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Top 10 Questions (and answers) About the Exchanges

By Andy Miller, Georgia Health News, with additional reporting by Rose Hoban
There’s a lot of confusion that has accompanied the run-up to the Oct. 1 start of open enrollment in the exchange, also called a marketplace. To help readers understand this new coverage option, our media partner Georgia Health News asked the Centers for Medicare and Medicaid Services for a list of frequently asked questions about the health insurance exchanges.
Here is the agency’s list of FAQs and their answers.
How much will plans cost me in the insurance exchange or marketplace? Where can I go to find this information?
Prices will be available Oct. 1, when open enrollment starts and you can begin shopping. In the meantime, visit for the latest information about the health insurance marketplace. Coverage for the new health plans will start Jan. 1.According to Kerry Hall from the N.C. Department of Insurance, people at her department are getting a lot of calls asking how the marketplace will work.”People are trying to get a feel for whether they can keep their current insurance, if they will be able to afford the premiums, how the penalties will work and which companies are going to participate on the Marketplace,” Hall wrote in an email. She said the DOI’s consumer counselors are referring people to the federal website and telling them they can compare plans starting in October.Because the North Carolina legislature declined federal funds to create a state-based marketplace, when consumers have trouble with the marketplace they’ll have to contact federal insurance advisers at 1-800-318-2596 for information.

Screenshot of the webpage

Screenshot of the webpage

What is the enrollment period each year if I miss the first one in 2013?

The initial open enrollment period ends March 31, 2014. After that, annual enrollment will begin again in October 2014.

Outside of open enrollment, you can’t enroll in marketplace coverage unless you have a “qualifying life event.’’ Those include moving to a new state, certain changes in your income and changes in your family size (for example, if you marry, divorce or have a baby).

What is the cancellation policy if I miss a premium payment for an exchange or marketplace plan?

For consumers who are not eligible for a premium tax credit or subsidy, the cancellation policy follows state law from the Department of Insurance.

For consumers eligible for the credit or subsidy, there is a three-month grace period. If after three months the premium amount owed is not paid in full (less the advanced premium tax credit if applicable), the coverage will be canceled. A person does not technically have coverage until the first month’s premium has been received.

What is the difference between a Silver plan, a Gold plan and a Platinum plan?

All private health insurance plans offered in the marketplace will offer the same set of “essential health benefits.’’ These are services all plans must cover.

Plans in the exchange or marketplace are primarily separated into four health plan categories — Bronze, Silver, Gold or Platinum. These levels are based on the percentage the plan pays of the average overall cost of providing essential health benefits to members.

The plan category you choose affects the total amount you’ll likely spend for essential health benefits during the year. The percentages the plans will spend, on average, are 60 percent (Bronze), 70 percent (Silver), 80 percent (Gold) and 90 percent (Platinum). This isn’t the same as co-insurance, in which you pay a specific percentage of the cost of a specific service.

There’s also a plan to only cover catastrophic health events, but that’s only available for people under 30 years of age.

With a Bronze plan, you’ll likely pay a lower premium, but you’ll pay a higher share of costs when you get care. At the other end of the spectrum are Platinum plans, which will likely have the highest monthly premiums and lowest out-of-pocket costs.

BCBSNC rate schedule

Image courtesy BCBSNC.

Can you give me more information about preventive services for my children who will be covered by an exchange or marketplace plan?

Most health plans must cover a set of preventive health services for children at no cost when delivered by an in-network provider. This includes marketplace and Medicaid coverage.

All marketplace or exchange health plans and many other plans must cover a list of preventive services for children without charging you a co-pay or co-insurance. This is true even if you haven’t met your yearly deductible.

Those services include:

  • Autism screening for children at 18 and 24 months
  • Behavioral assessments for children at several ages
  • Blood pressure screening for children at several ages
  • Depression screening for adolescents
  • Developmental screening for adolescents
  • Hearing screening for all newborns
  • Height, weight and BMI measurements
  • Immunization vaccines for children from birth to age 18
  • Obesity screening and counseling
  • Sexually transmitted infection prevention and screening for adolescents at higher risk
  • Vision screening

What are the eligibility requirements related to citizenship status? 

Most people will be eligible for health coverage through the health insurance marketplace.

To be eligible, you  must live in the U.S., must be a U.S. citizen or national (or be lawfully present) and can’t be currently incarcerated.

U.S. citizens living in a foreign country are not required to get health insurance coverage under the Affordable Care Act.

Generally, health insurance coverage in the marketplace covers health care provided by doctors, hospitals and medical services within the U.S. If you’re living abroad, it’s important to know this before you consider buying marketplace insurance.

Questions? Call 1-800-318-2596, 24 hours a day, 7 days a week.

How can I find an affordable plan that will cover me if I have had breast cancer? 

Starting in 2014, health insurance plans can’t refuse to cover you or charge you more just because you have a pre-existing health condition.

Once you have insurance, the plan can’t refuse to cover treatment for pre-existing conditions. Coverage for your health conditions begins immediately. This is true even if you have been turned down or refused coverage due to a pre-existing condition in the past.

The only exception is for “grandfathered” individual health insurance plans — the kind you buy yourself, not through an employer. They do not have to cover pre-existing conditions. If you have one of these plans, you can switch to a marketplace plan during open enrollment and immediately get coverage for your pre-existing conditions.

Can you tell me if I am eligible for extra help paying my premiums?

When you use the health insurance marketplace, you may be able to get lower costs on monthly premiums or out-of-pocket costs or get free or low-cost coverage.

You can save money in the exchange three ways. All of them depend on your income and family size.

  • You may be able to lower your costs on your monthly premiums.
  • You may qualify for lower out-of-pocket costs for co-pays, co-insurance and deductibles.
  • You or your child may get free or low-cost coverage through Medicaid or the Children’s Health Insurance Program, called Health Choice in North Carolina.

Until Oct. 1, you can get a rough estimate of your potential costs and savings by using the Kaiser Family Foundation calculator.

Questions? Call 1-800-318-2596, 24 hours a day, 7 days a week.

How do I become an agent/broker? 

Contact the state Department of Insurance to discuss the requirements for becoming a licensed agent/broker.

How do I become a “certified application counselor”?

You can apply to become a certified application counselor organization by visiting

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