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Federal Health Reform FAQs
   
Please note that this page will be updated regularly. The department is also welcoming health reform questions.  We will not be responding to submitted questions, one by one, but rather placing the question and answer on this page so all stakeholders will be able to see the information. Please send appropriate questions to healthreformquestions@insurance.ohio.gov.
 

While the Ohio Department of Insurance (ODI) is the state agency that regulates insurance in the state, the Department is not administering the Affordable Care Act mandated exchange.  The U.S. Department of Health and Human Services (HHS) will be operating the exchange.  
 
To contact the exchange: 
Individuals: www.healthcare.gov OR 1-800-318-2596
Small Businesses: https://www.healthcare.gov/small-businesses/ OR 1-800-706-7893

To contact Medicaid:
Office of Medicaid
www.benefits.ohio.gov
1-800-324-8680

 

 
 
 
 
*For help with health care terminology, please take note of the glossary of terms that can be found under the resources section of the page.  If you have further questions or need assistance.  Please contact healthreformquestions@insurance.ohio.gov.

 

Individuals


Seniors
 

Employers
 

Miscellaneous
 

Resources


 
  1. What is an exchange?
       
    •  An exchange, as created under the Affordable Care Act (ACA), is a place where consumers can purchase subsidized health insurance coverage. Each state will have an exchange, operated by either the federal government or by the state.  In Ohio, there will be a federally facilitated exchange. Each state’s exchange must begin offering coverage January 1, 2014 and will begin accepting enrollment October 1, 2013.      
           
         
  2. Who can purchase insurance from the exchange?
     
    • Qualified individuals include U.S. citizens and legal immigrants who are not incarcerated and do not have other public coverage.
    • While anyone can purchase, only certain individuals will have access to federal subsidies.  
    • The ACA also provides a separate Small Business Health Options Program (SHOP) exchange for small businesses (fewer than 50 eligible employees) to obtain health coverage for their employees.
    • It is important to note that there are no subsidies offered through the SHOP.    
        
       
  3. Must everyone have health insurance? 
     
    • Yes, individuals, except for a select few, are mandated to have basic health insurance coverage, referred to by the ACA as “minimum essential coverage.” This provision is called the individual mandate.
    • There are a few select groups that are exempt.  To learn more about who is exempt, please visit https://www.healthcare.gov/what-if-someone-doesnt-have-health-coverage-in-2014/ or call 1-800-318-2596.
             
            
  4. Must I purchase my health insurance on the exchange?
        
    • No.  There are a handful of ways to satisfy the individual mandate, including insurance on the regular market or from an employer, and not be penalized.
    • The exchange merely exists as a mechanism for those eligible to be able to receive subsidized health insurance. 
    • Consumers who do not qualify for subsidies may find more affordable options outside the exchange on the regular market. 
        
       
  5. What are the types of plans that will be offered in the exchange?
     
    • Every plan offered on the exchange must be certified as a Qualified Health Plan (QHP).
    • To receive the QHP certification, the plan must offer at least a uniform benefits package, called Essential Health Benefits (EHB), be licensed by the state and have a sufficient network.
    • Each exchange will offer four levels of coverage and a catastrophic plan for those under 30 or those who meet certain income levels.
    • Generally, the benefits will be the same among the plans, while the percentage of total average costs for covered benefits that a plan will pay will vary between metal tiers:
       
      Bronze: The plan must cover 60% of expected costs and the consumer is responsible for 40%.  This is the lowest level of coverage.
      Silver: The plan must cover 70% of expected costs and the consumer is responsible for 30%. 
      Gold: The plan must cover 80% of expected costs and the consumer is responsible for 20%. 
      Platinum: The plan must cover 90% of expected costs and the consumer is responsible for 10%.    
          
