To assist property insurers in reducing losses and speeding up recovery from natural disasters, the National Association of Insurance Commissioners’ (NAIC) adopted the first-ever National Climate Resilience Strategy for Insurance. Developed under the coordination of the NAIC’s Climate and Resiliency …
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The U.S. Senate on Wednesday passed a resolution that would overturn a federal agency’s rule requiring states to measure and set declining targets for greenhouse gas emissions from vehicles using the national highway system. The Federal Highway Administration rules were …
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The US Federal Trade Commission is asking Congress to change the law so it can handle its own privacy settlements and other consumer protection cases that it’s currently forced to refer to the Justice Department. The DOJ has been slow-walking …
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The U.S. Centers for Disease Control and Prevention (CDC) said on Monday bird flu risk to the public remains low even as it asked the state public health officials to be prepared to respond. The agency asked for plans to …
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It was another record-breaking year for vehicle thefts in 2023, with more than one million vehicles reported stolen – an overall increase of 1% nationwide from 2022 to 1,020,729 last year. A report from the National Insurance Crime Bureau shows …
https://www.maddoxinsured.com/wp-content/uploads/2024/04/car-thief-breaking-into-car-126185009-bigstock-580x387-1.jpg387580wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2024-04-10 11:08:112024-04-10 15:02:01National Crime Report Shows Vehicle Thefts Surged to More than 1 Million in 2023
Farmers Insurance Names Coleman President of Business Insurance Farmers Insurance announced that Eric Coleman has joined the organization as president of Business Insurance, effective April 10. In this role, Coleman is responsible for leading commercial underwriting, product, strategy, finance and …
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2024-04-10 10:37:492024-04-10 15:02:01People Moves: Farmers Insurance Names Coleman President of Business Insurance
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2024-04-10 10:00:002024-04-10 15:01:49Farmers Insurance® Names Eric Coleman as President of Business Insurance
Boeing Co. faces a deepening crisis of confidence after an engineer at the US planemaker alleged the company took manufacturing shortcuts on its 787 Dreamliner aircraft in order to ease production bottlenecks of its most advanced airliner. Factory workers wrongly …
https://www.maddoxinsured.com/wp-content/uploads/2024/04/workers-assemble-boeing-787-bloomberg-580x387-1.jpg387580wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2024-04-10 09:54:542024-04-10 15:02:02Boeing Crisis of Confidence Deepens With 787 Now Under Scrutiny
Slice Labs Inc., the New York-based insurtech that operates an on-demand insurance platform, has expanded into seven additional states and the District of Columbia with its contractors general liability insurance product for small businesses. Coverage purchased on Slice’s platform is …
https://www.maddoxinsured.com/wp-content/uploads/2024/04/bigstock-business-development-growth-368044879-580x302-1.jpg302580wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2024-04-10 07:36:522024-04-10 15:02:03Markets/Coverages: Insurtech Slice Expands Contractors General Liability Insurance Offering, Backed by Philadelphia Insurance
A freshly formed hacking gang claims to have won access to a massive stash of data stolen from UnitedHealth Group, the largest U.S. health insurer, but with little evidence to go on it is not clear whether they are telling …
https://www.maddoxinsured.com/wp-content/uploads/2024/04/cyber-security-768x512-1-580x387-1.jpg387580wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2024-04-10 06:27:432024-04-10 15:02:04Hackers Claim to Have UnitedHealth’s Stolen Data – But Is It a Bluff?
Executive Summary: While the advancement of technology in electric vehicles and other lithium-ion powered goods facilitates energy transition from fossil fuels, the fire risks associated with such products need proactive management, writes Dr. William Moore, global loss prevention director, The …
https://www.maddoxinsured.com/wp-content/uploads/2024/04/smoke-billows-from-burning-felicity-ace-AP-580x435-1.jpg435580wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2024-04-10 05:35:522024-04-10 15:02:05Viewpoint: Striking Risk-Reward Balance for Shipping Lithium-Ion Batteries
A finalized federal rule announced by the Departments of Treasury, Health and Human Services, and Labor on March 28, will impose new nationwide duration limits on short-term limited duration insurance (STLDI) plans.
The rule – which applies to plans sold or issued on or after September 1, 2024 – will limit STLDI plans to three-month terms, and to total duration including renewals of no more than four months.
A “renewal” will include a new policy issued by the same insurer (or another insurer in the same controlled group, meaning they’re treated as a single employer)) within 12 months of the effective date of the first policy. So a person will not be able to purchase multiple consecutive policies – a practice known as “stacking” – from the same insurer or an affiliated insurer. The part of the rule helps to avoid scenarios in which consumers enroll in multiple STLDI policies without realizing that it isn’t comprehensive coverage.
Why did the federal government implement this rule?
As the author has previously noted, the changes are designed to ensure that short-term coverage is used to fill a temporary gap between two comprehensive policies, rather than serving as a long-term coverage solution. Since STLDI is “excluded from the definition of individual health insurance” and is thus not regulated by federal rules such as the Affordable Care Act, the No Surprises Act, the Mental Health Parity and Addiction Equity Act, etc., the federal-level consumer protections for STLDI enrollees are limited.
The rule is also intended to make it easier for consumers to distinguish between ACA-compliant individual/family health insurance and STDLI and thus reduce the number of people who inadvertently purchase short-term coverage when trying to buy comprehensive coverage.
STLDI plans sold on or after Sept. 1, 2024 will need to include an updated and comprehensive disclosure notice that highlights the major differences between STLDI and ACA-compliant individual/family health insurance sold through the Marketplace.
The disclosure, which is illustrated on page 102 of the final rule, must be displayed on the first page of the policy/contract and any associated marketing or enrollment materials.
How does the rule affect STLDI plans currently in effect?
Under the new rules, there is no change to STLDI policies that are already in effect, or policies that are sold and issued before Sept. 1, 2024. The current rules continue to apply to those policies.
This means policy durations of plans that are sold and issued prior to Sept. 1, 2024 are up to the states and the insurers as long as the policies don’t have initial terms of more than 364 days or total duration of more than 36 months.
How will state regulations be affected by the rule?
As has been the case with previous federal rules for STLDI, states can impose stricter rules but not more lenient rules regarding STLDI duration.
So for example, a state will be able to limit STLDI to a duration of under four months (or ban them altogether, as some states have already done) or prohibit the sale of a second STLDI policy within 12 months – even if it’s issued by a different insurer.[footnote “States Step Up to Protect Insurance Markets and Consumers from Short-Term Health Plans” Commonwealth Fund. May 2, 2019]
In most of the country, current STLDI duration limits vary from six months up to the maximum 36 months allowed under current federal rules. STLDI plans sold in those states will have to come into compliance with the new federal rules starting with plans issued on or after Sept. 1, 2024.
In another three states — Delaware, Maryland, and Oregon — short-term health insurance is available but already limited to three months in duration, so the new rules won’t change anything about STLDI durations in those states. (Virginia also limits initial terms to three months but allows the total duration to extend to six months.1 So plans in Virginia will be further limited by the new federal rules.)
How many people have short-term health insurance?
