Health Insurance Marketplace Enrollment

Health plans that are offered in the Marketplace will cover certain health benefits that are             considered essential. Some of these benefits that are deemed essential are:

• Emergency health services
• Hospitalization
• Ambulatory patient services (these are services such as outpatient care that is provided without having to go to a hospital)
• Prescription drugs
• Newborn and maternity care (this is care before and after the birth)
• Laboratory services
• Substance use abuse services and mental health services (this includes behavioral treatment)
• Habilitative and rehabilitative devices and services (these are devices and services to help those with injuries, chronic conditions and disabilities)
• Pediatric coverage, such as vision and dental care
• Wellness and preventative services, including management for chronic disease

Keep in mind that details including what is covered can vary between each plan.

Health care plans that are offered in the Marketplace are required to meet the requirements of those that are “qualified health plans.” In other words, these plans will provide health benefits that are essential, provide protections that are required by the Affordable Care Act, and restrict co-pays and deductibles.

Certain health care plans vary when it comes to benefits that they offer. For example, differences can be found based on the amount of cost sharing that is required. Plans are labeled as Platinum, Gold, Silver and Bronze. These categories indicate the amount of cost sharing that is required. For example, Platinum plans will have the lowest deductibles, while Bronze plans will have the highest. These plans also vary according to health care providers and hospitals offered. Some plans will offer coverage when you are out-of-network, while others will require that you sign up for non-emergency care in-network.

No, as of 2014, it is not legal to charge you more for insurance if you have a pre-existing condition or other health status.

Yes, this is possible. In most states you can be charged, within limits, for your age. Certain federal rules can allow insurers to charge those individuals who are sixty years old, or older, three times as much as they charge younger adults. This age rating limit has the option of being applied to all small-group and non-group policies, regardless of if they are sold in the Marketplace or not. However, some states can prevent insurers from changing premiums for age.

Yes, this can potentially happen in some states. Some insurers can charge 50% more for those who are tobacco users. Some insurers can apply a low surcharge for using tobacco. Those who also qualify for tax credits, will not have a tobacco surcharge covered the credit. Some states can limit surcharges from tobacco and some have even decided to disregard tobacco ratings put into place by health insurers.

No. Most states will require you to make payments for premiums straight to your health insurance provider. When a plan has been selected, you will automatically be directed to your new insurance company to make the first payment for the premium. It is required for insurance companies to accept various forms of payment, and it is illegal for them to discriminate against those who do not own bank accounts or credit cards. Insurance providers are required to process the payment one day before your coverage is supposed to start. It’s important to understand the payment requirements and deadlines for your insurance provider, and to follow these requirements so insurance will start on time. Enrollment in your health plan will not be completed until your insurance company has processed the payment.

In the case that you have qualified for a tax credit, the credit will be applied to the amount owed to the insurer and you will be responsible for paying the remaining amount.

No, a health insurance company cannot require you to open a checking account. The Marketplace and insurers are required to accept a variety of payment methods, and cannot force an individual to make payments through automatic bank withdrawals. It is a federal law that insurers are required to accept cashier’s checks, paper checks, money orders, debit cards and electronic transfers. All of these methods must be available to those who are insured at the time of the first payment, and any payment thereafter.

The answer can vary depending on if you are currently the recipient of tax credits. For those who qualify for these credits and a payment is late, insurers are required to provide a grace period of ninety days. During this grace period, consumers are allowed to make payments, and their coverage will not be terminated. However, during this 90 day period all premiums must be paid and caught up to date or the policy will lapse. This will only apply if a consumer has made the first month’s premium.

However, if the grace period is over, and the amount owed is not paid, the insurance company can terminate any coverage.

Also, in the first thirty days of the grace period, the insurance company is required to pay any claim filed. After these thirty days have expired, the insurance company is not required to pay health care claims that were received during the first thirty days of the grace period. In other words, an individual may be responsible to pay for any health services received during the remaining days of the grace period. It is up to insurers to inform providers in the case that someone’s claims are held. Potentially, this could mean that health care could be halted, in the case that providers know they will not be compensated. Those who are not receiving tax credits, will receive a grace period that is shorter. The average grace period is 31 days, but this can vary by state.

If you are receiving premium tax credits, an insurance company is only obligated to pay for claims made during the first thirty days of a grace period. During the remaining time of the 90-day grace period, the insurance company can hold claims and only make payments for them, should you make payments on your premium.

Each Marketplace plan offers insurance according to the calendar year. If you signed up earlier in the year, the coverage will continue through the end of the year. The period of Open Enrollment is the time when coverage will be renewed. To renew your coverage, you should come into our office or give us a call and we will help you renew and select your plan for the upcoming year.

In some states, if you do not renew your coverage by the end of the year, the Marketplace coverage will automatically be renewed. However, you can change plans until the last day of Open Enrollment.

In this case, your coverage can be automatically renewed. Even if renewing, it may be wise to take actions to renew it manually during the period of Open Enrollment. If you are the recipient of a tax credit, you should go through the process of updating family information and income in order to see your eligibility for the new year’s premiums.

Based on where you live, the actual process of renewing your coverage could be different. If you are enrolled in a Marketplace policy, and you do not take actions to cancel coverage before the end of the Open Enrollment period, your coverage may be automatically renewed under the same policy for the next year. However, keep in mind that insurance companies may not offer the same policy next year. If you do not take action to renew your policy, the company may automatically place you in a policy that is like the one you currently have.

Yes. When you applied for federal marketplace coverage on last year’s application, you most likely authorized the Marketplace to inspect your data income that is online. This includes information from tax returns for the next 1-5 years.

If you did not authorize this (most people allowed authorization), any financial aid will be cancelled for the coming year. You will need to re-apply for your financial aid.

Also, if you gave authorization or the ability to inquire about your income, they will search for the most recent information. In most cases, it will be the last year’s federal tax return. In the case that the income reported on last year’s tax return is more than five hundred percent of poverty level, then the financial assistance you received will be not automatically continued for the next year. In order to receive the financial assistance that you need, you will need to fill out a re-application for financial aid and provide any expected income for the year.

Please keep in mind that financial aid renewal process will vary in different states. For example, in Maryland, any residents who have received tax credits for the previous year, will have to reapply for next year. If they do not apply, all tax credits will be cancelled. If residents do not reapply but still qualify for financial aid, they can still be recipients of the tax credit when they are filing for their next year’s tax return. Our Marketplace will send out consumer notifications before the beginning of Open Enrollment which will explain the re-applying application process or continuing financial aid in the next year.