium Insurance Tax Credits (PITC), available to individuals between 100-400 percent of the Federal Poverty Level. In addition, cost-sharing assistance may be available to individuals with annual incomes at or below 250 percent of the Federal Poverty Level.

Your eligibility for financial assistance is determined when you fill out your application during enrollment and is based on both income and the size of your family. Once you complete your application, you should be informed about the amount you would be able to receive in assistance immediately.

While the PITC is technically a tax credit, unlike other tax credits, you do not have to wait until you file your taxes to receive it. The PITC is provided as an advanced payment at the beginning of your coverage and is sent directly to your insurance plan to help reduce your monthly premium.

What if I need something that is not covered?

If your health plan is unable to cover everything you need, you have multiple options. You can pay for the non-covered services out-of-pocket; you can purchase supplemental health insurance through the commercial market to cover any gaps in your health plan's coverage; or you can appeal the decision to not cover a service. Specific appeals instructions will vary by state and information can be found on your state's Marketplace website. Navigators should also be able to help you with appeals.

What if I am unemployed?

You can still enroll in a Qualified Health Plan through a Marketplace. In addition, you may also qualify for Medicaid, the Children's Health Insurance Program, the Premium Insurance Tax Credit and/or lower cost sharing related to a Qualified Health Plan purchased through a Marketplace based on your household income and size. Your eligibility for these programs will be determined during the enrollment process.


When you apply for Marketplace coverage you will report your Modified Adjusted Gross Income from your most recent tax return and estimate your income for 2014. Based on household income and size, unemployed or low-income individuals may qualify for any of the following:

  • Medicaid. Medicaid provides coverage to millions of children, pregnant women, parents of Medicaid-eligible children who meet certain income requirements, and low-income seniors. Each state's Medicaid eligibility requirements are different. Many states are expanding Medicaid in 2014 to cover childless adults with incomes up to 133 percent of the Federal Poverty Level. You can apply for Medicaid in your state now to see if you are eligible. Or you can fill out a Marketplace application as soon as October 1, 2013 to find out if you qualify for Medicaid in your state in 2014.


  • Children's Health Insurance Program (CHIP). CHIP provides coverage for children, in some states pregnant women, within families with incomes too high for Medicaid but too low to afford private insurance. You can apply for CHIP in your state right now to find out if you're eligible. Or you can fill out a Marketplace application as soon as October 1, 2013 to find out if you are eligible for your state's CHIP in 2014.


  • Lower costs on Marketplace insurance You may qualify for financial assistance with QHP premiums in the form of the Premium Insurance Tax Credits (PITC), available to individuals between 100-400 percent of the Federal Poverty Level. In addition reduced cost-sharing associated with coverage obtained through a Marketplace may be available to individuals with annual incomes at or below 250 percent of the Federal Poverty Level.


What are catastrophic plans? Do I qualify?

Catastrophic plans are Qualified Health Plans (QHPs) sold through the Marketplace that are similar to High Deductible Health Plans. Catastrophic plans do not cover any benefits other than three primary care visits per year before you meet the plan's deductible. The premium amount you pay each month for health care is generally lower than for other QHPs, but the initial out-of-pocket costs are generally higher. To qualify for a catastrophic plan, you must be under 30 years old or obtain a "hardship exemption because the Marketplace determined that you are unable to afford other health coverage.

If you enroll in a catastrophic plan, you will not be eligible for Premium Insurance Tax Credits or cost-sharing assistance regardless of your household income.


Special Situations

What are the special situations that allow enrollment into a Marketplace plan outside of the open enrollment periods?

Most people will need to complete the enrollment process during the annual enrollment period each fall.

