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Tax credits are available for individuals and families who meet certain income requirements and do not have access to affordable health insurance through their employer that also meets minimum coverage requirements. Eligibility for tax credits is based on a standard, called the “federal poverty level,” that looks at family income and the number of people in the family. The size of the tax credit is based on a sliding scale, with those who make less money getting larger financial assistance to lower the cost of their insurance coverage. Individuals and families who make between 133 percent and 400 percent of the federal poverty level may be eligible for a tax credit. This means that an individual making up to $52,920 and a family of four earning up to $108,360 may be eligible for tax credits.
Some key facts about tax credits:
- Tax credits lower the cost of your premium. Tax credits reduce the amount of the premium you will pay for insurance.
- Tax credits help low- and middle-income individuals and families. Tax credits are available to individuals and families who meet certain income requirements.
- Tax credits can be used when you enroll. Tax credits can be applied to the cost of your health plan when you enroll – you do not need to wait until you file a tax return at the end of the year.
- Tax credits are only available through the Hawaiʻi Health Connector. You must enroll in a health plan through the Hawaiʻi Health Connector if you want to use your tax credits.
- Tax credits are paid directly to your health plan. These tax credits are paid by the Hawaiʻi Health Connector to your health plan to keep your costs low.
- Tax credits will be adjusted at the end of the year based on your actual income. At the end of the year, the tax credits may be adjusted if your income is different than you anticipated. This means that you will want to notify the Hawaiʻi Health Connector if your income changes.
- Small businesses with 25 or fewer full-time equivalent employees are also eligible for tax credits if they meet certain criteria. To learn more about small business tax credits, you can read the Small Business Tax Credit Fact Sheet.
- The cost of health insurance depends on how much coverage you choose to purchase and whether you qualify for financial assistance like tax credits. The Hawai‘i Health Connector is the only place where you can use these tax credits to make insurance more affordable.
Every plan on the Connector will be separated into one of four basic levels of coverage:
This ranking system will make it easy to compare different health plans. Each level represents a different percentage of medical expenses that the health plan will cover. The health plans that cover more of your medical expenses usually have a higher monthly payment. And the health plans that cover less of your medical expenses usually have a lower monthly payment. So:
- Plans with a higher monthly cost = more medical expenses covered
- Plans with a lower monthly cost = less medical expenses covered
This means you can choose the level of coverage that best meets your health needs and budget.
Starting in 2014, individuals seeking health coverage will be helped to afford coverage by:
- Tax credits: Tax credits are available to lower the cost of health coverage for individuals and families who meet certain income requirements and do not have health insurance from an employer or a government program. When you enroll in a health plan through the Hawaiʻi Health Connector, tax credits can be immediately applied to the insurance premium, which reduces the amount you pay each month.
- Cost-sharing subsidies: Cost-sharing subsidies reduce the amount of out-of-pocket health care expenses an individual or family has to pay. These expenses might include the copayments for health care services or other costs.
Legal residents of Hawaiʻi without access to affordable health insurance through their employer or another government program will be eligible to purchase health coverage through the Hawaiʻi Health Connector.
Comprehensive VA benefits and TRICARE for life count as coverage toward the individual mandate. You can continue on these programs without interruption.
The Hawai‘i Health Connector will open in the Fall of 2013. At that time you can shop for carriers, plans and rates and find the best plan for you. It is possible that you will qualify for premium tax credits. If you haven’t tried our calculator, it is available on our website. This is an estimation of what an average plan might cost. Again, we will not have the true plans and rates available until October, 2013.
There will be no waiting period if you do not have insurance.
When you enter your financial information into the Hawai‘i Health Connector, our system will be able to check availability for CHIP, which will still exist. Parents can continue through our system and choose a private plan, so we will be able to handle different eligibilities through our system.
The Hawai‘i Health Connector does not have Medicare Supplement products on our system. If your employer offers health insurance, it is possible that you can get supplemental coverage through that employer. You would need to check with them.
An individual can only sign up their dependents in the marketplace as individuals and have access to advanced premium tax credits IF the employer does NOT offer dependent coverage.If an employer offers dependent coverage, even if they do not pay any of the premium, the dependent would not be eligible for an Advanced Premium Tax Credit (APTC). They can always decline coverage and pay the full premium for a plan through the Hawai‘i Health Connector.
The Small Business Health Care Tax Credit was established under the federal health law and is only available to employers who purchase through the Connector in 2014.
The goal is for insurance premiums to moderate over time as the number of people who have health insurance increases and as cost-control initiatives outside our marketplace become implemented.
