Social Worker’s Guide to the Marketplace:
Getting clients enrolled in the Health Insurance
Marketplace, Medicaid, and CHIP
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[Presenter Name]
[date]
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Today’s Presentation Covers
 Background information on the Marketplace,
Medicaid, and CHIP
 Eligibility requirements
 Enrollment checklist
 Enrollment period, exceptions and penalties
 Opportunities to assist with enrollment
 Tips on how to encourage your clients to enroll
 Resources
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Why Help Clients Get Covered?
Coverage helps
prevent illness
Marketplace plans cover 100% of the
costs of:
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15 preventive services for
adults, such as screening and
counseling for tobacco use,
substance misuse, and obesity.

22 preventive services for
women, such as screening for
breast cancer and osteoporosis.
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26 preventive services for
children, such as hearing
screening, and immunizations.
Source: https://www.healthcare.gov/what-are-mypreventive-care-benefits/adults/
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Why Help Clients Get Covered?
Coverage protects
against high health
care costs
 The average cost of
a 3‐day hospital stay
is $30,000.
 Fixing a broken leg
can cost up to
$7,500.
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Why Help Clients Get Covered?
Coverage brings
peace of mind
 80.1 million people in the
U.S. have unintentional
injuries every year.
 10.3 million U.S. children
experience asthma.
 117 million adults (about
50% of adults) have one or
more chronic conditions.
Sources:
http://www.cdc.gov/nchs/fastats/injury.htm
http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf
http://www.cdc.gov/pcd/issues/2014/13_0389.htm
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Why Help Clients Get Covered?
Getting coverage is simpler
with one single application
through the Marketplace
Submit single, streamlined
application
Online, Phone,
Mail or In Person
Verify and determine eligibility
Eligible for Marketplace or Medicaid/CHIP
Enroll
(Medicaid/CHIP)
Enroll
(Marketplace)
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What is the Marketplace?
 A website where individuals and families can
directly compare private health insurance plans
and enroll in a plan.
 Some states operate their own Marketplace.
Everyone can get to the right Marketplace by
going to https://www.HealthCare.gov and
entering the state they live in.
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How Does the Marketplace Work?
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Step 1: Create a user account
Step 2: Complete the application
Step 3: Shop for a plan
Step 4: Enroll
To find in-person local assistance,
go to https://Localhelp.HealthCare.gov
or contact the Call Center 1-800-3182596
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Who is Eligible for
Marketplace Coverage?
A person is eligible for coverage
if he or she:
 is not eligible for job-based coverage.
 has job-based coverage that does not
meet minimum coverage.
 is a U.S. citizen or is a lawful resident.
 is under 26 years of age and is not
claimed as a tax dependent by parents.
 is not incarcerated at the time of
enrollment.
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Saving Money on Coverage
• Advanced Premium Tax Credit. Households
earning between 100% and 400% of the federal
poverty level (from about $23,850 to $95,400
for a family of four in 2014) can get financial
assistance in the form of a tax credit.
• Cost Sharing. Households that earn up to
250% of the federal poverty level (about
$29,175 for an individual and $59,625 for a
family of four) are eligible for cost-sharing
assistance. Cost sharing limits the amount a
household has to pay for out-of-pocket costs.
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Marketplace Enrollment Checklist
Social Security numbers (or document
numbers for lawfully residing residents)
Date of birth
Health insurance policy numbers
Income
An “Employer Coverage Tool” completed by
the employer(s)
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Marketplace Enrollment Period
OPEN
ENROLLMENT
PERIOD FOR
2015
BEGINS
2014 HEALTH
INSURANCE
COVERAGE
ENDS
FIRST DAY OF
COVERAGE
FOR 2015
BEGINS
OPEN
ENROLLMENT
PERIOD FOR
2015
ENDS
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Individual Shared
Responsibility Payment
In 2014, you
pay the greater
amount of:
In 2015, you
pay the greater
amount of:
In 2016* you
pay the greater
amount of:
1% of your yearly
household income
2% of your annual
household income
2.5% of your
annual household
income
— OR —
— OR —
— OR —
$95 per adult, and
$47.50 per child
under 18
$325 per adult, and
$162.50 per child
under 18
$695 per person,
and $347.50 per
child under 18
*After 2016, increase is based on cost of living.
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Fee Exemptions
A person is exempt from the penalty if he or she:
 was uninsured for less than 3 months of the year.
 would have to pay more than 8% of household income.
 is not required to file a tax return.
 would have been eligible but was denied Medicaid
because they live in a state that has not expanded its
Medicaid program.
 opposes insurance for religious reasons.
 was incarcerated.
 a member of a federally recognized tribe or eligible for
services through an Indian Health Services provider.
 experienced extreme hardship, such as homelessness.
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Special Enrollment Period
Qualifying life event
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Getting married or divorced
Having or adopting a baby
Moving
Gaining citizenship
Rejoining the community after
incarceration
 Involuntarily losing other health
coverage, such as by losing a job or
aging off of a parent’s plan
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How to Motivate Clients to Enroll
I can’t
afford it
I would rather
pay the fee
than enroll in
healthcare
It’s too
complicated
I don’t need
healthcare,
so I don’t
need
insurance
I struggle
reading
English
I don’t know
where to go
for help
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Questions about the Marketplace?
