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 email@example.com.
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.
Below are frequently asked questions regarding the healthcare exchange.
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 has an exchange, operated by either the federal government or by the state. In Ohio, there is a federally-facilitated exchange.
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?
No. On December 22nd, 2017 Congress passed sweeping tax reform legislation that included changes to the individual mandate. The legislation "zeroed out" the penalty that is associated with the individual mandate meaning there is no longer a fine for not having insurance. However, it did not eliminate the mandate itself.
4. Must I purchase my health insurance on the exchange?
No. There are a handful of ways to purchase insurance including purchasing insurance on the regular market or from an employer. 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?
The Affordable Care Act (ACA) requires that every state have an exchange where consumers can buy individual health insurance policies. In Ohio, the federal government runs the health insurance exchange. Ohioans who do not have health insurance through their employer, Medicare, or Medicaid may be eligible to purchase coverage through the exchange. Open enrollment for coverage next year is November 1 to December 15. A summary of Ohio’s individual market for the current year is available here. The data is based on product filings the Ohio Department of Insurance is currently reviewing.
7. What types of benefits will be offered?
Since 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,
- Maternity and newborn care,
- Mental health benefits and substance use disorder services, including behavioral health treatment,
- 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 Essential Health Benefits (EHB) Summary. It is important to note that grandfathered plans and transitional plans are not required to cover EHBs.
8. How much do the plans cost on the exchange?
Premiums are consumer-specific and 2019 plans and prices are available to view at www.healthcare.gov or 1-800-318-2596.
9. Are Essential Health Benefits and other ACA provisions only offered on the exchange?
- No, since 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 are 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 or comply with the EHB package and certain other ACA requirements.
- Transitional plans, those non-grandfathered health plans in the individual and small-group market that otherwise would have been canceled as a result of ACA mandated reforms and can be extended until December 31, 2019, pursuant to the federal announcement on April 9, 2018, are also not required to contain the EHB package or comply with certain other ACA requirements.
10. How do I enroll in the exchange?
Open enrollment begins Nov. 1, 2018, for coverage effective Jan. 1, 2019 - 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.
11. 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 conditions (extends to all individuals in 2014)
- Excessive waiting periods are prohibited (began 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 may be covered to age 26.
12. I have my adult-dependent child on my insurance coverage. Will he/she still be able to stay on my health insurance?
Dependent children can stay on their parent’s insurance until they turn 26.
13. Which ACA requirements do not apply to transitional plans?
- Community rating
- Guaranteed availability and renewability of coverage
- In the individual market only - nondiscrimination based on health status
- In the individual market only - pre-ex prohibition
- Nondiscrimination against health care providers
- The requirement to provide the EHB package
- Coverage for certain clinical
For additional information on transitional plans, please visit the Extension of Transitional Policy Through 2019 bulletin on the CMS website.
14. Can I be denied coverage for a pre-existing condition?
No. Insurers are no longer able to turn down adults for coverage due to pre-existing conditions for all new plans.
15. 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 for more information on exchange plan premiums.
16. What happens if I cannot afford the premiums through the exchange?
- 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 of what could be expected in 2019.
- 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.
17. Are co-payments for preventive care prohibited? What about coinsurance and deductibles?
Yes, all cost-sharing mechanisms are prohibited for preventive services.
18. If I need help enrolling with the application process, have questions about my plan options, or any 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 1-800-706-7893 for small businesses to assist in exchange-related issues. There will also be navigators that conduct public education activities, distribute information and facilitate enrollment.
19. When is open enrollment?
Open Enrollment for 2020 coverage is Nov. 1 through Dec. 15, 2019.
20. Can I still use an insurance agent to enroll in 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 enrollment. Other consumer assistance is only allowed to inform the consumer of their options.
21. Are Flexible Spending Accounts still allowed?
Yes, however, the ACA limits deposits to $2,600 per year into an FSA.
22. 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 plan selection.
