The document outlines the essentials individuals need to know about the new individual health insurance marketplace. It discusses 5 key points: 1) guaranteed issue mandate which prohibits health-related questions, 2) open enrollment periods during which one must enroll, 3) special enrollment periods for life events, 4) shared responsibility requiring all individuals to have coverage, and 5) minimum essential coverage defining standardized plan levels and essential benefits. The individual marketplace aims to give more choice and access to individuals seeking health insurance.

1. ESSENTIALS:
THE “NEED-TO-KNOWS” ABOUT THE
NEWINDIVIDUAL HEALTH
INSURANCE MARKETPLACE

2. With the onset of healthcare reform, the landscape in the individual health
insurance marketplace has changed dramatically.
There are LOTS
of questions.

3. We’ll describe what you need to know in order to navigate the NEW individual
segment of the health insurance industry.
Get. Ready.

4. Let’s share a very short background about the differences between individual
health insurance and employer health insurance.
They’re not
Differences?
the same.

5. You’ll know that individual versus
employer health insurance are two
completely different ballgames
when it comes to plan design.
There are different rules. There are
different tax incentives. There are
different eligibility criteria. The list
goes on.
And THAT’S a whole
different article.
IF YOU KNOW MUCH ABOUT THE HEALTH INSURANCE INDUSTRY AT ALL…

6. As an individual or BUSINESS OWNER you’ll want to know the “ins and
outs” of both: employer plans AND the new individual marketplace.

7. BECAUSE FOR CERTAIN BUSINESS OWNERS:
THE INDIVIDUAL SEGMENT WILL BE MOST IMPORTANT NOW ANYWAYS.

8. HERE ARE THE “ESSENTIALS” OF THE NEW INDIVIDUAL
HEALTH INSURANCE MARKETPLACE. THIS IS WHAT YOU
NEED TO KNOW.

9. THIS IS PROBABLY THE BIGGEST GAME-CHANGER OF THEM ALL:
“Guaranteed Issue.” One of those big insurance words.
ESSENTIAL #1: “GUARANTEED ISSUE” MANDATE

10. For years-upon-years, if you were going to
apply for an individual health insurance
plan….
You had to go through a series of
health-related questions in order to
apply for coverage. There were 50,
60, and sometimes even 70 or more
questions. If you’ve applied for
coverage before 2014, you know
what this is all about.
YES. MISERY.

11. You heard that right: OUTA’ HERE. It’s
still difficult for many to
comprehend. There are NO MORE
health-related questions on
individual health insurance
applications anymore.
THIS is what is called
“Guaranteed Issue” in the
insurance world.
LOVE. That.
Starting in 2014: these health related questions are all GONE.

12. ALL GUARANTEED ISSUE MEANS, IS THAT IF YOU APPLY FOR COVERAGE, YOU
HAVE GOT TO BE ACCEPTED.
You’re in.

13. Q: How does this change the ballgame?
Game changer.
A: You don’t need
access to an employer
health insurance plan
to apply for coverage
anymore.
This is huge. Especially
for those with
preexisting conditions.

14. It can’t be emphasized enough how much this has freed
up individual choice in health insurance plans.
We like options.
You can literally pick
any plan from any
company, and apply for
coverage now.

15. And to boot: if you’re eligible for subsides at the new
health insurance marketplaces…
Game changing.
Again.
You could end up
receiving quite a bit
of money in the form
of subsidies that will
help you pay for your
premiums.

16. This all sounds fine and dandy, right? It is. But there are
some important concepts that need to be understood.
Movin’ on.

17. In the past (before 2014),
you could apply for an
individual health
insurance plan at any
time during the year.
You could go out, pick a
plan, and apply for
coverage… but you might
be denied.
ESSENTIAL #2: OPEN ENROLLMENT PERIODS
WELL THAT’S ALL
HISTORY NOW.

18. BECAUSE TODAY (in 2014 and Beyond):
There’s now an “individual open enrollment period.”
Save the date.
Q: What’s an open
enrollment period?
A: It’s a time-frame at the
end of the year when you
can enroll for individual
health insurance.
OPEN
ENROLLMENT
PERIOD

19. THIS is that exact same concept. Except it’s in the new individual
health insurance marketplace now.
AND IT’S A BIG ENROLLMENT: IT’S THE ENTIRE USA.
If you’ve ever worked for an employer that has a company health
insurance plan, you’ll know that you’ve usually got to apply for
coverage during yearly enrollment.

20. Need an appendectomy in the middle of June? It’s too
late. Open enrollment is over.
Get covered.
You’ve now got to enroll
during open enrollment
each year.
This can be very important,
because if you miss open
enrollment, you don’t get an
opportunity to apply again
until the end of the next year.

