Insurance Exchanges: What the Pharmacist Needs to Know

The Health Insurance Marketplace, commonly called insurance exchanges, are marketplaces laid out in the Affordable Care Act for Americans to buy health insurance or face tax penalties.

Open enrollment began on October 1, 2013. Coverage begins as early as January 1, 2014. During the initial enrollment period from October 1, 2013 to March 31, 2014, seven million people are expected to sign up for health insurance.

All plans offered through the insurance exchanges must cover ten essential benefits, including prescription drugs.

States had the opportunity to run their own state-based exchanges (16 states and the District of Columbia), participate in a shared responsibility federal-state partnership (7 states), or default to the federal-facilitated exchange (27 states). The Kaiser Family Foundation has information on each state’s exchange decision:

Individuals and families will fill out one application in the Marketplace, available at The application automatically determines if the applicant is eligible for Medicaid, Children’s Health Insurance Program, government subsidies, or cost-sharing. Approximately 90% of uninsured Americans will receive some financial assistance to purchase health insurance.

Community pharmacists have the flexibility to take an active role in helping patients find the best plan for the patient’s needs in most states. Pharmacists looking to capture new business and foster goodwill should consider hosting an insurance enrollment event in their store. To find consumer assisters, visit

The Affordable Care Act created a small business marketplace known as Small Business Health Options Program (SHOP). The SHOP Marketplace opens November 1, 2013 with coverage beginning as early as January 1, 2014 for small businesses. The employer mandate requiring businesses with 50 or more employees to offer employee health insurance or pay tax penalties has been pushed back until 2015. Tax credits are available for some small employers.
The definition of a full-time employee differs depending on the size of the business. Visit to learn how the Affordable Care Act will affect small businesses.

Visit for more information and resources to aid in assisting patients. Consumer information on how the exchanges operate, available plans, and general information can be found at

This information has been excerpted from the NCPA’s insurance exchanges resource center located under the Members-Only section of This comprehensive webpage features a Readiness List designed to prepare NCPA members for the implementation of the Affordable Care Act as well as exclusive marketing materials to present the pharmacy as an educational source on the Health Insurance Marketplace.

Tweet with @TheMPA