Consumers FAQ's

FAQ's

We want you to be fully informed. Whether you are a consumer, insurance producer or insurance issuer, you can find answers to your questions here.

How to Use Your New Health Care Coverage

If you have additional questions, call My Arkansas MarketPlace toll-free at 1-844-355-3262 Monday - Friday from 8 a.m. to 4:30 p.m.

Enrollment

How do I enroll?

If you are eligible to purchase coverage, you can enroll through www.healthcare.gov or through the Federal Call Center at 1-800-318-2596.

For assistance with enrollment you can find a local Insurance Agent/Broker, Certified Application Counselor, Navigator, or an In-Person Assister in your area from the Regulatory Health Link Division lists of licensed assisters.

What information do I need to have before I enroll?

A complete enrollment checklist may be found here.

I already have coverage for myself; can I buy a separate policy for my child?

Even if you already have coverage for yourself, you are eligible to obtain a policy for your child through the Marketplace. Federal law requires that any health plan offered on the Marketplace must also be offered as a child-only plan at the same tier of coverage. You may also be eligible for tax credits. [Your child may also be eligible for the Arkansas Children’s Health Insurance Program (CHIP) commonly referred to as ARKids First]. To learn more about CHIP plans, visit insurekidsnow.gov.

Where can I find an insurance agent or broker or assister who can help me sign up for insurance in the Marketplace?

Lists are available through the Regulatory Health Link Division page on the Arkansas Insurance Department’s website.

Click here for a list of agents, brokers and assisters

Eligilibity

Will my eligibility for Medicaid change under the Affordable Care Act (ACA)?

If you are currently receiving Medicaid, the eligibility rules for your coverage will not change immediately. You will still need to be part of a categorically eligible group, such as children, pregnant women, parents (or other caretaker relatives), blind, disabled or elderly, and you will still need to meet the financial eligibility test set by Arkansas Medicaid. However a large group of individuals/families are newly eligible under ACA based on income only. Arkansas adults, not receiving Medicare, with incomes at or below 138 percent of the Federal Poverty Level will now be eligible for enrollment. All of their premiums will be paid by Medicaid.

What help is available if I can’t afford coverage? Who is eligible?

The ACA created the Premium Tax Credit for people who aren't eligible for coverage from a public program (such as Medicare, Medicaid or CHIP) or through their employer. Income requirements apply. The maximum allowable income depends on your family size.

Legal residents who have been in the country less than five years are not eligible for Medicaid but may be eligible for tax credits to purchase a policy through the Marketplace. However, undocumented residents are not eligible to purchase through the Marketplace and receive a tax credit or other cost-sharing reductions.

If I have access to employer coverage, can I still get a tax credit to buy a plan through the Marketplace?

Generally, no. The only time you could get tax credits to purchase coverage through the Marketplace is if your employer provides an employee-only plan that costs more in premiums than 9.5 percent of your household income, provides coverage of less than 60 percent of the medical costs covered by the plan, or that does not include the 10 Essential Health Benefits. The Summary of Benefits and Coverage for the employer plan will tell you if the plan is above or below that 60 percent threshold. You can also ask your employer whether the job-based coverage fails to meet any of these requirements or go to the Marketplace for more information.

Special Enrollment

What can I do when my employer group health coverage ends?

When an employee and his/her dependents lose employer group coverage, he/she is still eligible to continue on an employer’s group health plan even after that coverage would otherwise end under the Consolidated Omnibus Budget Reconciliation Act (COBRA), a federal health law since 1986. However, COBRA coverage can be very expensive, since the former employer is not required to make premium contributions. In such cases, people may be eligible to access the new tax credits to buy a more affordable individual or family policy through the Marketplace.

Where can I find an insurance agent or broker or assister who can help me sign up for insurance in the Marketplace?

Lists are available through the Regulatory Health Link Division page on the Arkansas Insurance Department’s website.

