The key points from this module are:
Each state and the District of Columbia has a Marketplace where qualified individuals, qualified employers, and qualified employees may purchase and select health insurance.
QHPs must be licensed and meet certain transparency requirements. To become certified, a QHP must meet a minimum set of criteria, including coverage of the EHB, benefit design standards, and network adequacy standards.
Other types of plans may be offered through
the Marketplace, including CO-OPs, Multi-State Plans, and stand-alone dental plans.
People who enroll in federal health care programs, such as Medicaid and Medicare, generally have minimum essential coverage and do not need to obtain additional coverage through the Marketplace in order to comply with the requirement to maintain minimum essential coverage.
Agents and brokers can assist individuals with enrolling in QHPs through the Individual Marketplace and can assist employers with
selecting and enrolling in SHOP coverage.
Web-brokers can assist consumers in the Individual Marketplace to select and enroll in a QHP through the web-brokers' own website.
Agents and brokers who participate in the Marketplace are compensated in accordance with their agreements with QHP issuers and any state-specific requirements. The Marketplace does not set compensation levels.
All agents and brokers—including web-brokers—seeking to enroll individuals through the Marketplace must be
licensed by the applicable state, adhere to all applicable state laws, and complete the applicable FFM registration requirements.
All agents, brokers, and web-brokers who participate in the Marketplace must comply with the FFM standards of conduct to protect against conduct that is harmful to consumers or prevents the efficient operation of the Marketplace.
HHS may terminate an agent's, broker's, or web-broker's Marketplace Agreement(s) with CMS for cause if HHS determines that a specific
finding of noncompliance or a pattern of noncompliance is sufficiently severe.
HHS may suspend an agent's, broker's, or web-broker's Marketplace Agreement(s) with CMS for up to 90 calendar days if it reasonably suspects that an agent, broker, or web-broker may have engaged in fraud or abusive conduct that may cause imminent or ongoing consumer harm using a consumer's PII or in connection with a Marketplace enrollment or application.
In addition to terminating an agent's, broker's, or
web-broker's Marketplace Agreement(s) with CMS, HHS may prohibit an agent, broker, or web-broker from participating in the Marketplace in future years, and/or may impose civil money penalties.
Benefit design standards, including non-discrimination requirements and limits on cost sharing
Coverage, at a minimum, of a comprehensive package of benefits, known as EHB
Network adequacy standards
Available for enrollment through the Marketplace for the full plan year for which the plan was certified
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