21. BUT. WHAT IF I LOSE MY COVERAGE IN THE MIDDLE OF THE
YEAR? LIKE CHANGE JOBS. OR GET DIVORCED.
BECAUSE:
You’re special.
IMPORTANT QUESTION.
Which leads us right into our next
individual marketplace essential:
SPECIAL ENROLLMENT.

22. ESSENTIAL #3: Special Enrollment Period
Q: What is a special
enrollment period?
A: It’s a time to enroll in the
middle of the year (outside
of the open enrollment we
just described), under
special circumstances.
THIS IS SPECIAL.

23. WHAT ARE THESE SPECIAL ENROLLMENT CIRCUMSTANCES?
They’re events.
It’s life.
They’re “life events” that can take
place in the middle of the year. If
you incur one, you can “special
enroll.” Here are examples:
• You get married.
• You get divorced.
• You have a child.
• You lose your coverage.
• You move. Plus others…
LIFE
EVENTS

24. In the KNOW.
Most events give you 60 days to
enroll in a plan from the time the
“life event” takes place.
HOWEVER: A Few of these events
only give you 30 days.
Be sure you know which event
applies to you, and how much
time you have to enroll.
YOU’LL WANT TO MAKE SURE TO UNDERSTAND THESE LIFE EVENTS IF YOU
EVER NEED TO UTILIZE THE SPECIAL ENROLLMENT PERIOD.

25. Rolling.
CONGRATULATIONS: MOVING RIGHT ALONG.
THERE ARE ONLY A COUPLE OF “ESSENTIALS” LEFT.
We’re going to briefly go
over these terms:
• ESSENTIAL #4: SHARED RESPONSIBILITY
• ESSENTIAL #5: MINIMUM ESSENTIAL COVERAGE

26. ESSENTIAL #4: “Shared Responsibility”
“Shared responsibility” is a
term that has been coined in the
healthcare reform law.
It means everybody has got to
be “in” in order to make these
reforms work:
• Individuals.
• Employers.
• The Government.
EVERYONE has got to have a
health insurance plan.

27. ESSENTIAL #5: Minimum Essential Coverage
“Minimum essential
coverage” is the type of
coverage you need to have
in order to satisfy the
requirements of the
Affordable Care Act (ACA).
There is a standard of
coverage that has to be
met.
THE BAR HAS
BEEN RAISED.

28. Effectively: “Minimum Essential Coverage”
has standardized health insurance.
There are now only FOUR metallic levels of coverage
when it comes to ALL health plans:
PLATINUM. GOLD. SILVER. BRONZE.
(For those under 30yo, there’s also a “Catastrophic” plan)
It’s minimum.
It’s essential.

29. Roger that.
IN ORDER TO AVOID PAYING A TAX PENALTY, YOU MUST BE ENROLLED IN A
“MINIMIUM ESSENTIAL COVERAGE” HEALTH PLAN.
There’s no doubt
about it.
There are tax penalties that start in
2014 if you don’t have a health
insurance plan.
You’ll need to participate in a
bronze, silver, gold, or platinum
level plan in order to avoid it.

30. THIS is where the bar was raised.
AND: THAT PLAN WILL NEED TO CONTAIN NEW
MANDATED “ESSENTIAL BENEFITS.”
Count ‘Em:

31. NO “ifs, ands,
or buts.”
#1) Outpatient Care.
#2) Trips to the Emergency Room.
#3) Inpatient Hospital Care.
#4) Well Baby Care.
#5) Mental Health Coverage.
#6) Prescription Drug Coverage.
#7) Services if you’re Disabled.
#8) Lab Testing.
#9) Preventive Services.
#10) Pediatric, Including Dental.
EVERY HEALTH PLAN MUST HAVE:

32. AND THAT’S IT. THOSE ARE THE ESSENTIALS OF THE NEW
INDIVIDUAL HEALTH INSURANCE MARKETPLACE. THEY’RE THE
“NEED-TO-KNOWS” SO THAT YOU CAN BEGIN TO NAVIGATE
THE INDIVIDUAL HEALTH INSURANCE SEGMENT MORE EASILY.

33. TYSON J LESTER, RHU, REBC
President, Policy Advantage Insurance Services
Toll Free: (800) 617-0089
Los Angeles Area: (424) 442-0170
Email: info@policyadvantage.com
www.policyadvantage.com | CA Insurance License #0F22799
ARTICLE WRITTEN BY

34. We help individuals and businesses sort out all of the aspects of employer
health plans, and the NEW individual health insurance marketplace.
Please contact us if you have questions. We share high-value
information and look forward to working with you. Thanks for
stopping by.
Toll Free: (800) 617-0089
Los Angeles Area: (424) 442-0170
Email: info@policyadvantage.com
www.policyadvantage.com | CA Insurance License #0F22799
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