Subsidy availability drives consumers to shop for health insurance

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A major premise of the Affordable Care Act (ACA) was that Americans who need to buy their own health coverage in the individual market should be able to obtain coverage – regardless of their medical history – and that the monthly premiums should be affordable.

The rules to facilitate those goals have been in place for several years now. And although they have worked quite well for some Americans, there have been others for whom ACA-compliant health coverage was still unaffordable.

But the American Rescue Plan, enacted earlier this year, has boosted the ACA’s subsidies, making truly affordable coverage much more available than it used to be.

The numbers speak for themselves: Exchange enrollment has likely reached a record high of nearly 13 million people in 2021, after more than 2.5 million people enrolled during the COVID/American Rescue Plan enrollment window, which ended this month in most states.

How much are consumers saving on health insurance premiums?

And the amount that people are paying for their coverage and care is quite a bit lower than it was before the APR’s subsidy enhancements. We can see this across the states that use the federally run exchange (HealthCare.gov), as well as the states that run their own exchanges:

  • Among the people who enrolled during the recent special enrollment period in the 36 states that use HealthCare.gov, average after-subsidy premiums were 27% lower than the amounts people were paying pre-ARP.
  • Among HealthCare.gov enrollees who signed up during the special enrollment period or who updated their enrollments to claim the enhanced subsidies, 35% are now paying less than $10/month for their coverage.
  • Average deductibles for new HealthCare.gov enrollees were 90% lower than pre-ARP deductibles, likely driven in large part by the number of people who were able to enroll in free or low-cost Silver plans with built-in cost-sharing reductions. (This includes people receiving unemployment compensation in 2021, as well as people who aren’t eligible for Medicaid and whose household income is between 100% and 150% of the federal poverty level.)
  • The state-run exchange in Washington reported that 78% of their enrollees are now receiving premium subsidies, versus 61% before the ARP was implemented. And consumers with income above 400% of the poverty level, who were not eligible for subsidies pre-ARP, are now paying an average of $200 less in premiums each month. Washington’s exchange also noted that 15% of their enrollees are now paying $1/month or less for their coverage, versus only 5% whose premiums were that low pre-ARP.
  • The state-run exchange in California reported that consumers with household incomes between 400% and 600% of the poverty level are saving an average of almost $800/month on their premiums. (That’s an individual with income up to about $76,000, or a household of four with an income up to about $157,000.)
  • The state-run exchange in Nevada reported that people who enrolled or updated their account since the ARP was implemented are paying an average of $154/month in after-subsidy premiums, whereas the after after-subsidy premium at the end of last winter’s open enrollment period (pre-ARP) was $232/month.
  • Maryland’s state-run exchange reported a 12% increase in the number of enrollees receiving subsidies; more than 80% of Maryland’s current exchange enrollees are subsidy-eligible.

These examples highlight the improved affordability that the ARP has brought to the health insurance marketplaces. People who were already eligible for subsidies are now eligible for larger subsidies. And many of the people who were previously ineligible for subsidies — but potentially facing very unaffordable health insurance premiums — are benefiting from the ARP’s elimination of the income cap for subsidy eligibility.

How long will the ARP’s subsidy boost last?

Although the ARP’s subsidies for people receiving unemployment compensation in 2021 are only available until the end of this year, the rest of the ARP’s premium subsidy enhancements will continue to be available throughout 2022 — and perhaps longer, if Congress extends them.

This means that the affordability gains we’ve seen this year will be available during the upcoming open enrollment period, when people are comparing their plan options for 2022.

Robust ACA-compliant coverage will continue to be a more realistic option for more people, reducing the need for alternative coverage options such as short-term plans, fixed indemnity plans, and health care sharing ministry plans.

Even catastrophic plans – which are ACA-compliant but not compatible with premium subsidies – are likely to see reduced enrollment over the next year, since more people are eligible for enhanced subsidies that make metal-level plans more affordable.

Can everyone find affordable health insurance now?

Unfortunately, not yet. There are still affordability challenges facing some Americans who need to obtain their own health coverage. That includes more than two million people caught in the “coverage gap” in 11 states that have refused to expand eligibility for Medicaid, as well as about 5 million people affected by the ACA’s “family glitch.”

There are strategies for avoiding the coverage gap if you’re in a state that hasn’t expanded Medicaid, and Congressional lawmakers are also considering the possibility of a federally-run health program to cover people in the coverage gap.

Families affected by the family glitch have access to an employer-sponsored plan that’s affordable for the employee but not for the whole family – and yet the family is also ineligible for subsidies in the marketplace/exchange. (It’s possible that the Biden administration could tackle this issue administratively in future rulemaking.)

Have ARP’s subsidy boosts been successful?

With the exception of those two obstacles, the ARP has succeeded in making affordable health coverage a more realistic option for most Americans who need to obtain their own health coverage. We can see success in the record-high exchange enrollment, the increased percentage of enrollees who are subsidy-eligible, and the reduction in after-subsidy premiums that people are paying.

If you’re currently uninsured or covered by a non-ACA-compliant plan (including a grandfathered or grandmothered plan), it’s in your best interest to take a moment to see what your options are in the ACA-compliant market. Open enrollment for 2022 coverage starts in just two months, but you may also find that you can still enroll in a plan for the rest of 2021 if you live in a state where a COVID/American Rescue Plan enrollment window is ongoing, or if you’ve experienced a qualifying event recently (examples include loss of employer-sponsored insurance, marriage, or the birth or adoption of a child).

Even if you shopped just last winter, during open enrollment for 2021 plans, you might be surprised at the difference between the premiums you would have paid then and now. The ARP wasn’t yet in effect during the last open enrollment period, so if you weren’t eligible for a subsidy last time you looked, or if the plans still seemed too expensive even with a subsidy, you’ll want to check again this fall.

The subsidies for 2022 will continue to be larger and more widely available than they’ve been in the past, and you owe it to yourself to see what’s available in your area.

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.

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Lost your job? Here’s how to keep your health insurance or find new coverage now.

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Most Americans under the age of 65 get their health insurance from an employer. This makes life fairly simple as long as you have a job that provides solid health benefits: All you need to do is enroll when you’re eligible, and if your employer offers a few options from which to choose, pick the one that best fits your needs each year during your employer’s annual enrollment period.

But the downside to having health insurance linked to employment is that losing your job will also mean losing your health insurance, adding stress to an already stressful situation.

The good news is that you’ve got options — probably several, depending on the circumstances. Let’s take a look at what you need to know about health insurance if you’ve lost your job and are facing the loss of your employer-sponsored health coverage.

Can I enroll in self-purchased insurance as soon as I’ve lost my job?

If you’re losing your job-based health insurance, you do not have to wait for the fall open enrollment period to sign up for a new ACA-compliant plan.

Although the COVID-related special enrollment window for individual/family health plans has already ended in most states, you’ll qualify for your own special enrollment period due to the loss of your employer-sponsored health plan.

This will allow you to enroll in a plan through the marketplace/exchange and take advantage of the subsidies that are available (and bigger than ever, thanks to the American Rescue Plan), without having to wait until 2022 to get coverage.

If you enroll prior to your coverage loss, your new plan will take effect the first of the month after your old plan ends, which means you’ll have seamless coverage if your old plan is ending on the last day of the month.

Your special enrollment period also continues for 60 days after your coverage loss, although you’d have a gap in coverage if you wait and enroll after your old plan ends, since your new plan wouldn’t take effect retroactively.

If you’re in that situation, you might find that a short-term health plan is a good option for bridging the gap until your new plan takes effect. Short-term plans won’t cover pre-existing conditions and are not regulated by the Affordable Care Act (ACA). But they can provide fairly good coverage for unexpected medical needs during a temporary window when you’d otherwise be uninsured.

Be sure to check your options again during open enrollment

If you sign up for coverage now in your special enrollment period, keep in mind that you’ll still need to re-evaluate your coverage during the upcoming open enrollment period, which begins November 1. Even though you’re enrolling fairly late in 2021, your new plan will reset on January 1, with new pricing and possibly some coverage changes. There also might be new plans available in your area for 2022.

So your special enrollment period (tied to your coverage loss) will be your opportunity to find the best plan to fit your needs for the rest of this year. And if you’re still going to need self-purchased coverage in 2022, the upcoming open enrollment period will give you a chance to make sure you optimize your coverage for next year as well.

