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My wife and I each make about $40,000 a year. If we file our taxes separately, can we each qualify for an exchange subsidy?

January 15, 2021

Q.  My wife and I each make about $40,000/year.  If we file our taxes separately, can we each qualify for an exchange subsidy?

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Use our calculator to estimate how much you could save on your ACA-compliant health insurance premiums.

A.  No. The guidelines for eligibility are determined by total household income and the number of people in the household. For a single individual purchasing coverage with a 2021 effective date, the 400 percent mark is $51,040 in annual income (this is based on 2020 poverty level numbers, as the prior year’s numbers are always used). For two people, it’s $68,960. This makes sense, as it’s less expensive for two people to maintain one household than to maintain two separate households.  Taxpayers whose filing status is married filing separately are explicitly ineligible to receive subsidies in the exchange, regardless of their income. (See this IRS publication for more details).

Premium subsidies have to be reconciled on your tax return, using Form 8962. If you receive a premium subsidy during the year and then end up using the married filing separately status, the full amount of the subsidy that was paid on your behalf would have to be repaid to the IRS with your tax return.

In March 2014, the IRS issued a special rule with regards to married people who are unable to file a joint return because of domestic abuse. If a taxpayer files as married filing separately, premium tax credits are still available as long as (1.) the spouses are not living together, (2.) the taxpayer is unable to file a joint return because of domestic violence, and (3.) the taxpayer indicates this information on his or her tax return.

For everyone else, the rules are clear that married couples must file a joint tax return in order to qualify for subsidies in the exchanges.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post My wife and I each make about $40,000 a year. If we file our taxes separately, can we each qualify for an exchange subsidy? appeared first on healthinsurance.org.

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What happens if my income changes and my premium subsidy is too big? Will I have to repay it?

January 15, 2021

Q: What happens if my income changes and my premium subsidy is too big? Will I have to repay it?

Obamacare subsidy calculator

Use our calculator to estimate how much you could save on your ACA-compliant health insurance premiums.

A: Monthly premium subsidy amounts (ie, the advance premium tax credit – APTC – that’s paid to your insurer each month to offset the cost of your premium) are estimated based on prior-year income and projections for the year ahead, but the actual premium tax credit amount to which you’re entitled depends on your actual income in the year that you’re getting subsidized health insurance coverage.

If recipients end up earning more than anticipated, they could have to pay back some of the subsidy. This can catch people off guard, especially since the tax credits are paid directly to the insurance carriers each month, but if overpaid, they must be returned by the insureds themselves.

The issue of reconciling APTCs was explained in a 2013 IRS publication (see the final column on page 30383, continued on page 30384) which clearly explains that they do expect people to pay back subsidies that are in excess of the actual amount for which the household qualifies.

But the portion of an excess subsidy that must be repaid is capped for families with incomes up to 400 percent of federal poverty level (FPL). Details regarding the maximum amount that must be repaid, depending on income, are in the instructions for Form 8962, on Table 5 (Repayment Limitation). These amounts are adjusted annually, but for the 2020 tax year, the repayment caps range from $325 to $2,700, depending on your income and your tax filing status (single filer versus any other filing status). GOP lawmakers considered various proposals in 2017 that would have eliminated the repayment limitations, essentially requiring anyone who received excess APTC to pay back the full amount, regardless of income. But those proposals were not enacted.

There are some scenarios in which repayment caps do not apply:

  • If a person projected an income below 400 percent of the poverty level (and received premium subsidies during the year based on that projection) but then ends up with an actual income above 400 percent of the poverty level (ie, not eligible for subsidies), the entire subsidy amount that was paid on their behalf has to be repaid to the IRS.
  • If a person projected an income at or above 100 percent of the poverty level (and received premium subsidies) but then ends up with an income below the poverty level (ie, not eligible for subsidies), none of the subsidy has to be repaid. This is confirmed in the instructions for Form 8962, on page 8, in the section about Line 6 (Estimated household income at least 100% of the federal poverty line). But there are new rules as of 2019 that make it less likely for people with income below the poverty level to qualify for premium subsidies based on income projections that are above the poverty level. This is explained in more detail here.

Is there any help for me if I have to repay premium subsidies?

The IRS noted that they would “consider possible avenues of administrative relief” for tax filers who are struggling to pay back excess APTC, including such options as payment plans and the waiver of interest and penalties for people who must return subsidy over-payments. If you find yourself in a situation where you must pay back a significant amount of the premium subsidies you received during the prior year, contact the IRS to see if you can work out a favorable payment plan/interest arrangement.

It’s also worth noting that contributions to a pre-tax retirement account and/or a health savings account will reduce your ACA-specific modified adjusted gross income, which is what the IRS uses to determine your premium tax credit eligibility. If you had HSA-qualified health coverage during the year, you can make HSA contributions up until the tax filing deadline the following spring. And IRA contributions can also be made up until the tax filing deadline. You’ll want to talk with your tax advisor to see what makes the most sense given your specific circumstances, but you may find that some pre-tax savings end up making you eligible for a premium subsidy afterall, or reduce the amount that you’d otherwise have to repay.

The COVID pandemic caused widespread financial uncertainty and employment upheavals throughout much of 2020. Additional federal unemployment benefits were provided to millions of people, but there are concerns that the premium tax credit reconciliation could be particularly challenging during the 2021 tax filing season, with many people having to repay subsidies that were paid on their behalf during a time they were unemployed in 2020.

In December 2020, insurance commissioners from 11 states sent a letter to President-elect Biden, recommending various immediate and long-term actions designed to improve access to health coverage and care. One of the short-term recommendations is to provide relief from subsidy claw-backs for the 2020 tax year. Even in the best of times, it can be challenging to accurately project your income for the coming year, but the uncertainty caused by the COVID pandemic made this much more challenging than usual. So it’s possible that the Biden administration and/or Congress might be able to take action to provide some relief in this area, for at least the 2020 tax year.

What if you get employer-sponsored health insurance mid-year?

Most non-elderly Americans get their health coverage from an employer. Individual health insurance is great for filling in the gaps between jobs, but what happens if you start off the year without access to an affordable employer-sponsored health insurance plan, and then get a job mid-year that provides health coverage?

If a premium subsidy was paid on your behalf during the months you had individual market coverage, you may end up having to repay some or all of the subsidy when you file your tax return. It all depends on your total income for the year, including income from your new job. If your total income still ends up being in line with the estimate you provided when you applied for your subsidy, you won’t have to pay that money back. But if your actual income for the year ends up being substantially higher than you initially projected, you may end up having to repay some or all of that subsidy when you file your taxes.

It doesn’t matter that your income was lower when you were covered under the individual market plan. In the eyes of the IRS, annual income is annual income — it can be evenly distributed throughout the year, or come in the form of a windfall on December 31. (As noted above, insurance commissioners have urged the Biden administration to consider ways of providing relief on this issue for the 2020 tax year, given that it was even more challenging than normal to accurately project an annual income during the COVID panemic).

Once you become eligible for an affordable health insurance plan through your employer that provides minimum value, you’re no longer eligible for premium subsidies as of the month you become eligible for the employer’s plan. But premium tax credit reconciliation is done on a month-by-month basis, so as long as your total income for the year is still in the subsidy-eligible range, you’ll almost certainly still be eligible for at least some amount of subsidy for the months when you had a plan that you purchased through the exchange.

Finally, if you’re offered health insurance through an employer that you feel is too expensive based on the share you have to pay, you can’t just opt out, buy your own health plan, and attempt to snag a subsidy. The fact that an affordable plan (by IRS definitions) is available to you renders you ineligible for money toward your premiums. Unfortunately, the cost of obtaining family coverage is not taken into consideration when determining whether an employer-sponsored plan is affordable, which leaves some families stuck without a viable coverage option.

How many people have to repay premium subsidies?

For 2015 coverage, subsidies were reconciled when taxes were filed in early 2016. The IRS reported in early 2017 that about 3.3 million tax filers who received APTC in 2015 had to repay a portion of the subsidy when they filed their 2015 taxes; the average amount that had to be repaid was about $870, and 60 percent of people who had to pay back excess APTC still received a refund once the excess APTC was subtracted from their initial refund. [IRS data for premium tax credit reporting is available here; as of 2019, data had only been reported for the 2014 and 2015 tax years.]