Small businesses (both for-profit and non-profit businesses and organizations) can benefit from the federal Small Business Health Care Tax Credit.You may qualify for the employer small business health care tax credits if you have fewer than 25 full-time equivalent employees making an average of about $50,000 a year or less. More importantly, starting in 2014 the federal Small Business Health Care Tax Credit is offered only through the Connector.For information on whether your business or organization qualifies for the federal tax credit and how to claim the credit, please consult your tax advisor and visit the IRS’s website at www.irs.gov/sbhtc.
Self-employed business people (sole proprietors) will shop for health insurance as individuals through the Connector, rather than as small group plans.
Yes. If you are self-employed (but also employ at least one employee and no more than 50 employees) you may be eligible to purchase health coverage for both you and your employees through the Small Business Health Options Program (SHOP).If you’re a sole proprietor without employees, you may purchase as an individual through the individual marketplace. By purchasing your health coverage as an individual consumer on the Connector, you can learn if you are eligible for financial help to lower the cost of coverage.
No, small businesses do not have to buy qualified health plans (QHPs) through the Connector. However, in order to be eligible for the federal Small Business Health Care Tax Credit, a small business must buy insurance through the Connector.The Connector encourages small business owners and employers to speak with their broker, agent or Professional Employer Organization (PEO) to learn about their options and what is in the best interest for their business. Agents and brokers will also have access to a training and certification program so they can assist their clients in using the Connector.
Hawai‘i Health Connector’s Small Business Marketplace lets you easily compare and contrast a variety of Qualified Health Plans (QHPs) offered by private insurers that will be rated and underwritten by a new set of consumer-friendly rules.Everything you need is available online, by phone or in person. You’ll be able to provide a broader range of health plan choices for your employees, which you can’t do today.The Connector will also provide expert counsel to help small businesses identify the policies that work best for them and their employees.
Hawai’i Health Connector will expand choice in the small group market, offering your employees the ability to chooser from many insurance plans from several insurance carriers.NO more one size fits all.Employers can set their “benefit budget” by selecting how much they wish to pay toward the cost on benefits. Employees can use this employer allowance to pay for their coverage or can ‘buy-up” to higher plan levels if they wish, allowing more options and flexibility and their families.
We’re here to help. The Connector is designed to make the complicated process of buying health insurance easier for both employers and employees. In September, you’ll be able to get help and assistance in multiple languages and at no additional cost:
- In person with our team of professionals known as Kōkua Marketplace Assisters. Locate the one closest to you here.
- By calling our local customer support center: 877-628-5076.
The Hawaiʻi Health Connector is an online health insurance marketplace that will give businesses easy access to the health insurance choices available to them through the Small Business Health Options Program (SHOP).SHOP will allow small employers to:
- Compare health plans from multiple carriers.
- Decide what plans or level of coverage to offer employees.
- Purchase and manage employee plans using the Connector’s simple online tools.
Coverage begins in 2014.
We encourage you to continue to visit our website for more information and tips as we get closer to opening and to check with your brokers about the new rules for employers.You can send questions to email@example.com.
Call us at 877-628-5076.
Find your nearest Marketplace Assister who can provide in-person assistance.
The first open enrollment period through the Connector will begin in October 2013.Health coverage for employees begins as early as January 2014.
For many small businesses, the Connector will reduce the burden and costs of enrolling employees by offering administrative flexibility and potential for tax savings.Through the Connector’s Small Business Health Options Plan (SHOP) you can:
- Go to a single place to learn about health insurance and get accurate information on plans.
- Make an apples-to-apples comparison of the prices, benefits and quality of health coverage options for your employees.
- Choose and purchase medical, and dental plans to fit your employees, your business and your budget.
- Manage your employee health coverage through the Connector’s easy-to-use online business management tools.
- Learn if your company is eligible for tax credits helps pay the cost of employee health coverage.
- Make payments from one straightforward monthly bill, no matter how many plans from different insurance carriers you select.
Not at this time. Beginning on January 1, 2016, employers with 100 or fewer full-time employees will be able to purchase insurance through the Connector.
Essential Community Providers
For Federally-facilitated and State Partnership Marketplaces, the Centers for Medicare & Medicaid Services (CMS) will use the non-exhaustive database of Essential Community Providers (ECPs) found here as the basis for determining the number of available ECPs in the Qualified Health Plan’s (QHP’s) service area.This database would form the denominator of the percentage of available ECPs included in the issuer’s provider networks, as referenced in the Letter to Issuers.
Recognizing that it typically takes issuers 12-18 months to fully contract their networks, we are evaluating issuers using the “Safe Harbor” standard and “Minimum Expectation” level (as described in the Letter to Issuers) for Federally-facilitated and State Partnership Marketplaces in the 2014 coverage year.The Centers for Medicare & Medicaid Services (CMS) will continue to assess Quality Health Plan (QHP) provider networks, including Essential Community Provides (ECPs), and may revise its approach to reviewing for compliance with network adequacy and ECPs in later years.