Click here for a list of agents, brokers and assisters

General

How do I get health insurance?

There are four ways to get health insurance:

Through the Health Insurance Marketplace, where you may qualify to have part or all of your premiums paid for you.
From a private insurance company on your own.
Through your job or through your spouse/partner’s job.
Through www.access.arkansas.gov (eligibility) and Medicaid Beneficiary Portal (enrollment) or call the Arkansas DHS Call Center at 1-855-372-1084.

What is the Health Insurance Marketplace?

The Health Insurance Marketplace is where Americans can compare health insurance plans to choose the one that best suits their needs. Enrolling through the Marketplace is the only way you can receive financial assistance on your monthly health insurance premiums.

How much will this cost?

Cost will be determined by your age, household income and size, where you live, tobacco use, and the type of insurance coverage you buy.

Financial assistance is available for those who qualify.

Can I get a break on costs?

Yes. Financial assistance is available through the Advanced Premium Tax Credit. In 2014, 90 percent of Arkansans who enrolled in coverage through the Marketplace received financial subsidies to lower their monthly premiums.

The amount of assistance you can get is determined by your household income and size. Some Arkansans will even be eligible to have all of their premiums paid through this financial assistance.

Does the new federal health law require me to purchase health coverage?

Effective January 1, 2014, most U.S. citizens and legal residents will be required to have health insurance coverage. This is commonly referred to as the “individual mandate.” Most forms of health coverage satisfy this requirement, including most coverage provided through an employer, Medicare, Medicaid and Department of Defense/Veterans Affairs coverage.

What happens if I do not obtain coverage?

Those who do not obtain coverage and are not exempted from the mandate will pay a tax penalty beginning in 2014. The penalty is set to increase each year as follows:

In 2014, it will be the greater of $95 per adult or 1 percent of taxable income.
In 2015, it will be the greater of $325 per adult or 2 percent of taxable income.
In 2016, it will be the greater of $695 per adult or 2.5 percent of taxable income.
After 2016, the tax penalty increases annually based on a cost-of-living adjustment.
The tax penalty is charged for each adult and the oldest three children in the household.

A person will pay 1/12 of the total annual penalty for each month without coverage. The penalty for a child (under age 19) is half that of an adult. A maximum penalty will be calculated based on premiums for plans offered through the Marketplace.

What’s covered?

By law, all qualified health insurance plans must cover the “10 Essential Health Benefits”: listed below.

Outpatient Services

Primacy-care physician office visits
Specialist office visits
Outpatient surgical services
Outpatient diagnostics, including advanced diagnostic services such as MRIs and CT scans
Outpatient physical and occupational therapy

Emergency services

Emergency care services
After-hours clinic or urgent care center visits
Observation services
Transfer to in-network hospital
Ambulance services

Hospitalization

Hospital services
Physician hospital visits
Inpatient services including surgical services, physical and occupational therapy, organ transplant services

Maternity and Newborn Care

Maternity and Obstetrics Care, including pre- and post-natal care
Certified nurse midwives
Newborn care in the hospital
In vitro fertilization for PPO plans
Genetic testing to determine presence of existing anomaly or disease
Prenatal and Newborn Testing

Mental Health and Substance Abuse Services

Professional services
Diagnostics
Inpatient and outpatient care at hospital or other covered facility

Prescription Drugs

Rehabilitative and Habilitative Services

Physical, occupational and speech therapy
Developmental services

Laboratory Services

Testing and evaluation

Preventive and Wellness Services and Chronic Disease Management

Case management communications made by primary-care physician
Preventive health services, including annual preventive check-up and routine screening tests
Routine immunizations

Pediatric Services, including Dental and Vision Care

Will the Marketplace allow me to see and compare prices for plans?

Yes. The Marketplace will allow consumers to compare policies on the basis of price, as well as provider network, covered medications, value, and other factors. You should know that, if a dental benefit is included in a medical plan, you will not be able to see the cost of the dental benefits alone.