But on the opposite end of the spectrum, about 2.4 million tax filers who were eligible for a premium tax credit ended up receiving all or some of it when they filed their return. These are people who either paid full price for their exchange plan in 2015 but ended up qualifying for a subsidy based on their 2015 income, or people who got an APTC that was less than the amount for which they ultimately qualified. The average amount of additional premium tax credit paid out on tax returns for 2015 was $670.

[The IRS noted that it was very uncommon for people to pay full price for their coverage and wait to claim their full refund on their return: 98 percent of the people who claimed a premium tax credit on their return had received at least some APTC during the year.]


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post What happens if my income changes and my premium subsidy is too big? Will I have to repay it? appeared first on healthinsurance.org.

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Did health insurance premiums go up or down for 2021?

January 14, 2021

Q. I’ve seen a lot of differing headlines about health insurance rates for 2021 – some say rates increased, some say they decreased. Can you shed some light on this? Do these rate changes apply to everyone?

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A. The vast majority of Americans get their health insurance either from an employer or from the government (Medicare, Medicaid, CHIP, TRICARE, VA, IHS). The rate changes that have been making headlines each fall for the last few years are for the individual market, which only accounts for about 4.2 percent of the population.

Do rate change headlines apply to all types of health insurance coverage?

When you see headlines about health insurance premium increases or decreases, the stories are typically about individual-market – and ACA-compliant – health insurance. The headlines aren’t referring to government coverage, or pre-ACA plans still in force.

More specifically:

  • If you get your health insurance through your employer or from the government, the subsidies, exchanges, and the individual market health insurance rates that you’re seeing in media reports don’t apply to you. Employer-sponsored insurance rates change annually, and your employer will provide you with information related to your plan options for the coming year, including how your plan, premiums and/or cost-sharing might be changing.
  • If you have Medicare, Medicaid, or CHIP coverage, you’ll receive information from the government or from your private insurer (if you’re enrolled in a Medicare Advantage, Medigap, Medicare Part D, or a Medicaid/CHIP managed care plan), letting you know how your coverage and/or costs might be changing for the coming year.
  • If your health insurance plan is grandfathered or grandmothered, you’re in a separate risk pool from the ACA-compliant plans offered by your health insurer, which means your rate increases for 2021 won’t necessarily match the rate increases you might be seeing in media reports about ACA-compliant plans issued by your insurance company. (There’s no requirement that carriers continue to renew grandfathered and grandmothered plans. They can decide to cancel them instead, and replace them with ACA-compliant plans.)

Headlines about rate increases (or decreases)

If you have an individual/family major medical health insurance plan, purchased on-exchange or off-exchange, that became effective January 2014 or later, it’s compliant with the ACA. The annual rate changes for these plans have been making headlines for the last several years, but the actual rate changes that apply to each enrollee’s premiums differ significantly because there are so many factors involved.

Here are some things to keep in mind:

  • When you see headlines about rate changes, they almost always apply to full-price premiums, before any premium subsidies are applied. But 86 percent of the people who get their coverage via the exchanges are receiving premium subsidies (and the majority of the entire individual market population has coverage via the exchanges). These subsidies make a huge difference in terms of how much people actually pay for their coverage and how much their after-subsidy premiums change from one year to the next.
  • Average full-price premiums increased significantly in 2017 and 2018. But they increased by less than 3% in 2019, decreased slightly for 2020, and increased slightly for 2021. But that’s doesn’t mean the rate changes were uniformly small: Average rates increased by more than 10 percent in Indiana, and decreased by more than 13 percent in Maine (and again, that’s for people who pay full-price premiums; changes in after-subsidies premiums can be very different).
  • CMS put out a press release in October 2020, noting that premiums in the exchanges were dropping for the third year in a row, and that benchmark premiums were decreasing by an average of 2 percent for 2021. This was widely reported in the media, but this 2% average rate decrease only applies to the average benchmark plans (second-lowest-cost silver plan) available via HealthCare.gov. That means it doesn’t apply to the vast majority of plans sold on HealthCare.gov, and it doesn’t apply to any of the plans sold in the 15 fully state-run exchanges.
  • You might have seen articles about very stable overall rates for 2021 — on the heels of rates that have been quite stable ever since 2018. Or about significant rate increases in places like Indiana. Or about significant rate decreases in Maine and Maryland. And sometimes, rates can decrease for people who don’t get premium subsidies while simultaneously increasing for people in the same area who do get premium subsidies. It’s no wonder people are confused.

What’s the biggest factor when it comes to premium increases?

The biggest factor is whether or not you get premium subsidies. If you don’t get a subsidy (which is the case for about 14 percent of exchange enrollees nationwide – plus everyone enrolled in off-exchange plans), your rate changes are pretty straightforward and just depend on how much your insurer is changing the premium for your plan next year.

Of course, you also have the option to shop around during open enrollment and select a different plan with a different premium.

But if you do get a subsidy, your rate change depends on multiple factors: How much your plan’s price changes, how much your area’s benchmark plan price changes (keeping in mind that the benchmark plan isn’t necessarily the same plan from one year to the next), as well as things like changes in your income and family size.

Because average benchmark premiums decreased for 2021, average premium subsidies are a little smaller in 2021 than they were in 2020 (and since the average benchmark premiums have decreased three years in a row, average premium subsidies have also decreased three years in a row). But that doesn’t mean your subsidy is smaller, since there’s a lot of variation from one area to another, and because your specific subsidy also depends on your own income, which can change from one year to the next.

And it’s important to keep in mind that although average benchmark premiums (on which subsidy amounts are based) decreased slightly for 2021, average premiums across the whole individual market increased slightly. So it was common for 2021 to see people who get premium subsidies ending up with an small overall average increase in their premiums for 2021 – assuming they weren’t enrolled in the benchmark plan in both years (the subsidies are designed to closely offset rate changes for the benchmark plan) or willing to switch to a lower-cost plan for 2021.

If you’re in an area where the benchmark premium decreased significantly, you may have found that your after-subsidy premium ended up increasing significantly, which can be disconcerting after you’ve seen headlines about rate decreases. This is what happened in some parts of Colorado in 2020, for example. And it can also happen in areas where a new insurer moves into the area and undercuts the previous benchmark plan; there are at least 20 states with new insurers for 2021 and numerous other states where existing insurers expanded their coverage areas.

Can you avoid health premium increases?

No matter what, you need to carefully compare your options when you enroll.

If you’re eligible for a premium subsidy, you need to shop in the exchange in your state. (Use our calculator to get an idea of whether you’re subsidy-eligible – it only takes a minute to find out. And make sure you understand what counts as income under the ACA and how you might be able to adjust yours to make yourself eligible for a subsidy.)

And if you currently have a plan you purchased outside the exchange, be sure to double-check your on-exchange options for next year before deciding whether to renew your off-exchange plan. And keep in mind that as the poverty level numbers increase each year, the limits for subsidy eligibility go up as well. In 2014, a family of four had to have a household income of no more than $94,200 in order to get a subsidy. For 2021, that number is nearly $105,000.

If you have a grandmothered or grandfathered plan and your insurer is letting you renew it, be sure to carefully compare it with the ACA-compliant options that are available to you. Consider the benefits as well as the premiums, and know that you’ll also qualify for a special enrollment period during which you can pick an ACA-compliant plan to replace your existing coverage, instead of renewing it.

So did health insurance premiums increase for 2021?

The answer is … it depends. It depends on where you live, what plan you have, whether you changed plans during open enrollment, and whether you get a premium subsidy. And if you do get a subsidy, there are several variables that go into how much your rates might have changed.

So ignore the headlines. Each year, focus on the plans that are available to you and see how your premium and out-of-pocket costs might change if you select a different plan versus keeping the one you have.

Thanks to the ACA, you have the option to shop from among all of the available plans in your area each year, regardless of whether you have health conditions or not (prior to the ACA, people in most states had limited access to new health plans in the individual market if they had pre-existing conditions).

The initial transition to ACA-compliant plans

The ACA makes health insurance available to anyone who applies (no more underwriting rejections or rate-ups) and subsidizes the cost for people who need it the most.

