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The Scoop: health insurance news – February 17, 2021

February 17, 2021/in 1115 waiver, covid-19, Farm Bureau, health reform, Medicaid work requirements, special enrollment period /by wpmaddoxins

In this edition

  • COVID-related enrollment window starts in most states
  • CMS notifies states that Medicaid work requirements are being reconsidered
  • South Dakota legislature passes bill to allow sale of Farm Bureau plans
  • Kansas Senate legislation would allow short-term health plans in Kansas to follow federal rules
  • Aetna plans to rejoin exchanges for 2022
  • Washington state Senate approves legislation to ensure coverage of gender-affirming healthcare
  • Rhode Island legislation would create commission to consider single-payer health program
  • Medicaid buy-in legislation introduced in West Virginia

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:

  • Connecticut – through March 15
  • Washington, DC – through the end of the pandemic emergency period
  • Idaho – March 1 to March 31
  • Massachusetts – through May 23
  • Minnesota – through May 17
  • New York – through March 31
  • Vermont – February 16 to May 14

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.

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 wpmaddoxins2021-02-17 12:04:482021-02-17 14:15:34The Scoop: health insurance news – February 17, 2021

The Scoop: health insurance news – February 10, 2021

February 10, 2021/in abortion, association health plan, covid-19, Farm Bureau, health reform, Medicaid buy-in, Medicaid expansion, Reinsurance, special enrollment period, The Scoop /by wpmaddoxins

In this edition

  • COVID-related enrollment window starts Monday in most states
  • House committees propose health insurance provisions as part of COVID package
  • Virginia House bill would implement reinsurance program in 2023
  • Montana House passes bill to prohibit abortion coverage for exchange plans
  • South Dakota Senate passes legislation to allow non-insurance Farm Bureau health plans
  • State lawmakers introduce Medicaid buy-in legislation
  • Biden administration puts Trump-era association health plan rule appeal on hold

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.

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 wpmaddoxins2021-02-10 13:59:122021-02-10 14:14:14The Scoop: health insurance news – February 10, 2021

The Scoop: health insurance news – February 3, 2021

February 3, 2021/in health reform, HealthCare.gov, mental health coverage, premium subsidies, special enrollment period, The Scoop /by wpmaddoxins

In this edition

  • Special enrollment periods underway (or soon to be underway) in most states
  • House, Senate legislation would make ACA premium subsidies more generous
  • Maryland legislation would create young-adult subsidy pilot program
  • Minnesota legislation calls for transition to HealthCare.gov
  • Minnesota bill would require more robust coverage of outpatient mental health treatment
  • Washington legislation would create state-based premium subsidies
  • Mississippi and Kentucky consider extension of postpartum Medicaid coverage
  • Montana legislative committee advances bill to prohibit abortion coverage for on-exchange plans
  • More states consider bills that would cap out-of-pocket costs for insulin

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:

  • California: February 1 to May 15
  • Colorado: February 8 to May 15
  • DC: Through the end of the pandemic emergency period
  • Maryland: Through March 15
  • Massachusetts: Through May 23
  • Minnesota: February 16 to May 17
  • Nevada: February 15 to May 15
  • New Jersey: Through May 15
  • New York: Through March 31
  • Pennsylvania: February 15 to May 15
  • Rhode Island: Through May 15
  • Washington: February 15 to May 15

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.

https://www.maddoxinsured.com/wp-content/uploads/2021/02/biden-executive-order-healthcare.jpg 1066 2100 wpmaddoxins https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.png wpmaddoxins2021-02-03 14:21:092021-02-04 14:05:51The Scoop: health insurance news – February 3, 2021

Biden administration announces three-month special enrollment period

January 28, 2021/in COBRA, executive order, health reform, open enrollment, special enrollment period /by wpmaddoxins

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

  • restoring funding for navigators and the outreach/education work that HealthCare.gov was able to do under the Obama administration,
  • rolling back the Trump administration’s relaxed rules for short-term health plans (in order to protect people with pre-existing conditions),
  • no longer approving Medicaid work requirements, rolling back the relaxed guardrails for 1332 waivers that the Trump administration championed,
  • changing the way affordability of employer-sponsored plans is calculated (in order to fix the family glitch), and
  • possible solutions that would eliminate the subsidy cliff and make coverage more affordable for people with income a little above 400 percent of the poverty level.