COBRA (or state continuation) versus self-purchased coverage

Depending on the size of your employer, COBRA might be offered to you. And even if your employer is too small for COBRA, you might have access to state continuation (“mini-COBRA”), depending on where you live. Either of these options will allow you to temporarily continue the coverage you already have, instead of switching to a new individual-market plan right away.

If COBRA or state continuation is available, your employer will notify you and give you information about what you’ll need to do to activate the coverage continuation and how long you can keep it.

Normally, you have to pay the full cost of COBRA or state continuation coverage, including the portion that your employer previously paid on your behalf — which was likely the bulk of the premiums. But until the end of September 2021 (so for just one more month), as part of the American Rescue Plan (ARP), the federal government will pay the full cost of COBRA or state continuation coverage for people who involuntarily lost their jobs.

For much of this year, the soon-to-end COBRA subsidy has changed the calculus that normally goes into the decision of whether to continue an employer-sponsored plan or switch to a self-purchased individual/family plan. But after the end of September, the normal decision-making process will again apply. And you’ll have a special enrollment period when the COBRA subsidy ends, which will allow you to transition to an individual/family plan at that point if you want to.

COBRA coverage vs individual-market health insurance

Here’s what to keep in mind when you’re deciding between COBRA and an individual-market health plan – either initially, or after the COBRA subsidy ends on September 30:

  • ACA marketplace subsidies are now available at all income levels, depending on the cost of coverage in your area (the American Rescue Plan eliminated the income cap for subsidy eligibility for 2021 and 2022). And the subsidies are substantial, covering the majority of the premium cost for the majority of marketplace enrollees. Unless your employer is continuing to subsidize your COBRA coverage after the federal subsidy expires, you’ll probably find that the monthly premiums are lower if you enroll in a plan through the marketplace, as opposed to continuing your employer-sponsored plan.
  • Have you already spent a significant amount of money on out-of-pocket costs under your employer-sponsored plan this year? You’ll almost certainly be starting over at $0 if you switch to an individual/family plan, even if it’s offered by the same insurer that provides your employer-sponsored coverage. Depending on the specifics of your situation, the money you’ve already paid for out-of-pocket medical expenses this year could offset the lower premiums you’re likely to see in the marketplace.
  • Do you have certain doctors or medical facilities you need to continue to use? You’ll want to carefully check the provider networks of the available individual/family plans to see if they’re in-network. And if there are specific medications that you need, you’ll want to be sure they’re on the formularies of the plans you’re considering.
  • Will you qualify for a premium subsidy if you switch to an individual/family plan? If you do qualify, you’ll need to shop in your exchange/marketplace, as subsidies are not available if you buy your plan directly from an insurance company. (You can call the number at the top of this page to be connected with a broker who can help you enroll in a plan through the exchange.) And again, as a result of the ARP, subsidies are larger and more widely available than usual; that will continue to be the case throughout 2022 as well.

Free health insurance if you collected unemployment in 2021

If you’re approved for even one week of unemployment compensation in 2021, you qualify for a premium subsidy that will fully cover the cost of the two lowest-cost Silver plans in the marketplace/exchange in your area, through the end of the year.

The subsidy will also likely cover the full cost of many of the Bronze plans, and possibly some of the Gold plans, depending on the pricing of plans where you live. This is a special subsidy rule created by the ARP, for 2021 only.

In addition to the subsidy that will allow you to get a free Silver plan, it will also ensure that any of the available Silver plans have full cost-sharing reductions.

What if my income is too low for subsidies?

In order to qualify for premium subsidies for a plan purchased in the marketplace, you must not be eligible for Medicaid, Medicare, or an employer-sponsored plan, and your income has to be at least 100% of the federal poverty level. (As noted above, for 2021 only, you’re eligible for subsidies if you receive unemployment compensation, regardless of your actual total income for the year, as long as you’re not eligible for Medicaid, Medicare, or an employer’s plan.)

In most states, the ACA’s expansion of Medicaid eligibility provides coverage to adults with household income up to 138% of the poverty level, with eligibility determined based on current monthly income. So if your income has suddenly dropped to $0, you’ll likely be eligible for Medicaid and could transition to Medicaid when your job-based coverage ends.

Unfortunately, there are still 11 states where most adults face a coverage gap if their household income is below the federal poverty level. They aren’t eligible for premium subsidies in the marketplace (unless they’ve received unemployment compensation in 2021 and can thus qualify for 2021 subsidies).

This is an unfortunate situation that those 11 states have created for their low-income residents. But there are strategies for avoiding the coverage gap if you’re in one of those states.

And keep in mind that subsidy eligibility in the marketplace is based on your household income for the whole year, even if your current monthly income is below the poverty level. So if you earned enough earlier in the year to be subsidy-eligible for 2021, you can enroll in a plan with subsidies based on that income, despite the fact that you might not earn anything else for the rest of the year.

When open enrollment begins in November, you’ll need to project your 2022 income as accurately as possible, if you’re still needing to purchase your own coverage for 2022. But for the rest of 2021, you can use the income you already earned this year to qualify for subsidies.

What if I’ll soon be eligible for Medicare?

There has been an increase recently in the number of people retiring in their late 50s or early 60s, before they’re eligible for Medicare. The ACA made this a more realistic option starting in 2014, thanks to premium subsidies and the elimination of medical underwriting.

And the ARP has boosted subsidies and made them more widely available for 2021 and 2022, making affordable coverage more accessible for early retirees. That’s especially true for those whose pre-retirement income might have made them ineligible for subsidies in the year they retired, due to the “subsidy cliff” (which has been eliminated by the ARP through the end of 2022).

So if you’re losing your job or choosing to leave it and you still have a few months or a few years before you’ll be 65 and eligible for Medicare, rest assured that you won’t have to go uninsured.

You’ll be able to sign up for a marketplace plan during your special enrollment period triggered by the loss of your employer-sponsored plan. And even if you earned a fairly robust income in the earlier part of the year, you might still qualify for premium subsidies to offset some of the cost of your new plan for the rest of 2021.

You’ll then be able to update your projected income for 2022 during the upcoming open enrollment period; your subsidies will adjust in January to reflect your 2022 income.

And marketplace plans are always purchased on a month-to-month basis, so you’ll be able to cancel your coverage when you eventually transition to Medicare, regardless of when that happens.

Don’t worry, get covered

The short story on all of this? Coverage is available, and obtaining your own health plan isn’t as complicated as it might seem at first glance, even if you’ve had employer-sponsored coverage all your life.

You can sign up outside of open enrollment if you’re losing your job-based insurance, and there’s a good chance you’ll qualify for financial assistance that will make your new plan affordable.

You can learn more about the marketplace in your state and the available plan options by selecting your state on this map. And there are zero-cost enrollment assisters – Navigators and brokers – available throughout the country to help you make sense of it all.

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.

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The COVID SEP ended in most states. The ARP is still making premiums more affordable.

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Although August 15 marked the end of a one-time COVID-related special enrollment period (SEP) for marketplace health insurance in most states, the enhanced subsidies that enticed millions of consumers are still available for many individual-market buyers (as noted below, the SEP is ongoing in some states).

The American Rescue Plan’s enhancements to the Affordable Care Act’s health insurance subsidies will continue long after the end of the COVID SEP. That means that when you do have an opportunity to buy coverage again – either through open enrollment or due to a personal qualifying life event – you’ll likely find individual health insurance much less expensive than you might have expected.

The ARP’s affordability provisions are still helping with premiums

As we’ve noted over the past few months, the American Rescue Plan included numerous provisions that make ACA-compliant plans more affordable than ever. The additional health insurance subsidy enhancements delivered by the ARP include:

All of those benefits continue to be available. The additional subsidies based on unemployment compensation continue through the end of 2021, while the other subsidy enhancements will be available through the end of 2022 (and possibly longer, if Congress extends them).

How popular are the ARP’s subsidy enhancements?

HHS reported last week that more than 2.5 million people had already enrolled in coverage during the COVID-related special enrollment period, and that another 2.6 million existing marketplace enrollees had activated their ARP subsidies.

Among all of the new enrollees, average after-subsidy premiums were just $85/month, as opposed to $117/month before the ARP’s subsidies became available. And across all of the new and renewing enrollees, about 35% had obtained coverage with after-subsidy premiums of less than $10/month.

