Health Plan FAQ’s

a. COVID-19 Special Enrollment Period: The Biden Administration has established a COVID-19 special enrollment period on healthcare.gov that runs between February 15 and August 15, 2021. This is a one-time special enrollment that is not scheduled to be repeated in 2022. Enrollment is effective the first of the following month. This applies to all the states that participate on healthcare.gov. Applicants will not have to provide proof of a qualifying life event (e.g. a birth, marriage, moving between a different county or state, etc.) if they enroll through healthcare.gov during this period. (See the last paragraph of FAQ 4 for further details about qualifying life events.)

b. Changes Made By The American Rescue Plan Act (ARPA): ARPA was signed into law on March 11 and made major changes to the Affordable Care Act. These changes apply only to 2021 and 2021 unless otherwise noted. New legislation will be needed to extend these changes or make them permanent.

Prior to (and after) ARPA, individuals and families in almost all cases are eligible for tax credits (also referred to as subsidies) based on their income falling between 100% (in non-Medicaid expansion states like Florida) and 138% (in Medicaid expansion states) and 400% of the Federal Poverty Level (see chart in FAQ 14). Individuals falling above 400% of the FPL could not previously qualify for tax credits. Under ARPA, people falling above 400% of the FPL are NOW eligible for tax subsidies for the first time.

These tax credits can be applied to reduce the premium of ANY plan offered through the health insurance marketplace (healthcare.gov).

People falling between 100% and 250% of the FPL could (and continue to) also qualify for what is called a cost sharing reduction plan (CSR). A CSR (see FAQ 16) reduces the deductibles, copays , and maximum out of pocket costs for what is called a silver plan (see FAQ 18 for a description of what are called the “metallic levels” of Affordable Care Act plans) FOR NO ADDITIONAL COST.

Tax subsidies are calculated based on a person’s age and zip code of residence. They’re calculated based on how their family income relates to the cost of the second lowest cost silver plan offered in their zip code. The cost of the plan differs according to age, zip code and family size, and the calculation assumes that all family members are non-smokers. As of April 1, 2021 the % of income requirements have been lowered for all poverty levels, and those making over 400% are NOW limited to paying 8.5% of their income for the second lowest cost silver plan in their area (this is referred to as the “benchmark” plan).

Here is a comparison of the calculations used prior to ARPA and the calculations used starting April 1, 2021 to determine subsidies:

Subsidy Calculations—Before And After ARPA
(Households Making Above 400% Of the FPL Can Now Be eligible For Subsidies)

The effect of these changes is that tax subsidies are increased for those who previously qualified for them. Many people making over 400% of the FPL—particularly those 50 and over—will NOW be eligible for subsidies for the first time, and these subsidies may be very significant.

Beginning April 1, 2021 individuals in states (e.g. Florida) that participate in healthcare.gov can update their tax subsidies and retain or change their present plans. People currently receiving tax subsidies (or those applying for ACA plans for the first time) can update their applications and remain in their current plan or change to a different plan. People who did not previously qualify for tax subsidies can apply for on-exchange (also called marketplace) plans starting April 1, 2021. Changes made during a month will be effective the first of the following month. See FAQ 8 for a description of marketplaces or exchanges.

Individuals continuously enrolled in an on-exchange plan since January 1, 2021 will be able to take tax credits retroactively to January 1, 2021 if they are enrolled in a subsidized plan by August 15, 2021. Their premiums will be adjusted to reflect their new subsidies as of the month following updating their application or changing to a subsidized plan, but they will receive credits for having the new subsidy retroactive to January 1 when they reconcile their income on their tax return. Individuals enrolled in off-exchange plans who enroll in an on-exchange subsidized plan will only be able to take tax credits for the period they’re enrolled in a subsidized plan.