Some people who don’t get a premium subsidy saw sharp rate increases in 2014, with the transition to a guaranteed-issue market and plans that cover the essential health benefits. But even among people who pay full-price for their coverage, some enrollees may have experienced a rate decrease when they switched to an ACA-compliant plan, even without a subsidy. That could be the case for a variety of populations:

  • If they already opted for a very comprehensive, low-deductible plan prior to 2014, they may have been able to find coverage in the exchanges that wasn’t significantly more expensive than what they paid prior to 2014.
  • If they had an underwriting rate-up on their pre-2014 plan, the new plans might have been a less-expensive alternative. Although the standard rates for ACA-compliant plans were higher than the pre-2014 base rates, there’s no additional charge for people with pre-existing conditions. Prior to 2014, that was not the case. People with pre-existing conditions were often charged rates that were at least 25 percent higher than the base rates, and sometimes 100 percent higher.
  • Older applicants get a better deal than they used to prior to 2014. Rates for older enrollees are limited to three times the rates for young enrollees under the ACA, which is a dramatic shift from the pre-ACA ratios that often ran as high as five to seven times as much for an older applicant.

Who’s paying more? Who’s paying less?

There are some people who are paying quite a bit more for their health insurance now that the ACA has been implemented: primarily enrollees who are younger, healthy, had plans with high out-of-pocket exposure prior to 2014 (potentially higher than the ACA now allows, like a $10,000 individual deductible, for example), and also have incomes high enough to make them ineligible for subsidies.

However, there are plenty of people who are ineligible for subsidies who don’t fall into those other categories. For them, there hasn’t been as much in the way of “rate shock” over the last few years, and they might have ended up with a better deal starting in 2014, even without accounting for subsidies.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post Did health insurance premiums go up or down for 2021? appeared first on healthinsurance.org.

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The federal exchange option

January 14, 2021

The federal health insurance marketplace (HealthCare.gov) opened for business in the fall of 2013, and has provided an affordable health insurance shopping platform for millions of Americans.  Admittedly, the federal exchange – along with many of the state-run exchanges – got off to a very rocky start in October 2013. But by December of that year, things were working better, and the exchange has been quite functional ever since.

In 2014, there were 191 health insurers selling policies on the federal exchange in 36 states (including states with partnership exchanges, as well as Idaho and New Mexico, both of which had federally supported state-based marketplaces in 2014). In September 2014, HHS issued a report on carrier participation for 2015, noting that the federally run exchange would have 57 additional insurers in 2015 – a 30 percent increase over the prior year. The number of participating carriers remained very stable in 2016; HHS reported that 238 carriers were offering plans across the states that use Healthcare.gov in 2016.

However, there was a widespread exodus of insurers leaving the exchanges nationwide for 2017 and again for 2018. By 2018, only 132 insurers were offering health plans through HealthCare.gov. But that trend then began to reverse itself, with insurers joining the marketplaces in many states for 2019, 2020, and 2021. As of 2021, there are 181 insurers offering plans through HealthCare.gov, despite the fact that the platform is now being used by only 36 states, after Pennsylvania and New Jersey transitioned to their own enrollment platforms in the fall of 2020.

During the open enrollment period for 2021 coverage — which ended in mid-December 2020 in states that use HealthCare.gov — more than 8.25 million people enrolled in plans through the federally-run exchange. Most of these enrollees receive premium subsidies that make their coverage much more affordable than it would otherwise be.

In addition, millions of people have enrolled in Medicaid through the federally run exchange, including many who are newly eligible due to Medicaid expansion (14 states have opted not to expand Medicaid however, and all of them are states that use the federally run exchange; Oklahoma and Missouri will both expand Medicaid in mid-2021).

Healthcare.gov does the heavy lifting

There are 24 states that have a fully federally run exchange (five of them provide plan oversight for the plans sold through the exchange: Kansas, Montana, Nebraska, Ohio, and South Dakota).

In addition, another six states (Delaware, Illinois, Iowa, Michigan, New Hampshire, and West Virginia) have established partnership exchanges, working together with the federal government to run the exchange. They use HealthCare.gov for enrollment, but the states also take on varying levels of plan management, consumer assistance, and outreach. The partnership states are counted together with the other 24 states, with all 30 states considered to be relying fully on the federally run exchange.

Some of the state-run exchanges also use HealthCare.gov for enrollment. Prior to the 2013 launch of the exchanges, some states wanted to operate their own exchange, but weren’t able to get an enrollment platform up and running in time. Idaho and New Mexico both opted to establish federally-supported state-based exchanges for 2014, meaning that while their exchanges were run by the state, they were using the Healthcare.gov enrollment platform, just like the states that rely fully on the federally run exchange.

Ultimately, Idaho was able to transition to running its own exchange by the time the second open enrollment period began in the fall of 2014. New Mexico opted to continue to use Healthcare.gov as a supported state-based marketplace, but plans to have its own website up and running by the fall of 2021.

As described here, there have been several changes to the approaches that states use in the ensuing years, and additional changes planned for the future. As of 2021, Arkansas, Kentucky, Oregon, New Mexico, Maine, and Virginia have state-run marketplaces but use the HealthCare.gov enrollment platform. Utilizing Healthcare.gov’s economies of scale and technologically smooth enrollment software simply proved to be a better choice than operating their own enrollment platform. But some of them are actively working towards running their own enrollment platforms in order to take advantage of the flexibility and control that provides.

All told – including states with partnership exchanges and federally supported state-based exchanges – Healthcare.gov is used in 36 states as of the 2021 plan year.

A changing carrier landscape

Prior to 2014, many people looking to buy individual health insurance had few options. A 2011 study by the Kaiser Foundation found that the individual insurance market was dominated by a single insurance company in 30 states and the District of Columbia.

The American Medical Association (AMA) also conducted a series of studies analyzing competition among health insurers, and found similar results. A 2012 AMA study determined that in nearly 40 percent of US metropolitan areas, a single insurance company had at least half of the market share. The same study also found that a single carrier had at least 30 percent of the market share in nearly nine out of ten U.S. markets.

Although 2014 ushered in a new era of guaranteed-issue individual health insurance – a dramatic change from the medically underwritten markets that existed in most states prior to 2014 – some states still had relatively few carriers offering coverage, particularly in the exchange.

In 2014, West Virginia and New Hampshire had only one participating exchange carrier, and several other states – Alabama, Wisconsin, North Carolina, Florida, Mississippi, and Arkansas – had only one carrier in at least a portion of the state (all eight of those states either rely fully on the federally run exchange, or have a partnership exchange model). In 2015, West Virginia still had just one carrier, although they gained a second carrier in 2016. New Hampshire now has three exchange carriers (although they had reached a high of five in 2015), and the other six states each gained at least one additional exchange carrier in 2015.

But carrier participation started to decline in 2016, and large swaths of the country had just one insurer offering coverage through the exchange by 2018. UnitedHealthcare, Humana, Aetna, Cigna, and Anthem all scaled back their exchange participation in 2017 or 2018.

Insurers started to join or rejoin the exchanges in 2019. By 2021, every state in the country (including those that use HealthCare.gov and those that run their own exchange platforms) had at least two participating insurers, although there are still some rural areas of some states where only one insurer offers plans in the marketplace (this brief from CMS shows how insurer participation changed in each county for 2021 in the states that use HealthCare.gov).

Long-term success

Healthcare.gov was created to fill a need when more than half the states decided that they didn’t want to run their own exchanges – either because they didn’t think it would be financially or technologically feasible, or because they were simply opposed to the ACA and didn’t want to participate in any activities that helped to implement the law.

But with eight years of enrollment in the books and many hurdles overcome, Healthcare.gov has proved to have staying power, and has also become a feasible solution for states that have run into problems with their own exchanges. In late 2013, the federal exchange’s glitchy website was the butt of many jokes and the cause of many headaches. But it has become an integral part of the individual health insurance market in two-thirds of the states. And while the Trump administration sharply reduced funding for HealthCare.gov’s outreach and enrollment support, the Biden administration could restore that funding.

The post The federal exchange option appeared first on healthinsurance.org.