         
       
  6. What health insurance providers are selling plans on the exchange?
         
    Individual Market Small Group Market
    Community (Anthem) Community (Anthem)
    AultCare AultCare
    Buckeye Community Health Plan HealthSpan
    CareSource Kaiser
    Coventry Medical Health Insuring Corp. of Ohio
    HealthSpan SummaCare
    Humana Health Plan of Ohio
    Kaiser
    Medical Health Insuring Corp. of Ohio
    Molina
    Paramount
    SummaCare

    *This chart only represents the providers offering plans on the exchange.  There are more providers offering plans in the traditional insurance market, outside of the exchange.
    **Please note that not all these companies are offered throughout Ohio.  Where you live in the State affects the cost of your premium, as well as the health insurance providers available to you in your area. 
      
           
  7. What types of benefits will be offered?
      
    • After 2014, every new plan sold to individuals and small group, both on and off the exchange must include a basic package of benefits, called Essential Health Benefits (EHB). 
         
      Ohio's EHB package consists of benefits in at least the following categories:
      • Ambulatory patient services,
      • Emergency services,
      • Hospitalization,
      • Maternity and newborn care,
      • Mental health benefits and substance use disorder services,
      • 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. 

        Please click here for the EHB summary. It is important to note that grandfathered plans are not required to cover EHBs.  

           
  8.  How much do the plans cost on the exchange?
      
    • Premiums are consumer specific and will be available to view beginning October 1, 2013 at www.healthcare.gov OR 1-800-318-2596

           
  9. Are Essential Health Benefits and other ACA provisions only offered on the exchange?
       
    • No, beginning in 2014, all new plans sold in the individual and small group market in Ohio will contain the full set of Essential Health Benefits. 
    • Other reforms, such as no cost sharing for preventive services, no annual dollar limit for EHB and charging more or denying coverage for those with pre-existing conditions required of all individual and small group plans on the regular insurance market. 
    • Grandfathered plans, those that have existed continuously since before March 23, 2010 without significant changes, are not required to contain the EHB package and other ACA requirements.

         
  10. When can I begin using the exchange?
     
    • Open enrollment begins October 1, 2013 with coverage beginning January 1, 2014. 
      • If you sign up before December 23, 2013, your coverage will begin January 1, 2014.
      • If you sign up between December 24, 2013 – March 15, 2014, your coverage start dates depends when you enrolled. 
        * Please note that enrollment in the SHOP exchange via the online website was delayed until November 2014.  You will need to work directly with an agent or health insurance company to enroll in a SHOP plan.
          
    • If you sign up between the 1st through the 15th of any month (except for December 2013), your coverage begins the first day of the next month. 
    • If you sign up between the 16th and the end of the month, your coverage will begin the first day of the second following month. For example:

      For Example: 
      • If you enroll on December 30, 2013 – your coverage begins February 1, 2014
      • If you enroll January 20, 2014 – your coverage begins March 1, 2014
      • If you enroll on February 2, 2014 – your coverage begins March 1, 2014
          
         
           
  11. How do I enroll on the exchange?
      
    • Beginning October 1, 2013 – you may use an agent to assist in enrollment, a navigator to guide you through the exchange or you can enroll yourself at www.healthcare.gov OR 1-800-318-2596.
      * Please note the open enrollment for the SHOP exchange was delayed until November 1, 2013.
        
  12. I’m a veteran. What will happen to my health care coverage?
     
    • Nothing. Veterans will continue to receive benefits as they do today.
        

        
  13. If I am currently insured, will I be required to purchase new health insurance coverage?
        
    • All health plans that were in place as of March 23, 2010, are grandfathered in under the law and are considered minimum essential coverage and satisfy the individual mandate – provided they continue to meet the requirements to be grandfathered.
    • Consumers can check with their employer or insurance company to verify that their current plan has grandfathered status. 
    • On November 14, 2013, it was announced that non-grandfathered health plans in the individual and small-group market that otherwise would have been cancelled as of a result of ACA mandated reforms, now can be extended.  It is up to the health insurance company to decide if they would like to extend those plans for a policy year.
    • Companies must send each consumer a letter explaining how their premium may be affected and the time any changes to their coverage or premium may take place. 
    • Please check with your health insurance company if you need further explanation or have any questions.
            