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.

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Biden administration announces COVID-related special enrollment period

January 28, 2021/in Blog, COBRA, executive order, health reform, open enrollment, special enrollment period /by wpmaddoxins

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):

  • California: February 1 to May 15
  • Colorado: February 8 to May 15
  • Connecticut: February 15 to April 15
  • DC: Through the end of the pandemic emergency period
  • Idaho: March 1 to March 31
  • Maryland: Through May 15 (retroactive coverage is available, depending on when a person enrolls)
  • Massachusetts: Through July 23
  • Minnesota: February 16 to May 17
  • Nevada: February 15 to May 15
  • New Jersey: Through May 15
  • New York: Through May 15
  • Pennsylvania: February 15 to May 15
  • Rhode Island: Through May 15
  • Vermont: February 16 to May 14
  • Washington: February 15 to May 15

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

  • restoring funding for navigators and the outreach/education work that HealthCare.gov was able to do under the Obama administration,
  • rolling back the Trump administration’s relaxed rules for short-term health plans (in order to protect people with pre-existing conditions),
  • no longer approving Medicaid work requirements or block grant proposals,
  • rolling back the relaxed guardrails for 1332 waivers that the Trump administration championed,
  • changing the way affordability of employer-sponsored plans is calculated (in order to fix the family glitch), and
  • possible solutions that would eliminate the subsidy cliff and make coverage more affordable for people with income a little above 400 percent of the poverty level.

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?

January 15, 2021/in ACA plan benefits, Coronavirus, covid-19, special enrollment period /by wpmaddoxins

Key takeaways

  • Health insurance – coverage, availability and rules – varies dramatically from state to state.
  • Under the the Families First Coronavirus Response Act, Medicare, Medicaid, and private health insurance plans are required to fully cover the cost of COVID-19 testing.
  • But plans that aren’t considered minimum essential coverage aren’t required to cover COVID-19 testing.
  • H.R.6201 allows states to use their Medicaid programs to cover COVID-19 testing for uninsured residents.
  • All non-grandfathered health plans are required to cover COVID-19 vaccines with no cost-sharing.
  • Coverage of the costs of treatment will vary according to the type of health coverage a patient has.
  • Some states are requiring state-regulated insurers to cover treatment — telehealth in most cases, but some go beyond that.
  • If you’re uninsured, check whether your state is offering a special enrollment period.

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?”

Many Americans who lose their jobs during the coronavirus crisis will be eligible either for Medicaid or for subsidized private plan coverage in the ACA marketplace.

Uninsured in a pandemic? Here are your options.


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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How to buy health insurance during the COVID-19 crisis

January 7, 2021/in Coronavirus, health plan enrollment, short term health insurance, special enrollment period /by wpmaddoxins

Can you buy health insurance now?

  • Open enrollment for 2021 is still ongoing in 10 states and DC, and Maryland has opened a new COVID-related special enrollment period for uninsured residents.
  • If you’re losing your existing health coverage (or if you have another qualifying event or are Native American), you can buy ACA-compliant coverage today, but probably will have to wait until the start of next month before the coverage is in force.
  • If you’ve lost your job due to the pandemic, your loss of income may make you eligible for Medicaid and CHIP – and enrollment is available year-round.
  • Consumers in most states can buy short-term coverage at any time during the year and coverage can be effective within days – often by the next business day (but COVID coverage requirements don’t apply to short-term plans in most states).
  • If you aren’t eligible for a special enrollment period (or Medicaid, Medicare, or CHIP), you can’t buy ACA-compliant coverage until open enrollment.
  • People with modest incomes in New York, Minnesota, and Massachusetts can enroll in health programs year-round.

