the health insurance marketplace
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THE HEALTH INSURANCE MARKETPLACE. Tennessee chose to let the federal government operate a Health Insurance Marketplace (“Marketplace”), also known as the exchange, where individuals can enroll and choose a health insurance plan.

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the health insurance marketplace


Tennessee chose to let the federal government operate a Health Insurance Marketplace (“Marketplace”), also known as the exchange, where individuals can enroll and choose a health insurance plan.

The Marketplace helps eligible individuals apply for health insurance coverage, compare options, enroll, and learn if they will receive help paying their monthly premiums.

Individuals cannot be denied health insurance because of their health status or because of preexisting conditions. In addition, the cost of health insurance cannot be increased because of preexisting conditions.

The Marketplace (for purchasing private insurance plans) opened October 1, 2013, with coverage beginning January 1, 2014. Enrollment ends March 31, 2014.

groups that are exempt from buying health insurance

a. People with low income who are not required to file a tax return. In 2012, this amount was $9,750.00 for singe persons under 65 and $19,500.00 for couples under 65.

b. Certain religious groups.

c. Incarcerated people.

d. Undocumented residents.

e. Members of Indian tribes.

f. People who go without coverage for less than three months.

g. People who do not have an affordable offer of coverage. This means that, if the monthly premium for the coverage offered exceeds more than 8% of the monthly household income for 2014, the coverage is not affordable.


Unless an individual is in an exempt group, in 2014 there will be a tax penalty starting at $95.00 per adult plus $47.50 per child and rising up to a maximum of $285.00 for a family or 1% taxable income. Penalties will increase for years after 2014.

basic health insurance plans
  • The four basic plans: (1) Bronze, (2) Silver, (3) Gold, and (4) Platinum
  • In general, the plans will include the same essential benefits, but the four plans differ in the amount that consumers will pay for deductibles, co-payments, and other services. The amount that the plans will pay for the benefit of the insured are as follows:

A. Platinum 90%

B. Gold 80%

C. Silver 70%

D. Bronze 60%

  • The insured will pay the amounts not paid for by the plan.
affordability provisions

There may be financial help for eligible individuals and families buying insurance at the Marketplace. The financial help depends on the insured’s income level. The financial help is called premium tax credits.

navigators duties
Navigators Duties

An entity that serves as a navigator under a grant under this subsection shall—

(A) conduct public education activities to raise awareness of the availability of qualified health plans;

(B) distribute fair and impartial information concerning enrollment in qualified health plans, and the availability of premium tax credits under section 36B of the Internal Revenue Code of 1986 and cost-sharing reductions under section 1402;

(C) facilitate enrollment in qualified health plans;

(D) provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the Public Health Service Act, or any other appropriate State agency or agencies, for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage; and

(E) provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange or Exchanges.

a navigator shall not
A navigator shall not:

(i) be a health insurance issuer; or

(ii) receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any qualified individuals or employees of a qualified employer in a qualified health plan.

(5) FAIR AND IMPARTIAL INFORMATION AND SERVICES.—The Secretary, in collaboration with States, shall develop standards to ensure that information made available by navigators is fair, accurate, and impartial.

(6) FUNDING.—Grants under this subsection shall be made from the operational funds of the Exchange and not Federal funds received by the State to establish the Exchange.

navigator lawsuits example
Navigator Lawsuits - Example
  • A health care advocacy group is suing to halt emergency rules enacted in Tennessee to require background checks for people giving advice on new insurance marketplaces
  • Gov. Bill Haslam has defended the background checks as a way to prevent scams and identity theft in a process that involves divulging personal information.
  • The lawsuit argues that the rules are overly broad because they apply not just to designated “navigators,” but to anyone who might give advice on health insurance — which could include family, clergy, civic organizations or other acquaintances and advisers.
  • The rules authorize a fine of $1,000 per violation.
obamacare vs tenncare
  • TennCare = Medicaid
    • More than 40 eligibility categories
    • Income levels of between 74% and 250% of poverty level, depending on medical status and care needed
      • Average $25,596 / family of four
    • Largely limited to children of low-income families, pregnant women, and the elderly and disabled.
    • Approx. 1.2 million people on TennCare roles
      • Plus 53,200 in 2014?
obamacare vs tenncare1
  • Affordable Care Act Medicaid Expansion
    • Federal government covers Medicaid 100% of costs for all Tennesseans up to 138% of poverty level.
      • Approx. $32,000 / family of four
    • In 2019, Federal government will scale back coverage to 90% of costs.
obamacare vs tenncare2
  • The “Tennessee Plan”
    • “To leverage the federal dollars available to our state to transform health care in Tennessee without expanding our TennCare rolls.”
    • “I’d like to put in place a program to buy private health insurance for Tennesseans that have no other way to get it by using the federal money.”
        • Gov. Bill Haslam, March 27, 2013