         
       
  14. Will the grandfathered plans have to be updated to meet new requirements?
     
    • Yes, but only certain requirements:
      • All enrollees under the age of 19 cannot be discriminated against for pre-existing condition (extends to all individuals in 2014)
      • Excessive waiting periods are prohibited (begins in 2014)
      • No lifetime limits
      • Rescissions are prohibited except for fraud or intentional misrepresentation
      • Restricted annual limits on the dollar value of essential benefits  
      • Young adults are covered to age 26 (28 in Ohio), unless they are eligible for coverage elsewhere (beginning in 2014)  


          
  15. I have my adult dependent child on my insurance coverage.  Will he/she still be able to stay on my health insurance?
     
    • Yes, this previously enacted provision will not change.
    • Ohio has its own set of dependent care regulations that allows for certain young adults to be covered on their parents insurance until the age of 28.
    • For more information regarding the difference between federal and state rules, please click here.
    • According to the ACA, dependent children can stay on their parent’s insurance until they turn 26.  
       
       
  16. Can I be denied coverage for a pre-existing condition?
     
    • No.  Starting in 2014, insurers will no longer be able to turn down adults for coverage due to pre-existing conditions.
         
       
         
  17. What is the penalty for those who opt not to get health insurance coverage?
     
    • The penalty for people who decline to purchase health insurance is the greater of two amounts: a specified percentage of income or a specified dollar amount.
    • The percentages of income/dollar amount are phased in over time with annual increases to be determined after 2016. 

      ​Year ​Percentage of Income ​Dollar Amount
      2014​ ​1% ​$95
      ​2015 ​2% ​$325
      ​2016 ​2.5% ​$695

       
         
       
  18. How much will the policies cost?
     
    • The cost will vary by type of plan, location, coverage level, age and tobacco use, number of family members and if applicable, your subsidy.  
    • Please visit www.healthcare.gov to more information on exchange plan premiums.  
        
       
  19. What happens if I cannot afford the premiums through the exchange?
     
    • Starting in 2014, individuals and families with incomes between 100% and 400% of the Federal Poverty Level (FPL) are eligible to receive subsidies for premiums, in the form of advanceable tax credits.
    • The premium subsidies will vary with income and are structured so that the premium an individual or family will have to pay will not exceed a specific percentage of income.
    • Individuals may use this subsidy calculator tool to get a better idea of whether or not they qualify for premium subsidies. Please note this tool is simply an estimate to what could be expected in 2014.
    • If an individual is qualified for Medicaid, they will be referred to Ohio’s Office of Medicaid.
    • For more information regarding health insurance subsidies for individuals, please click here.
    • Please visit www.healthcare.gov for more information. 
        
        
       
  20. Are copayments for preventive care prohibited? What about coinsurance and deductibles?
       
    • Yes, all cost sharing mechanisms are prohibited for preventive services.
       
        
       
  21. If I need help with enrolling, the application process or questions about my plan options, other exchange related issues, who do I contact?
       
    • Consumers can continue to get information about their plans via their agent or health insurance professional. 
    • If you need help finding an agent in your area, please use the department’s agent/agency locator tool. You can also search by agents who are able to sell plans on the exchange.
    • In addition, www.healthcare.gov and 1-800-318-2596 are available for individuals and 1-800-706-7896 for small businesses to assist in exchange related issues.  There will also be navigators that conduct public education activities, distribute information and facilitate enrollment.
        
       
         
  22.   When is open enrollment?
        
    • Open Enrollment is October 1, 2013 through March 31, 2014. 
    • In 2014, Open Enrollment will be from November 14, 2014 through January 15, 2015.
    • In the subsequent years, open enrollment will be October 15 through December 7. 
      * Please note that enrollment in the SHOP exchange via the online website was delayed until November 2014.  You will need to work directly with an agent or health insurance company to enroll in a SHOP plan.
       