If you live in a state that operates its own exchange, that exchange (e.g. Covered California in California) may have established different rules re enrollment dates and eligibility. For example, Colorado will not permit people to change plans; only those who did not enroll previously will be able to enroll during their COVID-19 special enrollment period. California will permit enrollment through the end of the year. Please contact your local state exchange for details. A few states have limited the special enrollment period rules extensively: In Idaho, for example, the COVID-19 Special Enrollment Period will only run through April, and previously enrolled individuals will not be permitted to change plans or carriers.

There’s another significant change that was made by ARPA. For 2020 (ONLY), those who underestimated their earnings will be exempt from having to pay back the government the difference between the subsidy based on the earnings they projected and the lower subsidy that would have been applicable based on their actual earnings. The IRS has announced that those who have already submitted tax returns WILL NOT have to submit amended returns. The IRS will be issuing refunds automatically to those who had reconciled and paid back any overpayments.

1. Individuals who have received unemployment compensation in 2021 (this provision is applicable ONLY in 2021) will be considered as making 133% of the FPL when making subsidy calculations. Note: guidance on this provision won’t be issued until early July. Meanwhile, those with unemployment compensation who can project earnings to at least 100% of the FPL should make application as soon as possible if they have not already done so.

2. People who were involuntarily terminated or who lost coverage due to a reduction in hours will be eligible to receive premium-fee COBRA through September 30, 2021. This provision is effective April 1, 2021 and ends the earlier of September 30, 2021 or when the individual’s COBRA eligibility ends. Beginning April 1, 2021 employers will have until May 31, 2021 to provide notice to affected individuals. Employers must also give advance notice to individuals before their premium-free COBRA period ends. NOTE: Rules have not yet been issued about what individuals can do after August 15 to enroll in an ACA plan if their statutory COBRA period has not yet ended as of the same date their COBRA subsidy ends.

Prior to January 1, 2014, individuals could enroll in health plans at any time. However, the Affordable Care Act established an Open Enrollment Period during which individuals and families must enroll UNLESS they have a "qualifying life event" (see answer to FAQ 4 and also see the special rules concerning the COVID-19 Special Enrollment Period that ends August 15,2021 as described in FAQ 1.)

During the Trump administration open enrollment for ACA-compliant health coverage for individuals and families began November 1 and ended December 15 for a January 1 of the following year effective date. The December 15 deadline applied in all 36 states (including Florida) that use healthcare.gov and in some of the 15 states that run their own exchanges. Look ­here for information about state exchanges.

Open enrollment lasted for a longer period during the Obama administration. Nothing has been published about open enrollment for next year, but we expect that the period for open enrollment for 2022 plans will be expanded this year.

Carriers are permitted to offer non-subsidized plans purchased directly from the carrier (these are called “off-exchange” plans). Carriers are permitted to establish different dates for off-exchange open enrollment, but most carriers use the same dates for on-exchange and off-exchange open enrollment. Most, but not all, carriers offering ACA plans in Florida also offer off-exchange plans. See FAQ 8 for an explanation of exchanges.

You won't be eligible to enroll outside the Open Enrollment Period (or the COVID-19 Special Enrollment Period) UNLESS you experience a "qualifying life event" and become eligible for a Special Enrollment Period (SEP). Please see this link that contains more information about Special Enrollment Periods.

Applicants who attest to certain types of SEP qualifying events (loss of coverage; permanent move; marriage; gaining or losing a dependent through adoption, placement for adoption, placement in foster care, child support, or other court order; and Medicaid or CHIP denial) are subject to a Special Enrollment Period Pre-Enrollment Verification (SEPV) process. Note: This process does not apply to the COVID-19 Special Enrollment Period that runs between February 15 and August 15, 2021 (see FAQ 1, above).

Eligible consumers must submit documents that confirm their SEP eligibility before they can start using their Marketplace coverage.

Current regulations state that special enrollment periods are intended only for individuals who have had continuous coverage (i.e. coverage for at least one day within the past 60 days).