22. What are the restrictions on lifetime maximums?
The ACA prohibits health insurance issuers from establishing any lifetime limits on the dollar amount of benefits.
23. 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.
24. 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.
25. 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:
- Out-Patient Physical Habilitative Services including:
- Speech and Language Therapy and/or Occupational therapy, performed by a licensed therapist, 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;
- Out-Patient Physical Habilitative Services including:
- 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.
26. 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.
*Please note that all Medicare-related questions should be directed to the Ohio Senior Health Insurance Information Program (OSHIIP) within the department. Additional information can be found at Medicare.gov.OSHIIP: 1-800-686-1578
1. How does the exchange affect my Medicare benefits?
- It doesn't, the exchange does not play a role in Medicare. For more information, please contact OSHIIP. The exchange does not affect your Medicare coverage. 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 an exchange plan.
2. Will the ACA affect my Medicare Supplement plan?
No. However, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provides that on or after January 1, 2020, a Medicare supplemental policy that provides coverage of the Part B deductible may no longer be sold or issued to a person newly eligible for Medicare. This means that benefit packages C and F will no longer be available to those newly eligible for Medicare and will instead be classified as D or G respectively.
3. Will the exchange offer or provide information regarding Medicare Advantage products?
No. Please note that during times of 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.
*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.
1. As an employer, do I need to provide my employees with information about the Exchange?
Yes. If your company is subject to the Fair Labor Standards Act, written notice must be provided, free of charge, to employees within 14 days of their start date. The written notice must:
- inform 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;
- inform the employee that 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, 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
- inform the employee that 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 specific fine or penalty under the ACA or other law for failing to provide notice to employees.
For more information, please read the guidance on Notice to Employees of Coverage Options from the U.S. Department of Labor.
2. 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.
*Please note that the ACA defines dependents such 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.
3. How does the ACA define a full-time employee?
Federal law specifies 30 hours per week.
4. How does Ohio define a full-time employee?
For purposes of a small employer health benefit plan, Ohio law specifies 30 hours per week.
5. How will seasonal workers be factored into the employer size determination?
- If an employer's workplace 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
6. 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.
7. 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 through 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 to the plan's 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 and several forms of transitional relief were available to some employers in 2015 and 2016. The IRS has begun assessing penalties to employers that had 100+ full-time equivalent (FTE) employees and did not offer health coverage in 2015.
8. 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 chooses to purchase a plan on the exchange, their employer does not have to pass the employer contribution to the exchange plan.
9. What health insurance providers are selling plans on the exchange in 2020?
- AultCare Insurance Company
- Buckeye Community Health Plan
- Community Insurance Company
- Medical Health Insuring Corp. of Ohio
- Molina Healthcare of Ohio, Inc.
- Oscar Buckeye State Insurance Corporation
- Oscar Insurance Corporation of Ohio
- Paramount Insurance Company
- Summa Insurance Company
*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.
10. 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.
11. Can an employer receive tax credits for providing insurance to their employees?
- Beginning in 2014, the small business tax credit changed in a few ways. The maximum credit amount increased, an employer is required to contribute a uniform percentage of premiums on behalf of each employee, and cost-of-living adjustments must be made to the average annual wage phase-out amounts. Further, an employer may claim the credit for no more than two consecutive taxable years, beginning with the first taxable year in or after 2014 in which the eligible small employer files for the credit. For more information, please reference: https://www.irs.gov/newsroom/small-business-health-care-tax-credit-questions-and-answers-who-gets-the-tax-credit
- 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.
- Through 2015, the tax credit increases to 50% (35% for non-profits) for qualifying businesses, and coverage must be purchased through the SHOP.
1. How can I become a navigator?
Please visit the department’s page on agent & navigator exchange information.
2. How will health care reform affect my taxes?
The Ohio Department of Insurance acts as a regulator in the insurance market in Ohio and does not have a role in determining tax-related policy or interpretation.