What will my out-of-pocket costs be?

All private health insurance plans feature a wide variety of out-of-pocket costs for Arkansas consumers with incomes over 50 percent of the Federal Poverty Level ($5,835 for an individual and $11,925 for a family of four) starting in 2015. Federal law requires that all plans limit consumers’ out-of-pocket costs for services to no more than $6,600 for individuals and $13,200 for families in 2015. They are also required to cover certain preventive services without cost-sharing.

If your income is below a certain amount, you may be able to buy a plan that features lower cost-sharing at no additional premium expense. Check with the Marketplace to see if you qualify.

What help is available if I can’t afford coverage? Who is eligible?

The ACA reated the Premium Tax Credit for people who aren't eligible for coverage from a public program (such as Medicare, Medicaid or CHIP) or through their employer. Income requirements apply. The maximum allowable income depends on your family size.

Legal residents who have been in the country less than five years are not eligible for Medicaid but may be eligible for tax credits to purchase a policy through the Marketplace. However, undocumented residents are not eligible to purchase through the Marketplace and receive a tax credit or other cost-sharing reductions.

What happens to my Health Insurance Premium Tax Credit if my income changes during the year? To whom should I report income changes?

If you choose to take your tax credit in advance, as a subsidy toward your monthly health insurance premium, you need to tell the Marketplace where you bought your coverage if your income changes, or your family size changes (like having a baby), or you get a new job that offers health insurance coverage. The Marketplace will change your tax credit amount to reflect the new information. If you forget, you might owe money at tax time OR find you could have been getting a larger tax credit amount in advance.

If you don’t take your tax credit in advance, you don’t have to do anything. The IRS will determine if you are eligible for a refund when you file your taxes. And remember, you can always take just a portion in advance, if that’s better for you.

I already have health insurance through my employer.

If you already have affordable health insurance provided by your employer, you do not need to do anything.

However, if you’re paying more than 9.5 percent of your household income for health insurance premiums for an employee-only plan, then you may be eligible for financial assistance. If you have insurance through your employer and apply for assistance, the Marketplace will determine if your current plan is considered affordable. If that coverage is determined to be unaffordable, you will receive financial assistance. If it is determined to be affordable, you won’t be eligible for financial assistance.

I don't have health insurance through my employer. Will my employer now be required to provide insurance?

Starting in 2015, if your company has 100 or more full-time or full-time equivalent employees, your employer will be required to provide health insurance or pay a tax penalty. Starting in 2016, if your company has 50 or more full-time or full-time equivalent employees, your employer will be required to provide health insurance or pay a tax penalty.

If your company has fewer than 50 full-time employees, your employer is not required to provide health insurance. Talk with your employer and find out what the company plans to do when the new health coverage becomes available. If your employer chooses not to provide coverage, you have insurance options as an individual or family through the Health Insurance Marketplace

What can I do when my employer group health coverage ends?

If I have employer coverage, is my employer required to cover my children?

Employers are not required to offer or pay for coverage for employees, spouses, or for employees’ dependents, including their children. However, under federal law, if an employer of 50 or more employees does not offer affordable coverage to an employee and his/her dependents, the employer may have to pay a fine. Dependents may be eligible for other types of coverage, such as through the Arkansas Children’s Health Insurance Program (CHIP, commonly referred to as ARKids First) or Medicaid. For more information about other coverage options for children, visit insurekidsnow.gov or call 800-285-6477.

If I have access to employer coverage, can I still get a tax credit to buy a plan through the Marketplace?

Will my employer drop coverage as a result of the law?

It is unlikely that most employers, and in particular large employers, will not drop coverage under the law. All the reasons they currently have for offering coverage (tax advantages, employee demand, maintaining a healthy workforce) remain in place, plus employers may be penalized if they don’t cover their employees and their employees end up getting a premium tax credit. Some employers in businesses that pay low wages, however, may conclude that their employees can get insurance at a lower cost through the Marketplace and could choose to stop offering coverage.