         
  23. Can I still use an insurance agent to enroll into a plan on the exchange?
       
    • Yes, your agent is a good way to find more personalized information for your circumstance as long as he or she is registered with the exchange. 
    • Unlike other enrollment assistors, agents are the only group allowed to advise a consumer or business which plan is the best suited for purchase and enroll. Other consumer assistance is only allowed to inform the consumer of their options. 
          

         
  24. Are Flexible Spending Accounts still allowed?
       
    • Yes, however, beginning in 2013, you can only deposit up to $2,500 per year into an FSA.
         
        
       
  25. How is prescription coverage handled in the ACA?
       
    • Prescription coverage is one of the essential health benefits that all plans containing EHB must have. 
    • The type of prescription coverage will depend on the policy option chosen.  
          
        
       
  26. What are the new restrictions on lifetime maximums?
     
    • The ACA prohibits health insurance issuers from establishing any lifetime limits on the dollar amount of benefits.
         
       
       
  27. What is the practical implication of the Governor’s Habilitative Services letter?  
          
    • Ohio's EHB will include coverage for certain individuals with a diagnosis of autism spectrum disorder by all plans that are mandated to meet Essential Health Benefit (EHB) requirements. 
    • Generally, all new plans sold to small employer groups (50 or fewer employees) and to individuals, both inside and outside of the exchange, are required to meet EHB requirements.  For more information about EHB, click here.
        
        
           
  28. What does the Habilitative Services definition encompass?
          
    • Habilitative Services benefits will be determined by the individual plans and must include, but shall not be limited to, Habilitative Services to children (0 to 21) with a medical diagnosis of Autism Spectrum disorder. 
           
         
       
  29. What are the Habilitative Services benefits offered for those children (0-21) with a medical diagnosis of Autism Spectrum Disorder?
     
    • Habilitative Services must include, but are not limited to:
       
      1. Out-Patient Physical Habilitative Services including:
         
        • Speech and Language therapy and/or Occupational therapy, performed by a licensed therapists, 20 visits per year of each service; and
           
        • Clinical Therapeutic Intervention defined as  therapies supported by empirical evidence, which include but are not limited to Applied Behavioral Analysis,  provided by or under the supervision of a professional who is licensed, certified, or registered by an appropriate agency of this state to perform the services in accordance with a treatment plan, 20 hours per week;
           
      2. Outpatient Mental/Behavioral Health Services performed by a licensed Psychologist, Psychiatrist, or Physician to provide consultation, assessment, development and oversight of treatment plans, 30 visits per year total. 
           
         
            
         
  30. What is the difference between habilitative services and rehabilitation services?
     
    • Habilitative services are provided in order for a person to attain, maintain or prevent deterioration of a skill or function never learned or acquired due to a disabling condition.
    • Rehabilitation services, on the other hand, are provided to help a person regain, maintain or prevent deterioration of a skill or function that has been acquired but then lost or impaired due to illness, injury, or disabling condition. 
         
        
          
  31. Where can I get more information regarding the ACA?
     
  32.    
    Seniors 
     
    *Please note that all Medicare related questions should be directed to the Ohio Senior Health Insurance Information Program within the Department.  More information can be found at Medicare.gov OR Ohio Senior Health Insurance Information Program.
     
    OSHIIP: 1-800-686-1578

     
     
     
  33. How does the exchange affect my Medicare benefits?
     
    • It doesn’t, the exchange will not play a role in Medicare.  For more information, please contact OSHIIP. The Exchange won’t have any effect on your Medicare coverage. Your Medicare benefits aren’t changing. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan, you’ll still have the same benefits and security you have now, and you won’t have to make any changes.  
    • It’s against the law for someone who knows that you have Medicare to sell you a Marketplace plan.
        
       
  34. Will the ACA effect by Medicare Supplement plan?
     
    • No.  However, the law will add cost-sharing requirements to plans C & F after January 1, 2015.
       
       
  35. Will the exchange offer or provide information regarding Medicare Advantage products?
     
    • No.