It’s difficult to pin down the exact number of enrollees, as data reporting of STLDI coverage is not consistent across states. The final rule cites a 2023 report from the National Association of Insurance Commissioners, which indicated that 235,775 people were covered by short-term health plans at the end of 2022.2
But, as noted in the final rule, that doesn’t include people who had STLDI for only part of the year, nor does it include people with association-based STDLI coverage, which is a significant portion of the market.
The final rule (see page 163) also notes that the Congressional Budget Office and the Joint Committee on Taxation had previously estimated that as many as 1.5 million people might be enrolled in STLDI. But the rule also clarified that was before the ACA’s premium subsidies were enhanced by the American Rescue Plan and Inflation Reduction Act – legislation that made Marketplace coverage more affordable and perhaps reduced the number of people who opted for STDLI.
Will people with STLDI have a special enrollment period to switch to individual/family coverage?
No. The final rule (page 68) notes that while there is already a special enrollment period (SEP) for group health insurance when an STLDI policy terminates, there is no similar SEP for individual/family health coverage. That will continue to be the case under the new rule.
States that operate their own health insurance Marketplaces are allowed to establish SEPs that differ from those available through the federally run Marketplace, HealthCare.gov. But HealthCare.gov, the Marketplace platform in 32 states, will continue its current protocol of not allowing a SEP due to the termination of a short-term health insurance policy.
However, as we’ll discuss below, the timing of the new rule is designed to ensure that people can purchase a STLDI plan that can continue through the end of 2024 (assuming they’re healthy enough to enroll in STLDI and assuming that insurers in their state offer STLDI with the maximum allowable four-month duration). By then utilizing the open enrollment period for ACA-compliant coverage, the consumer would be able to transition without interruption in coverage to an individual-market policy that starts on January 1, 2025, if they choose to do so.
What can people do when their short-term policy terminates?
The current maximum duration limit for policies sold or issued before September 1, 2024 varies by state, and it’s also important to understand that insurers can further limit their short-term policies beyond what state or federal rules allow. (An insurer can, for instance, cap total policy durations at six months, even if state and federal rules allow for 36 months.)
If a person enrolls in a new STLDI plan on or after September 1, the plan will be allowed to cover them through the end of 2024, as that will be no more than four months away. But again, four months will be the maximum allowable duration, not the required duration. Insurers will be able to offer, for example, a three-month policy that isn’t renewable. For this reason, consumers need to be well-informed about their policy details.
Assuming a person purchases a policy with a four-month duration that starts on September 1, they will be able to select a non-temporary major medical plan for calendar year 2025 during open enrollment for individual/family coverage which will be effective as early as January 1, 2025. Open enrollment begins on November 1, 2024. This will allow them to avoid having a coverage gap.
If a person chooses to purchase or renew an existing longer-term STLDI policy before the end of August 2024, their plan termination dates will vary depending on the plan they choose. For example, a policy purchased while the current rules are still in effect might last for six months (i.e., into early 2025) or it might last for 36 months. This is where consumers will need to be vigilant in understanding the implications of what they’re purchasing.
If they buy a six-month, non-renewable short-term policy that takes effect August 15, 2024, it will terminate in mid-February 2025. At that point, open enrollment for ACA-compliant 2025 individual/family coverage will be over.
The person will not be able to switch to an ACA-compliant plan unless they have a qualifying life event that triggers a special enrollment period (note here that some special enrollment periods are only available if the person had prior minimum essential coverage, and STLDI is not considered minimum essential coverage.)
Under the terms of the final rule, consumers will still be able to buy another STLDI policy from a different insurer after their policy ends.
But this will depend on their health status, as the new insurer will be able to use medical underwriting.
Marketplace coverage is available
More than 21 million people enrolled in Marketplace plans during the open enrollment period for 2024 coverage. About 92% of them qualified for advance premium tax credits that reduced their average monthly premiums to just $74/month.3
These Marketplace policies cover the ACA’s essential health benefits without any annual or lifetime caps on how much the plan will pay. They have caps on out-of-pocket costs, cover pre-existing conditions, and don’t base premiums on gender or medical history, unlike STLDI policies.
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.
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The tax filing deadline is April 15, 2024. If anyone in your household had a Marketplace plan in 2023, use Form 1095-A, Health Insurance Marketplace®, to file your federal taxes. You’ll get this form from the Marketplace, not the IRS.
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It’s important to review your Form 1095-A and reconcile your premium tax credit because it could impact your refund or the amount of taxes you owe.
If you (or anyone in your household) qualified for or used the premium tax credit to lower your Marketplace plan premium:
Use your Form 1095-A to fill out IRS Form 8962 (PDF, 110 KB) to reconcile — to check if there’s any difference between the premium tax credit you used and the amount you actually qualify for on your taxes.
You’ll include Form 8962 with your federal tax return.
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2024-03-06 19:00:002024-03-07 14:11:20File your taxes using Form 1095-A, Health Insurance Marketplace Statement®
Make sure your household and coverage information, the “second lowest cost Silver Plan” amount, and the monthly premium are correct.
If you find a mistake, contact the Marketplace Call Center.
“Reconcile” with your Form 1095-A
If you qualified for or used the premium tax credit to lower your Marketplace plan premium:
Use the information from your Form 1095-A to complete Part II of Form 8962 (PDF, 110 KB).
If there’s a difference between the amount of the premium tax credit you used during the year and the amount you actually qualify for, it will impact your refund or the amount of taxes you owe.
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The federal government has proposed a wide range of health insurance rule changes for 2025 and – if approved – they’re likely to affect Marketplace enrollment deadlines and plan benefits as well as enrollees’ transition from Marketplace coverage to Medicare.
Two agencies – the Centers for Medicare & Medicaid Services (CMS), and Department of the Treasury – proposed the rule changes in November 2023 and have already accepted public comments on the proposals. The final rule, including potential modifications to the initial proposals, will be published in early 2024.
The proposed rule addresses a wide range of issues. Let’s take a look at six that are most likely to have a direct effect on Marketplace consumers in 2025 and future years:
1. Open enrollment start dates would be standardized in state exchanges
The proposed rule would require state-run exchanges to more closely align their open enrollment periods with the federal exchange, HealthCare.gov, beginning open enrollment on November 1, and ending it no earlier than January 15. This rule could help reduce confusion for consumers in some states.
Under current rules, the open enrollment period for the federally run Marketplace, HealthCare.gov, (used in 32 states) runs from November 1 to January 15, and most state-run exchanges follow the same schedule.
But state-run exchanges can have different start dates (Idaho’s starts in mid-October and New York’s starts in mid-November) and different end dates, as long as the end date isn’t before December 15. Idaho currently ends open enrollment on December 15, and is the only state where open enrollment ends before January 15.
If finalized, this rule change would require Idaho to change both the start and end dates of its open enrollment period, and New York would have to change its start date. And state-run exchanges created after these rules go into effect would also have to follow the standardized schedule of November 1 through at least January 15.
2. Special enrollment period effective dates would be standardized
The proposed rule would require state-run exchanges to have first-of-the-following-month effective dates for applications submitted at any time during a calendar month during special enrollment periods.