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Avoid scams while shopping for insurance

January 9, 2021

It’s been more than seven years since the health insurance marketplaces (exchanges) first opened for business. Well over 11 million people have enrolled in plans through the exchanges for 2021, and some people also have ACA-compliant individual market coverage obtained outside the exchanges (directly from insurers). And thanks in large part to the ACA’s expansion of Medicaid, enrollment in Medicaid coverage has grown by nearly 20 million people since 2013 (there’s been a significant increase in Medicaid enrollment as a result of the COVID pandemic). And the uninsured rate is still in the single digits, despite the fact that it’s been rising during the Trump administration’s tenure, after dropping to a record low by 2016.

But while there’s plenty to celebrate, any major change like the ACA — especially with the subsequent decade of additional health care reform debate — comes with scammers who take advantage of the confusion that invariably surrounds a major policy shift. Here are some tips to keep in mind:

Scammers tap into confusion over ACA

The ACA was signed into law in 2010, and almost immediately, scammers began looking for ways to make a quick buck. Soon after the law passed, Jim Quiggle, spokesman for the Coalition Against Insurance Fraud, says he wasn’t surprised by the sudden influx of health insurance scams. “Crooks are exploiting the mass confusion over what the health reform means to the average consumer,” Quiggle said. “With each new aspect of reform, another opportunity for fraudulent marketing opens up.”

Quiggle explained that rip-off artists go door to door and use blast emails or pop-up ads to convince unsuspecting customers that they’re selling “ObamaCare.” And, to create a sense of urgency, the scammers tell potential scam victims that the law requires them to buy the insurance they’re selling and do it before an “enrollment period” closes.

It’s true that the ACA created an annual open enrollment period for individual market health insurance; outside of open enrollment, coverage can only be obtained if you have a qualifying event (prior to 2014, people could apply for individual health insurance whenever they liked, but the applications were then medically underwritten and could be rejected based on medical history). But again, buyer beware. If in doubt, double-check the facts with a third party to make sure you’re dealing with a legitimate source of coverage.

Marc Young, spokesman for Insurance Commissioner Kim Holland, co-chair of the National Association of Insurance Commissioners’ Anti-Fraud Task Force, explains that criminals sometimes cleverly mask themselves as insurance companies, selling plans that are completely fraudulent. “Unfortunately, the criminals provide all of the materials that legitimate companies provide,” Young says. “They’ll use the industry language to describe levels of coverage. They’ll issue authentic-looking insurance cards.”

Some companies will even set up storefronts in communities, selling policies and sticking around just long enough to file bogus claims – only to completely vanish into thin air overnight. These companies are “very deceptive, very misleading, with very professional looking materials,” Young says.

Again, it’s a good idea to double-check with your state’s department of insurance to make sure that the person and company you’re dealing with are both licensed to do business in your state.

Understand your state’s exchange

In addition to outright scams like identity theft, consumers need to be aware of the possibility that some agents might try to portray their agency as “the exchange” and attract customers who think they’re purchasing coverage through the official exchange. This is further complicated by the fact that licensed agents and brokers who are certified by their state’s exchange can help consumers enroll in exchange plans.

Individual policies can still be purchased outside of the exchanges. Like exchange plans, they are ACA-qualified which means they are guaranteed issue, cover the essential health benefits, and have the ACA’s limits on out-of-pocket maximums. Some are sold by carriers who also sell policies in the exchange, but some carriers only offer plans outside the exchange.

From a consumer perspective, the primary difference between exchange and non-exchange plans is the availability of subsidies. Premium subsidies and cost-sharing subsidies are only available on plans that are purchased through the exchange. Each state has just one official exchange where subsidies are available and in 36 states as of 2021, it’s Healthcare.gov.

If you’re in DC or one of the 14 states that run their own exchanges, you can still use Healthcare.gov to get to the exchange website in your state so that there’s no doubt you’re on the correct site. If a certified broker or agent assists you with your exchange plan application, you will still be submitting your application on the official exchange web site. If you’re submitting an application anywhere else, you’re applying for an off-exchange plan and subsidies will not be available.

It’s important to understand, however, that there are approved direct enrollment entities that are authorized to enroll people in on-exchange plans via their own websites, without having to use the actual exchange website. HealthSherpa is an example of this; they only enroll people in on-exchange plans, and enrolled 1.9 million of the 8.2 million people who signed up for plans through the federally-run marketplace (HealthCare.gov) for 2021. CMS has a list of entities that are approved to provide direct enrollment. But if you’re using one of them, you’ll still want to confirm that you’re enrolling in an on-exchange plan, if that’s your preference.

Know how the law affects you, or doesn’t

Another commonly misunderstood aspect of the ACA – and one that scammers have tried to target – is that the majority of Americans do not need to obtain health insurance through the exchanges.

Most Americans haven’t had to make any changes at all under the ACA. If you get your coverage through Medicare, Medicaid, or your employer, you do not need to worry about the exchanges at all.

[If you’re enrolling in Medicaid, you may be able to do so through the exchange, depending on why you’re eligible for Medicaid. For MAGI-based Medicaid (most enrollees under the age of 65), some states have switched their entire application system to run through the exchange, so check with your state Medicaid office if you have questions.]

In addition to being a portal for Medicaid enrollment, the exchanges were primarily designed to provide a shopping platform for people who purchase individual health insurance (and for small-business health plans if the employer chooses to obtain coverage through the SHOP exchange, which is still available in some states). This includes people who already had individual health insurance prior to 2014, as well as people who were previously uninsured and didn’t have access to a group plan through an employer. But nearly two-thirds of the population have either employer-sponsored coverage or Medicare — and can ignore the exchanges — while another 20 percent have Medicaid and may be able to ignore the exchange, depending on how their states have set up the enrollment and renewal process.

If you’re purchasing individual health insurance, the exchanges are likely the best option if you’re eligible for subsidies. If not, you can shop both in and out of the exchange to find the policy that best fits your needs and budget. Although the exchanges’ online comparison and enrollment features have been heavily publicized, applicants can also enroll by mail or in person. You can contact your state’s department of insurance to verify that the person, agency, or website you’re working with is certified with the state’s exchange.

If you’re shopping for an off-exchange plan, your state’s department of insurance can help you make sure you’re working with a properly licensed agent and buying a legitimate health insurance policy.

Watch out for fakes and frauds

Navigators and brokers will not charge you any sort of fee for their services (in a few states, brokers are allowed to charge fees if they’re not paid a commission by the insurer; but these fee-based brokers are rare and there are extensive rules regarding the disclosures they have to provide to their clients). The only money you need to pay is your first month’s premium, either when you enroll or once you get the invoice. If people are asking you for any additional fee, be wary of a scam.

Seniors who are enrolled in Medicare don’t need to do anything differently. They benefit from Obamacare, but don’t need to make any changes to their coverage and certainly don’t need to “enroll in Obamacare” or do anything with the exchanges.

If you enroll in a health plan, you’ll need to provide relatively extensive personal information, particularly if you’re applying for premium subsidies (and if you get a premium subsidy, you have to reconcile it on your tax return). There’s no legitimate way to enroll in just a minute or two with nothing more than a name and social security number, so be wary of potential scams in which the salesperson is attempting to gather some basic — but personal — information under the pretense of enrolling you in health coverage.

If the plan you’re enrolling in will take effect immediately, chances are it’s not an ACA-compliant plan. The same is true if it excludes pre-existing conditions or doesn’t cover some of the essential health benefits. Here’s more about how you can determine whether the plan you’re considering is compliant with the ACA.

Discount card scams leave consumers holding the bag

Some salespeople offer discount medical cards or “buyers clubs” – some of which legitimately provide discounts on certain expenses such as prescription drug costs and dental services through a network of providers. In some cases, however, unscrupulous marketers are overstating the size of those networks, or offering unbelievable discounts – “sometimes up to 85 percent off,” Quiggle says.

And, in some cases, consumers are being drawn into those plans on the false promise that the discount card programs will pay for major medical expenses. “We see cases where people are showing up at hospitals presenting their discount card because they think they have health insurance, only to be told they’ll have to pay for services out of pocket,” Quiggle says.

In other cases, consumers incur large medical expenses, then find out that “pre-authorized surgeries” or other large expenses won’t be reimbursed.

Discount plans have existed since long before the ACA was written. But since they’re not considered insurance, they’re not regulated under the ACA, which means that unless a state takes steps to limit them, they can still legally be sold. They don’t provide much in the way of benefits though, particularly in the case of a large claim.