      Please note that during times in major reform, fraud flourishes.  As the ACA is phased-in, be aware of con artists that might try to steal consumers’ money or identity through various health insurance schemes.  You will not receive a new Medicare card under the ACA, or a federal health care card. 
       
      Remember this simple formula: STOP – CALL – CONFIRM.
        
      STOP – Consumers should ask the person for identification and a phone number where they may be reached later. If the person refuses to give this information for any reason, or tries to pressure them into signing any document, consumers should immediately hang up, close their door, or walk away.
       
      Consumers should NOT volunteer their Social Security Number or a credit/debit card number to anyone unless they personally know the individual. Likewise, they should NOT sign any paperwork or write a check.
       
      CALL – Consumers then should contact the Ohio Department of Insurance or the exchange. The insurance company or agent, as well as the navigator, must be registered or licensed with the Department of Insurance before they can sell coverage or counsel consumers through the exchange. 
        
      CONFIRM
      – Consumers always should always confirm that the company, or agent offering insurance coverage, or the navigator trying to provide assistance, is authorized to provide information or coverage before they sign any documents or give any personal information.
           
      Remember that if something seems too good to be true, it usually is.
       
       
       
      Top
       
       
       
       
    Employers
     
    *Please note that the below information is based on guidance released from the federal government and can change at any time. Please keep in mind that each case is different and the Department encourages the consultation of a health insurance professional.
     
      
     
  36. As an employer, do I need to inform my employees of health reform changes?
     
    • Yes. If your company is covered by the Fair Labor Standards Act, by October 1, 2013, all new hires and current employees must be given written notice of the following:
        
      1. informs the employee of the existence of an Exchange, including a description of the services provided by such Exchange, and the manner in which the employee may contact the Exchange to request assistance; 
         
      2. if the employer plan's share of the total allowed costs of benefits provided under the plan is less than 60 percent of such costs, that the employee may be eligible for a premium tax credit under section 36B of the Internal Revenue Code of 1986 and a cost sharing reduction under section 1402 of the Patient Protection and Affordable Care Act [42 USC §18071] if the employee purchases a qualified health plan through the Exchange; and 
          
      3. if the employee purchases a qualified health plan through the Exchange , the employee may lose the employer contribution (if any) to any health benefits plan offered by the employer and that all or a portion of such contribution may be excludable from income for Federal income tax purposes.
          
    • There is no fine or penalty under the ACA or other law for failing to provide notice to employees.
       
      For more information, please read guidance from the U.S. Department of Labor.

        
       
  37. Are employers required to provide health insurance coverage to their employees?
     
    • No, however, if the business employs more than 50 FTE, they are required to provide qualified coverage to all employees and their dependents* or must pay a penalty.** 
    • Small businesses with fewer than 50 employees are not required to offer coverage to their dependents.   
       
        
      *Please note that the ACA defines dependents as children, not spouses.  Therefore, the employer is only responsible for offering coverage for employees and their children and will not be penalized for not offering spousal coverage.   
        
      **The employer mandate has been delayed and penalties will not be assessed to large businesses that do not offer health coverage until 2015. 
        
       
  38. How does the ACA define a full-time employee?
     
    • Federal law specifies 30 hours per week.     
        
       
  39. How does Ohio define a full-time employee?
     
    • Ohio law specifies 25 hours per week. 
        
      Please note:
      While the federal government defines 30 hours a week as full time, Ohio’s definition of 25 hours is used only to determine if an employee is eligible for health coverage in the small group market (Ohio businesses with 50 or fewer employees).  
       
       
  40. How will seasonal employees be factored in to the employer size determination?
     
    • If its workforce exceeds 50 full-time employees for more than 120 days a calendar year, then they will have to provide qualified and affordable coverage or face penalties.
        
      For More information: http://www.irs.gov/pub/irs-drop/n-12-58.pdf
       
        
       
  41. Will employers have to pay a penalty if they do not provide health coverage?
     
    • Generally, if an employer has more than 50 full-time employees and at least one employee is receiving a subsidy through the exchange due to the employer sponsored plan being unaffordable or inadequate, they will be assessed a penalty for coverage beginning in 2015.  
           