Starting in 2022, HealthCare.gov switched to this approach. Before that, HealthCare.gov and most of the state-run exchanges required an application to be submitted by the 15th of the month for the coverage to be effective the first of the following month. (Some qualifying life events, including marriage, loss of other coverage, and birth/adoption, had more flexible enrollment deadlines.) This meant that an application submitted on June 20 would have an August 1 effective date. But under the protocol that HealthCare.gov and some state-run exchanges adopted in 2022, that application now gets a July 1 effective date.
When HealthCare.gov switched to the new rules under which coverage is effective at the start of the next month – regardless of the day of the month the application was submitted during a special enrollment period – it was optional for state-run-exchanges to also make the change. Some have since adopted the same approach, but others have not.1
If the proposed rule is adopted, consumers in every state will be able to get coverage effective as of the first of the month following their application during a special enrollment period, regardless of the date they apply. The goal? Minimizing gaps in coverage by reducing the amount of time that people in some states currently have to wait for their SEP enrollments to take effect.
This proposed rule did not generate much feedback in the public comments, but there were some comments on either side of the issue. For example, it’s opposed by the state of Georgia, which plans to be running its own exchange by the fall of 2024. It’s supported, however, by the Massachusetts Health Connector (Massachusetts Marketplace), which currently requires SEP applications to be submitted by the 23rd of the month to have coverage effective the first of the following month.
3. It would be easier for states to add to their essential health benefit requirements
Under current rules, states can use the benchmarking process (directly updating the EHB benchmark plan, as opposed to a legislative or regulatory benefit mandate) to add benefits without defraying the cost. But states have reported that updating the benchmark plan is burdensome, and only nine states have updated their benchmark plans since this became available in 2020.2 If a state adds required benefits via regulatory or legislative state mandates (as opposed to the benchmarking process) after 2011, they have to defray the cost, even if they subsequently add it via the benchmarking process.
The proposed rule would ensure that if a particular benefit is covered by a state’s EHB benchmark plan, the cost doesn’t have to be borne by the state, even if the state mandated the benefit via regulation or legislation. And separately, the proposed rule calls for a more simplified process for states to update their EHB Benchmark plan, making it easier to add new benefits over time. (States have reported that the current process can be burdensome and onerous.)
To clarify, a state would not be required to make any change to its EHB Benchmark plan or add any new benefits. But for states that wish to do so, the proposed rules are designed to make the process easier and less costly.
There are a variety of services that a state could choose to add to its EHB benchmark plan, including some services that have only become available in recent years, after the original EHB benchmark plans were established (weight loss medication, for example). Other examples are gender-affirming care, vasectomies, infertility treatment, and substance use disorder treatments that have been developed since EHB Benchmark plans were first created.
Among the public comments received, the National Association of Insurance Commissioners strongly supports this proposed rule change, while Elevance Health (formerly Anthem) opposes it.
4. States would be allowed to add adult dental to essential health benefits
The proposed rule would allow – but not require – states to add adult dental coverage to their essential health benefits package. States are prohibited from adding adult dental to their EHBs under current rules.
If a state chose to add adult dental to EHB, individual and small-group health plans would have to start providing adult dental benefits without dollar limits on how much the plan would pay. Carriers could accomplish this by providing the benefits directly or by contracting with a dental plan to administer the coverage, as long as it’s “seamless to the enrollee.”
Self-insured and large-group plans are not required to cover EHBs (and most covered workers are in self-insured or large group plans). But to the extent that they do, they cannot impose annual or lifetime limits on how much the plan will pay for those services.
The proposed rule clarifies that if a state chooses to add adult dental coverage to its EHB benchmark plan and an employer purchases that plan for its workers in the large group market (51 or more employees in most states)3 the carrier would have to provide dental benefits without annual or lifetime benefit caps. But if a large employer uses a stand-alone dental plan in addition to a medical plan, the dental plan could continue to have benefit caps.
(For clarification, small-group health plans are sold to employers with up to 50 employees in most states, and up to 100 employees in four states.4 If the employer has more employees than the small-group threshold and is purchasing commercial insurance — as opposed to self-insuring — they are buying coverage in the large-group market, which is regulated under different rules than the small-group market.)
States are responsible for determining the specific services that must be covered as essential health benefits, but the Affordable Care Act prohibits states from including adult dental in their EHB package. This is because the EHB package was meant to be representative of a typical employer-sponsored health plan, and employer-sponsored health plans generally do not include dental coverage.
In the proposed rule, the government notes that they’re now looking at this from the perspective of an overall employer benefit package, which often includes separate dental coverage in addition to the medical plan. So while it continues to be the case that employer-sponsored medical plans typically do not include dental coverage, the proposed rule change would allow states to bring their EHB-Benchmark plan more in line with a typical employer benefits package, which often includes both medical and dental coverage.
Quite a few public comments were submitted in response to the proposal to allow states to add adult dental to EHB.
The agencies clarified in the proposed rule that they are not proposing a change to allow states to add adult vision or custodial long-term care coverage to EHB (both of which are also not allowed to be added to EHB at this point), but they are seeking feedback from stakeholders and the public regarding whether they should consider that in future rulemaking.
5. The low-income special enrollment period would become permanent
The proposed rule would make the low-income special enrollment period (SEP) permanent, instead of ending it if and when the American Rescue Plan’s (ARP) subsidy enhancements expire.5
The rationale behind the low-income SEP is that subsidy-eligible enrollees with income up to 150% of the federal poverty level (FPL) are currently eligible for $0 premium coverage, so the adverse selection risk is low. (That means it’s unlikely that a person would let their coverage lapse when they’re healthy if they’re not having to pay for it. Adverse selection refers to situations in which healthy people do not maintain coverage, and the overall risk pool becomes less healthy and more expensive to treat.)
Under current rules, subsidy-eligible applicants with household income up to 150% of FPL will continue to be able to enroll year-round as long as the ARP subsidy enhancements remain in effect. They’re currently in place through 2025, and an extension would require Congressional action. If the proposed rule is finalized, the low-income SEP will remain in place even if the subsidy enhancements end.
The National Association of Community Health Centers supports this proposal, while Elevance Health (formerly Anthem) opposes it. Another insurer, Priority Health, expressed general opposition to the expansion of special enrollment opportunities and wants CMS to “reduce the total number of SEPs,” noting that “ongoing enrollment contributes to adverse selection and encourages healthy persons to delay enrollment until they need care.”
Conversely, CMS and the IRS note in the proposed rules that because most consumers with income up to 150% FPL would continue to be eligible for some zero-cost plans in the Marketplace even without the ARP subsidy enhancements, they “would be unlikely to use the proposed 150 FPL SEP in a way that caused adverse selection.”
6. Marketplace plans could be terminated retroactively if an enrollee is eligible for backdated Medicare
Under current rules, the option to retroactively terminate Marketplace coverage is extremely limited. The proposed rule would allow a retroactive coverage termination date if a person becomes eligible for backdated Medicare coverage. .
In most cases, Marketplace plans can only be canceled prospectively (or at the earliest, on the day the cancellation request is made). This works well in situations where a person knows that their Medicare will take effect on a particular day in the future and can schedule the termination of their Marketplace plan for the same time. But it becomes much more complicated when a person learns that they’ve been enrolled in Medicare with a backdated effective date.