The COVID-19 pandemic has caused millions of Americans to lose their jobs, and in many cases, that means losing health insurance as well. About half of all Americans get their health insurance from an employer’s plan, and it’s a cruel irony that so many people have lost their jobs in the midst of a time when we need health coverage more than ever. A Commonwealth Fund analysis found that by June 2020, nearly 15 million Americans had lost their employer-sponsored health insurance. And about 5.4 million of them became uninsured (as opposed to switching to another form of health coverage), resulting in the largest-ever increase in the uninsured rate.

But the good news is that loss of coverage triggers a special enrollment period during which you can buy ACA-compliant individual health insurance. You can buy your new coverage on- or off-exchange, although premium subsidies and cost-sharing reductions are only available through the exchange.

Loss of a job does not, in and of itself, trigger a special enrollment period. The special enrollment period only applies if you’re losing health coverage (the plan you had must have been minimum essential coverage – which all employer-sponsored plans are – and you can’t have voluntarily canceled the plan or lost it due to non-payment of premiums).

A drop in income that makes a person newly-eligible for financial assistance in the exchange will trigger a special enrollment period during which a person can switch plans – but that only applies if they already had minimum essential coverage in place before the income change.

If you’re uninsured, whether it’s a recent development or a long-term situation, you may still be able to obtain coverage for 2021. Here’s a summary of your options:

1. ACA-compliant coverage via extended open enrollment or a COVID-19 special enrollment period

A handful of states are offering special enrollment periods in response to the coronavirus pandemic.

Click to see which states are offering special enrollment periods in response to the coronavirus pandemic.

In most states, open enrollment for 2021 health plans ran from November 1 to December 15, 2020. This gave people an opportunity to sign up for new individual/family health coverage if they needed it. And in 10 states and DC, open enrollment is still underway as of early January 2021.

In addition, Maryland has opened another COVID-related special enrollment period for uninsured residents (people who don’t currently have minimum essential coverage), which will continue through March 15, 2021. Unlike normal enrollment period rules, Maryland is allowing retroactive coverage in some cases, and effective dates that are never more than two weeks after the enrollment is submitted.

Maryland previously offered a COVID special enrollment period that ran from March to December in 2020. Most of the other fully state-run exchanges also offered special enrollment periods in 2020 to address the COVID pandemic, allowing people without health coverage a chance to sign up without having to wait for open enrollment or experience a specific qualifying event. But with the exception of Maryland, those windows are no longer ongoing.

Most states use HealthCare.gov, which is run by the Department of Health and Human Services (HHS). Throughout 2020, the Trump administration refused to open a special enrollment period through HealthCare.gov – despite the fact that several states that use the federally run exchange asked HHS to do so. The Biden administration might open a COVID-related special enrollment period after taking office in January 2021; this is one of the recommendations that state insurance commissioners have made to President-elect Biden, and it’s well within the scope of immediate changes the incoming administration could make to ensure more people are covered.

The takeaway point here is that if you’re uninsured, you’ll want to check to see if open enrollment is ongoing in your state (it continues through the end of January in a few states), and keep an eye out to see if a COVID-related special enrollment period becomes available via HealthCare.gov. If you’re eligible to enroll — either because the exchange is offering an extended enrollment period or a special enrollment period, or because you’ve experienced a qualifying event — it’s in your best interest to enroll in an ACA-compliant plan as quickly as possible.

2. Loss-of-coverage special enrollment period (and other SEPs that might apply to your situation)

If you’re in a state where open enrollment has ended, you’ll need to have a qualifying event in order to enroll in coverage. Our guide to qualifying events and special enrollment periods covers all of the details about how these work, including rules for effective dates and prior coverage requirements.

And if your income has taken a hit, know that if you enroll in a plan through the exchange during a special enrollment period, you may qualify for financial assistance (premium subsidies and cost-sharing subsidies). Use this subsidy calculator to estimate the size of your subsidy.

For most qualifying events, your coverage will take effect either the first of the next month, or the first of the month after that, depending on how late in the month you enroll. Typically, if you enroll during the first 15 days of the month, your coverage will take effect on the first day of the next month. Enroll after the 15th and coverage won’t kick in until the first of the following month.

