COMMON CONCERNS ABOUT HOW THE ACA AFFECTS CONSUMERS
Q 87: Does the ACA include new rules about insurance premiums?
Premiums may vary based on an individual’s age, the area of the state in which the policy is sold, tobacco use, and family composition. Under the ACA, these are the only factors that an insurance company can use when they set premiums for individual and small group health insurance. Insurance companies can’t charge higher premiums to consumers with medical problems. Some states, including Maine, have had similar requirements before the ACA, but some of the details have changed.
To help make coverage affordable, many consumers who buy health insurance in the individual market will be eligible for premium tax credits. Also, consumers under age 30 or who can’t afford coverage may be eligible to buy catastrophic plans, which cost less.
Q 88: Does the ACA address discrimination?
The ACA explicitly prohibits insurance companies from discriminating on the basis of age, disability, or expected length of life. ACA regulations prohibit discrimination against individuals on the basis of race, color, national origin, sex, age, disability, sex stereotypes, gender identity, or sexual orientation. These nondiscrimination standards apply to the Marketplaces, insurers and insurance plans, and the essential health benefits, among others.
Also, health insurers must follow all Maine laws and regulations related to marketing and can’t use marketing practices or benefit designs that discourage individuals with significant health needs from enrolling.
Q 89: What are the income tax implications of the ACA?
The Maine Bureau of Insurance does not interpret or enforce obligations under the tax code. Consumers can contact the IRS or their tax advisor for information.
Q 90: What does the health plan “accreditation status” information on the marketplace website mean?
Accreditation is a comprehensive process conducted by private, non-profit organizations that review how well health plans deliver care and how they work to improve the delivery of care over time. Accreditation ensures that the plans sold meet minimum quality, access, non-discrimination, and fair marketing standards in the ACA and Maine law. Health plans offered through Maine’s Health Insurance Marketplace are certified by the National Committee for Quality Assurance, a nationally recognized accrediting body.
Q 91: What does the health plan “consumer experience” information on Maine’s Health Insurance Marketplace website mean?
Consumer experience ratings come from surveys that ask individuals who have coverage through a health insurance plan how they like the plan. These individuals also rate the quality of the medical care they receive and the accessibility of the medical care that they need.
Q 92: What appeal rights do consumers have?
Consumers have a right to appeal an unfavorable coverage decision by their health insurance company. Insurance companies must give consumers owning an individual policy a first-level internal appeal, administered by the company, and then a second-level external review administered by an independent third party. For group policies, the insurance company may require two levels of internal appeals before the external review. For more information about how to appeal a health insurance company’s unfavorable decision, contact the Maine Bureau of Insurance at 1-800-300-5000.
Consumers also can file complaints directly with the Maine Bureau of Insurance when claims are denied, or when they believe that their health insurance company isn’t properly following the legal appeals process.
Also, if a consumer is dissatisfied with an eligibility decision made by Maine’s Health Insurance Marketplace, there will be an appeals process. The consumer can contact the Marketplace at 1‑800-318-2596 for more information.
Q 93: Where do consumers file a complaint for a product sold through Maine’s Health Insurance Marketplace? What about plans sold in the market outside Maine’s Health Insurance Marketplace?
Consumers should first contact the insurance company with any complaint about benefits or services they’re not receiving. If consumers aren’t satisfied, they should contact Maine’s Health Insurance Marketplace for help with questions or complaints.
The Maine Bureau of Insurance investigates complaints about insurance companies and can either look up consumers’ complaints or direct consumers to the right place to file a Marketplace-related complaint. The Maine Bureau of Insurance is ready to help consumers with any question or complaint they may have about their coverage; to find out more, contact the Maine Bureau of Insurance at 1-800-300-5000.
Q 94: If consumers apply for coverage in the market outside Maine’s Health Insurance Marketplace, what are the rules regarding open and special enrollment?
Enrollment periods for coverage outside Maine’s Health Insurance Marketplace are the same as enrollment periods through the Marketplace. The first open enrollment period will run from October 1, 2013 through March 31, 2014, and special enrollment periods will be available based on life events such as changes in family or employment status.