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What is Medicaid?
 A partnership between the federal and state
governments to provide free or low-cost health
coverage.
 There are minimum core Medicaid coverage and
eligibility requirements that apply across all states.
 No two states are alike. Each state may elect to
expand coverage to include different groups or
income levels, or to increase covered services.
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Who is Eligible for Medicaid?
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Low-income pregnant women
Low-income children
Low-income parents
Adopted children, those in foster care, or
those who aged out of foster care and are
under 26 years old
 People who receive Supplemental Security
Income
 People on Medicare who have low incomes
(dual-eligible)
 Childless Adults (in certain states)
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How the Medicaid Expansion
Affects Your Clients
 If you live in a state that's expanding Medicaid, your
clients probably qualify if they make up to $16,105 a
year for 1 person ($32,913 for a family of 4).
 If they live in a state that hasn't expanded Medicaid,
qualifying will depend on income.
 Even if your state hasn’t expanded Medicaid
coverage, they should still apply. They may qualify
under your state’s existing rules.
 States are continuing to make coverage decisions.
They could expand Medicaid in the future.
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Medicaid Enrollment Checklist
Citizenship or eligible immigration status
Foster care status
Identity
Income
Pregnancy status
State residency
Tribal memberships
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Medicaid Enrollment Period
 Clients can sign up for Medicaid through the
Marketplace or through their state agencies at
any time of the year.
 If they qualify for coverage, Medicaid may
retroactively cover their medical expenses for
up to three months, as long as they qualified
for Medicaid at the time the expenses were
incurred.
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How to Motivate Clients to Enroll
I have to wait
until open
enrollment to
enroll in
Medicaid?
Too much
paperwork
Medicaid is
only for
people on
welfare
I already
have
Medicare so I
don’t need
Medicaid
I struggle
reading
English
I’m an
immigrant so
I can’t get
Medicaid
Where can I
get more
information on
Medicaid?
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Questions about Medicaid?
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What is CHIP?
 CHIP provides health coverage for
children whose families earn too
much to qualify for Medicaid yet do
not have access to affordable
insurance through their employers.
 At minimum, CHIP covers checkups and preventive care,
immunizations, hospitalization, lab
and x-ray services, and dental care
at no cost to families. Other health
care may require copayments.
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Who is Eligible for CHIP?
 Children and teens 18 years of age
and younger.
 Children in families earning about
$47,700 a year for a family of 4 are
generally eligible.
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Streamlining Eligibility
Express lane
eligibility
Presumptive
eligibility
Continuous
eligibility
Allows states to use
findings from
“express lane
agencies” to enroll
children in CHIP.
Allows health care
providers to make a
rapid assessment of
a child’s eligibility
and provide
temporary eligibility
until an official
determination is
made by the state.
Means that children
who are already
enrolled in CHIP can
be covered up to a
full year, regardless
of changes in family
status.
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CHIP Enrollment Checklist
Age
Child’s citizenship or eligible immigration status
Identity
Income
Other health insurance a child might qualify for
Pregnancy status
State residency
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CHIP Enrollment Period
 Your clients can apply for CHIP through the
Marketplace at www.HealthCare.gov or calling
1-800-318-2596.
 They can also go through their state agencies
or by calling 1-877-KIDS-NOW (1-877-5437669).
 Enrollment is available year round
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How to Motivate Clients to Enroll
I’m not poor,
so my children
won’t qualify
I don’t want to
sign up now
because soon
I’ll have a
better job with
good benefits
I don’t have a
computer at
home
I can’t verify
my income; I
get paid in
cash
I’m too busy to
enroll; I have
too many
things to deal
with already
I don’t want to
get deported if
I try to enroll
my child
I don’t read
English very
well
My kids are
teenagers;
they really
don’t need
health care
I applied once
before, but I
didn’t qualify
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Questions about CHIP?
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Resources to Help Enroll
Special Populations
There is a document called Resources for
Special Populations with additional
information. Populations include but are
not limited to:
 African American
 Agricultural/Migrant workers
 Formerly incarcerated individuals
 Hispanics/Latinos
 Homeless people
 Immigrants
 Students/Young adults
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Resources for Newly Insured Clients
 From Coverage to Care
http://marketplace.cms.gov/technical-assistanceresources/c2c.html
 What If I Have New Medicaid or CHIP Coverage?
https://www.healthcare.gov/what-if-i-have-newmedicaid-or-chip-coverage/
 Using Your New Insurance Coverage
https://www.healthcare.gov/using-your-newmarketplace-coverage/
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How You Can Help
 Use social media to share links with partners and
clients
 Display HealthCare.gov and Marketplace.cms.gov
materials in your office or website
 Share resources with client during in-person
meetings and through professional networks
 Become a Champion for Coverage organization
 Become a Certified Application Counselor (CAC)
organization
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Become a Certified Application
Counselor Organization
 What is it? An organization whose staff and volunteers
help people understand, apply, and enroll for health coverage
through the Marketplace.
 What are the qualifications? Your organization needs
to be a community health center or other health care provider,
hospital, a non-federal governmental or non-profit social
service agency in a state with a Federally-facilitated
Marketplace or a State Partnership Marketplace
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