But the effective date rules are different if your qualifying event is the loss of your existing health coverage. If you’re losing your coverage, you can enroll up until the last day you have coverage and your new plan will take effect the first of the following month. Since health plans usually terminate on the last day of a month, this means you can have seamless coverage in most cases, as long as you enroll by the day that your old plan ends, and assuming your old plan is ending on the last day of the month (if your plan is ending on a day other than the last day of the month, it will likely not be possible to have seamless coverage unless you’re able to qualify for Medicaid). So for example, if you’re getting laid off and your employer-sponsored coverage is going to end on January 31, you have until January 31 to enroll in a new plan (on- or off-exchange) and your coverage will take effect August 1.

It’s important to understand that in many cases, you’re only eligible for a special enrollment period if you already had some sort of minimum essential coverage in place before the qualifying event – this is obviously true if your qualifying event is loss of coverage, but it’s also true for several other qualifying events. You can read more about the rules for each type of qualifying event here.

Native Americans can enroll in plans through the exchange year-round, although the coverage doesn’t take effect until the first of the next month or the first of the month after that, depending on the enrollment date. As is the case with special enrollment periods, Native Americans must enroll by the 15th to have coverage effective the first of the next month.


Not eligible for a SEP or Medicaid (or CHIP, a Basic Health Program, Medicare, etc.)? Unless a blanket COVID special enrollment period is opened via HealthCare.gov (and other state-run exchanges follow suit), you’ll have to wait until next fall’s open enrollment to buy coverage, and the plan won’t take effect until next January. But as described below, a short-term health insurance plan might still be an option, and it would allow you to have coverage this year.

3. Losing your income? Apply for Medicaid.

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Millions of Americans have faced a sudden drop in income as a result of the COVID-19 pandemic. But the majority of the states have expanded Medicaid under the Affordable Care Act, which allows residents with low income (up to 138 percent of the poverty level) to enroll in Medicaid.

Medicaid enrollment is year-round, as is CHIP (Children’s Health Insurance Program) enrollment. And CHIP eligibility extends to higher income levels than Medicaid. For both Medicaid and CHIP eligibility, income is calculated on a monthly basis, so they are available if your current income is within the eligible range – even if your income later in the year is expected to be much higher.

Medicaid coverage can also be immediate, or backdated to the first of the month or even a previous month, depending on the state and the circumstances. (States can seek federal approval to eliminate prior month retroactive coverage availability, and some have done so under the Trump administration). So you won’t have to wait for your Medicaid coverage to take effect.

In states that have not expanded Medicaid, coverage is not available based solely on income; low-income residents have to also meet other criteria, such as being pregnant, caring for minor children, being elderly, or being disabled. But if you’re facing a loss of income, you’ll want to check with your state’s Medicaid program to see if you might be eligible for coverage.

When your income picks back up in the future and makes you ineligible for Medicaid, that will trigger a loss-of-coverage special enrollment period during which you can enroll in a private individual market plan or an employer-sponsored plan if one is available to you. Note that in order to qualify for the additional federal Medicaid funding that’s being provided to states to address the COVID-19 pandemic, states cannot take action to terminate Medicaid coverage until after the COVID-19 emergency ends. Your Medicaid coverage can be terminated if you request it — perhaps because you become eligible for a new employer’s plan, or your income increases enough to make you eligible for premium subsidies in the exchange — or if you move out of state. But otherwise, your Medicaid coverage should continue until the end of the COVID-19 emergency period. If you request a termination or move out of state, however, your Medicaid coverage will end and that will trigger a special enrollment period during which you can sign up for a private plan.

This federal poverty level calculator will help you determine whether you meet the Medicaid eligibility level for your state. Your eligibility for ACA subsidies also depends on your income and percentage of the federal poverty level (FPL).

  • Related: Frequently asked questions about eligibility for health insurance.

4. The short-term fix

For millions of Americans who aren’t eligible for a SEP or Medicaid, buying a short-term medical plan offers the fastest way to get some level of coverage in place. Short-term plans aren’t ACA-compliant, but can still provide protection from catastrophic medical expenses – and you can purchase the plans at any time during the year.