If my employer does not offer health insurance, how do I find out if I am eligible to purchase a policy through the Marketplace?

Contact the Marketplace through their website at healthcare.gov or call the Federal Call Center at 1-800-318-2596. You may call the Consumer Services Division at 1-800-852-5494 for helpful information. A licensed insurance agent or broker, guide, or navigator or certified application counselor can help you with this process.

If I or my spouse or dependents have Medicare and employer coverage, what do I need to do?

Generally, you don’t need to do anything just because the new Health Insurance Marketplace has opened. If you or your spouse works for an employer and your employer’s current benefits pay first and Medicare pays second, the Affordable Care Act does not change that.

If the employer changes the benefits that cover you or your spouse or your dependents, then you will get a notice about those changes. You can ask your employer’s human resources department how those changes work with Medicare.

If you need more information about how your employer’s benefits work with Medicare, contact Arkansas Senior Health Insurance Information Program (SHIIP) at 800-224-6330 or 501-371-2782.

How will my Medicare prescription drug “donut hole” be affected?

What rights do I have if I am denied coverage for a service?

You have the right to appeal an unfavorable decision by your health insurance company. Your insurance company must provide you with a first-level internal appeals procedure, administered by the company, and then a second-level external appeals procedure administered by an independent third party. For more information about how to appeal an unfavorable decision by your health insurance company, call the Arkansas Insurance Department’s Consumer Services Division at 1-800-852-5494.

You can also file complaints with the Arkansas Insurance Department’s Consumer Services Division when claims are denied or to make sure the company is following the legal appeals process. Contact the Consumer Services Division at 501-371-2640, 800-852-5494 or at insurance.consumers@arkansas.gov

How do I learn more about my rights?

Contact the Arkansas Insurance Department’s Consumer Services Division’s at 501-371-2640, 800-852-5494 or at insurance.consumers@arkansas.gov. They can advise you regarding laws and your legal rights and can refer you to resources for further assistance if needed.

Where can I find an insurance agent or broker or assister who can help me sign up for insurance in the Marketplace?

Lists are available through the Regulatory Health Link Division page on the Arkansas Insurance Department’s website.

Click here for a list of agents, brokers and assisters

Local Assistance

Need one-on-one help to enroll in a plan? Locate a licensed assister.

A variety of sources of assistance are available in your area:

Licensed Insurance Agents, Brokers and Assisters
Certified Application Counselors (CAC)
Federal Navigators

For questions related to the information below, or questions related to enrollment in the Health Insurance Marketplace, please contact the Arkansas Health Connector Resource Center at 1-855-283-3483.

Here’s a list of ways you can protect your personal information, appeal a Marketplace decision or appeal an insurance decision.

Personal Information

When you enroll in health insurance, you will have to provide some personal information. Below are a few tips to help you keep your personal information safe.

Don’t give any personal information to anyone without official identification. All licensed Arkansas Health Connector guides, agents, brokers and navigators have the proper ID, and by law they are not permitted to share any of your information.
If you created a Marketplace account at HealthCare.gov., protect it.
There’s no need to give out your Social Security number except when you’re enrolling. Unless you’re completing the application, keep it to yourself.
To get an estimate of what insurance might cost you, only provide the minimum amount of demographic personal information necessary (like your household income and the number of people in your family, never your Social Security number).
Click here for a complete list of licensed guides, agents, and brokers.

Marketplace Appeals

If you don’t agree with a decision made by the Health Insurance Marketplace, you may be able to file an appeal. Below are examples of the kinds of Marketplace decisions you can appeal.

