Which states have their own health insurance marketplaces?

States with their own health insurance marketplaces include California, Colorado, Connecticut, Georgia, Idaho, Illinois, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, and Washington. Oklahoma will be introducing a state-based exchange starting in 2027 for 2028 coverage.

What is the difference between a state and federal marketplace?

With a state-based exchange, the state controls plan eligibility, enrollment, customer support, enrollment assistance, verifying premium tax credit eligibility, marketing efforts, and creating any state-specific subsidies. They also work directly with carriers to determine which plans are listed on the exchange and any rate increases or decreases. With the federal exchange, the federal government handles this on behalf of the states.

Can I use HealthCare.gov if my state has its own exchange?

You can only use HealthCare.gov if your state has no exchange or if your state hosts its exchange on the federal platform. For 2026 Open Enrollment for 2027 coverage, only Oklahoma and Arkansas have state-based exchanges on the federal platform. Otherwise, if your state has an exchange, you must use your state exchange to shop for coverage. HealthCare.gov will prompt you to visit your state exchange website after you input your ZIP code, so you can always start there.

Can a small business offer a self-insured health plan?

Yes, but self-insured plans require employers to take on the financial risk of paying employee healthcare claims. Many small businesses choose alternatives, like the ICHRA or QSEHRA, to offer benefits with more predictable costs.

What's the difference between a self-insured health plan and an HRA?

With a self-insured plan, employers pay employee healthcare claims directly. With an HRA, employers set a fixed monthly allowance for eligible expenses, creating predictable costs without taking on claims risk.

How do I choose between a fully-insured health plan, a self-insured health plan, and an HRA?

It depends on your company's size, budget, and risk tolerance. Fully-insured plans offer simplicity, self-insured plans offer flexibility, and HRAs offer predictable employer costs while allowing employees to choose their own individual health insurance coverage.

Can I pay the PCORI fee electronically?

Yes, you can pay the PCORI fee electronically. You can use the Electronic Federal Tax Payment System (EFTPS).

Do I owe a PCORI fee if I offer both an ICHRA and a group health plan?

Yes, you need to pay a PCORI fee if you offer an ICHRA. The PCORI fee for ICHRA is separate if the group plan is a fully-insured plan, as PCORI only applies to self-funded models. If you offer a self-funded plan alongside an ICHRA to different employees, and they share the same plan year, you can combine them for PCORI fee reporting purposes. Count the average number of participating employees and dependents for the self-funded plan plus the average number of participating ICHRA employees.

Why is employee engagement important for health benefits?

Employee engagement helps ensure workers understand, use, and appreciate the health benefits available to them. When employees participate in their benefits program, employers often see higher job satisfaction, better retention, and a stronger return on their benefits investment.

How can employers increase participation in health benefits?

Employers can increase participation by communicating regularly, educating employees about their options, offering personalized benefits, creating wellness initiatives, providing incentives, and gathering employee feedback. These strategies help employees better understand and use their benefits.

How do HRAs improve employee engagement?

Health reimbursement arrangements (HRAs) give employees more choice and flexibility by allowing them to select the individual health insurance coverage that best fits their needs. This personalized approach can increase benefit utilization and employee satisfaction while helping employers control healthcare costs.

What is the main difference between an HDHP and an LDHP?

The primary difference is the deductible. A high deductible health plan (HDHP) requires you to pay more out of pocket before your insurance begins covering costs, while a low deductible health plan (LDHP) has a lower deductible but typically comes with higher monthly premiums.

Is a high deductible health plan better than a low deductible health plan?

It depends on the individual consumer’s needs. An HDHP may be a good choice for healthy individuals who don't expect many medical expenses and want lower premiums. An LDHP is often better for people who need frequent medical care and prefer lower out-of-pocket costs when they receive treatment.

Can you have a health savings account (HSA) with a low deductible health plan?

No. To contribute to an HSA, you must enroll in an HSA-qualified HDHP. Most low deductible health plans aren't eligible for HSA contributions.

Can employers offer both HDHP and LDHP options to employees?

Yes. Employers can offer multiple plan options through a traditional group health insurance program. Alternatively, employers can provide a QSEHRA or ICHRA, which allows employees to choose the individual health plan, including an HDHP or LDHP, that best fits their medical needs.

How can employers help employees with out-of-pocket healthcare costs?

Employers can supplement health coverage with benefits such as health savings accounts (HSAs), group coverage HRAs (GCHRAs), qualified small employer HRAs (QSEHRAs), or individual coverage HRAs (ICHRAs). These benefits can help employees pay for out-of-pocket medical expenses on a tax-free basis to make healthcare more affordable.

Why are so many health insurance claims denied?

Health insurance carriers deny claims to defend profit margins and manage rising costs. Insurers deny claims based on their policies, such as provider networks, medical necessity, and pre-authorization. You should consult with your plan documents to determine what your specific plan covers.

What is the success rate of insurance appeals?

The success of health insurance claim appeals varies significantly. For Medicare Advantage plans, KFF reports that when beneficiaries appeal claims, 80% of those denials are overturned. Additionally, researchers at Brown University, the University of Texas at San Antonio, and the University of Chicago found that 78% of home healthcare denials in New York were overturned when appealed.

What happens if I lose an insurance appeal?

If you lose an appeal, you can ask for an independent review organization to review it. However, once an IRO reviews the appeal, their decision is final.

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