With most of the Affordable Care Act’s major provisions now in effect, the nation’s health insurance marketplace has undergone a significant transformation. Obamacare impacts individuals, families and small business owners alike. Most Americans are required to have minimum essential coverage unless they qualify for an exemption; however, the law is designed to make health insurance more accessible and affordable with income-based financial assistance and one-stop shopping via state-based and federally facilitated exchanges. Meanwhile, the private marketplace remains a place to shop for quality, affordable health insurance plans that meet ACA requirements.
The following guide offers a glimpse at the various types of ACA-compliant health insurance in Virginia, including individual and family health plans, small group health plans, coverage for high-risk applicants, mini-COBRA continuation coverage, Medicaid, and CHIP.
Health and healthcare in Virginia
Virginia ranked 21st in United Health Foundation’s 2014 America’s Health Rankings. Its strengths include a low rate of drug deaths, a low rate of violent crime, and a low percentage of children in poverty. Challenges included a high prevalence of diabetes, a high infant mortality rate, and a large disparity in health status by educational attainment.1
Virginia individual and family health insurance
When the Obamacare health insurance exchanges opened for 2014 enrollment, Virginia elected to become part of the federally facilitated marketplace, healthcare.gov. Individuals and families living in Virginia may purchase health insurance coverage through the state’s federally facilitated exchange and in the private marketplace.
Those who buy health insurance through healthcare.gov may be eligible for income-based subsidies, including premium tax credits that may be applied to any metal plan and cost-sharing subsidies that apply to silver plans. Individuals who go without health insurance may face a tax penalty known as the shared responsibility payment.
The U.S. Department of Health and Human Services reported that 216,356 individuals in Virginia selected a marketplace plan through the exchange from Oct. 1, 2013, through April 19, 2014.2 In 2015, the number of individuals in Virginia enrolled in a marketplace plan increased to 385,154 during the open enrollment period.3
|Virginia’s health insurance exchange:||healthcare.gov|
|Virginia Department of Insurance:||Virginia State Corporation Commission|
Virginia small group health insurance plans
In Virginia, small businesses with 50 or fewer employees may purchase small group health insurance plans through the federally facilitated Small Business Health Options Program, SHOP Marketplace, at healthcare.gov/marketplace/shop and in the private marketplace. Small businesses that use SHOP and have 25 or fewer employees may qualify for a Small Business Healthcare Tax Credit.
Self-employed individuals with no employees must apply for an individual health insurance plan on or away from healthcare.gov.
State COBRA variations for small groups
The Consolidated Omnibus Reconciliation Act (COBRA) allows those employed by businesses with 20 or more employees to continue their group health insurance plan for a limited time should they lose coverage due to qualifying events such as termination of employment due to reasons other than gross misconduct, a reduction in work hours, divorce or legal separation, and loss of dependency status. To learn more about the federal COBRA program, visit dol.gov/ebsa/cobra.html.
In some states, those who work for a small business and lose health insurance coverage due to a qualifying event may qualify for health insurance continuation through mini-COBRA programs. State mini-COBRA programs allow those who work for a small business and lose health insurance coverage due to a qualifying event to continue coverage, too. These programs generally work like the federal COBRA continuation coverage, but their terms may vary. Virginia’s small group COBRA continuation variations are as follows:4 5
|Eligible group sizes||Employers with fewer than 20 employees|
|Maximum continuation period – standard||12 months|
|Maximum premium Increase||Individuals who elect continuation coverage may be up responsible for up to 102 percent of their premium cost (premium cost plus administrative fees)|
|State legislation reference||Virginia House Bill 315|
|More Information||804-371-9741 or 800-552-7945 (Virginia Bureau of Insurance) | scc.virginia.gov/boi|
|Additional notes||Employers must notify employees within 14 days of loss of group health plan eligibility due to a qualifying event. Employees have a maximum of 60 days after loss of eligibility to apply for continuation coverage.|
Virginia high-risk pools
It used to be that health insurance companies could deny applicants or charge them more based on health history and preexisting conditions. When the Affordable Care Act was passed in 2010, many states created federally funded preexisting condition insurance programs or accepted federal funding to assist with similar high-risk pool programs they already operated.6
The Affordable Care Act prohibits this practice for health insurance plans considered minimum essential coverage with effective dates beginning Jan. 1, 2014, and later. As such, the PCIPs and state high-risk pools created to provide health insurance for those once considered uninsurable are being phased out.
Medicaid is a state health insurance program for low-income individuals under age 65, pregnant women, children, disabled individuals, and seniors over age 65; it is partially funded by the federal government. In 2014, states were given the option to accept additional federal funding and expand their Medicaid program eligibility to those who make up to 138 percent of the federal poverty level.
Virgin opted not to expand its Medicaid program in 2014. A resulting coverage gap exists for those whose incomes are too high for Medicaid but too low to receive federal premium and cost-sharing assistance when shopping healthcare.gov.
The information below is specific to Virginia’s Medicaid program:
|Governing agency||Centers for Medicare & Medicaid|
|Administrator||Virginia Department of Medical Assistance Services|
|Where to apply||healthcare.gov| coverva.org/main_apply.cfm(includes options beyond online application)|
|Phone number||855-242-8282 (TDD: 888-221-1590)|
|Eligibility||Income and resource requirements vary by category; some groups covered include low-income pregnant women, children, individuals with disabilities, individuals age 65 and older, some parents and caregivers.|
|Open-enrollment period||Year-round in all states|
|Additional programs||Virginia also offers the following low- and no-cost health insurance programs:FAMIS Plus – Medicaid for children), FAMIS – Virginia’s health insurance program for children, FAMIS MOMS, Medicaid for pregnant women, Plan First – family planning for men and women, Coverage for former foster care youth under age 26, starting at their 18th birthday, Hospital Presumptive Eligibility – temporary coverage program/short-term Medicaid,Visit for more informationcovereva.org/main_programs.cfm|
The Children’s Health Insurance Program is a partnership between the states and federal government. CHIP provides health insurance to uninsured children who meet certain eligibility guidelines. The information below is specific to Virginia’s health insurance program for low-income children:
|Where to apply||healthcare.gov | coverva.org/main_apply.cfm|
|Phone number||855-242-8282 (TDD: 888-221-1590)|
|Eligibility17||Low-income, uninsured children under 19 who are not eligible for Children’s Medicaid (also known as FAMIS Plus), live in Virginia, and are U.S. citizens or qualified non-citizens|
1 United Health Foundation. 2014 America’s Health Rankings Annual Edition. “Annual State Health Rankings.” http://www.americashealthrankings.org
2 Kaiser Family Foundation http://kff.org/other/state-indicator/state-marketplace-statistics-2014/.
3 Kaiser Family Foundation http://kff.org/other/state-indicator/state-marketplace-statistics-2015/.
4 U.S. Department of Health & Human Services, Office of the Assistant Secretary for Planning and Evaluation. “Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment: For the Period: October 1, 2013–March 31, 2014 (Including Additional Special Enrollment Activity Reported through 4-19-14).” May 1, 2014. Retrieved fromhttp://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf.
6 National Conference of State Legislators. Coverage of Uninsurable Pre-Existing Conditions: State and Federal High-Risk Pools. Updated April 2014. Retrieved from http://www.ncsl.org/research/health/high-risk-pools-for-health-coverage.aspx.
7 The Henry J. Kaiser Family Foundation. “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid.” April 2, 2014. Retrieved from http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/.