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ENROLLING IN HEALTH CARE COVERAGE: WHERE CAN I GET HELP?

Q 54: Where do consumers go for help to choose and enroll in a plan?

Many if not most consumers will find it helpful to reach out for assistance when choosing healthcare coverage, especially those who have not had coverage before.   Before getting started it will be a good idea for the consumer to gather information about household income and review current coverage, if they have health insurance.    
Consumers should gather information about household income.  Consumers should find out if they can stay with their current doctors and pharmacy, and understand how insurance works—including deductibles, out-of-pocket maximums and copayments.

For help getting started to understanding your options, check out www.enroll207.comThere are also a number of national resources from the Kaiser Family Foundation,  Consumer Reports, the National Association of Insurance Commissioners, and the U.S. Department of Health and Human Services and the Department of Labor to help consumers understand how insurance works, the different insurance options, and what to consider when buying coverage.  Both the Bureau of Insurance and Maine’s Health Insurance Marketplace also can direct consumers to more information and resources about the options that will be available starting in October.

When comparing plans, a helpful new standard form, called the Summary of Benefits and Coverage (SBC), is available to help consumers compare different plans.  Consumers can get the form and definitions through Maine’s Health Insurance Marketplace at www.healthcare.gov, or ask the health insurer for it. When considering a new plan consumers should ask  find out if they can stay with their current doctors and pharmacy, and (if needed) ask for assistance in understanding  how insurance works—including deductibles, out-of-pocket maximums and copayments.
If a consumer is eligible to buy coverage through Maine’s Health Insurance Marketplace, he or she can enroll through its website at www.healthcare.gov, or by phone at 1-800-318-2596.

Three types of individuals are trained to help consumers in Maine make decisions about health coverage:

A.   Insurance agents or brokers (also known as “producers”)

Insurance agents and brokers sell insurance coverage from one or more companies.  They are licensed by the Bureau of Insurance and receive continuing education related to their job.  They educate consumers about health insurance policies, help consumers apply for coverage, and advise consumers about the type of health insurance that best suits them and their family.  Agents and brokers can sell consumers insurance plans in the market outside the marketplace, as they always have.  Agents and brokers who want to sell policies through Maine’s Health Insurance Marketplace must obtain extra training from the U.S. Department of Health and Human Services (HHS), and pass a test.

B.   Navigators

Navigators are individuals trained to help consumers understand the insurance policies available through Maine’s Health Insurance Marketplace, and to answer consumer questions about insurance affordability programs, including MaineCare and CHIP.  Navigators also can help consumers apply for coverage.  Navigators receive training on how to help consumers, then must pass a test and be certified. 

Http://www.enroll207.com/locator/ enables consumers to type a zip code and find out how to contact their closest navigators and consumer assisters.  Consumers can also dial 2-1-1 for information on navigators.

C.   Certified application counselors

Certified application counselors provide enrollment assistance.  Certified application counselors successfully complete comprehensive training, and can educate consumers about health insurance plans and help them complete an application for coverage.  Examples of application counselors include staff at local community health centers or hospitals or consumer non-profit organizations.

Q 55: How are the people who help consumers make decisions about health coverage paid?

Insurance agents and brokers may have agreements with one or more insurance companies that the company will pay them if they enroll consumers in a health insurance policy.

Navigators will get funding from contracts they have with the Marketplace.  Some navigators are paid; others are volunteers.  Navigators aren’t allowed to get payments from insurance companies or to charge consumers a fee.

Certified application counselors will not be paid through Maine’s Health Insurance Marketplace.  They don’t get enrollment- based payments from insurance companies and aren’t allowed to charge a fee.  They may, however, receive federal funding through other grant programs or Medicaid, or from another source.

Q 56: How can consumers find an insurance agent or broker to help them enroll in a plan?

Agents and brokers often advertise in the Yellow Pages and similar media.  Consumers can also search for a licensed agent or broker in the Maine Bureau of Insurance’s website -- http://www.pfr.maine.gov/almsonline/almsquery/welcome.aspx?board=1040.  Click “Search for an Individual,” then for “Authority” choose “Health.” If you type in your county, your zip code or a nearby zip code, the search engine will generate a list of all licensed health insurance agents and brokers in that zip code, including phone numbers.  Consumers can also call the Bureau at 1-800-300-5000 for assistance finding licensed health insurance agents and brokers in their area.  Some agents and brokers don’t contract with all health plans, so consumers must make sure they know the full list of plans that are available to them before they ask an agent or broker for help.  Also, health insurance agents and brokers may or may not be able to help individuals complete the enrollment process for MaineCare or CHIP after they get an eligibility decision.

Q 57: What are the qualifications required for health insurance agents and brokers to participate in Maine’s Health Insurance Marketplace?