Once the Marketplace has confirmed eligibility based on received and approved documents, applicants will receive notice they can pay their premium and start using their coverage retroactive to the effective date of coverage indicated in their application for enrollment.

We're available to help consumers understand what may make them eligible for a SEP and what documentation they need to submit to prove eligibility for a SEP.

Carriers are not required to follow healthcare.gov rules for off-marketplace special enrollment periods, although in the past many carriers have made verification requirements for such plans equally or more restrictive than those of healthcare.gov on-marketplace plans.

Qualified Health Plans (see FAQ 7) must have networks. A network is a group of healthcare providers or pharmacies who are contracted with the insurance carrier to provide medical services or prescription drugs at a discounted rate.

ACA networks in many cases are smaller and more restrictive than they were before the advent of the ACA. Before the ACA, PPO (Preferred Provider Organization) plans with large networks were common. These plans permitted you to go either in- or out-of- network (you would have paid more for going outside-of-network). While PPO networks still exist, new, smaller PPO networks have been introduced in some cases, and most ACA carriers don’t offer PPO’s at all.

Now, most ACA plans offer Exclusive Provider Organization (EPO) networks that allow you to use any provider without a referral but you must use network providers except in a medical emergency) or HMO networks (some HMO networks require referrals and others don’t but all require you to use network providers except in an emergency).

If a particular plan is important to you, you need to check before you enroll to determine if your desired provider accepts that plan. If not, you may want to select a different plan (if available) whose network includes that provider.

Please note that networks and network provisions can change each year and that providers can leave networks any time in the year when their contracts with the carrier expire.

All Affordable Care Act plans must cover these ten conditions called "Essential Health Benefits" ("EHB"):

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative and habilitative (conditions a person is born with) services
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including dental and vision care and services for children under age 19

Plans that cover these conditions and meet other requirements like not exceeding maximum permitted deductibles and having adequate networks of providers are referred to as "Qualified Health Plans" ("QHP").

Exchanges are marketplaces where individuals and families can:

• Learn about some of their health coverage options,
• Qualify for tax credits and Cost Sharing Reductions ("CSR") [see answers to FAQ's 15 and 16 for an explanation],
• Compare health insurance plans based on costs, benefits, and other important features,
• Choose a plan, and
• Enroll in coverage.

Individuals MUST enroll through an exchange/marketplace in order to qualify for a tax subsidy or CSR. Because these determinations are quite complicated, we recommend that you call us at 877-734-3884 to help you determine your eligibility for tax subsidies or a CSR and assist in making your choice. There is no cost to you for our services.

The exchange run by the Federal government is called the Health Insurance Marketplace (or Federally Facilitated Marketplace). States running their own exchange may also name their exchanges - for example, "Access Health Connecticut" or "Covered California." Determine what type of exchange operates in your state. Find the marketplace in your state, compare plans, and enroll.

If you qualify for tax credits or a CSR, you must enroll using the link in the last sentence of the above paragraph, through a direct link from an insurance carrier’s site to the marketplace, or a web brokerage system (see FAQ 21 for a description of web brokerage systems).

Those individuals/families who do not qualify for tax credits or a CSR can shop for coverage the same way they always have: through brokers and agents or directly from health insurers (this is called buying "off-exchange").

Carriers can’t inquire or base premiums for Affordable Care Act Plans on health conditions nor can they exclude pre-existing conditions. The only factors that can be considered in determining premiums are age, smoking status, size of the family unit, and geography (usually county of residence).

ACA plans set limits on the maximum deductible a plan can have (considerably lower than maximum deductibles offered before January 1, 2014). ALL plans now have an individual deductible and a family deductible that is TWO times the individual deductible. Some plans count co pays against the deductible and all plans must count co pays against the "out-of-pocket limit" (see next paragraph).