This can happen when a person is approved for Social Security Disability Insurance (SSDI) benefits with a retroactive effective date more than 25 months in the past. (Medicare becomes available in the 25th month of SSDI benefits.) It can also happen when a person enrolls in Medicare after they’re initially eligible and their Medicare Part A coverage is backdated up to six months.
In those scenarios, the person doesn’t have an opportunity to cancel their Marketplace plan prospectively, since they’re finding out after the fact that their Medicare coverage has already begun. The proposed rule would allow them to request that their Marketplace coverage be canceled back to the day before their Medicare took effect. This could result in premium savings for the individual, and also reduce the likelihood that they’ll have to repay excess premium tax credits to the IRS when they file their taxes.
The proposed rule does not allow retroactive terminations in a situation where an individual enrolled prospectively didn’t understand that they needed to cancel their Marketplace plan once they’ve got Medicare coverage and later tries to retroactively terminate enrollment in a QHP. But it could address some of the challenges Marketplace enrollees currently face when they are retroactively enrolled in Medicare.
If the proposed rule is finalized, retroactive termination would become available via HealthCare.gov, but would be optional for the state-run Marketplaces.
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.
• 10 essential health benefits, including prescription drugs, emergency services, hospitalization, laboratory services, and mental health and substance use disorder services. • Free preventive health services at no cost to you when delivered by a doctor or provider in your plan’s network. • Treatment for pre-existing conditions. • Some prescription drugs. Your plan’s list of covered drugs is called a “formulary.” Find your plan’s formulary by calling Member Services, or review your Summary of Benefits and Coverage.
How do I find a doctor?
You’ll usually get the best cost for services when you use “in-network” providers. You may be able to use providers who aren’t in your plan’s network, but you may pay more.
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Did someone in your household have a Marketplace plan in 2023? When you file your taxes, you’ll need Form 1095-A, Health Insurance Marketplace® Statement. This form comes from the Marketplace, not the IRS.
Is it correct? It should include information about any Marketplace plans that members of your household had last year.
3. Use your form
If it’s accurate, use the information on your 1095-A form to “reconcile”any premium tax credit you or your household qualified for or used. To reconcile, you compare two amounts: the premium tax credit you used in advance during the year; and the amount of tax credit you qualify for based on your final income.
Find a problem or mistake? Contact the Marketplace Call Center to get a corrected form. Don’t file your federal taxes until you get a corrected version.
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On January 8, Olympic gymnast Mary Lou Retton attracted national attention and an outpouring of support when she appeared on the Today Show, explaining the health scare she faced in the fall of 2023. Retton recounted how she fell gravely ill with a rare form of pneumonia and – because she couldn’t afford health insurance – faced thousands of dollars in hospital bills.
The story fortunately has a happy ending: Retton was discharged from the hospital after about a month, and is recovering at home. And her daughters had organized a fundraiser that raised more than $459,000 in contributions. The family has confirmed that any funds beyond what’s needed for medical bills will be donated to charity. And Retton reports that she now has health insurance.
But to me, Retton’s story also included some important lessons for consumers, many of whom may assume that the celebrity’s health scare is a sign of barriers to affordable health coverage. Here’s what consumers can learn from Retton’s experience:
1. Having health coverage is critical.
Retton reported that her unexpected illness resulted in a month of hospital treatment, much of which was in the intensive care unit. With the per-day cost of a hospital stay in Texas averaging $2,913 in 2021,1 it’s easy to see how expenses can rack up quickly — and ICU costs are higher than regular inpatient care. Retton lives in Texas and was hospitalized there, but the national average cost is similar to the Texas average, at $2,883 per day for regular inpatient care.2
2. Pre-existing conditions are no longer a barrier to coverage.
On the Today Show, Retton pointed to previous health issues as a reason why she didn’t have coverage.
“When COVID hit and after my divorce and all my pre-existing (conditions), I mean, I’ve had over 30 operations of orthopedic stuff, I couldn’t afford it… But who would even know that this was going to happen to me?”
Unfortunately, that may leave some viewers with the impression that coverage might be unaffordable due to pre-existing medical conditions. In fact, medical underwriting hasn’t been used for individual/family health insurance policies since 2013.
One possible reason that Retton didn’t have coverage is that she may have tried to enroll in comprehensive health coverage outside of open enrollment, and if she wasn’t eligible for a special enrollment period, she would have had to wait until open enrollment (with coverage effective in January).
4. Consumers in some states still face a coverage gap.
Retton, like many people in Texas, could be in the coverage gap, which exists because Texas has not yet elected to expand Medicaid under the Affordable Care Act (ACA). Texas is one of nine states where there’s a coverage gap, and an estimated 772,000 low-income Texas residents are in the coverage gap.
If a Texas resident’s household income is less than the federal poverty level, they’d be in the coverage gap, meaning they would not be eligible for Texas Medicaid or Marketplace premium subsidies.
It’s important to note that Marketplace premium subsidy eligibility is based on income, and assets are not taken into consideration. (Here’s how income is calculated under the ACA). So a person with considerable assets could still fall into the coverage gap in Texas, if their income is below the poverty level.
A person in the coverage gap can still enroll in Marketplace coverage, but will not qualify for any subsidies. Their decision to enroll in coverage will depend on whether they can afford to pay full price premiums.
5. Income affects subsidy eligibility.
On the other end of the spectrum, Retton’s income might have been too high to qualify for any Marketplace subsidies. Using HealthCare.gov’s 2023 plan comparison tool for a 55-year-old in her area, we can see that subsidies would have phased out at an income of roughly $98,000. (Subsidies phase out at the point where the price of the second-lowest-cost Silver plan becomes no more than 8.5% of the person’s household income, which is what the American Rescue Plan and Inflation Reduction Act consider affordable at that income level.)
If her income had been above that, she would have been paying full price for a plan, with 2023 premiums somewhere in the range of $501 to $1,075/month, depending on the plan. (These premiums are specific to Retton’s age and location; they will vary for other applicants).
6. But the income range for subsidy eligibility is wide.
But if an individual Retton’s age and living in her area had a 2023 household income between $13,590 (the 2022 poverty level) and about $98,000 (the level at which subsidies in that case would have phased out altogether), they would have been eligible for Marketplace premium subsidies that covered some or all of the cost of the coverage, depending on where in that income range they were, and the plan they selected.
Although the ACA prohibits insurers from considering an applicant’s medical history, a person might not know about that if they haven’t had experience with purchasing coverage in the individual market in recent years.
And if a person hasn’t applied for coverage or used a subsidy calculator, they may not be aware of how substantial the premium subsidies can be in the Marketplace.
Ultimately, even an unsubsidized premium of several hundred dollars a month is a bargain compared with having to pay for a month-long stay in the ICU. But fortunately, most Marketplace enrollees do not pay anything close to the full amount of their premiums.
In 2023, the average full-price Marketplace premium in Texas was $578/month. But thanks to premium subsidies, the average enrollee paid just $65/month. And out of the 2.4 million Texas residents who enrolled in Marketplace coverage in 2023, more than 1.4 million were paying less than $10/month for their coverage.