However, in certain circumstances you may be eligible to enroll at other times throughout the year. The situations that allow consumers to be eligible for special enrollment are:

  • Immediately following a marriage, birth or adoption
  • When you gain citizenship or qualifying immigration status
  • If you lose minimum essential coverage, such as through loss of employer- based coverage
  • If you gain or lose eligibility for Premium Insurance Tax Credits or assistance with cost-sharing
  • If you move your permanent residence to a new state
  • Consumers who are currently enrolled in non-qualifying employer-based coverage
  • Consumers who are recognized as a member of a federally recognized tribe, including American Indian or Alaska Native Tribes
  • If your enrollment/non-enrollment in a QHP is the result of an error or inaction by the Marketplace
  • If you demonstrate that the QHP in which you are enrolled violated its contract with you
  • If your insurance policy is removed from the Marketplace for not adhering to legal standards
  • Exceptional circumstances, in accordance with guidelines issued by the Department of Health and Human Services (HHS) and as accepted by the Marketplace

Note: The initial enrollment period ends on March 31, 2014. Outside of the enrollment period, you cannot enroll in a QHP through a Marketplace unless you meet one of these situations, and must seek other coverage or pay the penalty. In order to qualify under any of these scenarios, you may need to provide documentation to show that you meet the above listed exceptions for special enrollment.

What happens if I miss my enrollment period?

The initial enrollment period is from October 1, 2013 through March 2014. After that, enrollment periods will occur each fall. If you miss the initial enrollment period and are not able to enroll through one of the exceptions listed above, you will have to wait until the next enrollment period in the fall.

There will not be automatic re-enrollment in your plan, so you will need to be sure to renew your coverage each year. If you miss the open enrollment period and are not covered under another health insurance plan, you may need to pay a penalty for not being covered.

What happens if I move to another state?

If you move to another state permanently you will need to change insurance to a plan in your new state. Moving to a new state meets one of the enrollment exceptions listed above, so you will not have to wait for the new open enrollment period, and can enroll in a plan in your new state right away. Your state may provide a grace period until you are able to secure new insurance coverage, during which your previous insurance would continue to cover you. However, it is important to remember that you may be seeking coverage out of network during this time.

What if I have a pre-existing medical condition?

Starting in 2014, health insurance plans cannot refuse to cover you or charge you more just because you have a pre-existing health condition. Additionally, a plan cannot impose any waiting periods before they cover treatment for a pre-existing condition. This is true even if you have been turned down or refused coverage due to a pre-existing condition in the past.

There is an exception for grandfathered health plans sold on the individual market. If you have one of these plans you can switch to a QHP sold through a Marketplace during open enrollment and get coverage for your pre-existing condition.

Can I add a family member to my policy after enrollment?

There are no family policies sold through the Marketplace. Everyone will receive insurance coverage as an individual and will have their own policy. The only exception is for newborn care, which will be covered temporarily under the mother's policy for a grace period.

What are my options as a non-citizen lawful US resident?

You are eligible to participate in the Marketplace, as well as receive Premium Insurance Tax Credit assistance.

Is there an age limit for those who can purchase insurance in the Marketplaces?

No. Insurance products will be available on Marketplaces for people of all ages.

However, if you are over 65 and already enrolled into a Medicare plan or are Medicare- eligible, there is no need for you to utilize the Marketplace for your insurance needs. Rather, you can apply and enroll in Medicare. Marketplaces are useful for seniors who are NOT Medicare eligible and are seeking insurance coverage (for example, older adults that have not worked for at least 10 years in Medicare-covered employment are not Medicare-eligible).

What if I currently have COBRA insurance?

If you currently have, or are eligible for COBRA continuation health coverage, you can choose to keep it if you prefer. Beginning in October 2013, you will have the option to switch to a health plan in the Marketplace for coverage beginning on January 1, 2014.

If you lose your COBRA coverage, you will qualify for a special enrollment period in which you can enroll in a plan through a Marketplace outside of the open enrollment period. This is true whether the coverage runs out or you choose to end it.

Can those living in US territories access a Marketplace?

Marketplaces are only available to residents of the fifty states and the District of Columbia. If you live in any of the U.S. territories, including the Virgin Islands, Guam, Puerto Rico, American Samoa or the Northern Mariana Islands, you are not eligible to use a Marketplace to apply for health insurance. Check with your territory's government offices to learn more about health coverage options available to you.