What has changed as a result of Obamacare is the affordability of real health insurance for people with low- and mid-range incomes. Discount plans stood out in the past because of their price, which was far cheaper than real health insurance. But because of the ACA’s premium tax credits (subsidies), the average after-subsidy premium for the 86 percent of exchange enrollees who got a subsidy in 2020 was just $84/month.

Ignore exchange naysayers

It’s inevitable that there have been some unscrupulous people who attempt to sell worthless “insurance” under the guise of Obamacare. If a policy seems too good to be true, it probably is. If in doubt, contact your state’s department of insurance before you submit an application.

Consumers should also be aware that some groups have a vested interest in fighting against Obamacare. They are often politically motivated, and aren’t above spreading outright lies about the ACA in order to turn people against it. Focus on what’s best for you and your family, and ignore people who tell you to avoid the exchanges without having any knowledge of your specific situation.

There is no one-size-fits-all when it comes to healthcare, which is why there are a variety of plans available in the individual market, both in and out of the exchanges. Open enrollment for 2021 individual market coverage ended in most states in December 2020, but opportunities to enroll in ACA-compliant coverage are available year-round if you experience a qualifying event. If you do, take your time, compare all of the available plans, seek help from a reputable source, and be sure that you read the fine print on the plans you’re considering before you enroll.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post Avoid scams while shopping for insurance appeared first on healthinsurance.org.

https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png 512 512 wpmaddoxins https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.png wpmaddoxins2021-01-09 16:26:362021-01-24 00:51:58Avoid scams while shopping for insurance

Qualifying events that can get you coverage

January 6, 2021

Key takeaways

  • You’ll need to provide proof of your qualifying event in order to enroll in a new plan.
  • Learn more about the specific qualifying events in the individual market and the rules that apply to them.
  • Who doesn’t need a qualifying event?
  • Need coverage at the end of the year? A short-term plan might help to bridge the gap to January 1.

Open enrollment for health insurance plans in the individual market (on- and off-exchange) runs from November 1 to December 15 in most states. DC, California, and Colorado have extended open enrollment windows, and most of the other fully state-run exchanges generally extend their enrollment windows by at least a week each year.

Once open enrollment ends, ACA-compliant plans are only available to people who experience a qualifying event. The plans available outside of open enrollment without a qualifying event are not regulated by the ACA, and most are not a good choice to serve as stand-alone coverage (short-term health insurance is intended to serve as stand-alone coverage for a short period of time, but it’s much less robust than ACA-compliant coverage).

Qualifying events

Outside of open enrollment, you can still enroll in a new plan if you have a qualifying event that triggers your own special open enrollment (SEP) window.

People with employer-sponsored health insurance are used to both open enrollment windows and qualifying events. In the employer group market, plans have annual open enrollment times when members can make changes to their plans and eligible employees can enroll. Outside of that time frame, however, a qualifying event is required in order to enroll or change coverage.

In the individual market, this was never part of the equation prior to 2014 — people could apply for coverage anytime they wanted. But policies were not guaranteed issue, so pre-existing conditions meant that some people couldn’t get coverage or had to pay more for their policies.

All of that changed thanks to the ACA. Individual coverage is now quite similar to group coverage. As a result, the individual market now utilizes annual open enrollment windows and allows for special enrollment windows triggered by qualifying events.

So you could still have an opportunity to enroll in ACA-compliant coverage outside of the open enrollment window if you experience a qualifying event. Depending on the circumstances, you may have a special open enrollment period – generally 60 days but sometimes there’s an additional 60-day window before the event as well – during which you can enroll or switch to a different plan.

Got a qualifying event? You’ll need proof

It’s important to note that HHS began ramping up enforcement of special enrollment period eligibility in 2016, amid concerns that enforcement had previously been too lax.

In February 2016, HHS confirmed that they would begin requiring proof of eligibility in order to grant special enrollment periods triggered by birth/adoption/placement for adoption, a permanent move, loss of other coverage, and marriage (together, these account for three-quarters of all qualifying events in Healthcare.gov states).

The new SEP eligibility verification process was implemented in June 2016. In September 2016, HHS answered several frequently asked questions regarding the verification process for qualifying events, and noted that SEP enrollments since June were down about 15 percent below where they had been during the same time period in 2015 (after staying roughly even with 2015 numbers in the months prior to the implementation of the new eligibility verification process).

But HHS stopped short of issuing an explanation for the decline: it could be that people were previously enrolling who didn’t actually have a qualifying event, but it could also be that the process for enrolling had become more cumbersome due to the added verification step, deterring healthy enrollees from signing up. The vast majority of people who are eligible for SEPs do not enroll in coverage during the SEP, and this could simply have been heightened by the new eligibility verification process.

Nevertheless, the eligibility verification process was further stepped-up in 2017, thanks to “market stabilization” rules that HHS finalized in April 2017.

Starting in June 2017, HHS was planning to implement a pilot program to further enhance SEP eligibility verification (this plan was created by HHS under the Obama Administration). Fifty percent of SEP enrollees were to be randomly selected for the pilot program, and their enrollments would be pended until their verification documents were submitted. They’d have 30 days to submit their proof of SEP eligibility, and as long as they did so, their policy would be effective as of the date determined by the date of their application/plan selection (so for example, a person could enroll on July 10 for an August 1 effective date, but the enrollment would then be pended. If the applicant submitted proof of SEP eligibility on August 5, the enrollment would be completed, with coverage effective August 1).

Under the new rules finalized in April 2017, however, that SEP eligibility verification process began to apply to 100 percent of SEP applications, starting in June 2017. So if you’re planning to enroll in a HealthCare.gov plan outside of open enrollment, be prepared to provide proof of your qualifying event when you apply. Most of the state-run exchanges have followed suit, and HHS has proposed a requirement that state-run exchanges conduct SEP eligibility verification for at least 75 percent of all SEP applications by 2022.

The SEP verification program has generated controversy, with some consumer advocates noting that it could further deter healthy people from enrolling when they’re eligible for a SEP. At Health Affairs, Tim Jost suggested some alternative solutions, including a requirement that insurance carriers pay broker commissions for SEP enrollments in order to incentivize brokers to help more people enroll (at that point, insurers were increasingly paying no commissions for SEP enrollments, although many have started doing so in more recent years), and a requirement that group health plans provide certificates of creditable coverage to people losing their group coverage (this used to be required, but isn’t any longer; reinstating a requirement that the certificates be issued would make it easier for people to easily prove that they had lost coverage and had thus become eligible for a SEP).

But as a general rule, be prepared to provide proof of your qualifying event when you enroll.

Off-exchange special enrollment periods

Note that most qualifying events apply both inside and outside the exchanges. There are a few exceptions, however. For policies sold outside the exchanges, there are a few qualifying events that HHS does not require carriers to accept as triggers for special enrollment periods (however, the carriers can accept them if they wish). These include gaining citizenship or a lawful presence in the US or being a Native American (within the exchanges, Native Americans can make plan changes as often as once per month, and enrollment runs year-round).

In addition, when exchanges grant special enrollment periods based on “exceptional circumstances” those special enrollment periods apply within the exchanges; off-exchange, it’s up to the carriers as to whether or not they want to implement similar special enrollment periods.

And carriers tend to have fairly strict rules regarding proof of SEP eligibility. If you’re enrolling directly with an insurer, outside of open enrollment, you will need to provide proof of your qualifying event (the insurer will let you know what will count as acceptable documentation; these same documentation requirements are generally enforced for on-exchange enrollments as well).

What counts as a qualifying event?

Although special enrollment period windows are generally longer in the individual market, many of the same life events count as a qualifying event for employer-based plans and individual market plans. But some are specific to the individual market under Obamacare. [For reference, special enrollment period rules for employer-sponsored plans are detailed here; for individual market plans, they’re detailed here and described in more detail below and in our guide to special enrollment periods.]

When will coverage take effect if I enroll during a special enrollment period?

For most qualifying events, in states using HealthCare.gov and some of the state-run exchanges, applications completed by the 15th of the month will be given a first-of-the-following-month effective date.

Massachusetts and Rhode Island both allow enrollees to sign up as late as the 23rd of the month and have coverage effective the first of the following month.

Applications received from the 16th (or the 24th if you’re in MA or RI) to the end of the month will have an effective date of the first of the second following month. (Marriage, loss of other coverage, and birth/adoption have special effective date rules, described below.)