Whether you’re eligible to buy a Marketplace plan
Whether you can enroll in a Marketplace plan outside the regular open enrollment period
Whether you’re eligible for lower costs based on your income
The amount of savings you’re eligible for
Whether you’re eligible for Medicaid or ARKids 1st
Whether you are eligible for an exemption from the individual responsibility requirement

Learn more about appealing a Marketplace decision.

Insurance Claims Appeals

If your health insurance carrier has denied a claim for benefits or has cancelled your policy, you may appeal that decision with your carrier. Information regarding the appeals process with your carrier will be included with a denial letter or your explanation of benefits (EOB).

If no resolution is reached you may also file a complaint against the carrier with the Consumer Services Division of the Arkansas Insurance Department. You can file a complaint online by filling out an electronic complaint form or you may download a complaint form from the Arkansas Insurance Department Consumer Services Division website.

If you have exhausted the internal appeal process with your carrier, you may also be eligible for an external review by a third party. For information on filing an external review and to download the external review form, please visit our external review FAQ page

Special Enrollment

Special Enrollment Period

After Open Enrollment, you may qualify for a Special Enrollment Period allowing you to buy a health insurance plans through the Marketplace. A Special Enrollment Period generally qualifies you for an enrollment period for Marketplace policies for 60 days following certain life events such as losing other health coverage, changes in employment, marriage, having a baby or change in household status.

Apply now if you think you qualify for a Special Enrollment Period.

To find assistance near you, view a list of licensed agents and brokers or licensed guides here.

Agents, Brokers, & Assisters

Arkansas Works Program

You may qualify for the Arkansas Works Program based on your household income. If your total household income, including the combined income of everyone in your household, is below 138% of the Federal Poverty Level you may qualify for health coverage through Private Option. View the household income chart to learn if you may qualify for the Private Option.
If you believe you qualify, enroll online at Access.Arkansas.gov or over the phone at Access Arkansas’s Call Center at 1-855-372-1084.

Options Outside of the Marketplace

As a consumer, you may purchase a health insurance coverage outside of the Marketplace even if it is not Open Enrollment. Contact an Agent or Broker in your area to determine what plans are available to you and what those cost may be.

Appeals

When you apply for coverage in the Marketplace, you’ll get an eligibility notice that explains what you qualify for. It will provide appeals instructions for each person in your household, including the number of days you have to file an appeal. Learn more about filing an appeal.

If you have additional questions, call the Consumer Services Division toll-free at 1-855-283-3483. Assistance is available Monday - Friday from 8 a.m. to 4:30 p.m.

Consumer Protection

For questions related to the information below, or questions related to enrollment in the Health Insurance Marketplace, please contact the Consumer Services Division at 1-855-283-3483.

Here’s a list of ways you can protect your personal information, appeal a Marketplace decision or appeal an insurance decision.

Personal Information

When you enroll in health insurance, you will have to provide some personal information. Below are a few tips to help you keep your personal information safe.

Don’t give any personal information to anyone without official identification. All licensed Regulatory Health Link guides, agents, brokers and navigators have the proper ID, and by law they are not permitted to share any of your information.
If you created a Marketplace account at HealthCare.gov, protect it.
There’s no need to give out your Social Security number except when you’re enrolling. Unless you’re completing the application, keep it to yourself.
To get an estimate of what insurance might cost you, only provide the minimum amount of demographic personal information necessary (like your household income and the number of people in your family, never your Social Security number).
Click here for a complete list of licensed guides, agents, and brokers.

Marketplace Appeals

If you don’t agree with a decision made by the Health Insurance Marketplace, you may be able to file an appeal. Below are examples of the kinds of Marketplace decisions you can appeal.

Whether you’re eligible to buy a Marketplace plan
Whether you can enroll in a Marketplace plan outside the regular open enrollment period
Whether you’re eligible for lower costs based on your income
The amount of savings you’re eligible for
Whether you’re eligible for Medicaid or ARKids 1st
Whether you are eligible for an exemption from the individual responsibility requirement

Learn more about appealing a Marketplace decision.