Affordable Care Act plans have maximum "out-of-pocket limits" for all services covered by the plan. The maximum out-of-pocket is the most you can pay toward covered expenses in a calendar year, including deductibles, co pays, coinsurance, and medications included in the plan’s formulary. Before January 1, 2014, co pays and outpatient drug co pays and deductibles usually did not count against out-of-pocket limits.

The maximum permitted out-of-pocket limit for ANY ACA plan in 2021 is $8,550 for individuals and $17,100 for families.

In some cases the plans have the same deductibles and out-of-pocket maximums. If a plan's deductible is lower than the maximum out-of-pocket maximum, that plan will usually have some form of coinsurance that applies after the deductible until the out-of-pocket maximum is met.

Smoking is defined as smoking four or more times per week within the last 6 months and does not include smoking electronic cigarettes. Smoking was more strictly defined before the ACA became effective.

See FAQ 2 for information about the premium-free COBRA provision created under ARPA and that will run between April 1 and September 30, 2021. Otherwise, the rules concerning COBRA and Affordable Care Act plans are as follows:

COBRA is not replaced by the Affordable Care Act, BUT individuals should carefully consider the effects of electing COBRA instead of purchasing an Affordable Care Act plan.

If an individual elects COBRA s/he either must have exhausted COBRA or apply during Open Enrollment (or during the COVID-19 Special Enrollment Period). Otherwise, an individual who has elected COBRA and loses coverage either due to non-payment or who wishes to convert to an ACA plan before exhausting COBRA MUST wait until Open Enrollment occurs to make the change, which would then be effective the following January 1.

In most (but not all) cases individuals will find it less expensive to elect an Affordable Care Act plan instead of COBRA. Contact us at 877-734-3884 for more information.

Losing coverage and NOT electing COBRA is a qualifying life event (see FAQ 4) and entitles an individual to a Special Enrollment Period. Likewise, exhaustion of COBRA is also a qualifying life event.

LEARN MORE.

Certain individuals can also qualify for a catastrophic plan. These are health plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but don't cover more than 3 primary care office visits per year before the plan's deductible is met. The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles, co payments, and coinsurance are generally higher.

You can't qualify for tax credits or CSRs if you elect one of these plans. To qualify for a catastrophic plan, you must be under age 30 OR qualify for a "hardship exemption" because the marketplace determined that you're unable to afford health coverage.

The Federal Poverty Level ("FPL") is used to determine your eligibility for a subsidy (see FAQ 15). You're eligible for a subsidy if your income (MAGI is the measure of income that is used to determine income) is equal to the number below (depending on the number of individuals in your family) up to 4 times that amount. In accordance with ARPA (see FAQ 1), effective April 1, 2021 you’re eligible for a subsidy if your income is more than 8.5% of the second lowest cost silver plan (called the “benchmark” plan) in your zip code. (See FAQ 18 for a discussion of the ACA metallic levels.)

Moreover, you're not eligible for a tax subsidy if your income is below your state's level for Medicaid eligibility. (Please see the exception that will apply for those receiving at least one week of unemployment compensation in 2021; guidelines won’t be published on this provision until July. See FAQ 2). Some states have set that level at 1.38 times the FPL while other states like Florida have maintained that level at the FPL. The FPL changes each year and is used for determining eligibility for subsidies for the next year. The FPL (note that FPL differs for Alaska and Hawaii) used for determining 2021 subsidies is:

• $12,760 for a single individual
• $17,240 for a family of 2
• $21,720 for a family of 3
• $26,200 for a family of 4
• $30,680 for a family of 5
• $35,160 for a family of 6
• $39,640 for a family of 7
• $44,120 for a family of 8

Federal Poverty Level For 2021 Plans

Every year, the Federal Poverty Level (FPL) (see below) changes based on the cost of living. Individuals and families need to understand where they fall on the FPL so they know whether they may qualify for Medicaid in their state (modified adjusted gross income either below 100%, or 138% of the FPL for states that have enacted Medicaid expansion); whether they are eligible for a tax subsidy (also called an Advanced Premium Tax Credit; see below) because they earn between 100/138% and 400% of the FPL (or, starting April 1, 2021 those who have income above 400% of the FPL and whose cost for the benchmark silver plan in their zip code is more than 8.5% of their income); or whether they’re eligible for a Cost Sharing Reduction if they purchase a silver plan (see FAQ 18) and earn less than 250% of the FPL and also earn above the Medicaid threshold in their state.