Starting in 2022, the federally-run marketplace (HealthCare.gov, which is used in 36 states as of 2021) will eliminate the requirement that applications be submitted by the 15th of the month in order to get coverage the first of the following month. For all special enrollment periods, coverage will simply take effect the first of the month after the application is submitted. States will have the option to require this of off-exchange insurers, and fully state-run exchanges will also have the option to switch all of their special enrollment periods to first-of-the-following-month effective dates, regardless of when the application is submitted.

Note that in early 2016, HHS eliminated some little-used special enrollment periods that were no longer necessary. For example, the special enrollment period that had previously been available for people whose Pre-Existing Conditions Health Insurance Program (PCIP) had ended; coverage under those plans ended in 2014; but there’s still a special enrollment period for anyone whose minimum essential coverage ends involuntarily).

12 special open enrollment triggers

The qualifying events that trigger special enrollment periods are discussed in more detail in our extensive guide devoted to qualifying events and special enrollment periods. But here’s a summary:

[Note that in most cases, the market stabilization regulations now prevent enrollees from using a special enrollment period to move up to a higher metal level of coverage; so if you have a bronze plan and move to a new area mid-year, for example, you would not be allowed to purchase a gold plan during your special enrollment period.]

Involuntary loss of other coverage

The coverage you’re losing has to be minimum essential coverage, and the loss has to be involuntary. Cancelling the plan or failing to pay the premiums does not count as involuntary loss, but voluntarily leaving a job and thus losing employer-sponsored health coverage does count as an involuntary loss of coverage. In most cases, loss of coverage that isn’t minimum essential coverage does not trigger a special open enrollment.

[There is an exception for pregnancy Medicaid, CHIP unborn child, and Medically Needy Medicaid: These types of coverage are not minimum essential coverage, but people who lose coverage under these plans do qualify for a special enrollment period (this includes a woman who has CHIP unborn child coverage for her baby during pregnancy, but no additional coverage for herself; she will qualify for a loss of coverage SEP for herself when the unborn child CHIP coverage ends). And although they are not technically considered minimum essential coverage, they do count as minimum essential prior coverage in the case of special enrollment periods that require a person to have previously had coverage (this is a requirement for most special enrollment periods).]

Your special open enrollment begins 60 days before the termination date, so it’s possible to get a new ACA-compliant plan with no gap in coverage, as long as your prior plan doesn’t end mid-month. (See details in Section (d)(6)(iii) the code of federal regulations 155.420, and the updated regulation that makes advance open enrollment possible for people with individual coverage as well as employer-sponsored coverage.) You also have 60 days after your plan ends during which you can select a new ACA-compliant plan.

If you enroll prior to the loss of coverage, the effective date is the first of the month following the loss of coverage, regardless of the date you enroll (ie, if your plan is ending June 30, you can enroll anytime in May or June and your new plan will be effective July 1). But if you enroll in the 60 days after your plan ends, the exchange can either allow a first-of-the-following-month effective date regardless of the date you enroll, or they can use their normal deadline, which is typically the 15th of the month in order to get a plan effective the first of the following month.

As noted above, starting in 2022, the federally-run marketplace (HealthCare.gov) will eliminate the requirement that enrollments be submitted by the 15th of the month to have coverage effective the first of the following month. So as of 2022, a person who loses coverage and enrolls in a new plan after the coverage loss will simply have coverage effective the first of the month after the enrollment is submitted.

Individual plan renewing outside of the regular open enrollment

HHS issued a regulation in late May 2014 that included a provision to allow a special open enrollment for people whose health plan is renewing — but not terminating — outside of regular open enrollment. Although ACA-compliant plans run on a calendar-year schedule, that is not always the case for grandmothered and grandfathered plans, nor is it always the case for employer-sponsored plans.

Insureds with these plans may accept the renewal but are not obligated to do so. Instead, they can select a new ACA-compliant plan during the 60 days prior to the renewal date and 60 days following the renewal date. Initially, this special enrollment period was intended to be used only in 2014, but in February 2015 HHS issued a final regulation that confirms this special enrollment period would be on-going. So it continues to apply to people who have grandfathered or grandmothered plans that renew outside of open enrollment each year. And HHS also confirmed that this SEP applies to people who have a non-calendar year group plan that’s renewing; they can keep that plan or switch to an individual market plan using an SEP. [Note that if the employer-sponsored plan is considered affordable and provides minimum value, the applicant is not eligible for premium subsidies in the exchange.]

Becoming a dependent or gaining a dependent

Becoming or gaining a dependent (as a result or birth, adoption, or placement in foster care) is a qualifying event. Coverage is back-dated to the date of birth, adoption, or placement in foster care (subsequent regulations also allow parents the option to select a later effective date). Because of the special rules regarding effective dates, it’s wise to use a special enrollment period in this case, even if the child is born or adopted during the general open enrollment period.

The current regulation states that anyone who “gains a dependent or becomes a dependent” is eligible for a special open enrollment window, which obviously includes both the parents and the new baby or newly adopted or fostered child. But HealthCare.gov accepts applications for the entire family (including siblings) during the special open enrollment window.

The market stabilization rule that HHS finalized in April 2017 added some new restrictions to this SEP: If a new parent is already enrolled in a QHP, he or she can add the baby/adopted child to the plan (or enroll with the new dependent in a plan at the same metal level, if for some reason the child cannot be added to the plan). Alternatively, the child can be enrolled on its own into any available plan. But the SEP cannot be used as an opportunity for the parent to switch plans and enroll in a new plan with the child. New rules issued in 2018 clarify that existing dependents do not have an independent SEP to enroll in new coverage separately from the person gaining a dependent or becoming a dependent. But they do state that an individual who gains a dependent “may enroll in or change coverage along with his or her dependents, including the newly-gained dependent(s) and any existing dependents.” That would seem to indicate that a new parent who already has individual market coverage does have the option to switch to a different plan using the SEP. As is the case with other SEPs, if you live in a state that is running its own exchange, check with your exchange to see how they have interpreted the regulations.

Marriage

If you get married, you have a 60-day open enrollment window that begins on your wedding day. However, rules issued in 2017 limit this special enrollment period somewhat. At least one partner must have had minimum essential coverage (or lived outside the U.S. or in a U.S. Territory) for at least one of the 60 days prior to the marriage. In other words, you cannot use marriage to gain coverage if neither of you had coverage before getting married.
Assuming you’re eligible for a special enrollment period (which includes providing proof of marriage), your policy will be effective the first of the month following your application, regardless of what date you complete your enrollment. Since marriage triggers a special effective date rule, it might make sense to use your special enrollment period if you get married during the general open enrollment period. For example, if you get married on November 27, you can select a new plan that day (or up until the 30th) and have coverage effective December 1 if you use your special enrollment period triggered by your marriage. But if you enroll under the general open enrollment period, your new coverage won’t be effective until January 1.

Divorce

If you lose your existing health insurance because of a divorce, you qualify for a special open enrollment based on the loss of coverage rule discussed above.
If a court orders a parent to obtain health insurance as part of a custody agreement, the exchange must allow the parent the option to backdate the coverage to the date the court order was issued, although the parent can also opt for the normal effective dates described above.
Exchanges also have the option of granting a special enrollment period for people who lose a dependent or lose dependent status as a result of a divorce or death, even if coverage is not lost as a result. This special enrollment period was due to become mandatory in all exchanges as of January 2017, but HHS removed that requirement in May 2016, so it’s still optional for the exchanges. In most states, including the 36 states that use HealthCare.gov, divorce without an accompanying loss of coverage generally does not trigger a special enrollment period.

Becoming a United States citizen or lawfully present resident

This qualifying event only applies within the exchanges — carriers selling coverage off-exchange are not required to offer a special enrollment period for people who gain citizenship or lawful presence in the US.
There are special rules that allow recent immigrants to qualify for premium subsidies in the exchange even with an income below the poverty level, since they aren’t eligible for Medicaid until they’ve been in the US for at least five years.