        
        
  42. What is the penalty for an employer?
       
    • Generally, if an employer does not offer qualified coverage and at least one employee is eligible for a premium subsidy though the exchange, the employer will be assessed a $2,000 penalty.
    • If the employer does offer coverage, but at least one full-time employee is eligible for a premium subsidy due do the plans unaffordability, the employer will be assessed a penalty of $3,000 per employee that receives the subsidy.
    • For more information, please review this employer responsibility flow chart, to learn more information on employer responsibility and penalties. 
       
      *The employer mandate was delayed. Penalties will be assessed starting January 1, 2016 to employers with 50+ full-time equivalent (FTE) employees not offering health coverage in 2015.
          
        
  43. Why would an employee be eligible for a premium subsidy?
     
    • Subsidies are possible if an individual has employer sponsored insurance and:
      • The employee’s portion of the employer’s plan exceeds 9.5% of the employees household income, OR
      • The employer offers coverage in which the plan’s share of total allowed costs of benefits provided is less than 60% of such costs. 
    • If an employee choses to purchase a plan on the exchange, their employer does not have to pass the employer contribution to the exchange plan.  
         
        
         
  44. What health insurance providers are selling plans on the exchange?
          
    Individual Market Small Group Market
    Community (Anthem) Community (Anthem)
    AultCare AultCare
    Buckeye Community Health Plan HealthSpan
    CareSource Kaiser
    Coventry Medical Health Insuring Corp. of Ohio
    HealthSpan SummaCare
    Humana Health Plan of Ohio
    Kaiser
    Medical Health Insuring Corp. of Ohio
    Molina
    Paramount
    SummaCare
     
    *This chart only represents the providers offering plans on the exchange.  There are more providers offering plans in the traditional insurance market, outside of the exchange.
    **Please note that not all these companies are offered throughout Ohio.  Where you live in the State affects the cost of your premium, as well as the health insurance providers available to you in your area. 
        
  45. Is an employer required to purchase insurance through the exchange?
      
    • No. While the Small Business Health Program (SHOP) gives employers an option to purchase group insurance through an exchange, employers may continue to purchase insurance through the market outside the exchange. 
       
      *Employer choice has been delayed a year. For 2014 plans, employers will decide the plan or plans from which employees can choose their coverage* 
      **Please note that enrollment in the SHOP exchange via the online website was delayed until November 2014.  You will need to work directly with an agent or health insurance company to enroll in a SHOP plan.**  
       
       
  46. Can an employer receive tax credits for providing insurance to their employees?
       
    • If you have less than 25 employees, pay average annual wages below $50,000, provide health insurance and pay at least 50% of the premium, you may qualify for a small business tax credit.
    • From 2010 to 2013, eligible employees can receive a tax credit of up to 35% (up to 25% for non-profits) to offset the cost of the insurance.
    • In 2014, the tax credit increases to 50% (35% for non-profits) for qualifying businesses, and coverage must be purchased through the SHOP.  
          
       
  47. Where can I find more information regarding how the Affordable Care Act affects Employers? 
         
  48. Miscellaneous
     
     
  49. How can I become a navigator?
     
    • Please visit the Department’s page on agent & navigator exchange information.
       
       
       
  50.  How will health care reform affect my taxes?
      
    • The Ohio Department of Insurance acts as regulators in the insurance market in Ohio and does not have a role in determining tax related policy or interpretation. 
    • Here is a link to the IRS website regarding health care reform.
       
        
       
  51. Are there any exchange-related career opportunities?
       
 
 
Glossary


      

The State of Ohio is an Equal Opportunity Employer

Ohio Department of Insurance
50 W. Town Street, Third Floor - Suite 300
Columbus, Ohio  43215
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John Kasich, Governor | Mary Taylor, Lt. Governor / Director
General Info: 614-644-2658 | Consumer Hotline: 800-686-1526
Fraud Hotline: 800-686-1527 | OSHIIP Hotline: 800-686-1578