Health insurance agents and brokers are regulated by the Maine Bureau of Insurance.  Agents and brokers receive training from Maine’s Health Insurance Marketplace.  The insurance companies must appoint the agents and brokers who sell their plans.  The health insurance company appointing agents and brokers will make sure their licenses are valid and registered with Maine’s Health Insurance Marketplace.

Q 58: How will insurance agents and brokers be able to help consumers enroll through Maine’s Health Insurance Marketplace?

The agent can help consumers log-on to Maine’s Health Insurance Marketplace website at www.healthcare.gov.  Consumers will log-in to their own accounts.  The agent or broker will then work with them to complete the application.  Consumers will be prompted to enter the insurance professional’s Marketplace user identification number and national producer number on the application to show that the professional helped them.

The agent or broker can help consumers compare plans and submit the application.  The agent or broker can answer questions about the differences in plans and which one would be best for them and their families.

Q 59: How will a navigator be able to help consumers enroll through Maine’s Health Insurance Marketplace?

Navigators can help consumers log-on to Maine’s Health Insurance Marketplace.  Consumers will log-in to their own accounts.  The navigator can help consumers complete the application.  Consumers may be prompted to enter the navigator’s Marketplace user identification number on the application to show that the navigator helped them.

The navigator can help consumers to compare plans and answer questions about health insurance policies in general.  The navigator can answer questions about the differences in plans and what they might mean for them, but the navigator CANNOT recommend or suggest which health plan would be best for consumers and their families.  Navigators are not permitted to collect premium payments on behalf of an insurer or Maine’s Health Insurance Marketplace.

Navigators CANNOT sell, solicit, or negotiate a plan through Maine’s Health Insurance Marketplace.  They CANNOT suggest that one plan would be better for the individual than another plan.

Q 60: How will the certified application counselor be able to help consumers enroll through Maine’s Health Insurance Marketplace?

The certified application counselor can help consumers log-on to Maine’s Health Insurance Marketplace.  Consumers will log-in to their own Marketplace accounts.  The certified application counselor can help consumers complete the eligibility application.  Consumers may be prompted to enter the in-person assistor’s or the certified application counselor’s Marketplace user identification number on the application to show that the assistor or counselor helped them.

The certified application counselor can help consumers to compare health plans and answer questions about health insurance policies.  The counselor can answer questions from the consumer about the differences in plans and what that might mean to them (such as explaining deductibles or out-of-pocket limits), but CANNOT recommend or suggest which health plan would be best for consumers and their families.

The certified application counselor CANNOT sell, solicit, or negotiate a health plan through Maine’s Health Insurance Marketplace.  They CANNOT suggest that one plan would be better for the individual than another.

Q 61: Can small employers use licensed insurance agents or brokers to buy health insurance through Maine’s Health Insurance Marketplace?

Yes, licensed insurance agents and brokers are available to help small employers compare and determine which health plan best meets their needs, like they do today.  This is true whether they’re interested in buying coverage through the SHOP (the branch of the Maine’s Health Insurance Marketplace that serves small employers) or in the market outside the Marketplace.

Licensed insurance agents and brokers will be able to compare plans in the market outside the Maine’s Health Insurance Marketplace against those offered through the Marketplace to decide where employers can buy the best plan for them.  Employers may wish to talk with more than one agent or broker before making a decision on which plan to buy.

Q 62: Will small employers be able to use navigators to better understand their health insurance options?

Navigators can provide assistance but aren’t allowed to sell health insurance.  Navigators are not permitted to collect premium payments on behalf of an insurer or Maine’s Health Insurance Marketplace.  They are available to help small employers view plan options displayed on www.healthcare.gov and can help consumers with enrolling through the SHOP.  Navigators can explain the details of the plans offered through the Maine’s Health Insurance Marketplace but CANNOT legally offer advice as to which plan is a better fit for the small employer.  Only a licensed insurance agent or broker is qualified and allowed to recommend a particular plan.

Q 63: Will an insurance agent or broker show consumers all the plan choices available through Maine’s Health Insurance Marketplace?

If the consumer is using Maine’s Health Insurance Marketplace website (www.healthcare.gov) with the help of an agent or broker, all qualified health plan choices will be displayed.  If the agent or broker goes through an insurance company portal, all plans available through the Marketplace may not be shown, but other plans available in the market outside the Marketplace that aren’t eligible for the advance premium tax credit may be shown.  Consumers should ask the insurance agent or broker if they’re being shown all of the plans available through the Marketplace and whether tax credits or cost-sharing reductions apply to the plans they are reviewing.

All agents and brokers must follow applicable Maine laws, regulations, and Marketplace requirements, including standards related to relationships or appointments with insurance companies.

Q 63: What is the benefit of using an insurance agent to enroll in Maine’s Health Insurance Marketplace?

Agents and brokers are licensed professionals who have a working knowledge of the qualified health plans and their benefits.  Consumers may be more comfortable sharing their medical wants and needs for a health insurance policy with an agent or broker.  Consumers should understand, however, that agents and brokers are sales personnel who are working on behalf of the insurers they represent.