I am self-employed. Can I enroll through a Marketplace?

Yes, if you are self-employed and have no employees, you may buy insurance through the Marketplace.


I'm currently enrolled in a plan from my employer, but it is not meeting the needs of my family (or budget). Can I enroll in a plan from the Marketplace and forgo my employer's plan?

Yes, you may purchase health insurance through a Marketplace instead of through your employer. However, you will no longer receive employer contributions toward your health insurance premiums and you will not be eligible for the Premium Insurance Tax Credit or for assistance with your cost-sharing obligations, regardless of your household income and/or size, if the health insurance offered through your employer is deemed 'afford- able' (less than 9.5 percent of your annual household income for 2014) and provides minimum value. For more information on this, visit or request assistance through one of the resources provided at the end of this publication.

What if I choose not to purchase insurance?

If you do not purchase insurance, you may be required to pay an annual penalty if you are uninsured for three months or more in a given year. In 2014, the total amount of the penalty is $95 per adult and $47.50 per child, with a maximum penalty of $285 per family, OR one percent of family income, whichever is greater.

In 2015, the penalty is $325 per adult and $162.50 per child, with a maximum penalty of $975 per family, OR two percent of family income, whichever is greater.

In 2016 and beyond, the penalty is $695 per adult and $347.50 per child, with a maximum penalty of $2,085 per family, OR 2.5 percent of family income, whichever is greater.

You are not required to pay the penalty even if you are uninsured if:

  • You are not required to file a tax return because your income is too low ($10,000 for an individual, $20,000 for a family in 2013);
  • You have to pay more than 8 percent of your annual income to obtain health insurance, after taking into account any employer contributions or tax credits;
  • You would qualify under the new income limits for Medicaid, but your state has chosen not to expand Medicaid eligibility;
  • You are a member of a federally recognized Indian tribe;
  • You are a member of a recognized religious sect with religious objections to health insurance; or
  • You are incarcerated.

What is not considered minimum essential coverage?

"Minimum essential coverage is defined to include coverage under a government- sponsored plan (including Medicare, Medicaid, CHIP, TRICARE or Veterans health care programs), health plans sold through Marketplaces, employer plans and health plans purchased on the individual market.

Plans that do not meet minimum essential coverage requirements and would cause individuals to incur the penalty for failure to maintain minimum essential coverage include:


  • Plans that only cover dental or vision
  • Short-term and long-term disability insurance or workers' compensation plans
  • Long-term care insurance, nursing home or community-based care plans
  • Cancer, hospital, or accident-only insurance
  • Health care, medical and pharmacy discount cards or coupon programs
  • Medical payment coverage within an automobile insurance plan
  • Medicare supplemental insurance


What resources are available for Spanish-speakers?/¿Cuáles son los recursos para los hispano hablantes?

Spanish-speaking consumers who have questions about the Marketplaces should visit, which is an informational website presented entirely in Spanish. In addition, representatives are available to answer questions in Spanish and other languages through a toll-free hotline, at (800) 318-2596.

InsureUStoday also has bilingual representatives to help Spanish-speakers answer any questions they have on Marketplaces. They can be reached at (866) 207-8023.

El sitio de web está completamente disponible en español para ayudar a los consumidores con las cuestiones sobre el Mercado de Seguros Médicos. Adicionalmente, los representantes pueden plantear preguntas en español y otros idiomas por medio de una línea de traducción, al llamar a (800) 318-2596.

InsureUStoday también utiliza representantes bilingües para ayudarles a los hispano hablantes a contestar sus preguntas sobre el Mercado de Seguros Médicos al comunicarse a (866) 207-8023

Small Business and the Marketplace

What is the Small Business Health Options Program (SHOP)?