That illustrates how substantial premium subsidies have become under the ARP. And again, nothing has changed about those subsidies: the special enrollment window has ended in most states, but the subsidies are still available if you’re eligible to enroll for the remainder of 2021 — and again during open enrollment for 2022, which starts November 1.

So if you’re in a state where enrollment is still open, or if you’re eligible for an individual special enrollment period in any state, it’s certainly in your best interest to see what plan options are available to you.

Enrolling as soon as you’re eligible will mean that you’re able to start taking advantage of the ARP’s subsidies right away, rather than having to wait for open enrollment and coverage that starts in 2022.

States where enrollment continues

Although the COVID SEP ended on August 15 in the states that use HealthCare.gov – and some of the states that run their own exchanges – enrollment is still actually ongoing in several states:

Enrollment if you have a qualifying life event

Not in one of those states? Special enrollment periods are available to individuals who experience a wide range of “life changes.” The most common trigger for a personal SEP is a loss of other coverage — usually job-based coverage.

(Note that there’s usually only a 60-day window to enroll in a new plan after losing other coverage. But HealthCare.gov is making an exception for people who lost their coverage as long ago as January 2020, if they missed their enrollment deadline because they were “impacted by the COVID-19 emergency.” People who need to utilize this flexibility have to call the marketplace directly to qualify for a special enrollment period on a case-by-case basis.)

In addition to a loss of coverage, there are also other situations in which you’ll qualify for a SEP. They include events such as the birth or adoption of a child, marriage (as long as at least one spouse already had minimum essential coverage), or even your grandmothered or grandfathered plan coming up for renewal.

More opportunities to enroll in ACA-compliant coverage

In addition to the states with ongoing COVID-related enrollment periods and the individual SEPs triggered by qualifying life events, there are other circumstances under which you might still be eligible to enroll in affordable health coverage:

Mark your calendar for 2022 open enrollment

If you don’t have an enrollment period now, be sure to mark your calendar for the start of open enrollment on November 1. That’s when you’ll be able to sign up for health coverage that will take effect in January, with coverage for essential health benefits and pre-existing conditions. During open enrollment, your medical history won’t matter, and neither will your coverage history.

And if you’re already enrolled in an ACA-compliant plan – or soon will be – you’ll still want to pay attention to open enrollment this fall. There are new insurers joining the marketplaces in many areas, which might have an unexpected effect on your premium subsidy. And even if you’re happy with the plan you have now, you might find that a different plan works better for the coming year.

Fortunately, the ARP’s subsidy enhancements will continue to be available for 2022. So if you’re eligible for subsidies – and most people are – your coverage for next year is likely to be quite affordable.

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.

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Why you should care about the August 15 special enrollment deadline

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This spring and summer, more than 2 million Americans have already flocked to the health insurance marketplaces in their states, enticed by larger health insurance subsidies during a one-time special enrollment period (SEP). This SEP was created to address the COVID-19 pandemic and allow people to take advantage of the extra subsidies created by the American Rescue Plan (ARP).

But this limited enrollment opportunity is about to end in most states.

There are a few state-run exchanges where the COVID-related SEP has already ended, and a few others where it extends past August 15. But in most of the country, August 15 is the last day to sign up for 2021 coverage without needing to show proof of a qualifying life event.

How many people bought individual health insurance during the SEP?

HHS reported that 2.1 million people had already enrolled in coverage under this SEP by the end of June. This is two to three times higher than typical enrollment volume during that time of year (when a qualifying event would normally be necessary).

And enrollment likely increased even more in July, when the additional subsidies were made available for people who had received unemployment compensation in 2021.

What happens when the SEP ends on August 15?

Once the COVID/American Rescue Plan special enrollment period ends in your state, regular individual-market enrollment rules will apply. This means that you’ll need a qualifying event in order to enroll in coverage with a 2021 effective date.

The next open enrollment opportunity will start nationwide on November 1, but that enrollment period will be for coverage that takes effect January 1, 2022.

Why review your coverage before the SEP deadline?

Even if you’re already enrolled in a health plan through the marketplace in your state and you’re happy with your coverage, you should take a few minutes to double check everything before the SEP ends.

You can update your account to make sure that you’re receiving the enhanced subsidy amount available under the ARP. And if you need to switch plans to best take advantage of that subsidy, now’s your chance to do so.

This could be the case, for example, if you’re newly eligible for cost-sharing reductions because you’ve received unemployment benefits this year. (You need to be enrolled in a Silver plan to receive that benefit.)

It could also be the case if you’re currently enrolled in a plan that costs less than your new subsidy amount. You might find that you can upgrade your coverage and still have minimal premiums each month.

One thing to note: Before you make a plan change, make sure you understand whether deductible and out-of-pocket amounts will transfer to the new plan. They probably will, as long as you stick with the same insurer.

If you’re enrolled through HealthCare.gov and you don’t update your account to activate the new subsidies, you should still see your subsidy amounts updated as of September. HHS will be updating accounts in August to align the ARP’s subsidy structure with the income amounts that enrollees had previously projected for 2021.

This will be helpful in terms of giving people more affordable coverage for the final few months of the year, as opposed to having to wait until tax season to claim the extra subsidy. But there will be no opportunity to change your 2021 coverage at that point, unless you have a qualifying event.

Why should you enroll now if you haven’t already?

Millions of Americans are already enrolled in health coverage through the exchanges. But there are still millions more who are uninsured or enrolled in non-ACA-compliant coverage such as short-term health plans or health care sharing ministry plans.

If that’s you or someone you know, the current enrollment period is an excellent opportunity to make the switch to comprehensive major medical health insurance. And chances are, it’ll be less expensive than you’re expecting, especially if it’s been a while since you checked your coverage options.

There are several reasons for this:

Will my premiums be higher if I wait until November?

The current SEP is for 2021 coverage, whereas the open enrollment period that starts in November will be for 2022 coverage. If you buy health coverage now, you’ll be locking in your premiums for the rest of this year.

In January 2022, your premium is likely to change, though we don’t yet have a clear picture of exactly how premiums will be changing. Across the states where rate filings have been made public, we’re seeing insurers proposing mostly single-digit rate increases, although there have also been some decreases and a handful of larger increases proposed.

But since most marketplace enrollees receive premium subsidies, changes in benchmark premium prices (and the related changes in subsidy amounts) will play a significant role in how much your net premiums change for 2022.

Should I enroll before the deadline if I’m uninsured?

If you’re uninsured, there’s no benefit to skipping coverage now and waiting for the start of open enrollment. That will just guarantee that you won’t have coverage in place until January, and your 2022 premium will be the same either way.

If a sudden and serious health condition were to arise while you’re uninsured, you would have no way to obtain coverage that starts before January 2022 unless you experience a qualifying event.

When will my coverage start if I enroll during the SEP?

As is always the case, your coverage won’t take effect immediately. If you enroll during the current SEP in most states, your plan will take effect the first of the following month.

How long will my coverage last if I enroll by the SEP deadline?

ACA-compliant individual/family health plans renew each year on January 1. This is true regardless of when you sign up for the plan. So if you’re enrolling during the current SEP, the specifics of your health plan – including the monthly premium – will remain the same through the end of December. (Note that your after-subsidy monthly premium could change if your income changes later in the year.)

At that point, your plan will likely be available for renewal for 2022, but the premiums and the coverage details might change. So for example, the deductible and out-of-pocket limit might change, and your premium will almost certainly change – due to both the change in your own plan’s premium, as well as changes to your subsidy amount caused by fluctuations in the benchmark premium amount in your area.

If I enroll now, do I need to enroll again in November?

In most cases, coverage will auto-renew if you don’t log back into your account during the fall open enrollment to manually pick your coverage for 2022. But for a variety of reasons, auto-renewal is not in your best interest.

Instead, you should plan to spend at least a few minutes this fall comparing your options for 2022. Even though the open enrollment window is just around the corner (it starts November 1) the options for 2022 might be very different from what you’re seeing right now for the rest of 2021. Insurers are joining the marketplaces in many states, and existing insurers are expanding their coverage areas.

That can affect plan availability as well as subsidy amounts, so you’ll want to plan to spend some time reconsidering your options for 2022.

Is there any way to enroll in 2021 coverage after August 15?