I’m glad that Retton recovered and has secured health insurance going forward. These circumstances remind us that ACA-compliant health insurance can be obtained – regardless of our medical history, and with substantial subsidies available to most applicants.
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.
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2024-01-23 10:03:322024-01-23 14:02:376 lessons Mary Lou Retton’s health scare can teach us about coverage
Marketplace Open Enrollment for health coverage in 2024 ended January 15. If you missed the Open Enrollment window, you might still have options for health coverage for the rest of the year.
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2024-01-16 19:00:002024-01-17 14:03:16Explore your health care options after Open Enrollment
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People Moves: Farmers Insurance Names Coleman President of Business Insurance
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Markets/Coverages: Insurtech Slice Expands Contractors General Liability Insurance Offering, Backed by Philadelphia Insurance
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Hackers Claim to Have UnitedHealth’s Stolen Data – But Is It a Bluff?
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Executive Summary: While the advancement of technology in electric vehicles and other lithium-ion powered goods facilitates energy transition from fossil fuels, the fire risks associated with such products need proactive management, writes Dr. William Moore, global loss prevention director, The …
Finalized federal rule reduces total duration of short-term health plans to 4 months
A finalized federal rule announced by the Departments of Treasury, Health and Human Services, and Labor on March 28, will impose new nationwide duration limits on short-term limited duration insurance (STLDI) plans.
The rule – which applies to plans sold or issued on or after September 1, 2024 – will limit STLDI plans to three-month terms, and to total duration including renewals of no more than four months.
A “renewal” will include a new policy issued by the same insurer (or another insurer in the same controlled group, meaning they’re treated as a single employer)) within 12 months of the effective date of the first policy. So a person will not be able to purchase multiple consecutive policies – a practice known as “stacking” – from the same insurer or an affiliated insurer. The part of the rule helps to avoid scenarios in which consumers enroll in multiple STLDI policies without realizing that it isn’t comprehensive coverage.
Why did the federal government implement this rule?
As the author has previously noted, the changes are designed to ensure that short-term coverage is used to fill a temporary gap between two comprehensive policies, rather than serving as a long-term coverage solution. Since STLDI is “excluded from the definition of individual health insurance” and is thus not regulated by federal rules such as the Affordable Care Act, the No Surprises Act, the Mental Health Parity and Addiction Equity Act, etc., the federal-level consumer protections for STLDI enrollees are limited.
The rule is also intended to make it easier for consumers to distinguish between ACA-compliant individual/family health insurance and STDLI and thus reduce the number of people who inadvertently purchase short-term coverage when trying to buy comprehensive coverage.
STLDI plans sold on or after Sept. 1, 2024 will need to include an updated and comprehensive disclosure notice that highlights the major differences between STLDI and ACA-compliant individual/family health insurance sold through the Marketplace.
The disclosure, which is illustrated on page 102 of the final rule, must be displayed on the first page of the policy/contract and any associated marketing or enrollment materials.
How does the rule affect STLDI plans currently in effect?
Under the new rules, there is no change to STLDI policies that are already in effect, or policies that are sold and issued before Sept. 1, 2024. The current rules continue to apply to those policies.
This means policy durations of plans that are sold and issued prior to Sept. 1, 2024 are up to the states and the insurers as long as the policies don’t have initial terms of more than 364 days or total duration of more than 36 months.
How will state regulations be affected by the rule?
As has been the case with previous federal rules for STLDI, states can impose stricter rules but not more lenient rules regarding STLDI duration.
So for example, a state will be able to limit STLDI to a duration of under four months (or ban them altogether, as some states have already done) or prohibit the sale of a second STLDI policy within 12 months – even if it’s issued by a different insurer.[footnote “States Step Up to Protect Insurance Markets and Consumers from Short-Term Health Plans” Commonwealth Fund. May 2, 2019]
How many people have short-term health insurance?
It’s difficult to pin down the exact number of enrollees, as data reporting of STLDI coverage is not consistent across states. The final rule cites a 2023 report from the National Association of Insurance Commissioners, which indicated that 235,775 people were covered by short-term health plans at the end of 2022.2
But, as noted in the final rule, that doesn’t include people who had STLDI for only part of the year, nor does it include people with association-based STDLI coverage, which is a significant portion of the market.
The final rule (see page 163) also notes that the Congressional Budget Office and the Joint Committee on Taxation had previously estimated that as many as 1.5 million people might be enrolled in STLDI. But the rule also clarified that was before the ACA’s premium subsidies were enhanced by the American Rescue Plan and Inflation Reduction Act – legislation that made Marketplace coverage more affordable and perhaps reduced the number of people who opted for STDLI.
Will people with STLDI have a special enrollment period to switch to individual/family coverage?
No. The final rule (page 68) notes that while there is already a special enrollment period (SEP) for group health insurance when an STLDI policy terminates, there is no similar SEP for individual/family health coverage. That will continue to be the case under the new rule.
States that operate their own health insurance Marketplaces are allowed to establish SEPs that differ from those available through the federally run Marketplace, HealthCare.gov. But HealthCare.gov, the Marketplace platform in 32 states, will continue its current protocol of not allowing a SEP due to the termination of a short-term health insurance policy.
However, as we’ll discuss below, the timing of the new rule is designed to ensure that people can purchase a STLDI plan that can continue through the end of 2024 (assuming they’re healthy enough to enroll in STLDI and assuming that insurers in their state offer STLDI with the maximum allowable four-month duration). By then utilizing the open enrollment period for ACA-compliant coverage, the consumer would be able to transition without interruption in coverage to an individual-market policy that starts on January 1, 2025, if they choose to do so.
What can people do when their short-term policy terminates?
The current maximum duration limit for policies sold or issued before September 1, 2024 varies by state, and it’s also important to understand that insurers can further limit their short-term policies beyond what state or federal rules allow. (An insurer can, for instance, cap total policy durations at six months, even if state and federal rules allow for 36 months.)
If a person enrolls in a new STLDI plan on or after September 1, the plan will be allowed to cover them through the end of 2024, as that will be no more than four months away. But again, four months will be the maximum allowable duration, not the required duration. Insurers will be able to offer, for example, a three-month policy that isn’t renewable. For this reason, consumers need to be well-informed about their policy details.
Assuming a person purchases a policy with a four-month duration that starts on September 1, they will be able to select a non-temporary major medical plan for calendar year 2025 during open enrollment for individual/family coverage which will be effective as early as January 1, 2025. Open enrollment begins on November 1, 2024. This will allow them to avoid having a coverage gap.
If a person chooses to purchase or renew an existing longer-term STLDI policy before the end of August 2024, their plan termination dates will vary depending on the plan they choose. For example, a policy purchased while the current rules are still in effect might last for six months (i.e., into early 2025) or it might last for 36 months. This is where consumers will need to be vigilant in understanding the implications of what they’re purchasing.
If they buy a six-month, non-renewable short-term policy that takes effect August 15, 2024, it will terminate in mid-February 2025. At that point, open enrollment for ACA-compliant 2025 individual/family coverage will be over.