Small business owners may benefit from the Small Business Health Options Program (SHOP) beginning in 2015. There will be a period each year during which small business owners with 50 or fewer full time employees may compare health insurance plans offered on the Marketplace, and select which coverage to offer their employees. Employers will have many options when selecting these plans, including the level of coverage to provide to their employees, as well as how much to contribute to help employees pay their health insurance premiums.

Like health insurance plans offered to individuals through the Marketplace, plans available in the SHOP will be run by private insurance companies, will be explained in plain language, and will allow for comparisons in coverage, quality and cost. Small businesses will also be eligible for financial assistance, as tax credits are provided to help employers cover more medical costs for their employees related to coverage purchased through the SHOP.

Beginning in 2016, the SHOP Marketplace will expand to include businesses with 100 or fewer full-time equivalent employees. More information on the SHOP will be available in 2014.

Have questions about the SHOP Marketplace for businesses with 50 or fewer full-time equivalent employees?

Call 1 (800) 706-7893    TTY users: 1 (800) 706-7915


State Health Insurance Marketplace Websites

No matter what state you live in, you'll be able to use the Marketplace to apply for coverage, compare your options, and enroll. The list below identifies each state's website that should serve as your starting point when seeking individual plans or SHOP plans for small businesses and employees.

District of Columbia
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Rhode Island
South Carolina
South Dakota

*For residents of Utah seeking individual and family coverage, visit For small businesses and their employees, the Small Business Health Options Program (SHOP) marketplace is located at
West Virginia

If You Need A Helping Hand..

If you need help learning about or selecting a Marketplace product, you may reach the Patient Advocate Foundation (PAF) through our website at, by visiting our health reform blog at, or by calling the toll free phone line (866) 207-8023 which allows you to ask questions to experts at PAF.

PAF is a national 501(c)(3) non-profit organization which provides professional case management services to Americans with chronic, life threatening and debilitating illnesses.

PAF case managers serve as active liaisons between the patient and their insurer, employer and/or creditors to resolve insurance, job retention and/ or debt crisis matters as they relate to their diagnosis.

Patient Advocate Foundation seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their financial stability.

Additional Ways To Stay Informed And Get Help


Online at 

Phone 24/7 Support at (800) 318-2596       TTY: (855) 889-4325

Chat Online at

Get news, updates and alerts via email or text at

Stay involved and informed through social media!

Pick your favorite social media channel or join them all to keep up with the latest Marketplace news and get answers to your health insurance questions

YouTube --Visit's YouTube channel at  to watch videos highlighting important information about the Marketplace and featuring people like you who are looking forward to getting covered.

Facebook --"Like on Facebook at  and share your thoughts.

You may also follow Patient Advocate Foundation's Facebook and its Health Care Reform tab at

Twitter-Follow @HealthCareGov on Twitter for up-to-date Marketplace news.

Google+--Use Google+ to follow  at 


Introduction to the Patient Action Council


Established by Patient Advocate Foundation in 2008, the Patient Action Council is a forum comprised of skilled pharmaceutical and biotechnology industry leaders who maintain current positions within the field of patient advocacy in their organization.

Each year, the Patient Action Council members identify and deliver one patient tool to the Marketplace that will improve health care access to millions of Americans.

The 2013 Patient Action Council members are:

  • Kathryn West, Amgen Oncology
  • Cara Thompson, Celgene Corporation
  • Timothy Wert, Lilly
  • Alissa Jaffe Nagler, Novartis Oncology
  • Patti Jewell, MPA, Pfizer Inc
  • Jim Caro, RPh, MBA, Sanofi U.S.

Previous Patient Action Council projects now publicly available:

  • National Underinsured Resource Directory
  • National Uninsured Resource Directory
  • My Resource Search mobile phone app

At the annual meeting in February 2013, members of the Patient Action Council with Patient Advocate Foundation leaders decided to jointly support the development and publication of a patient guide to assist with understanding and enrollment in the Health Insurance Marketplaces. This guide, entitled Health Reform and You: A User's Guide to Health Insurance Marketplaces is the result  of that effort.