In California, DC, New Jersey, New York, and Vermont, the COVID-related special enrollment period is already scheduled to extend past August 15. (In Vermont, this applies to uninsured residents. Current enrollees who wish to switch plans must do so by August 15.) But even in those states, it’s in your best interest to enroll sooner rather than later, in order to take advantage of the enhanced subsidies that are available under the American Rescue Plan.

After August 15, in most states, you’ll need a qualifying event to be able to sign up for coverage that starts prior to January 2022. You’ll have access to open enrollment this fall, but that coverage won’t take effect until January, even if you enroll right away on November 1.

What do I need to do if I’m getting a COBRA subsidy?

The American Rescue Plan’s COBRA subsidy continues through the end of September. Assuming your COBRA or state continuation coverage is eligible to continue past that date, you’ll have the option to keep it by paying the full premiums yourself as of October, or switch to a self-purchased individual/family plan instead.

If you want to switch to a self-purchased plan, you can enroll in a plan in the marketplace in September and have your new coverage take effect seamlessly on October 1. Although the COVID-related special enrollment period will have ended by that point, you’ll be eligible for a special enrollment period triggered by the termination of the COBRA subsidy.

If you’re choosing to switch to a new plan when the COBRA subsidy ends, you’ll want to pay close attention to details regarding any deductible and out-of-pocket costs you’ve accumulated this year. As a general rule, you should assume that those will reset to $0 when you switch to an individual market plan. But it’s possible that your insurer might allow you to transfer them if you switch to an individual plan offered by the same insurer that provides your group coverage.

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.

 

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The Scoop: health insurance news – February 17, 2021

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In this edition

COVID-related enrollment window starts in most states

Although open enrollment ended two months ago in most of the country, a new one-time enrollment opportunity is available for 2021 coverage. Uninsured Americans nationwide have access to this enrollment window, and in most states, it can also be used by people who want to pick a different plan or switch from off-exchange to on-exchange coverage.

This enrollment window – a response to the ongoing COVID emergency – is now underway nationwide, with the exception of Idaho, which announced on Monday that a special enrollment period would begin March 1. In almost every state, the enrollment period continues through May 15, although there are seven state-run exchanges that have – for now – different end dates:

If you’re not yet enrolled in health coverage for 2021, or if you’re enrolled in something like a short-term plan, Farm Bureau plan, or health care sharing ministry plan, this enrollment window – which does not require a qualifying event – is an opportunity to secure real health insurance coverage for the rest of the year.

And keep an eye on the COVID relief legislation that Congress is considering. It could end up providing enrollees with much larger and more widely available premium subsidies, making it particularly important that people get enrolled in on-exchange coverage before the end of this enrollment window.

CMS notifies states that Medicaid work requirements are being reconsidered

Last week, the Biden administration began notifying states with approved Medicaid work requirements that CMS is considering withdrawing the approval for these programs. The letters were sent to Arizona, Arkansas, Georgia, Indiana, Nebraska, New Hampshire, Ohio, South Carolina, Utah, and Wisconsin, and clarify that CMS “has preliminarily determined that allowing work and other community engagement requirements to take effect … would not promote the objectives of the Medicaid program.”

There are currently no Medicaid work requirements in effect. Some have been overturned by the courts, some have been postponed voluntarily by the states, and others have been suspended or postponed due to the COVID pandemic and the ban on coverage terminations that states are required to adhere to in order to receive enhanced federal Medicaid funding during the pandemic. The Supreme Court will hear oral arguments next month in Arkansas v. Gresham, to determine whether the Trump administration’s approval of a Medicaid work requirement in Arkansas was lawful.

CMS also sent a letter (see Michigan’s here) last week to states that currently operate 1115 waivers, rescinding a previous letter that former CMS Administrator Seema Verma sent to states in early January. Verma’s letter had stated that if CMS were to terminate or withdraw approval for part or all of a state’s 1115 waiver, there would be a nine-month delay before the changes took effect.

South Dakota legislature passes bill to allow sale of Farm Bureau plans

Last week, we told you about a bill in South Dakota that would allow the state to join Tennessee, Kansas, Iowa, and Indiana in allowing Farm Bureau (or other agricultural organizations domiciled in the state for at least 25 years) to sell medically underwritten health plans that would specifically not be considered health insurance and thus would be exempt from insurance laws and regulations, including state laws as well as the Affordable Care Act’s rules.

The bill had already passed the Senate at that point, and has since passed in the South Dakota House as well. It’s now under consideration by GOP Gov. Kristi Noem, who consistently voted against the Affordable Care Act during her time in Congress.

There are other states where Farm Bureau partners with health insurers to offer ACA-compliant health insurance (Michigan is an example), and the Nebraska Farm Bureau partners with Medica to offer guaranteed-issue short-term health insurance during a limited annual enrollment period. But these approaches are not the same as allowing an agricultural organization to offer products that are specifically not considered health insurance.

Kansas Senate legislation would allow short-term health plans in Kansas to follow federal rules

Kansas is one of the states where the rules for short-term health plans are more restrictive than the current federal rules. But S.B. 199, introduced last week in the Kansas Senate, would change that. Kansas currently limits short-term health plans to a single renewal, which means their total duration cannot exceed 24 months. S.B. 199 would allow short-term health plans in Kansas to have total durations of up to 36 months – in line with current federal rules. The Biden administration may roll back the Trump-era rules for short-term plans, however, which would eventually make more relaxed state rules moot.

Aetna plans to rejoin exchanges for 2022

CVS Health/Aetna plans to offer health coverage in at least some health insurance exchanges during the open enrollment period that starts this November, although the insurer has not yet provided details in terms of where it will participate. Aetna had previously offered coverage in some exchanges, but had exited all of them by the end of 2017, and has not participated since. CVS/Aetna opting back into the exchanges would continue the trend that has been ongoing in 2019, 2020, and 2021, with insurers joining or rejoining the exchanges, after numerous insurers – including Aetna – left the exchanges in 2017 and 2018.

Aetna’s previous exit from the health insurance exchanges happened before the company was acquired by CVS. But the exit was controversial, and linked to the Department of Justice’s decision to block a merger between Humana and Aetna. Here’s what David Anderson wrote about this in 2016, and Charles Gaba has put together a timeline of Aetna’s 2016 decision-making process.

Washington state Senate committee approves legislation to ensure coverage of gender-affirming healthcare

Washington state lawmakers are considering S.B. 5313, which would require state-regulated health plans to provide non-discriminatory coverage for medically necessary gender-affirming care. Insurers would not, for example, be able to deny coverage for services needed by transgender members, such as facial feminization, breast reductions, breast implants, etc. by classifying them as cosmetic procedures.

The bill was overwhelmingly approved last week by the Washington Senate’s Committee on Health and Long Term Care.

Rhode Island legislation would create commission to consider single-payer health program

Legislation was introduced in Rhode Island last week that calls for the creation of a special legislative committee tasked with “a comprehensive study to determine the pros and cons of implementing a single-payer (health coverage) program in Rhode Island.” The legislation notes that an “improved Medicare-for-all type single-payer program” would be in the state’s best interest. There are not currently any states that have single-payer health coverage systems, although there are others that are considering similar studies.

Medicaid buy-in legislation introduced in West Virginia

Legislation has been introduced in several states this year that would create Medicaid buy-in programs. With the introduction of H.B. 2241, West Virginia is the latest state where lawmakers are considering this possibility. The idea is to create a public option program by allowing residents – who would not otherwise be eligible for Medicaid – to purchase Medicaid coverage as an alternative to purchasing private health insurance. There are not yet any states where Medicaid buy-in programs have been enacted; Nevada has come the closest, but the Medicaid buy-in legislation that lawmakers passed in 2017 was vetoed by Nevada’s governor.

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 – February 17, 2021 appeared first on healthinsurance.org.

The Scoop: health insurance news – February 10, 2021

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In this edition

COVID-related enrollment window starts Monday in most states

In every state except Connecticut, Idaho, and Vermont, a COVID-related enrollment window will be open by next week. (In a few states, they’re already open.) During these enrollment windows, consumers can sign up for ACA-compliant health coverage without a qualifying event.

In most states, the enrollment window applies to anyone eligible to use the marketplace, including people who are already enrolled and want to make a plan change. But some of the state-run exchanges are limiting eligibility to only people who are currently uninsured, or to people who aren’t already enrolled through the exchange. And some states are extending the COVID-related enrollment window to off-exchange plans as well, although financial assistance is never available outside the exchange.