Subsidy (Also Called An Advance Premium Tax Credit)

The Affordable Care Act requires that subsidies be provided to individuals and families who need help paying their monthly health insurance bills. Depending on age and county of residence, an unmarried individual or a family filing a joint return who makes between 100% (138% in Medicaid expansion states) and 400% of the Federal Poverty Level will usually be eligible for a subsidy (unless employer group coverage has been offered). Also, per ARPA, starting April 1, 2021 those with income above 400% whose cost for a benchmark silver plan is more than 8.5% of their income will also be eligible for subsidies.

Federal Poverty Level and Cost Sharing Reductions

Cost Sharing Reductions are offered ONLY for silver level metallic plans. The following chart indicates the various percentages (150, 200 and 250%) of the Federal Poverty Level that are used for determining eligibility for one of the three levels of Cost Sharing Reduction.

The chart shows various levels of FPL that are used for making tax subsidy and Cost Sharing Reduction determinations for 2021 Affordable Care Act calendar year plans. Unmarried individuals and families can be eligible for subsidies if their Modified Adjusted Gross Income (MAGI) is below the 400% level or, starting April 1, 2021 per ARPA if the cost of the benchmark silver level plan in their zip code is greater than 8.5% of their income. Unmarried individuals and families can be eligible for a Cost Sharing Reduction if their Modified Adjusted Gross Income is less than 250% of the FPL: eligibility for a level 6 CSR is for MAGI to be between 100/138% (depending on the state's eligibility level for Medicaid) and 150% of FPL; level 5 eligibility is between 150 and 200% of FPL; and level 4 eligibility is between 200 and 250%. See the first paragraph of FAQ 14 for a definition and explanation of MAGI.

Federal Poverty Level guidelines used for determining tax subsidies and Cost Sharing Reductions for 2021 plans

Starting April 1, 2021 those with MAGI above 400% may qualify for tax subsidies
if the cost of the benchmark silver plan in their zip code exceeds 8.5% of their income

How Can An Employee Who Is Offered Group Coverage Become Eligible For An ACA Subsidy?

Generally, if an employee is offered group coverage NEITHER the employee NOR his or her family is eligible for an Affordable Care Act tax subsidy. HOWEVER, if the employee’s portion of the premium is more than 9.83% of his or her income, s/he CAN qualify for an ACA tax subsidy if his or her income is above 100% (non-Medicaid expansion state) or 138% (Medicaid expansion state) of the Federal Poverty Level.

The Affordable Care Act provides a tax credit (called an "advance premium tax credit") to help certain individuals afford health coverage purchased through a marketplace. Advance payments of the tax credit can be used to lower your monthly premium costs.

You'll be able to calculate the amount of any tax subsidy as well as any possible Cost Sharing Reduction (see FAQ 14) for which you're eligible by going to healthcare.gov and making an application. (We can help you make an application by using one of our web brokerage systems (see FAQ 21).

After you complete the application, this information will be contained in the downloadable PDF (determination letter) that will be shown on your account. You should download and print this PDF for your records. Together with showing you the subsidy and any Cost Sharing Reduction information, this document will also notify you of any information (e.g. birth certificate, proof of income, copy of green card, etc.) that you must forward to the marketplace (address is shown in the PDF) by the due date shown.

If you have a qualifying life event and are eligible for a Special Enrollment Period, the determination letter will also indicate what kind of proof you need to submit to substantiate (1) that you have actually experienced that event and (2) that you had prior coverage.