That means you could buy a short-term plan today and – if you’re approved through the underwriting process – you could have coverage in force as soon as tomorrow.

Short-term coverage is temporary, but federal regulations now allow short-term plans to have initial terms of up to 364 days, and total duration, including renewals, of up to three years. Many states have their own rules, however, that limit short-term plans to shorter durations than the federal rules allow.

Many short-term health plans have voluntarily agreed to waive cost-sharing for COVID-19 testing. But the general rules that the federal government imposed to require insurers to fully pay for COVID-19 testing and COVID-19 vaccines do not apply to short-term plans, so their actions on this are voluntary rather than mandated (unless a state takes action to further regulate short-term plans). And although many ACA-compliant health plans agreed to temporarily waive cost-sharing for COVID-19 treatment in 2020 (as opposed to just testing, as required by law), very few short-term plans agreed to take this step.

And the basic rules of thumb for short-term plans still apply: Pre-existing conditions are generally not covered at all, and insurers will tend to look back at your medical records if and when you have a claim, to make sure that the claim isn’t related to any condition you might have had before enrolling. Short-term plans are also not required to cover the ACA’s essential health benefits, which means that some of the treatment you might need for COVID-19 (or other conditions) might not be covered at all by the plan. Many short-term plans do not, for example, cover outpatient prescription drugs. Others place limits on how much they’ll pay for inpatient hospital care.

  • Related: Read about short-term plan availability in your state.
  • Related: Is short-term health insurance right for you?
  • Related: ‘So long’ to limits on short-term plans?

5. NY, MN, and MA residents with fairly low income can enroll year-round

New York and Minnesota have Basic Health Programs (the Essential Plan and MinnesotaCare), both of which offer year-round enrollment and are available to residents with income up to 200 percent of the poverty level.

Massachusetts has a program called ConnectorCare, which is available to residents with income up to 300 percent of the poverty level. ConnectorCare enrollment is available year-round, but only for people who are newly eligible or who haven’t enrolled previously.

If you’re in one of these states and have an eligible income, you may still be able to sign up for coverage regardless of what time of year it is.


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 How to buy health insurance during the COVID-19 crisis appeared first on healthinsurance.org.

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The Scoop: health insurance news – January 6, 2021

January 6, 2021/in covid-19, health reform, immigrant coverage, open enrollment, short term health insurance, special enrollment period /by wpmaddoxins

In this edition

  • Democrats win both Georgia Senate races, paving way for federal health policy reforms
  • Maryland opens a new COVID-related special enrollment period
  • Open enrollment ends in five states on January 15
  • Legislation introduced in New York to create a health insurance guaranty fund
  • North Dakota legislation calls for longer but more robust short-term health insurance plans
  • Haven shutting down three years after beginning a joint venture to improve healthcare quality and affordability
  • Appeals court panel allows Trump administration to deny visas to immigrants without health insurance, but Biden expected to reverse this rule
  • California prohibits insurers from denying gender-affirming medical care based on age
  • New prior authorization consumer protections in Minnesota

Democrats win both Georgia Senate races, paving way for federal health policy reforms

The biggest health policy news this week is the victory of both Rev. Raphael Warnock and Jon Ossoff in Georgia’s runoff Senate races. Their wins bring the Senate to a 50-50 split, with Vice President-elect Kamala Harris casting tie-breaking votes as necessary. There is a wide range of administrative health policy actions that the Biden administration will be able to implement without involving Congress, but the shift in power in the Senate opens the door for a variety of changes that require legislation but that can be accomplished with just 51 votes in the Senate – including making the California v. Texas lawsuit moot before the Supreme Court issues its ruling later this year.

Maryland opens new COVID-related special enrollment period

Maryland was one of just two state-run exchanges that opted to not extend open enrollment for 2021 coverage. But Maryland announced this week a new COVID-related special enrollment period for uninsured residents, which will continue through March 15. Maryland previously offered one of the nation’s longest COVID-related special enrollment periods, which began last March and continued through December 15, 2020. The new special enrollment period offers the same generous effective date rules that the state was using in 2020, allowing uninsured residents to sign up for coverage with an effective date that’s either retroactive or no more than two weeks after the date they enroll. Uninsured Maryland residents who enroll by January 15 will have coverage backdated to January 1.