If you’re uninsured or know someone who is, this is an opportunity to have coverage in place for the rest of 2021, with an effective date as early as March 1. Millions of uninsured Americans are eligible for premium subsidies substantial enough to cover the full cost of at least some plans in the marketplace. And Congress is considering COVID relief measures (described below) that would make coverage even more affordable.

House committees propose health insurance provisions as part of COVID package

The House Ways and Means Committee unveiled a set of nine COVID relief proposals this week. Subtitle G, related to “promoting economic security,” includes several important health insurance provisions:

  • For 2021 and 2022, the normal rules for the percentage of income a person is expected to pay for on-exchange health insurance would be modified to be much more generous. People with income up to 150 percent of the federal poverty level would pay nothing for the benchmark plan. And nobody would pay more than 8.5 percent of their income, including people who earn over 400 percent of the poverty level (and are currently not eligible for a premium tax credit at all, regardless of how much of their income they have to pay for health coverage).
  • For 2020 only, excess premium tax credits would not have to be repaid to the IRS. This is something that several insurance commissioners from around the country suggested to President Biden before he took office. Premium subsidy reconciliation can catch people off guard at the best of times — and 2020 was a particularly complicated year.
  • People receiving unemployment benefits in 2021 would receive a premium tax credit that would fully cover the cost of the benchmark plan.

The House Energy and Commerce Committee also published its proposed COVID relief measures this week, including a provision that would provide additional financial incentives for the states to expand Medicaid eligibility if they haven’t already. There are still a dozen states that haven’t expanded Medicaid.

Under current rules, if and when they expand eligibility, the federal government will cover 90 percent of the cost for the newly eligible population, and will continue to fund the rest of the state’s Medicaid program at the state’s normal matching rate (varies from 50 percent to about 76 percent, depending on the state). But under the committee’s legislative proposal relating to Medicaid, states that newly expand Medicaid would get an additional 5 percent federal funding match for their whole Medicaid program, for the first two years of Medicaid expansion.

The committees will markup these proposals this week, and a floor vote in the House on the final COVID relief legislation is planned for later this month.

Virginia House bill would implement reinsurance program in 2023

Legislation was introduced in Virginia last month to create a reinsurance program in the state. Last week, the Virginia House of Delegates passed the bill by a wide margin, and a Virginia Senate committee unanimously agreed to consider the bill during a special session that starts today.

If it’s passed and signed into law, the legislation calls for the state to submit a 1332 waiver proposal to the federal government by January 2022, and for the reinsurance program to be implemented by January 2023. (This is a fairly long timeline. We’ve seen several states implement reinsurance programs over the last few years, often with the program in place for the plan year immediately following the passage of the legislation that authorized it.)

Montana House passes bill to prohibit abortion coverage for exchange plans

Last week, we told you about a bill in Montana’s House that would prohibit on-exchange health plans in Montana from covering abortion services. On Friday, the bill passed in the House by a wide margin, and mostly along party lines. (Four Democrats voted yes, while one Republican voted no.) It’s now with the Montana Senate’s Judiciary Committee for further review. Montana is currently among the minority of states where abortion coverage can be provided under on-exchange plans and at least some plans do offer this coverage.

South Dakota Senate passes legislation to allow non-insurance Farm Bureau health plans

South Dakota’s Senate passed S.B.87 last week, which would allow a nonprofit agricultural organization, domiciled in the state for at least 25 years, to offer non-insurance health benefits to its members. The legislation, which was proposed by South Dakota Farm Bureau, would specifically exempt such health plans from insurance laws or oversight. Tennessee, Kansas, Iowa, and Indiana already allow Farm Bureau health plans to be sold with similar rules. (The plans are not considered health insurance and are thus not subject to insurance laws or regulations.)

The bill is now with the South Dakota House of Representatives, where the Agriculture and Natural Resources Committee approved it 11-1 this week, sending it to a vote on the House floor. The American Cancer Society has expressed strong opposition to the bill, noting that the proposed non-insurance health plans “have the potential of segmenting the insurance market, driving up premiums and making it harder for South Dakotans who live with serious or chronic disease to find health insurance.”

State lawmakers introduce Medicaid buy-in legislation

The concept of Medicaid buy-in as a way of establishing a public option has been debated for several years. Nevada lawmakers passed a Medicaid buy-in bill in 2017, but it was vetoed by the governor. Similar legislation was considered in New Mexico in 2019, but did not pass. (United States of Care has an extensive list of the actions that various states considered in 2019 related to Medicaid buy-in programs.)

This year, lawmakers in several states have introduced various forms of Medicaid buy-in legislation:

  • Georgia: S.B. 83/H.B. 214 would create a Medicaid buy-in program that would be available to anyone not otherwise eligible for Medicaid, Medicare, or PeachCare for Kids (Georgia’s CHIP).
  • Iowa: S.F. 220 would create a buy-in program for the Hawk-i program (Iowa’s CHIP). It would allow families to purchase coverage for their kids (and young adults up to age 26) through the program if their household income is too high to meet the normal eligibility guidelines. (Currently, 302 percent of the federal poverty level.) The plan would be available through Iowa’s marketplace and could be used with premium tax credits and cost-sharing reductions for eligible enrollees.
  • Oklahoma: H.B. 1808 would create a Medicaid buy-in program in the state. The bill would alter the existing Oklahoma statute that directs the state to create a Medicaid buy-in program for people with disabilities if funds become available. The funding aspect is key; Oklahoma has not yet created a Medicaid buy-in program for people with disabilities. But another bill was introduced in Oklahoma last week, calling for the removal of the “if funds become available” language in the existing statute.
  • South Carolina: H. 3573 would create a Medicaid buy-in program that would be available to people who are not eligible for premiums tax credits under the ACA, Medicaid, Medicare, or affordable employer-sponsored coverage.
  • Tennessee: S.B. 418/H.B. 602 would create a Medicaid buy-in program that would be available to people who are not eligible for premium tax credits, affordable employer-sponsored coverage, Medicaid, or Medicare. (The wording of the Tennessee legislation is very similar to the South Carolina legislation).

Biden administration puts Trump-era association health plan rule appeal on hold

In 2018, the Trump administration relaxed the rules for association health plans (AHPS), allowing self-insured people to join AHPs, as well as small groups that share only a common geographical location. The rules would also have allowed for the creation of these associations for the sole purpose of offering health insurance, without any other business purpose. These rules were soon challenged in court, and vacated by a judge in 2019. The Trump administration appealed the decision, and oral arguments in the appeal were heard by the D.C. Circuit Court in November 2019.

But a ruling had not yet been handed down by the time the Biden administration took office, and the new administration soon asked the court to stay the appeal. The court granted that request this week, so the appeal is on hold while the new leadership at the Department of Labor reviews the case, with status reports due every two months.

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 – February 10, 2021 appeared first on healthinsurance.org.

The Scoop: health insurance news – February 3, 2021

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In this edition

Special enrollment periods underway (or soon to be underway) in most states

White House

An executive order signed by President Biden has authorized a COVID-related special enrollment period on HealthCare.gov. The SEP will run from February 15 to May 15.

Last week, the Biden administration announced a special enrollment period for HealthCare.gov, which will run from February 15 to May 15. This window will allow anyone eligible to use the marketplace to enroll or make a plan change, without needing a qualifying event.

The SEP applies in the 36 states that use HealthCare.gov, but 12 of the other 15 state-run exchanges have also announced similar enrollment windows — some of which are already underway:

These state-run exchanges are taking a mixed approach to this enrollment window, with some allowing anyone to enroll, and others limiting it to only people who are currently uninsured. There are only three other states that run their own exchange platforms but have not yet announced COVID-related special enrollment periods: Connecticut, Idaho, and Vermont.

House, Senate legislation would make ACA premium subsidies more generous

Democrats in Congress have long been considering various proposals to enhance the ACA’s premium subsidies and make more robust coverage more affordable. Last month, Rep. Lauren Underwood (D-Ill.) introduced the Health Care Affordability Act (H.R. 369) and Sen. Mark Warner (D-Va.) introduced the Health Care Improvement Act of 2021. Both bills include the basic health care provisions that President Biden has proposed as part of his American Recovery Plan.