The agent or broker may help individual consumers or small employers to create their accounts with Maine’s Health Insurance Marketplace if needed, but consumers, or legally authorized representatives, must create their own username and password.  Consumers should not share this information with third parties, including insurance agents or brokers.

Q 64: Will consumers have to share their personal information, including their tax returns, with an agent, broker, navigator, or certified application counselor?

No.  If a consumer is completing the application on Maine’s Health Insurance Marketplace website with the help of an agent, broker, navigator, or counselor, the consumer should fill out and submit their eligibility application without the agent, navigator, or counselor in direct view of the application.  Income figures from the IRS won’t be shown during the application process, whether or not the consumer gets help filling out the application or does it independently.  After completing the registration and training, agents, brokers, navigators, and certified application counselors will fill out a privacy and security agreement and get a user ID to use with Maine’s Health Insurance Marketplace.

Q 65: Should consumers share their account username and password with an insurance agent, broker, navigator, or certified application counselor?

No.  If a consumer is asked to share a username or password, he or she should contact the Bureau of Insurance at 1-800-300-5000 and discuss this with the consumer assistance representatives.

Q 66: What help should an insurance agent, broker, navigator, or certified application counselor give consumers if they or their dependents are eligible for MaineCare (Medicaid) or CHIP?

Agents, brokers, navigators, and certified application counselors will work with all consumers who ask for help with Maine’s Health Insurance Marketplace enrollment, including those eligible for MaineCare or CHIP.  Maine’s Marketplace will send a notice to consumers who are eligible for MaineCare or CHIP.  An agent, broker, navigator, or certified application counselor working with these consumers is expected to refer consumers to the Maine Department of Health and Human Services.  Agents and brokers should be able to give consumers a referral to a navigator, certified application counselor or the Maine Department of Health and Human Services.

Q 67: May an insurance agent or broker continue to work with consumers once they’re enrolled in a plan through Maine’s Health Insurance Marketplace]?

Insurance agents and brokers may continue to communicate with consumers after they’ve enrolled in a plan, as long as the communications follow any laws and regulations that apply.  The communications also must follow the privacy and security standards Maine’s Health Insurance Marketplace has adopted (pursuant to 45 C.F.R. §155.260).  These standards limit how an agent or broker may use any information gained to provide help and services to qualified consumers.

The federal government expects to issue more rules about privacy and security requirements.

Q 68. May consumers directly enroll for coverage through insurers?

Yes, consumers may buy coverage directly from an insurance company.  However, subsidies and cost-sharing reductions are only available if a consumer buys a health plan through Maine’s Health Insurance Marketplace. If the consumer is not eligible for a subsidy, he or she may want to consider plans offered in the market off the Marketplace in addition to those on the Marketplace.  Before buying in the market off the Marketplace, a consumer should check with the Bureau of Insurance (http://www.maine.gov/pfr/insurance/index.shtml) to make sure the health insurer is licensed in Maine. 

Q 69: Where should consumers go with a problem enrolling in a plan through Maine’s Health Insurance Marketplace?

Maine’s Health Insurance Marketplace should be able to help consumers with any problems regarding enrollment or eligibility.  It operates a call center to help answer questions at 1-800-318-2596.  Insurance agents, brokers, navigators, and certified application counselors also should be able to help.

Q 70: Under what circumstances can consumers enroll if they didn’t when enrollment was first available?

If consumers don’t enroll during the initial enrollment period (October 1, 2013 – March 31, 2014), they can enroll during annual open enrollment (October 15 – December 7 of each year starting in 2014) or may be eligible to enroll during a 60-day special enrollment period under certain circumstances.  Examples of special enrollment periods are when an individual or dependent loses health insurance coverage, or an individual gains a dependent or becomes a dependent through marriage, birth, or adoption, or an individual moves into a new marketplace service area.Maine’s Health Insurance Marketplace will let consumers know whether they can enroll after processing the application.

Q 71: Do consumers have to re-enroll annually?

Eligibility for premium assistance will be decided annually using updated income, family size, and tax information.  Each year before the enrollment period, Maine’s Health Insurance Marketplace will check income data and send a notice to consumers who are determined eligible to enroll in a plan through the Marketplace.  This notice explains the consumer’s eligibility for the upcoming year and tells him or her to let the Marketplace know of any changes.  After this, there will be an annual enrollment period for consumers to change plans or insurance companies if they want to.

During the year, consumers must report any changes in circumstances to Maine’s Health Insurance Marketplace within 30 days after experiencing the change, including changes in income from a new job.  Consumers who have not requested financial assistance do not need to report changes related to financial assistance eligibility.  Maine’s Health Insurance Marketplace will review available data sources on a quarterly basis for individuals who become eligible for Medicare, MaineCare, or CHIP.

Last Updated: September 27, 2013