A permanent move

This special enrollment period applies as long as you move to an area where different qualified health plans (QHPs) are available. This special enrollment period is only available to applicants who already had minimum essential coverage in force for at least one of the 60 days prior to the move (with exceptions for people moving back to the US from abroad, newly released from incarceration, or previously in the coverage gap in a state that did not expand Medicaid; there’s also an exemption for people who move from an area where there were no plans available in the exchange, although there have never been any areas without exchange plans).

For people who meet the prior coverage requirement, a permanent move to a new state will always trigger a special open enrollment period, because each state has its own health plans. But even a move within a state can be a qualifying event, as some states have QHPs that are only offered in certain regions of the state. So if you move to a part of the state that has plans that were not available in your old area, or if the plan you had before is not available in your new area, you’ll qualify for a special open enrollment period, assuming you had coverage prior to your move.

HHS finalized a provision in February 2015 that allows people advance access to a special enrollment period starting 60 days prior to a move, but this is optional for the exchanges. It was originally scheduled to be mandatory starting in January 2017 (ie, that exchanges would have to offer a special enrollment period in advance of a move), but HHS removed that deadline in May 2016, making it permanently optional for exchanges to allow people to report an impending move and enroll in a new health plan. If the exchange in your state offers that option, you can enroll in a new health plan on or before the date of your move and the new plan will be effective the first of the following month. If you enroll during the 60 days following the move, the effective date will follow the normal rules outlined above (ie, in most states, enrollments submitted by the 15th of the month will have first of the following month effective dates, although HealthCare.gov will remove this deadline as of 2022).

In early 2016, HHS clarified that moving to a hospital in another area for medical treatment does not constitute a permanent move, and would not make a person eligible for a special enrollment period. And a temporary move to a new location also does not trigger a special enrollment period. However, a person who has homes in more than one state (for example, a “snowbird” early retiree) can establish residency in both states, and can switch policies to coincide with a move between homes (HHS has noted that this person might be better served by a plan with a nationwide network in order to avoid resetting deductibles mid-year, but such plans are not available in many areas).

An error or problem with enrollment

If the enrollment error (or lack of enrollment, as the case may be) was the fault of the exchange, HHS, or an enrollment assister, a special enrollment period can be granted. In this case, the exchange can properly enroll the person (or allow them to change plans) outside of open enrollment in order to remedy the problem.

Employer-sponsored plan becomes unaffordable or stops providing minimum value

An employer-sponsored plan is considered affordable in 2021 as long the employee isn’t required to pay more than 9.83 percent of household income for just the employee’s portion of the coverage. And a plan provides minimum value as long as it covers at least 60 percent of expected costs for a standard population and also provides substantial coverage for inpatient and physician services.

A plan design change could result in a plan no longer providing minimum value. And there are a variety of situations that could result in a plan no longer being affordable, including a reduction in work hours (with the resulting pay cut meaning that the employee’s insurance takes up a larger share of their household income) or an increase in the premiums that the employee has to pay for their coverage.

In either scenario, a special enrollment period is available, during which the person can switch to an individual market plan instead. And premium subsidies are available in the exchange if the person’s employer-sponsored coverage doesn’t provide minimum value and/or isn’t affordable.

An income increase that moves you out of the coverage gap

There are 13 states where there is still a Medicaid coverage gap, and an estimated 2.3 million people are unable to access affordable health coverage as a result. (Wisconsin has not expanded Medicaid under the ACA, but does not have a coverage gap; Oklahoma and Missouri will expand Medicaid in mid-2021 and will no longer have coverage gaps at that point).

For people in the coverage gap, enrollment in full-price coverage is generally an unrealistic option. HHS recognized that, and allows a special enrollment period for these individuals if their income increases during the year to a level that makes them eligible for premium subsidies (ie, to at least the poverty level).

As mentioned above, the new market stabilization rules only allow a special enrollment period triggered by marriage if at least one partner already had minimum essential coverage before getting married. However, if two people in the coverage gap get married, their combined income may put their household above the poverty level, making them eligible for premium subsidies. In that case, they would have access to a special enrollment period despite the fact that neither of them had coverage prior to getting married.

Gaining access to a QSEHRA or Individual Coverage HRA

This is a new special enrollment period that became available in 2020, under the terms of the Trump Administrations’s new rules for health reimbursement arrangements that reimburse employees for individual market coverage. QSEHRAs became available in 2017 (as part of the 21st Century Cures Act) and allow small employers to reimburse employees for the cost of individual market coverage (up to limits imposed by the IRS). But prior to 2020, there was no special enrollment period for people who gained access to a QSEHRA.

As of 2020, the Trump administration’s new guidelines allow employers of any size to reimburse employees for the cost of individual market coverage. And the new rules also add a special enrollment period — listed at 45 CFR 155.420(d)(14) — for people who become eligible for a QSEHRA benefit or an Individual Coverage HRA benefit.

This includes people who are newly eligible for the benefit, as well as people who were offered the option in prior years but either didn’t take it or took it temporarily. In other words, anyone who is transitioning to QSEHRA or Individual Coverage HRA benefits — regardless of their prior coverage — has access to a special enrollment period during which they can select an individual market plan (or switch from their existing individual market plan to a different one), on-exchange or outside the exchange.

This special enrollment period is available starting 60 days before the QSEHRA or Individual Coverage HRA benefit takes effect, in order to allow people time to enroll in an individual market plan that will be effective on the day that the QSEHRA or Individual Coverage HRA takes effect.

An income or circumstance change that makes you newly eligible (or ineligible) for subsidies or CSR

If your income or circumstances change such that you become newly eligible or newly ineligible for premium tax credits or newly-eligible for cost-sharing subsidies, you’ll have an opportunity to switch plans. This rule already existed for people who were already enrolled in a plan through the exchange (and as noted above, for people in states that have not expanded Medicaid who experience a change in income that makes them eligible for subsidies in the exchange — even if they weren’t enrolled in any coverage at all prior to their income change).

But in the 2020 Benefit and Payment Parameters, HHS finalized a proposal to expand this special enrollment period to include people who are enrolled in off-exchange coverage (ie, without any subsidies, since subsidies aren’t available off-exchange), and who experience an income change that makes them newly-eligible for premium subsidies or cost-sharing subsidies.

This special enrollment period was added at 45 CFR 155.420(d)(6)(v), although it is optional for state-run exchanges. HealthCare.gov planned to make it available as of 2020, although there have been numerous reports from enrollment assisters indicating that it’s still difficult to access as of mid-2020. This is an important addition to the special enrollment period rules, particularly given the “silver switch” approach that many states have taken with regards to the loss of federal funding for cost-sharing reductions (CSR). In 2018 and 2019, people who opted for lower-cost off-exchange silver plans (that didn’t include the cost of CSR in their premiums) were stuck with those plans throughout the year, even if their income changed mid-year to a level that would have been subsidy-eligible. That’s because an income change was not a qualifying event unless you were already enrolled in a plan through the exchange (or moving out of the Medicaid coverage gap). But that will change in 2020 in states that use HealthCare.gov, and in states with state-run exchanges that opt to implement this special enrollment period.

[It’s important to keep in mind, however, that a mid-year plan change will result in deductibles and out-of-pocket maximums resetting to $0, so this may or may not be a worthwhile change, depending on the circumstances.]

As of 2022, there will also be a special enrollment period for exchange enrollees with silver plans who have cost-sharing reductions and then experience a change in income or circumstances that make them newly ineligible for cost-sharing subsidies. This will allow people in this situation to switch to a plan at a different metal level, as the current rules limit them to picking only from among the other available silver plans.

For people already enrolled in the exchange, SEP applies if the plan substantially violates its contract

A special enrollment period is available in the exchange (only for people who are already enrolled through the exchange) if the insured is enrolled in a QHP that “substantially violated a material provision of its contract in relation to the enrollee.” This does not mean that enrollees can switch to a new plan simply because their existing carrier has done something they didn’t like – it has to be a “substantial violation” and there’s an official channel through which such claims need to proceed. It’s noteworthy that a mid-year change in the provider network or drug formulary (covered drug list) does not constitute a material violation of the contract, so enrollees are not afforded a SEP if that happens.

Who doesn’t need a qualifying event?