The person will not be able to switch to an ACA-compliant plan unless they have a qualifying life event that triggers a special enrollment period (note here that some special enrollment periods are only available if the person had prior minimum essential coverage, and STLDI is not considered minimum essential coverage.)
Under the terms of the final rule, consumers will still be able to buy another STLDI policy from a different insurer after their policy ends.
But this will depend on their health status, as the new insurer will be able to use medical underwriting.
Marketplace coverage is available
More than 21 million people enrolled in Marketplace plans during the open enrollment period for 2024 coverage. About 92% of them qualified for advance premium tax credits that reduced their average monthly premiums to just $74/month.3
These Marketplace policies cover the ACA’s essential health benefits without any annual or lifetime caps on how much the plan will pay. They have caps on out-of-pocket costs, cover pre-existing conditions, and don’t base premiums on gender or medical history, unlike STLDI policies.
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.
Footnotes
Farmers Insurance® Names John Griek as Chief Financial Officer
File your taxes using Form 1095-A, Health Insurance Marketplace Statement®
The tax filing deadline is April 15, 2024. If anyone in your household had a Marketplace plan in 2023, use Form 1095-A, Health Insurance Marketplace®, to file your federal taxes. You’ll get this form from the Marketplace, not the IRS.
It’s important to review your Form 1095-A and reconcile your premium tax credit because it could impact your refund or the amount of taxes you owe.
Check your online account for Form 1095-A
If you didn’t get your Form 1095-A in the mail, or you can’t find it, check your Markteplace account.
Check your Form 1095-A to make sure your information is correct. If you can’t find your form or think there’s a mistake, contact the Marketplace Call Center.
“Reconcile” using Form 1095-A
If you (or anyone in your household) qualified for or used the premium tax credit to lower your Marketplace plan premium:
Health insurance and your taxes
If you had Marketplace coverage at any point in 2023 and got the premium tax credit, here’s what you need to know about filing your federal taxes.
Keep your Form 1095-A in a safe place
This form has important information about the Marketplace plans your household had in 2023.
Check that your Form 1095-A is correct
“Reconcile” with your Form 1095-A
If you qualified for or used the premium tax credit to lower your Marketplace plan premium:
Six ways proposed federal rule changes might affect Marketplace enrollees
In this article
The federal government has proposed a wide range of health insurance rule changes for 2025 and – if approved – they’re likely to affect Marketplace enrollment deadlines and plan benefits as well as enrollees’ transition from Marketplace coverage to Medicare.
Two agencies – the Centers for Medicare & Medicaid Services (CMS), and Department of the Treasury – proposed the rule changes in November 2023 and have already accepted public comments on the proposals. The final rule, including potential modifications to the initial proposals, will be published in early 2024.
The proposed rule addresses a wide range of issues. Let’s take a look at six that are most likely to have a direct effect on Marketplace consumers in 2025 and future years:
1. Open enrollment start dates would be standardized in state exchanges
The proposed rule would require state-run exchanges to more closely align their open enrollment periods with the federal exchange, HealthCare.gov, beginning open enrollment on November 1, and ending it no earlier than January 15. This rule could help reduce confusion for consumers in some states.
Under current rules, the open enrollment period for the federally run Marketplace, HealthCare.gov, (used in 32 states) runs from November 1 to January 15, and most state-run exchanges follow the same schedule.
But state-run exchanges can have different start dates (Idaho’s starts in mid-October and New York’s starts in mid-November) and different end dates, as long as the end date isn’t before December 15. Idaho currently ends open enrollment on December 15, and is the only state where open enrollment ends before January 15.
If finalized, this rule change would require Idaho to change both the start and end dates of its open enrollment period, and New York would have to change its start date. And state-run exchanges created after these rules go into effect would also have to follow the standardized schedule of November 1 through at least January 15.
This proposal is supported by various entities, including the National Association of Community Health Centers, but opposed by other entities, including the National Association of Insurance Commissioners, the state of Idaho, and the state of Georgia (Georgia plans to have a fully state-run Marketplace by the fall of 2024).
2. Special enrollment period effective dates would be standardized
The proposed rule would require state-run exchanges to have first-of-the-following-month effective dates for applications submitted at any time during a calendar month during special enrollment periods.
Starting in 2022, HealthCare.gov switched to this approach. Before that, HealthCare.gov and most of the state-run exchanges required an application to be submitted by the 15th of the month for the coverage to be effective the first of the following month. (Some qualifying life events, including marriage, loss of other coverage, and birth/adoption, had more flexible enrollment deadlines.) This meant that an application submitted on June 20 would have an August 1 effective date. But under the protocol that HealthCare.gov and some state-run exchanges adopted in 2022, that application now gets a July 1 effective date.
When HealthCare.gov switched to the new rules under which coverage is effective at the start of the next month – regardless of the day of the month the application was submitted during a special enrollment period – it was optional for state-run-exchanges to also make the change. Some have since adopted the same approach, but others have not.1
If the proposed rule is adopted, consumers in every state will be able to get coverage effective as of the first of the month following their application during a special enrollment period, regardless of the date they apply. The goal? Minimizing gaps in coverage by reducing the amount of time that people in some states currently have to wait for their SEP enrollments to take effect.
This proposed rule did not generate much feedback in the public comments, but there were some comments on either side of the issue. For example, it’s opposed by the state of Georgia, which plans to be running its own exchange by the fall of 2024. It’s supported, however, by the Massachusetts Health Connector (Massachusetts Marketplace), which currently requires SEP applications to be submitted by the 23rd of the month to have coverage effective the first of the following month.
3. It would be easier for states to add to their essential health benefit requirements
The proposed rule would make it easier for states to update their essential health benefits (EHB) benchmark plan requirements, and would allow states to add mandated benefits via the regulatory or legislative process without having to cover the cost of the new benefit. (Current rules require the state to pay the cost of adding the new benefits by sending money directly to the health plan or its enrollees.)
Under current rules, states can use the benchmarking process (directly updating the EHB benchmark plan, as opposed to a legislative or regulatory benefit mandate) to add benefits without defraying the cost. But states have reported that updating the benchmark plan is burdensome, and only nine states have updated their benchmark plans since this became available in 2020.2 If a state adds required benefits via regulatory or legislative state mandates (as opposed to the benchmarking process) after 2011, they have to defray the cost, even if they subsequently add it via the benchmarking process.
The proposed rule would ensure that if a particular benefit is covered by a state’s EHB benchmark plan, the cost doesn’t have to be borne by the state, even if the state mandated the benefit via regulation or legislation. And separately, the proposed rule calls for a more simplified process for states to update their EHB Benchmark plan, making it easier to add new benefits over time. (States have reported that the current process can be burdensome and onerous.)
To clarify, a state would not be required to make any change to its EHB Benchmark plan or add any new benefits. But for states that wish to do so, the proposed rules are designed to make the process easier and less costly.
There are a variety of services that a state could choose to add to its EHB benchmark plan, including some services that have only become available in recent years, after the original EHB benchmark plans were established (weight loss medication, for example). Other examples are gender-affirming care, vasectomies, infertility treatment, and substance use disorder treatments that have been developed since EHB Benchmark plans were first created.