Open enrollment ends in five states on January 15

Open enrollment for individual/family health plans is still ongoing in ten states and DC. But it ends next Friday, January 15, in five of those states:

  • Colorado
  • Connecticut
  • Pennsylvania
  • Nevada
  • Washington

Residents in those states can still enroll in a plan with a February 1 effective date. But after January 15, a qualifying event will be necessary in order to enroll.

Legislation introduced in New York to create a health insurance guaranty fund

Legislation has been introduced in New York that would create a health insurance guaranty fund that would step in to cover unpaid claims if a health insurance company becomes insolvent. Most states already have health insurance guaranty funds, but New York’s existing guaranty fund covers life insurance companies but not health insurance companies.

New York’s legislature considered similar legislation in 2016 after New York’s health insurance CO-OP failed (and again in each of the subsequent legislative sessions). But it was opposed by both Gov. Cuomo and the state’s health insurers, who objected to the assessment that would have been charged to fund the program. The current bill has 35 sponsors in New York’s Assembly, all of whom are Democrats.

North Dakota legislation calls for longer but more robust short-term health insurance plans

Legislation (SB2073) has been introduced in North Dakota, at the request of Insurance Commissioner Jon Godfread, that would allow for short-term health insurance plans with longer durations but also stronger consumer protections. Under North Dakota’s current rules, short-term health insurance plans can have terms of no more than 185 days. One renewal is permitted, but the total duration of these plans cannot exceed one year, including the renewal period.

The newly introduced legislation calls for the state to allow association short-term limited duration health plans to follow current federal rules, which means they could have total durations of up to 36 months. But while federal rules allow short-term plans to be renewable (for up to 36 months in total), North Dakota’s SB2073 would require association short-term plans to be renewable at the option of the insured.

SB2073 would also require association short-term health plans to cover all of the ACA’s essential health benefits, with the exception of pediatric dental and vision services. This would be a significant change, as short-term health plans are not currently required to cover essential health benefits, and most tend to lack coverage in at least a few of the essential health benefit categories.

Haven closing three years after beginning joint venture to improve healthcare quality and affordability

Three years ago, Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. announced a new partnership to “address healthcare for their U.S. employees, with the aim of improving employee satisfaction and reducing costs.” Their new joint venture, named Haven, was an independent entity, “free from profit-making incentives and constraints,” which set out to shake up the conventional health insurance model and provide “simplified, high-quality and transparent healthcare at a reasonable cost.”

But as David Anderson noted at the time, this was never going to be an easy road. And Haven announced this week that it will no longer exist as an independent entity as of the end of February. Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. plan to “continue to collaborate informally” as they work on health care solutions for their own employees, but they’re winding down their joint venture.

Appeals court panel allows Trump administration to deny visas to immigrants without health insurance, but Biden expected to reverse this rule

More than a year ago, the Trump administration issued a proclamation that requires immigrants to have health insurance – or proof that they would have coverage within 30 days of entering the country – in order to obtain a visa. The rule was blocked by a judge before it could take effect, but a three-judge panel for the U.S. Court of Appeals for the Ninth Circuit overturned that injunction last week in a 2-1 ruling.  The court’s ruling does not take effect immediately, however, and the Biden administration is expected to overturn the rule soon after taking office, making it unlikely that the health insurance requirements for immigrants will be implemented.

California prohibits insurers from denying gender-affirming medical care based on age

Last week, the California Department of Insurance notified health insurers in the state that they cannot deny coverage solely based on age when an insured is undergoing a gender-affirming female-to-male transition and seeking male chest reconstruction surgery. The Department was made aware of several insurers that had denied these claims solely due to the patient being under the age of 18, and took action to address the issue. The state’s letter to insurers clarifies that mastectomy and male chest reconstruction can be carried out while the person is still a minor, and that any claims decisions should be made on a case-by-case basis and cannot discriminate based on age.