One of the most important aspects of these pieces of legislation is a fundamental change in the formula for calculating premium subsidies. Under these bills, the subsidies would become more generous, allowing more Americans to purchase coverage with minimal or zero premiums, and capping premiums at no more than 8.5 percent of income, regardless of a household’s income. At ACA Signups, Charles Gaba has created graphics that will help you visualize after-subsidy premiums as a percentage of income under the status quo versus H.R. 369, as well as a previous piece of federal legislation and California’s state-based subsidy system.

Maryland legislation would create young-adult subsidy pilot program

A bill (H.B. 780) introduced last week in Maryland calls for the state to create a pilot program that would provide state-funded premium subsidies to young adults with fairly low incomes. The legislation calls for the state to use $10,000,000 per year in 2022 and 2023 to provide additional premium assistance to people between the ages of 18 and 41, with incomes between 133 percent and 140 percent of the poverty level.

The ACA already provides federal premium subsidies for people at this income level, but the subsidies aren’t as strong for young people as they are for older enrollees. The pilot program would be designed to make net premiums more affordable and boost enrollment for this demographic.

Minnesota legislation calls for transition to HealthCare.gov

Minnesota H.F. 536 – introduced on Monday – calls for the state to transition away from MNsure as of 2022 and start utilizing HealthCare.gov instead. The measure is not likely to pass in the Minnesota House, given the Democratic majority in that chamber and the lawmakers’ general support for MNsure.

In 2017, former Gov. Mark Dayton vetoed a bill that would have transitioned the state to HealthCare.gov, and MNsure has continued to be a successful state-run exchange ever since.

Over the first few years the exchanges were in operation, several states shifted from their own enrollment platforms to HealthCare.gov (although Idaho took the opposite approach, switching from HealthCare.gov to their own platform as of the 2015 plan year). But the opposite trend has been ongoing for the last couple of years, with Nevada, Pennsylvania, and New Jersey all switching away from HealthCare.gov and operating their own exchange platforms, and other states planning to follow suit over the next few years. (You can see a full timeline of all the changes here.)

Minnesota bill would require more robust coverage of outpatient mental health treatment

Minnesota H.F. 415 and S.F. 377 – both introduced last week – would require major medical plans regulated by the state of Minnesota (ie, individual and fully-insured group plans, but not self-insured group plans) to cover a member’s first four outpatient mental health visits each year with cost-sharing that doesn’t exceed $25 per visit.

There’s no mention of an exclusion for HSA-qualified high-deductible health plans (HDHP), but that would need to be added to the legislation in order to allow HSA-compliant plans to continue to be available in Minnesota. IRS rules do not allow HDHPs to pay for services like mental health care until the member has met their deductible.

Washington legislation would create state-based premium subsidies

Washington state’s Cascade Care program, including standardized plans and public option plans, is underway this year. But part of the original 2019 Cascade Care legislation called for the state to develop a plan to provide state-based premium subsidies to people earning up to 500 percent of the poverty level.

Legislation to get the ball rolling on that did not advance in last year’s session, but a new bill was introduced last week with a similar intent. S.B. 5377 calls for the state to provide premium subsidies to people with income up to 500 percent of the poverty level (and possibly a cost-sharing assistance program), as long as they’re enrolled in the lowest-cost Bronze, Silver, or Gold standardized plan available in their area. Washington’s exchange conducted a detailed analysis of various approaches to state-based premium subsidy programs last year; their report includes a recommendation that the state-funded premium subsidies be provided as a fixed-dollar amount.

S.B. 5377 also addresses some aspects of the state’s existing public option program, including participation requirements for hospitals and surgical facilities, as well as a reduction in the reimbursement rate for hospitals (currently set at 160 percent of Medicare rates, but it would decline to 135 percent of Medicare rates under S.B. 5377, leading to lower premiums for enrollees).

Mississippi and Kentucky consider extending postpartum Medicaid coverage

Mississippi lawmakers are considering S.B. 2799, which would make a variety of changes to the state’s Medicaid program, including an extension of postpartum Medicaid coverage. Under current rules, a woman in Mississippi who qualifies for Medicaid due to pregnancy is eligible for 60 days of postpartum Medicaid coverage after the baby is born, but S.B. 2799 would extend that to 12 months (during the COVID pandemic, postpartum Medicaid coverage does not terminate after 60 days, due to the current rules that prevent states from terminating Medicaid coverage for any enrollees unless they move out of the state or request a coverage termination). Medicaid covers nearly two-thirds of all births in Mississippi — the highest proportion in the nation.

The Kentucky House Democratic Women’s Caucus has created a plan they’re calling the Kentucky Maternal and Infant Health Project, comprised of 21 proposed bills that would address a wide range of issues. Among them is a measure that would extend postpartum Medicaid coverage from 60 days to 12 months. The proposal also calls for pregnancy to be considered a qualifying event, which is currently only the case in New York, Connecticut, and DC.

Montana legislative committee advances bill to prohibit abortion coverage for on-exchange plans

Last week we told you about legislation in Arizona, Texas, and Virginia that would remove state rules that prohibit abortion coverage on health plans that are sold in the exchange/marketplace in those states. Montana lawmakers are considering the opposite approach, however, with H.B. 229. The bill, which was approved by the House Judiciary Committee last week, would prohibit abortion coverage on plans sold in the Montana exchange. The only exception would be in cases where the mother’s life is in danger.

Montana is currently one of a minority of states where there is no ban on abortion coverage for on-exchange plans, and at least one insurer does offer plans that include abortion coverage.

More states consider bills that would cap out-of-pocket costs for insulin

Last year, several states enacted legislation to cap consumers’ out-of-pocket costs for insulin. Other states are considering similar bills this year, including Montana ($35/month cap), Tennessee ($100/month cap), New Jersey ($50/month cap), and New York ($30/month cap; New York already passed a bill last year that limits out-of-pocket costs for insulin, but the cap is $100. The new legislation would reduce that to $30 instead).

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 – February 3, 2021 appeared first on healthinsurance.org.

Biden administration announces three-month special enrollment period

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This morning, the White House announced that today, President Biden will sign two highly anticipated executive orders related to healthcare. The first is aimed at strengthening Medicaid and the Affordable Care Act, and will include a provision to create a COVID-related special enrollment period (SEP) on HealthCare.gov, for Americans who don’t currently have health coverage. State officials, insurers, and consumer advocates repeatedly asked the Trump administration for a COVID-related special enrollment period in 2020, but to no avail. (Almost all of the state-run exchanges did open COVID-related SEPs in 2020.)

When will the HealthCare.gov special enrollment period start?

The special enrollment period will run from February 15 to May 15, giving uninsured Americans three months in which to pick a health plan, even if they don’t otherwise have a qualifying event.

Who can use the COVID special enrollment period on HealthCare.gov?

This window is expected to be aimed at Americans who are uninsured, much like the COVID-related special enrollment periods that had already been announced in Maryland, Massachusetts, and New York. But the COVID-related SEP in Massachusetts also applies to people who have COBRA and would prefer to drop it and switch to a plan offered through the marketplace – it’s possible that the SEP on HealthCare.gov could be extended to populations like that as well.

Americans are technically considered uninsured if they have coverage under short-term health plans, Farm Bureau non-insurance plans, fixed indemnity plans, healthcare sharing ministry plans, direct primary care plans, and other similar types of coverage, since none of those are considered minimum essential coverage. So people with these types of coverage will be able to use the COVID special enrollment period on HealthCare.gov. And again, it’s also possible that this window could be extended to other groups as well, including those who have COBRA or state continuation coverage after a recent job loss.

Will state-run marketplaces also offer a special enrollment period for uninsured residents?

HealthCare.gov is used in 36 states, and the COVID SEP will apply in all of them. But it’s also likely that many of the state-run exchanges – in addition to Massachusetts, Maryland, and New York – could follow suit. Colorado’s exchange announced today that they’ll open a special enrollment period for uninsured residents, which will run from February 8 through May 15, and Washington’s exchange announced a special enrollment period, with the same dates that HealthCare.gov will use, for “anyone seeking health insurance coverage.”

Last month, insurance commissioners from 11 states sent a letter to President Biden, encouraging him to take various actions to improve access to health coverage and care. Opening a special enrollment period was among their recommendations, along with “restoring outreach funding, restoring flexibility on eligibility rules like failure to reconcile, and immediately revoking public charge rules.”

