Reform Alert - News from the Blues' Office of National Health Reform

CMS issues draft health insurance marketplace applications

Feb. 15, 2013

Under Sections 1311 and 1413 of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) must develop and provide each state with a single, streamlined enrollment application form. States also may elect to develop and use their own application, with approval by CMS.

On January 29, 2013, CMS published the draft online and paper applications for the Individual Marketplace and the Small Business Health Options Program (SHOP).

What is the Individual application process?

CMS is designing the online application to be a dynamic process that will tailor the required data to the applicant’s individual circumstances and responses to specific questions. As provided in previous rulemaking, individuals will be able to submit an application online, through the mail, over the phone or in person.

The goal is to solicit enough information during the application process so that in most cases no further inquiry will be needed. The Marketplace will begin taking applications for coverage when open enrollment begins on October 1, 2013.

How is the online application intended to work?

The online system will be designed to catch inadvertent errors instantly and verify most information immediately. It will also allow individuals to save information through a unique user account and access instant help resources.

The length of time it takes to complete the application will vary depending on whether a person is applying for Marketplace-only coverage or coverage in an Insurance Affordability Programs (e.g., Medicaid, CHIP and advance payment of the premium tax credit).

Do applicants have to apply online?

Individuals are encouraged to apply online, but there will also be a separate paper application. Applications can be submitted without all required information. The instructions indicate that an eligibility determination will be available within one to two weeks of submitting the application.

The application includes a reminder about the availability of financial assistance, highlighting that a family of four with an annual income of $92,000 may qualify for help.

What is the Employer Coverage Form?

An Employer Coverage Form is available to help applicants obtain necessary information about access to employer-sponsored coverage, which pertains to eligibility for Insurance Affordability Programs (Medicaid, CHIP and advance payment of the premium tax credit). This form can be taken to an employer, who will provide information about the employer-sponsored coverage (e.g., eligibility for coverage; minimum value standard; cost of lowest cost plan).

In addition to the information identified above, CMS plans to develop online help resources such as pop-ups and links to explanations. CMS believes these resources will help individuals successfully complete the online application. This information is expected to be developed in the next several weeks.

How does the SHOP application process differ from the Individual process?

While much of the information for the Individual application process aligns with the SHOP guidance, some things differ greatly, for example, for SHOP:

  • Eligibility application does not contain questions about employee finances.
  • Brokers cannot use the paper application, so employers who choose to use a broker will apply online.
  • Employers are required to attest that they are offering coverage to all full-time employees and to submit an employee roster.
  • Employers will receive a follow up notice on their eligibility within 3 to 4 weeks of submitting a paper application.
  • The Employer Coverage Form does not apply at all for the SHOP.

Comments on these draft application materials are due February 28, 2013.

Where can I find more information?

You can view two YouTube videos – one for an individual and one for a family of three – demonstrating the online application experience. In addition, the draft online and paper applications for the Individual Health Insurance Marketplace and SHOP are available at:

  • Individual Application for Eligibility and IAPs (CMS-10440)
  • SHOP Employer Application (CMS-10439)
  • SHOP Employee Application (CMS-10438)

1 You may have heard the Health Insurance Marketplace (Marketplace) previously referred to as the Exchange. The Health Insurance Marketplace is the official name adopted by the Department of Health and Human Services (HHS) and BCBSM/BCN. The Blues agree this is a more consumer-friendly term.

The information in this document is based on preliminary review of the national health care reform legislation and is not intended to impart legal advice. The federal government continues to issue guidance on how the provisions of national health reform should be interpreted and applied. The impact of these reforms on individual situations may vary. This overview is intended as an educational tool only and does not replace a more rigorous review of the law’s applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. As required by US Treasury Regulations, we also inform you that any tax information contained in this communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Revenue Code.

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