Among the public comments received, the National Association of Insurance Commissioners strongly supports this proposed rule change, while Elevance Health (formerly Anthem) opposes it.
4. States would be allowed to add adult dental to essential health benefits
The proposed rule would allow – but not require – states to add adult dental coverage to their essential health benefits package. States are prohibited from adding adult dental to their EHBs under current rules.
If a state chose to add adult dental to EHB, individual and small-group health plans would have to start providing adult dental benefits without dollar limits on how much the plan would pay. Carriers could accomplish this by providing the benefits directly or by contracting with a dental plan to administer the coverage, as long as it’s “seamless to the enrollee.”
Self-insured and large-group plans are not required to cover EHBs (and most covered workers are in self-insured or large group plans). But to the extent that they do, they cannot impose annual or lifetime limits on how much the plan will pay for those services.
The proposed rule clarifies that if a state chooses to add adult dental coverage to its EHB benchmark plan and an employer purchases that plan for its workers in the large group market (51 or more employees in most states)3 the carrier would have to provide dental benefits without annual or lifetime benefit caps. But if a large employer uses a stand-alone dental plan in addition to a medical plan, the dental plan could continue to have benefit caps.
(For clarification, small-group health plans are sold to employers with up to 50 employees in most states, and up to 100 employees in four states.4 If the employer has more employees than the small-group threshold and is purchasing commercial insurance — as opposed to self-insuring — they are buying coverage in the large-group market, which is regulated under different rules than the small-group market.)
States are responsible for determining the specific services that must be covered as essential health benefits, but the Affordable Care Act prohibits states from including adult dental in their EHB package. This is because the EHB package was meant to be representative of a typical employer-sponsored health plan, and employer-sponsored health plans generally do not include dental coverage.
In the proposed rule, the government notes that they’re now looking at this from the perspective of an overall employer benefit package, which often includes separate dental coverage in addition to the medical plan. So while it continues to be the case that employer-sponsored medical plans typically do not include dental coverage, the proposed rule change would allow states to bring their EHB-Benchmark plan more in line with a typical employer benefits package, which often includes both medical and dental coverage.
Quite a few public comments were submitted in response to the proposal to allow states to add adult dental to EHB.
The proposal is supported by the American Association of Endodontists, the National Rural Health Association, the National Association of Insurance Commissioners, the National Association of Community Health Centers, and the Tribal Technical Advisory Group.
But it’s opposed by Sanford and Priority Health (both insurers), and the Academy of General Dentistry.
The agencies clarified in the proposed rule that they are not proposing a change to allow states to add adult vision or custodial long-term care coverage to EHB (both of which are also not allowed to be added to EHB at this point), but they are seeking feedback from stakeholders and the public regarding whether they should consider that in future rulemaking.
5. The low-income special enrollment period would become permanent
The proposed rule would make the low-income special enrollment period (SEP) permanent, instead of ending it if and when the American Rescue Plan’s (ARP) subsidy enhancements expire.5
The rationale behind the low-income SEP is that subsidy-eligible enrollees with income up to 150% of the federal poverty level (FPL) are currently eligible for $0 premium coverage, so the adverse selection risk is low. (That means it’s unlikely that a person would let their coverage lapse when they’re healthy if they’re not having to pay for it. Adverse selection refers to situations in which healthy people do not maintain coverage, and the overall risk pool becomes less healthy and more expensive to treat.)
Under current rules, subsidy-eligible applicants with household income up to 150% of FPL will continue to be able to enroll year-round as long as the ARP subsidy enhancements remain in effect. They’re currently in place through 2025, and an extension would require Congressional action. If the proposed rule is finalized, the low-income SEP will remain in place even if the subsidy enhancements end.
The National Association of Community Health Centers supports this proposal, while Elevance Health (formerly Anthem) opposes it. Another insurer, Priority Health, expressed general opposition to the expansion of special enrollment opportunities and wants CMS to “reduce the total number of SEPs,” noting that “ongoing enrollment contributes to adverse selection and encourages healthy persons to delay enrollment until they need care.”
Conversely, CMS and the IRS note in the proposed rules that because most consumers with income up to 150% FPL would continue to be eligible for some zero-cost plans in the Marketplace even without the ARP subsidy enhancements, they “would be unlikely to use the proposed 150 FPL SEP in a way that caused adverse selection.”
6. Marketplace plans could be terminated retroactively if an enrollee is eligible for backdated Medicare
Under current rules, the option to retroactively terminate Marketplace coverage is extremely limited. The proposed rule would allow a retroactive coverage termination date if a person becomes eligible for backdated Medicare coverage. .
Once a Marketplace enrollee becomes eligible for premium-free Medicare Part A, they are no longer eligible for premium subsidies. And even if they aren’t receiving subsidies, Medicare doesn’t coordinate with individual/family coverage. The advice from CMS is that “In most cases, you’ll want to end your Marketplace coverage” when your Medicare coverage begins. And consumers are responsible for canceling their Marketplace coverage when they transition to Medicare.
In most cases, Marketplace plans can only be canceled prospectively (or at the earliest, on the day the cancellation request is made). This works well in situations where a person knows that their Medicare will take effect on a particular day in the future and can schedule the termination of their Marketplace plan for the same time. But it becomes much more complicated when a person learns that they’ve been enrolled in Medicare with a backdated effective date.
This can happen when a person is approved for Social Security Disability Insurance (SSDI) benefits with a retroactive effective date more than 25 months in the past. (Medicare becomes available in the 25th month of SSDI benefits.) It can also happen when a person enrolls in Medicare after they’re initially eligible and their Medicare Part A coverage is backdated up to six months.
In those scenarios, the person doesn’t have an opportunity to cancel their Marketplace plan prospectively, since they’re finding out after the fact that their Medicare coverage has already begun. The proposed rule would allow them to request that their Marketplace coverage be canceled back to the day before their Medicare took effect. This could result in premium savings for the individual, and also reduce the likelihood that they’ll have to repay excess premium tax credits to the IRS when they file their taxes.
The proposed rule does not allow retroactive terminations in a situation where an individual enrolled prospectively didn’t understand that they needed to cancel their Marketplace plan once they’ve got Medicare coverage and later tries to retroactively terminate enrollment in a QHP. But it could address some of the challenges Marketplace enrollees currently face when they are retroactively enrolled in Medicare.
If the proposed rule is finalized, retroactive termination would become available via HealthCare.gov, but would be optional for the state-run Marketplaces.
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.
Footnotes
Now that you’re covered, know how to use your insurance!
Get the most out of your Marketplace coverage with answers to some common questions, like how to use your coverage and what’s covered.
How do I use my coverage?
• Get more information about using your coverage, like getting regular and emergency care and how to improve your health.
• Learn how to put your health first (PDF, 1820 KB). You’ll find tips on how to find providers and prepare for appointments.
What’s covered?
All Marketplace plans cover:
• 10 essential health benefits, including prescription drugs, emergency services, hospitalization, laboratory services, and mental health and substance use disorder services.
• Free preventive health services at no cost to you when delivered by a doctor or provider in your plan’s network.
• Treatment for pre-existing conditions.