The insurance commissioners who wrote the letter – six of whom represent states that run their own exchanges (California, Colorado, Minnesota, Pennsylvania, Rhode Island, and Washington) – further noted that

“many of our states run our own state-based marketplaces and we would like to work with you to ensure that any effort to encourage marketplace enrollment is truly national and therefore inclusive of state-based marketplaces, in addition to HealthCare.gov. We ask you, as soon as possible, to coordinate with state-based marketplaces on the timing of any SEP, the messaging you intend to use, and key strategies you will employ to reach the uninsured so that we can align our plans with yours.”

So it’s quite likely that many of the remaining state-based marketplaces will open COVID-related SEPs this spring, allowing uninsured residents another opportunity to sign up for health coverage.

How can I get coverage between now and February 15?

If you’re uninsured and not in one of the states where open enrollment for 2021 plans is ongoing until the end of January, your options for getting coverage before the new special enrollment period will be limited.

But you likely do still have at least some options, as outlined here. If you’re eligible for Medicaid or CHIP, enrollment continues year-round, with coverage that can take effect immediately or even retroactively. Otherwise, you may have to consider a plan that’s not regulated by the Affordable Care Act, such as a short-term plan or health care sharing ministry, to tide you over until you can enroll in a plan through the marketplace.

What else will the executive orders do?

The special enrollment period for uninsured Americans is generating headlines and will be available in just a couple of weeks. But the executive order is expected to direct federal agencies to consider a variety of other reforms, which could have far more significant impact.

Among the most likely are

The second executive order will be aimed at protecting women’s health in America and around the world, including ensuring access to all necessary reproductive health care. It’s expected to rescind the global gag rule (Mexico City Policy), which blocks U.S. funding for international non-profits that provide women with abortion counseling or referrals. The rule was first implemented in the 80s and has been rescinded and reinstated several times under different administrations.

It’s also expected that the women’s health executive order will direct federal agencies to reconsider the Trump administration rule that eliminated federal funding for Planned Parenthood and other abortion providers.

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 Biden administration announces three-month special enrollment period appeared first on healthinsurance.org.

Biden administration announces COVID-related special enrollment period

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Today, President Biden signed two highly anticipated executive orders related to healthcare. The first is aimed at strengthening Medicaid and the Affordable Care Act, and directs HHS to consider creating a COVID-related special enrollment period (SEP) on HealthCare.gov. The Biden administration has also committed $50 million to outreach and education, in order to make people aware of the enrollment opportunity and the extensive financial assistance that’s available to help offset the cost of coverage and care.

State officials, insurers, and consumer advocates had repeatedly asked the Trump administration for a COVID-related special enrollment period in 2020, but to no avail. (Almost all of the state-run exchanges did open COVID-related SEPs in 2020.)

When will the HealthCare.gov special enrollment period start?

The special enrollment period runs from February 15 to August 15, giving people six months in which to pick a health plan, even if they don’t otherwise have a qualifying event (edit: this is an extension; the window was initially slated to end May 15, 2021, but was subsequently extended to August 15).

Who can use the COVID special enrollment period on HealthCare.gov?

Anyone who is eligible to use the marketplace can enroll during this special enrollment period. This includes people who are uninsured, under-insured, or already enrolled in a plan through the marketplace and wanting to switch to a different plan.

Previously, it was expected that this new special enrollment window would be aimed at Americans who are uninsured, much like the COVID-related special enrollment periods that had already been announced in the District of Columbia, Maryland, Massachusetts, and New York (the SEP in Massachusetts also applies to people who have COBRA and would prefer to drop it and switch to a plan offered through the marketplace). But when CMS published the details of the SEP, it was clear that they wanted to cast a wide net, making the special enrollment period available for those who are without coverage, but also for current marketplace enrollees.

They’ve clarified that “current enrollees will be able to change to any available plan in their area without restriction to the same level of coverage as their current plan.” They also note that “consumers won’t need to provide any documentation of a qualifying event (e.g., loss of a job or birth of a child), which is typically required for SEP eligibility.”

So regardless of whether you’ve got no coverage at all, are already enrolled in a plan through HealthCare.gov, or have coverage under something like a short-term health plan, Farm Bureau non-insurance plan, fixed indemnity plan, healthcare sharing ministry plan, direct primary care plan, or other similar types of coverage, you’ll be able to use HealthCare.gov to sign up for coverage during this window.

Are state-run marketplaces also offering a special enrollment period for uninsured residents?

HealthCare.gov is used in 36 states, and the COVID SEP applies in all of them. But all of the state-run exchanges have followed suit (in addition to DC, Massachusetts, Maryland, and New York, which had already announced COVID-related special enrollment periods). Here’s a summary of the COVID-related special enrollment periods in states that run their own exchanges (note that this list has been updated over time, as more state-run exchanges announce special enrollment periods):

Some of these enrollment windows apply only to uninsured residents, while others apply to anyone eligible to use the marketplace, including people who already have coverage and want to switch to a new plan.

Last month, insurance commissioners from 11 states sent a letter to President Biden, encouraging him to take various actions to improve access to health coverage and care. Opening a special enrollment period was among their recommendations, along with “restoring outreach funding, restoring flexibility on eligibility rules like failure to reconcile, and immediately revoking public charge rules.”

The insurance commissioners who wrote the letter – some whom represent states that run their own exchanges – further noted that

“many of our states run our own state-based marketplaces and we would like to work with you to ensure that any effort to encourage marketplace enrollment is truly national and therefore inclusive of state-based marketplaces, in addition to HealthCare.gov. We ask you, as soon as possible, to coordinate with state-based marketplaces on the timing of any SEP, the messaging you intend to use, and key strategies you will employ to reach the uninsured so that we can align our plans with yours.”

And the CMS press release notes that the administration “strongly encourages states operating their own Marketplace platforms to make a similar enrollment opportunity available to consumers in their states.” As of early February, only three state-run exchanges had not announced COVID-related special enrollment periods (edit: all three had announced COVID-related enrollment periods by mid-February; there are COVID-related enrollment periods nationwide, although the rules and deadlines vary a bit in some states).

How can I get coverage after the COVID-related enrollment period ends?

If you’re uninsured and don’t enroll during the COVID-related enrollment period in your state, your options for getting coverage for the remainder of 2021 will be limited.

But you likely do still have at least some options, as outlined here. If you’re eligible for Medicaid or CHIP, enrollment continues year-round, with coverage that can take effect immediately or even retroactively. Otherwise, you may have to consider a plan that’s not regulated by the Affordable Care Act, such as a short-term plan or health care sharing ministry, to tide you over until you can enroll in a plan through the marketplace.

What else will the executive orders do?

The special enrollment period for uninsured Americans is generating headlines and will be available in just a couple of weeks. But the executive order is expected to direct federal agencies to consider a variety of other reforms, which could have far more significant impact.

Among the most likely are

The second executive order is aimed at protecting women’s health in America and around the world, including ensuring access to all necessary reproductive health care. It rescinded the global gag rule (Mexico City Policy), which blocked U.S. funding for international non-profits that provide women with abortion counseling or referrals. The rule was first implemented in the 80s and has been rescinded and reinstated several times under different administrations.

The women’s health executive order also directs federal agencies to reconsider the Trump administration rule that eliminated federal funding for Planned Parenthood and other abortion providers.

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.

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Will my health insurance cover the costs of coronavirus testing, vaccines, and treatment?

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Key takeaways

Q: Will my health insurance cover the costs of coronavirus testing and treatment?

A: The COVID-19 pandemic has drastically impacted the world over the last year. A common question that people have is “How will my health insurance cover the coronavirus?”


The short answer? It depends. With the exception of Original Medicare, health insurance differs greatly in the U.S., depending on where you live and how you obtain your coverage. Including the District of Columbia, there are 51 different sets of state insurance rules, separate rules that apply to self-insured group plans (which are not regulated by the states), and 51 different Medicaid/CHIP programs.

Nearly half of all Americans – including a large majority of non-elderly Americans – get their health coverage from an employer. Those plans are regulated by a combination of state and federal rules, depending on the size of the group and whether it’s self-insured or fully-insured.

And about 6 percent of Americans buy their own health insurance in the individual market, where both state and federal rules apply.

Is testing for COVID-19 covered by health plans?