New prior authorization consumer protections in Minnesota

A new law took effect on January 1 in Minnesota, expanding consumer protections with regards to prior authorization in health insurance. When a consumer switches from one health plan to another, the state now requires the person’s new insurer to honor, for at least the first 60 days, any prior authorizations that had been granted by the prior insurer. The new law also prohibits insurers from revoking already-approved prior authorizations unless the authorization was based on fraud or misinformation or was in conflict with state or federal law. And insurers are required to publicize a wide range of data pertaining to prior authorizations, making it easier for consumers to see how frequently these requests are approved or denied, and the reasons that prior authorization requests are rejected.


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 – January 6, 2021 appeared first on healthinsurance.org.

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Qualifying events that can get you coverage

January 6, 2021/in citizenship, CO-OP, Consumer Operated and Oriented Plans, divorce, employer-sponsored health plan, federally facilitated exchange, health insurance exchange, health insurance marketplace, health plan enrollment, marriage, off-exchange plans, pre-existing condition, qualified health plan, qualifying event, special enrollment period /by wpmaddoxins

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.

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 wpmaddoxins2021-01-06 01:46:262021-01-07 15:01:28Qualifying events that can get you coverage

The Scoop: health insurance news – December 2, 2020

December 2, 2020/in health reform, mental health coverage, open enrollment, special enrollment period, The Scoop /by wpmaddoxins

In this edition

  • Open enrollment ends in 13 days in most states
  • Oregon’s bipartisan congressional delegation asks HHS to extend open enrollment
  • Washington Healthplanfinder accepting public comments on standardized plan designs for 2022
  • Delaware fines insurers nearly $600,000 for mental health parity violations
  • Proposed health insurance rule changes include waiver allowing states to eliminate exchanges

Open enrollment ends in 13 days in most states

In most of the United States, open enrollment for individual/family health plans is scheduled to end in just 13 days – on December 15. If you haven’t yet figured out your health coverage for next year, now’s the time to get that done!

open enrollment 2021

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

In 10 states and Washington, DC, the end of open enrollment has been extended, with deadlines that vary by state and continue well into January in some cases.

There are four other states (Connecticut, Idaho, Maryland, and Vermont) that run their own enrollment platforms and thus have the option to extend open enrollment if they choose to do so, although it’s still scheduled to end on December 15 in each of those states. In the rest of the country, the federal government runs the exchange and has control over the timing of open enrollment, currently slated to end December 15.

Oregon’s bipartisan congressional delegation asks HHS to extend open enrollment

Oregon’s entire bipartisan congressional delegation sent a letter to HHS this week, asking the federal government to extend the open enrollment period on HealthCare.gov. Oregon, like most of the rest of the country, relies on the HealthCare.gov enrollment platform, which means the state is unable to extend the enrollment deadline on its own.

The Oregon lawmakers pointed out that the COVID pandemic and this year’s devastating wildfires in Oregon are making it harder for people to enroll in health coverage for 2021 in a timely manner. They’re asking HHS to grant some extra flexibility by giving people until the end of December – instead of December 15 – to enroll in a health plan for 2021.

Washington Healthplanfinder accepting public comments on standardized plan designs for 2022

Washington State rolled out standardized plans in the individual market for the first time this fall. For the last month, some consumers in the state have been enrolling in these plans for 2021 coverage, but Washington’s exchange has already done much of the work to complete the standardized plan designs for 2022. They have publicized the draft plan designs, and are accepting public comments on the proposed plan designs through December 29. Comments can be emailed to standardplans@wahbexchange.org.

Delaware fines insurers nearly $600,000 for mental health parity violations

Delaware’s recently re-elected insurance commissioner, Trinidad Navarro, has imposed nearly $600,000 in fines for mental healthy parity violations by health insurers in the state. The Delaware Department of Insurance conducted a review of all four of the state’s major health insurers, checking for compliance with state and federal mental health parity requirements. (In general, the plan requirements and benefits provided for mental healthcare cannot be any more strict than the requirements and benefits that apply to other medical care.)

After finding “thousands” of violations, Delaware regulators worked with the insurers to remedy the problems and create more equitable access to mental health coverage and care in the state.