No, but there is a new requirement for Association Health Plan (AHP) issuers to include a sufficient number and geographic distribution in their provider networks participating in the Health Insurance Marketplaces.For Federally-facilitated and State Partnership Marketplaces, this is described in the Centers for Medicare & Medicaid Services’ (CMS) “Letter to Issuers on Federally-facilitated and State Partnership Exchanges” available here.The Letter to Issuers provides additional background on the Essential Community Provider (ECP) requirement. It also notes the expectation that issuers failing to meet a “Safe Harbor” or “Minimum Expectation” standard will need to offer a narrative justification explaining how the provider network(s) will provide an adequate level of service for low-income and medically underserved enrollees consistent with the regulatory standard. CMS also reserves the right to monitor issuers on a post-certification basis to ensure sufficient ECP participation.
At this time, the Centers for Medicare & Medicaid Services (CMS) is simply alerting providers that serve predominantly low-income and medically underserved individuals of an important potential new opportunity to participate in a Quality Health Plan (QHP) issuer’s network. Issuer requirements of providers serving in their networks will vary.
Issuers will be applying for certification as Quality Health Plan (QHP) providers through the month of April, but building and maintaining a network will be an ongoing process.The Marketplaces will be available for enrollment started on October 1, 2013, with initial coverage effective on January 1, 2014.
Issuers (health insurance companies) are currently building their provider networks to meet new requirements set by the Affordable Care Act and may be seeking participation.A provider’s uninsured patients may be eligible to participate in and purchase insurance via the Health Insurance Marketplace in your state.Issuers that offer plans on the Health Insurance Marketplaces now have a requirement under the Affordable Care Act (ACA) to include in their network a sufficient number and geographic distribution of providers that serve predominately low-income, medically underserved individuals.These providers are referred to as Essential Community Providers (ECPs).
Please see the “Letter to Issuers on Federally-facilitated and State Parternship Exchanges” from the Centers for Medicare & Medicaid Services (CMS) to obtain additional information on the Affordable Care Act (ACA) and the Essential Community Provider (ECP) inclusion standard.
Please use the following link to obtain more information: http://www.healthcare.gov/.Please note that the actual Quality Health Plans (QHPs) that will be offered on the Marketplaces will not be available for enrollment until October 1, 2013.
If you have questions, please direct them to: firstname.lastname@example.org.
The Quality Health Plans (QHPs) that will be offered on the Marketplaces will not be certified until later this year. In the meantime, potential Essential Community Providers (ECPs) should contact the insurance carriers’ association in their state, which may be aware of health insurance products being submitted for QHP certification.Finally, we also recommend that potential ECPs identify health insurance issuers with the greatest market share in the individual and small group markets, and reach out to those issuers directly.
Yes, the Center for Medicare & Medicaid Service (CMS) realizes that the list is not exhaustive and that issuers may identify and write in other providers who meet the regulatory standard.
Shopping & Enrollment
Yes. You can look for health plans that include your doctor or medical facility in the provider network.
Individuals who lose employer-sponsored coverage may apply and enroll in a health insurance plan outside of the open enrollment period due to the loss of minimum essential coverage and see if they qualify for financial assistance. Individuals do not have to accept COBRA Continuation Health Coverage and will be able to choose a health plan through the Hawai‘i Health Connector either during open enrollment or through a special enrollment period.
The Hawai‘i Health Connector will offer many ways to get expert help:
- You can ask questions by web chat.
- You can call the Customer Assistance Center at 877-628-5076.
- You can get in-person assistance with a Kokua to help you understand your options.
- And if you need professional advice about which plan to choose, you can find a licensed agent/broker who has been certified to serve customers of the Hawai’i Health Connector.
Hawai’i Health Connector is scheduled to open for business in the fall. At that time, people will be able to sign up for health plans, with coverage taking effect January 1, 2014.Customers can sign up until March 31, 2014. After that, open enrollment periods will be October 15 to December 7.
That is when the “shopping” takes place. You can take that time to find the plan that is best for you. Payment will have to be in by mid-December to meet the January 1, 2014 effective date.
Issuers: Eligibility for Individuals & Families
No. Assuming one month’s premium has been paid during the plan year there is a 3-month grace period for individuals receiving Advanced Premium Tax Credits (APTCs).
(See Title 45 Code of Federal Regulations 156.270 for reference.)
The Connector will accept self-attestation of consumers without independent verification.
The Issuer will be responsible for communicating this type of information to the member.The Connector will notify the member of the termination due to the change in residency and their right to appeal the eligibility re-determination, but will not assume responsibility to link the member to a plan in the new state of residence.