Under the terms of the Families First Coronavirus Response Act (H.R.6201), Medicare, Medicaid, and private health insurance plans – including grandfathered plans – are required to fully cover the cost of COVID-19 testing, without any cost-sharing or prior-authorization requirements, for the duration of the emergency period (which has most recently been extended through mid-April 2021). That includes the cost of the lab services as well as the provider fee at a doctor’s office, urgent care clinic, or emergency room where the test is administered.

Since it’s a federal law, the requirements apply to both self-insured and fully-insured health plans, whereas the testing coverage requirements that numerous states have imposed (see examples here and here) are only applicable to fully insured plans.

What kinds of health plans might not cover testing?

Health plans that aren’t considered minimum essential coverage are not required to cover COVID-19 testing under the federal rules. This includes short-term health plans, fixed indemnity plans, and healthcare sharing ministry plans. It also includes the Farm Bureau plans in Tennessee, Iowa, Indiana, and Kansas – which are not considered health insurance and are specifically exempt from insurance regulations. But some of these plans are voluntarily covering COVID-19 testing and telehealth, so the specifics depend on the plan.

States have the power to regulate short-term health plans, and Washington, for example, extended its testing coverage requirements to include short-term health plans. (Washington already has very strict rules for short-term health plans). But in most states, most plans that aren’t minimum essential coverage are not required to cover COVID-19 testing.

How will my health plan cover a COVID-19 vaccine?

The CARES Act (H.R.748, enacted in March 2020) requires all non-grandfathered health plans, including private insurance, Medicare, and Medicaid, to cover COVID-19 vaccines without any cost-sharing for the member (the same caveats described above apply, however, as plans that aren’t regulated by the ACA are not included in the vaccine coverage requirement unless a state steps up and imposes its own requirement).

The full coverage of COVID-19 vaccines includes both the vaccine itself and any charges from the provider or facility for the administration of the vaccine. The COVID-19 vaccine has been added to the list of recommended vaccines, and the CARES Act required private health plans to begin fully covering it within 15 business days — much faster than the normal timeframe (which can be nearly two years, depending on the circumstances) between when a preventive care recommendation is made and when insurers have to cover it with no cost-sharing.

How can the uninsured get COVID-19 testing and vaccines?

H.R.6201 allows states to use their Medicaid programs to cover COVID-19 testing for uninsured residents, and provides federal funding to reimburse providers for COVID-19 testing for uninsured patients. The CARES Act also provides funding to reimburse providers for the cost of administering COVID-19 vaccines to uninsured individuals.

It’s worth noting that people who don’t have minimum essential coverage are considered uninsured, so depending on availability, they would be eligible for covered testing and vaccines under these programs. In the weeks since the first COVID-19 vaccines were granted emergency use authorizations by the FDA, numerous state insurance departments have issued statements clarifying that residents will not have to pay for the vaccine, regardless of their insurance status.

How much of COVID-19 treatment costs will health plans cover?

Although the federal and state governments have stepped in decisively to ensure that most people won’t incur out-of-pocket costs for COVID-19 testing and vaccines, the cost of treatment is a different matter altogether.

Although the majority of patients are able to recover without hospitalization, Harvard’s Global Health Institute estimates that about 20 percent of COVID-19 patients need to be hospitalized, and about 20 percent of hospitalized patients will need intensive care, including ventilators.

Inpatient care, including intensive care, is an essential health benefit for all ACA-compliant individual and small group health plans (but states define exactly what’s covered for each essential health benefit, so the specifics do vary from one state to another). And although large group plans are not required to cover essential health benefits, they are required to provide “substantial” coverage for inpatient care. If they don’t, the employer can be subject to a penalty under the ACA’s employer mandate, but about 5 percent of large employers still opt to offer scanty plans that don’t comply with this regulation and would offer little in the way of coverage for COVID-19 treatment.

But even when it’s covered by insurance, inpatient care is expensive. And so is outpatient care, depending on the scope of the care that’s needed. This is where patients’ cost-sharing comes into play. Under the ACA, all non-grandfathered, non-grandmothered health plans must have in-network out-of-pocket maximums that don’t exceed $8,550 for a single individual in 2021 (this limit doesn’t apply to plans that aren’t regulated by the ACA, such as short-term health plans).

So for most patients who need COVID treatment in 2021, out-of-pocket costs won’t exceed $8,550. But that’s still a huge amount of money, and most people don’t have it sitting around. The majority of health plans have out-of-pocket limits well below that amount, but most people are still going to be on the hook for a four-figure bill if they end up needing to be hospitalized for COVID-19. Although employer-sponsored plans tend to be more generous than the plans people buy in the individual market, the average employer-sponsored plan still had an out-of-pocket maximum of $4,039 for a single employee in 2020.

With that said, however, many insurers around the country have opted to waive, at least temporarily, members’ out-of-pocket costs related to COVID-19 treatment. It’s important to understand, however, that if an insurer is acting as an administrator for a self-insured employer-sponsored plan, the employer would have to agree to waive the cost-sharing, as it’s the employer’s money (as opposed to the insurance company’s money) that pays the claims.

Some states work to ensure COVID-19 treatment is affordable

Some states (New Mexico and Massachusetts are examples) stepped up early in the pandemic and issued guidance requiring state-regulated insurers to cover treatment (as well as testing) with no cost-sharing, and others (Minnesota is an example) have strongly encouraged insurers to do so (note that the regulation in Massachusetts only applies to doctor’s offices, urgent care centers, and emergency rooms, but not to inpatient care). In addition, several states are requiring telehealth treatment with no cost-sharing. But for the most part, people who need extensive treatment for COVID-19 are going to have to meet their health plan’s deductible and likely the out-of-pocket maximum, unless the insurer has agreed to waive these costs.

Many states are encouraging or requiring state-regulated insurers to treat COVID-19 testing and treatment as in-network, regardless of whether the medical providers are in the plan’s network. And federal rules require this for the vaccine as well, with the cost fully covered regardless of whether the member gets the vaccine from an in-network or out-of-network provider. For vaccine administration, providers are generally not allowed to seek any payment from the patient, including via balance billing. But for COVID-19 testing and treatment provided by out-of-network medical providers, patients could still be subject to balance billing in some circumstances as the out-of-network provider doesn’t have to accept the insurance company’s payment as payment-in-full if it’s less than the billed amount.

And although H.R.6201 prohibits insurance plans from requiring prior authorization for testing, insurers are still allowed to impose their normal prior authorization rules for other services, including COVID-19 treatment, unless a state otherwise prohibits it on state-regulated plans.

How do I make sure I have coverage to protect myself from COVID-19?

So what can you do to protect yourself as much as possible in terms of your health insurance coverage during this pandemic? Here are a few pointers:

  • If you’re uninsured (which includes having a health plan that’s not minimum essential coverage), check to see if enrollment in 2021 health plans is still ongoing in your state, or if you’re eligible for a special enrollment period. If so, enrolling in an ACA-compliant plan is certainly in your best interest. And if your income is low (even temporarily, due to a layoff), check to see if you might be eligible for Medicaid.
  • If you have health insurance, make sure you understand what your plan covers and what your cost-sharing responsibilities are for various outpatient and inpatient care (check to see if your insurer is offering to waive costs associated with COVID-19 treatment).
  • Check to see how your health plan handles prior authorizations.
  • Pay attention to the details of your health plan’s provider network. Your best chance of avoiding balance billing is to make sure you see in-network providers, and you don’t want to be having to sort that out while you or a family member is very unwell.
  • Check with your plan to see how telehealth is covered, and be sure you understand how to use the telehealth services. For non-severe cases, telehealth is recommended as a way to prevent further spread of the disease, and many health plans have temporarily reduced or eliminating cost-sharing for telehealth services in an effort to encourage its use.
  • If you had an HSA-qualified health plan last year and didn’t contribute the maximum allowable amount to your HSA, consider doing so now if you have the money available. You can make contributions for 2020 up until April 15. And if you currently have an HSA-qualified plan, you can contribute pre-tax money to the account for this year as well, at any point during the year. Whatever money you contribute to your HSA will be available to withdraw tax-free if you end up needing it to pay out-of-pocket costs for medical care.

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 Will my health insurance cover the costs of coronavirus testing, vaccines, and treatment? appeared first on healthinsurance.org.

 

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