In some circumstances, enrollment is available year-round, without a need for a qualifying event:

  • Native Americans/Alaska Natives – as defined by the Indian Health Care Improvement Act – can enroll anytime during the year. Enrollment by the 15th of the month (or a later date set by a state-run exchange) will result in an effective date of the first of the following month. Native Americans/Alaska Natives may also switch from one QHP to another up to once per month (the special enrollment periods for Native Americans/Alaska Natives only apply within the exchanges – carriers selling off-exchange plans do not have to offer a monthly special enrollment period for American Indians).
  • Medicaid and CHIP enrollment are also year-round. For people who are near the threshold where Medicaid eligibility ends and exchange subsidy eligibility begins, there may be some “churning” during the year, when slight income fluctuations result in a change in eligibility.

    If income increases above the Medicaid eligibility threshold, there’s a special open enrollment window triggered by loss of other coverage. Unfortunately, in states that have not expanded Medicaid, the transition between Medicaid and QHPs in the exchange is nowhere near as seamless as lawmakers intended it to be.

  • Employers can select SHOP plans (or small group plans sold outside the exchange) year-round. But employees on those plans will have the same sort of annual open enrollment windows that applies to any employer group plans.

Need coverage at the end of the year?

If you find yourself without health insurance towards the end of the year, you might want to consider a short-term policy instead of an ACA-compliant policy. There are pros and cons to short-term insurance, and it’s not the right choice for everyone. But for some, it’s an affordable solution to a temporary problem.

Short-term insurance doesn’t cover pre-existing conditions, so it’s really only an appropriate solution for healthy applicants. And for applicants who qualify for premium subsidies in the exchange, an ACA-compliant plan is also likely to be the best value, since there are no subsidies available to offset the cost of short-term insurance.

But if you’re healthy, don’t qualify for premium subsidies, and you find yourself without coverage for a month or two at the end of the year, a short-term plan is worth considering. You can enroll in a short-term plan for the remainder of the year, and sign up for ACA-compliant coverage during open enrollment with an effective date of January 1. The temporary health plan would certainly be better than going without coverage for the last several weeks of the year, and it would be considerably less expensive than an ACA-compliant plan for people who don’t get premium subsidies.

So for example, if your employer-sponsored coverage ends in October and you want to use a short-term plan to bridge the gap to January, that may be a good option. Be aware, however, that it may not be a good idea to drop your ACA-compliant plan and switch to a short-term plan at the end of the year, particularly if you’re in an area with limited availability of ACA-compliant plans. The market stabilization rules allow insurers to require applicants to pay any past-due premiums from the previous 12 months before being allowed to enroll in new coverage. If you receive premium subsidies and you stop paying your premiums, your insurer will ultimately terminate your plan, but the termination date will be a month after you stopped paying premiums (if you don’t get premium subsidies, your plan will terminate to the date you stopped paying for your coverage). In that case, you essentially got a month of free coverage, and the insurer is allowed to require you to pay that month’s premiums before allowing you to sign up for any of their plans during open enrollment.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post Qualifying events that can get you coverage appeared first on healthinsurance.org.

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The Scoop: health insurance news – November 18, 2020

November 18, 2020

In this edition

  • Early open enrollment data indicate individual-market enrollment is trending higher than last year
  • Trump administration relaxes Medicaid rules for additional COVID funding
  • Healthcare emerges as key battle issue in Georgia run-off
  • HRSA proposes ACA plans cover no-cost counseling aimed at preventing obesity in women age 40-60

Early open enrollment data indicate individual-market enrollment is trending higher than last year

Open enrollment for individual/family health insurance has been underway nationwide since the start of November. It continues for nearly another month – through December 15 in most states – although the state-run exchanges in Washington, DC and ten states have extended enrollment deadlines.

open enrollment 2021

Our 2021 Open Enrollment Guide: Everything you need to know to enroll in an affordable individual-market health plan.

As of November 7, total enrollment via HealthCare.gov (the exchange in 36 states) had reached 818,635. As Charles Gaba explains here, the daily enrollment pace is trending about 20 percent higher than last year, although we obviously only have a short segment of data thus far.
CMS typically publishes weekly enrollment data throughout the open enrollment period. The state-run exchanges tend to have more sporadic updates on their enrollment progress, but some have started to publicize data:

  • Connecticut’s exchange reported 2,696 new enrollees as of November 13.
  • Washington’s exchange reported more than 6,000 new enrollees as of November 16. Enrollment in Washington is trending about 4 percent higher than this time last year, and more than a third of the new enrollees have selected one of the new Cascade Care plans that Washington rolled out this fall.
  • Pennsylvania’s brand-new exchange reported that 7,965 new enrollees had signed up for 2021 coverage as of November 15. Another 13,258 existing enrollees in Pennsylvania had actively renewed their coverage (or switched to a different plan for 2021).

All three states also have tens of thousands of current enrollees whose coverage will be auto-renewed if they don’t select a new plan for 2021.
Got questions about open enrollment? Our comprehensive guide has answers. And Kaiser Family Foundation has an excellent overview of why this year’s open enrollment period is so important, written by Cynthia Cox, Karen Pollitz, and Daniel McDermott.

Trump administration relaxes Medicaid rules for additional COVID funding

Earlier this month, the Trump administration published an interim final rule to update earlier rulemaking related to the COVID pandemic. The new rules took effect immediately, but public comments are being accepted through January 4.
We’ve covered this in more detail here, but the takeaway point is that the new rule allows states to reduce Medicaid benefits during the COVID pandemic (within certain constraints) without losing the additional federal Medicaid funding that states have been receiving as a result of the pandemic. Families USA, a consumer advocacy group, has criticized the fact that this new rule will allow states to reduce Medicaid benefits in the midst of a global health crisis.
States are still not allowed to make their Medicaid eligibility requirements any more strict than they were at the start of 2020, so Medicaid work requirements would still be a no-go for states receiving the additional federal Medicaid funding. There are several states where Medicaid work requirements have been approved but are not yet in effect. For the time being, this will continue to be the case.

Healthcare emerges as key battle issue in Georgia run-off

Sen. Kelly Loeffler, R-Georgia, is campaigning to keep her Senate seat during a runoff election scheduled for January 5, and healthcare has emerged as a key issue in the race. Loeffler has long expressed opposition to the Affordable Care Act, while her Democratic opponent, Raphael Warnock, has called for the ACA to be strengthened and improved, supports a public option, and has long pushed for Georgia to accept federal funding to expand access to Medicaid under the ACA.
Last week, Loeffler unveiled her own healthcare reform proposal, which is a compilation of various pieces of legislation that she has sponsored or co-sponsored, as well as several additional ideas.
Loeffler’s proposal states that it would “ensure Americans with pre-existing conditions are protected,” but gives few details about how that would be accomplished. She calls for the expansion of health savings accounts and a “one-time federal tax credit toward HSA contributions for low-income families with pre-existing conditions,” but does not clarify how big that tax credit would be, or exactly how eligibility for it would be determined. The proposal also calls for the creation of “Guaranteed Coverage Plans to help cover patients with pre-existing conditions,” but does not provide any details on how such plans would work.
Loeffler’s proposal also calls for the passage of a bill she introduced last spring, which would codify the Trump administration’s relaxed rules for short-term health plans into federal law. In nearly all cases, short-term health plans do not provide coverage for pre-existing health conditions.

HRSA proposes ACA plans cover no-cost counseling aimed at preventing obesity in women age 40-60

Under the Affordable Care Act, all non-grandfathered health insurance plans are required to cover a wide range of preventive services with no cost-sharing (ie, no deductible, copay, or coinsurance). This includes services for all adults, as well as services that are specific to children and to women.
The Health Resources and Services Administration – responsible for determining which benefits must be provided at no cost to women – is currently collecting public feedback on its recommendation to add coverage for counseling aimed at preventing obesity in women age 40-60. The proposed recommendation calls for this counseling service to be added to the women’s preventive health care guidelines – meaning that non-grandfathered health plans would have to cover it without any cost-sharing. The counseling would be provided to women with both normal-weight and overweight women, with an aim of helping them maintain their body weight or prevent future weight gain.
If the recommendation is adopted by HRSA, non-grandfathered health plans would have to start covering the no-cost obesity prevention counseling. But there’s a one-year delay, as new preventive care rules take effect for plan years that start on or after one year after a recommendation is issued. Comments on the new recommendation can be submitted here, through December 9, 2020.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post The Scoop: health insurance news – November 18, 2020 appeared first on healthinsurance.org.

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