Proposed health insurance rule changes include waiver allowing states to eliminate exchanges

Last week, CMS published the proposed Notice of Benefit and Payment Parameters for 2022 (summary available here). Many aspects of the ACA were left up to HHS/CMS to implement and require ongoing adjustments, so CMS issues this rulemaking guidance each year. There’s a 30-day public comment period, and it appears that the Trump administration is hoping to finalize the proposed rules before the Biden administration takes over on January 20, 2021.

The proposed benefit and payment parameters cover a wide range of issues, as is always the case. But the following proposals are the ones that are most likely to directly affect you and your health insurance coverage:

  • Allow states to eliminate their exchanges: This is generally considered the most dramatic change that CMS has proposed for 2022, and it’s very similar to the waiver approval that it granted to Georgia last month. If finalized, this rule change would allow states to eliminate their central exchange (HealthCare.gov or a state-run exchange) and switch to a system of direct enrollment via brokers, agents, and insurers. Many people already enroll in on-exchange plans via the enhanced direct enrollment pathway, utilizing a third party’s website instead of the exchange website. But there are widespread concerns that consumers will fall through the cracks in states that opt to abandon their exchange platforms altogether – potentially having to visit multiple websites in order to get comprehensive information, not being able to learn about their eligibility for programs like Medicaid and CHIP, or being sold lesser quality coverage, such as short-term health insurance.
  • Maximum out-of-pocket increasing to $9,100: Under the ACA, health plans that aren’t grandfathered or grandmothered (or excepted from ACA rules altogether) must cap in-network out-of-pocket costs for their enrollees. But this cap changes each year, under a formula that has evolved over time. This year, the maximum out-of-pocket for a single person was $8,150. Next year, it will be $8,550. And for 2022, CMS has proposed a maximum out-of-pocket limit of $9,100. (The family cap is always double the individual amount.) Many plans will continue to have lower out-of-pocket caps, although catastrophic plans have the maximum allowable out-of-pocket exposure, as do most bronze plans.
  • More flexible SEP for people who lose eligibility for premium subsidies: Under current rules, a person who is receiving a premium subsidy (premium tax credit) qualifies for a special enrollment period if they become ineligible for that premium subsidy mid-year (either due to an income change or a change in household size), but they’re limited to picking a different plan at the same metal level as the plan they already have. CMS is proposing a more flexible special enrollment period that would also allow the option of switching to a plan at a lower metal level in order to give people the opportunity to reduce their monthly premiums as much as possible. Here are all the details.
  • New SEP when employer terminates contributions to COBRA premiums: In some cases, employers subsidize the cost of COBRA benefits for a certain period of time – this has been particularly common this year amid the widespread layoffs that stemmed from the COVID pandemic. When that subsidy ends, the full cost of the COBRA coverage can be unaffordable, but there’s not technically a special enrollment period for this situation, as it’s not among the official triggering events. CMS notes that people enrolling through HealthCare.gov have been granted a loss-of-coverage SEP in this situation, but the proposed rule change would add this as an official qualifying event for individual market coverage, making it applicable nationwide, both on-exchange and off-exchange.
  • New affordability threshold for catastrophic plan eligibility: People who are 30 and older can only buy a catastrophic plan if they have a hardship/affordability exemption from the exchange, indicating that the lowest-cost metal-level plan available to them would cost more than a certain percentage of their income. In 2020, that threshold is 8.24 percent. For 2022, CMS has proposed an increase to 8.47 percent.
  • MLR rebates: Earlier this year, to address the COVID pandemic, CMS issued guidance that allowed insurance companies to issue medical loss ratio (MLR) rebates earlier than usual. CMS is proposing a rule change that would essentially make this year’s relaxed rules permanent, allowing insurers the option to prepay MLR rebates rather than waiting until the fall to issue them.

At Health Affairs, Katie Keith has three detailed articles about the proposed benefit and payment parameters: One addressing rules related to the health insurance exchanges, a second addressing the MLR rules, and a third addressing the rules related to risk adjustment.


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 – December 2, 2020 appeared first on healthinsurance.org.

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