• Some prescription drugs. Your plan’s list of covered drugs is called a “formulary.” Find your plan’s formulary by calling Member Services, or review your Summary of Benefits and Coverage.
How do I find a doctor?
You’ll usually get the best cost for services when you use “in-network” providers. You may be able to use providers who aren’t in your plan’s network, but you may pay more.
Learn how to find a doctor in your plan’s network.
It’s tax season! Check your mail for Form 1095-A
Did someone in your household have a Marketplace plan in 2023? When you file your taxes, you’ll need Form 1095-A, Health Insurance Marketplace® Statement. This form comes from the Marketplace, not the IRS.
1. Find your form
It’ll be in your mailbox by early February, or in your Marketplace account now. Get step-by-step instructions to find your Form 1095-A online.
2. Check your form
Is it correct? It should include information about any Marketplace plans that members of your household had last year.
3. Use your form
If it’s accurate, use the information on your 1095-A form to “reconcile” any premium tax credit you or your household qualified for or used. To reconcile, you compare two amounts: the premium tax credit you used in advance during the year; and the amount of tax credit you qualify for based on your final income.
Find a problem or mistake? Contact the Marketplace Call Center to get a corrected form. Don’t file your federal taxes until you get a corrected version.
6 lessons Mary Lou Retton’s health scare can teach us about coverage
On January 8, Olympic gymnast Mary Lou Retton attracted national attention and an outpouring of support when she appeared on the Today Show, explaining the health scare she faced in the fall of 2023. Retton recounted how she fell gravely ill with a rare form of pneumonia and – because she couldn’t afford health insurance – faced thousands of dollars in hospital bills.
The story fortunately has a happy ending: Retton was discharged from the hospital after about a month, and is recovering at home. And her daughters had organized a fundraiser that raised more than $459,000 in contributions. The family has confirmed that any funds beyond what’s needed for medical bills will be donated to charity. And Retton reports that she now has health insurance.
But to me, Retton’s story also included some important lessons for consumers, many of whom may assume that the celebrity’s health scare is a sign of barriers to affordable health coverage. Here’s what consumers can learn from Retton’s experience:
1. Having health coverage is critical.
Retton reported that her unexpected illness resulted in a month of hospital treatment, much of which was in the intensive care unit. With the per-day cost of a hospital stay in Texas averaging $2,913 in 2021,1 it’s easy to see how expenses can rack up quickly — and ICU costs are higher than regular inpatient care. Retton lives in Texas and was hospitalized there, but the national average cost is similar to the Texas average, at $2,883 per day for regular inpatient care.2
2. Pre-existing conditions are no longer a barrier to coverage.
On the Today Show, Retton pointed to previous health issues as a reason why she didn’t have coverage.
Unfortunately, that may leave some viewers with the impression that coverage might be unaffordable due to pre-existing medical conditions. In fact, medical underwriting hasn’t been used for individual/family health insurance policies since 2013.
For individual/family major medical policies with effective dates of 2014 or later, the insurer cannot take the applicant’s medical history into consideration. So pre-existing conditions will not affect the premium or the person’s eligibility for coverage. That was not true before 2014 in most states, but it has been true nationwide since 2014.
3. Enrollment windows are limited.
One possible reason that Retton didn’t have coverage is that she may have tried to enroll in comprehensive health coverage outside of open enrollment, and if she wasn’t eligible for a special enrollment period, she would have had to wait until open enrollment (with coverage effective in January).
Although coverage is guaranteed-issue regardless of medical history, enrollment in individual/family major medical plans is only available during open enrollment or a special enrollment period. This is the same as the employer-sponsored health coverage rules that have been used for decades.
4. Consumers in some states still face a coverage gap.
Retton, like many people in Texas, could be in the coverage gap, which exists because Texas has not yet elected to expand Medicaid under the Affordable Care Act (ACA). Texas is one of nine states where there’s a coverage gap, and an estimated 772,000 low-income Texas residents are in the coverage gap.
If a Texas resident’s household income is less than the federal poverty level, they’d be in the coverage gap, meaning they would not be eligible for Texas Medicaid or Marketplace premium subsidies.
It’s important to note that Marketplace premium subsidy eligibility is based on income, and assets are not taken into consideration. (Here’s how income is calculated under the ACA). So a person with considerable assets could still fall into the coverage gap in Texas, if their income is below the poverty level.
A person in the coverage gap can still enroll in Marketplace coverage, but will not qualify for any subsidies. Their decision to enroll in coverage will depend on whether they can afford to pay full price premiums.
5. Income affects subsidy eligibility.
On the other end of the spectrum, Retton’s income might have been too high to qualify for any Marketplace subsidies. Using HealthCare.gov’s 2023 plan comparison tool for a 55-year-old in her area, we can see that subsidies would have phased out at an income of roughly $98,000. (Subsidies phase out at the point where the price of the second-lowest-cost Silver plan becomes no more than 8.5% of the person’s household income, which is what the American Rescue Plan and Inflation Reduction Act consider affordable at that income level.)
If her income had been above that, she would have been paying full price for a plan, with 2023 premiums somewhere in the range of $501 to $1,075/month, depending on the plan. (These premiums are specific to Retton’s age and location; they will vary for other applicants).
6. But the income range for subsidy eligibility is wide.
But if an individual Retton’s age and living in her area had a 2023 household income between $13,590 (the 2022 poverty level) and about $98,000 (the level at which subsidies in that case would have phased out altogether), they would have been eligible for Marketplace premium subsidies that covered some or all of the cost of the coverage, depending on where in that income range they were, and the plan they selected.
Although the ACA prohibits insurers from considering an applicant’s medical history, a person might not know about that if they haven’t had experience with purchasing coverage in the individual market in recent years.
And if a person hasn’t applied for coverage or used a subsidy calculator, they may not be aware of how substantial the premium subsidies can be in the Marketplace.
Ultimately, even an unsubsidized premium of several hundred dollars a month is a bargain compared with having to pay for a month-long stay in the ICU. But fortunately, most Marketplace enrollees do not pay anything close to the full amount of their premiums.
In 2023, the average full-price Marketplace premium in Texas was $578/month. But thanks to premium subsidies, the average enrollee paid just $65/month. And out of the 2.4 million Texas residents who enrolled in Marketplace coverage in 2023, more than 1.4 million were paying less than $10/month for their coverage.
I’m glad that Retton recovered and has secured health insurance going forward. These circumstances remind us that ACA-compliant health insurance can be obtained – regardless of our medical history, and with substantial subsidies available to most applicants.
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.
Footnotes
Explore your health care options after Open Enrollment
Marketplace Open Enrollment for health coverage in 2024 ended January 15. If you missed the Open Enrollment window, you might still have options for health coverage for the rest of the year.
Your health coverage options
You may qualify for a Special Enrollment Period to get coverage or change plans if:
If eligible, you can enroll in Marketplace coverage for the rest of the year outside the annual Open Enrollment Period.
Find out if you qualify
You can also apply for health coverage through Medicaid or the Children’s Health Insurance Program (CHIP) any time if you’re eligible.
Now that Open Enrollment is over, learn more about coverage options for the rest of the year.