There should be no difference with how the Issuer treats individuals under the Quality Health Plans (QHPs) and how the Issuer treats individuals in their plans not offered through the Connector.
Citizenship and lawful immigration status (equal to or greater than 5 years).
Loss of coverage through head of household, loss of employer sponsored coverage, and eligibility for other Insurance Assistance Programs (IAPs) ends.
Marriage, death of spouse, divorce or annulment, and legal separation.
Birth, adoption or placement for adoption, death of dependent child, dependent child ages out, and legal guardianship.
The member’s age at the time of enrollment will be used for eligibility. The member’s age at the time of effective coverage date will be used for rate calculation.This applies to both individuals and Small Business Health Options Program (SHOP) members.
The member’s eligibility for enrollment in a Quality Health Plan (QHP) through the Connecter will be re-determined based on the new residency and they will be determined ineligible. The Connector will notify the member of the determination of ineligibility, which will result in a termination. The Connector will then notify the issuer and United States Department of Health and Human Services (HHS).The last day of coverage is the last day of the month following the month in which the redetermination notice was sent to the member.
(See Title 45 Code of Federal Regulations 155.330 & 430 for reference.)
All mailings will be mailed to the new address and state of residency remains the same as the home address state.
The member is only covered through the birth month.
At 19 years old.
Issuers: SHOP (Small Business Health Options Program) Eligibility
There is a yes / no flag on the 834 file. If yes, the member is disabled.
The Connector will send the Issuers a group client file indicating the termination of the group and an 834 file indicating the termination of the members.
Yes, the individual could have a medical plan on the SHOP and purchase stand-alone medical, dental, or vision.
The SHOP group eligibility for enrollment in a Quality Health Plan (QHP) through the Exchange will be re-determined based on the new business address and they will be determined ineligible.The Connector will notify the members in that group of the determination of ineligibility, which will result in a termination.
No, they must be treated as a qualified employer until they otherwise fail to meet the eligibility criteria of this section or elect to no longer purchase coverage for qualified employees through the SHOP.
No, the Connector will notify the customer of plan termination only.
The Connector will use a single application for enrollment. Therefore, the Issuers will need to provide the applicable terms and conditions (“T & C”) as part of each plan description.The members will be able to review the T & C on the plan description portion of the Connector website. When the member enrolls, the member will accept the plan as described in the plan description.The T & C will not be displayed on the application (both hard copy and electronic versions) or enrollment form.
In the case of birth, adoption or placement for adoption, the Exchange must ensure that coverage is effective on the date of birth, adoption, or placement for adoption.
(See Title 45 Code of Federal Regulation 155.420(b)(2)(i) for reference.)For changes resulting from eligibility appeals decisions, the Exchange must implement the appeal decision retroactive to the date the incorrect eligibility determination was made (Title 45 Code of Federal Regulation 155.545(c)(1) and Title 45 Code of Federal Regulation 155.740(l)(3)) or on the first day of the month following the date of the eligibility appeals decision notice (Title 45 Code of Federal Regulation 155.330(f)(1)(ii)).In the case of retro-termination of coverage of Advanced Premium Tax Credits (APTC) recipient that exhausts 3-month grace period, Quality Health Plan (QHP) issuers can terminate coverage retroactive to the end of the first month of the grace period and deny claims that were pended in months two and three. An issuer who terminated coverage in this fashion would be obligated to return the APTC made on behalf of the individual for the second and third months of the grace period.
(See Title 45 Code of Federal Regulation 156.270(e)(2) for reference.)
The system will let employers choose from three possible dates that the coverage could take effect based on the day that the employer adds them to the roster.In order for employees to have coverage by the first of a month, the employer needs to have already added them to the roster and the employee will have to make his/her plan selection before the on or before the 15th of the current month.If this occurs after the 15th, coverage will start on the 1st of the second month.
They will not receive coverage until the next open enrollment period, unless they qualify for a special open enrollment during the year, or they can purchase insurance on the individual market.
The dependents can enroll in a Small Business Health Options Program (SHOP) plan, but it must be the same plan as the employee. They also have the option to enroll in separate plans on the individual exchange.
Subscriber and a dependent or a related individual.
A child (natural, step, or adopted) under 21 years of age.
Subscriber and more than one dependent or related individual.
A spouse or a civil partner.
A subscriber and a dependent or related individual.
Once payment has been received by the Issuer.
Retroactive changes to eligibility (and enrollment as applicable) can occur in the case of birth, adoption or placement for adoption, and as a result of eligibility appeals decisions, and rescission.
(See Title 45 Code of Federal Regulations 147.128)Retroactive termination of coverage can occur in the case of non-payment of premiums for recipients of Advanced Premium Tax Credits (APTC) that exhaust the 3-month grace period without paying all outstanding premiums.