Generally, you have 30 days to submit proof required to substantiate a qualifying life event, 90 days to submit income verification, or 95 days to submit proof of immigration status or citizenship.

Failure to provide any of this required information by the due date indicated can and usually will result either in the cancellation of your coverage or elimination of your subsidy. This information must be forwarded to the address indicated in the determination letter (or updated in your healthcare.gov account).

We suggest keeping the original documents and either uploading the documents into the system or sending the information by certified mail with return receipt requested to the address listed in London, KY (we recommend the later method because we find that uploaded documents are sometimes lost in the system). If you mail the information you must put your name and application id on each page and also include the page with the bar code (with your name and application id), which usually is located between pages 8-10 of your eligibility verification notice. Click on the following link to find out more about submitting documents:

How To Submit Documents

Once you obtain subsidy and Cost Sharing Reduction information, you can then proceed to the next step and enroll in a plan.

The final step will be to make the first payment with the carrier you have chosen. You should always keep track of the application id (also shown on the downloadable PDF) as well as the user id and password you used to access the healthcare.gov website. The state exchanges contain similar capabilities.

Income for purposes of calculating subsidies is based on MAGI (Modified Adjusted Gross Income). LEARN MORE.

MAGI includes certain adjustments to Adjusted Gross Income (your income before exemptions and deductions) and can either be equal to or higher than AGI. (For example, AGI includes only taxable Social Security; MAGI includes the entire Social Security benefit, whether or not it is taxable.) Other major differences include how interest and foreign income are calculated for AGI vs. MAGI.

You'll be able to use a calculator included on your Federal or state marketplace to estimate the amount of your tax credit as well as your Cost Sharing Reduction. Actual subsidies and eligibility for a Cost Sharing Reduction are determined ONLY when you complete an application and it is submitted to the applicable marketplace. Upon submission, the marketplace calculates the exact amount of your subsidy as well as your Cost Sharing Reduction level, if applicable.

Please call us at 561-734-3884 or 877-734-3884 for help in determining the amount of your tax credit, if any, and to see if you're eligible for a Cost Sharing Reduction.

A CSR is a discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments, but a CSR DOESN'T change the amount of your tax subsidy. CSR's can be used ONLY if you purchase a silver level plan (see FAQ 18).

You can qualify for a CSR if you purchase health insurance through an exchange and your income is below a certain level (between your state's income cut-off for Medicaid eligibility and 250% of the Federal Poverty Level). There are three different levels of Cost Sharing Reduction and if you qualify for a CSR in 2021, the level will be indicated by where your income falls on the chart in FAQ 14 above.

• Level 4 applies if your reported income is between 200% and 250% of the Federal Poverty Level. Plans at this level have an actuarial value of 73% (actuarial value means that a plan will pay that % of the average individual's medical expenses).
• Level 5 applies if your reported income is between 150% and 200% of the Federal Poverty Level. CSR's at this level have an actuarial value of 87%.
• Level 6 applies if your reported income is between your state's eligibility for Medicaid and 150% of the Federal Poverty Level. CSR's at this level have an actuarial value of 94%.

Please note that levels 4, 5, and 6 are the designations used by the Federal marketplace. Some carriers use different designations (like A, B and C) but the carrier designations are based on and equate to the marketplace levels.

See the following chart to determine how 2021 out-of-pocket maximums change based on CSR level for individuals and families.

"Co-insurance" - a percentage of your medical and drug costs that you pay out of your pocket.

"Co-pay" - the fixed dollar amount you pay when you receive medical services or have a prescription filled.

"Deductible" - the amount you pay for medical services and/or prescriptions before your plan pays for your benefits.

Plans sold on an exchange are primarily categorized into four health plan categories (also known as "metallic levels") - bronze, silver, gold, or platinum - based on the percentage the plan pays of the average overall cost of providing benefits to members.

The plan category you choose reflects the total amount an average person (i.e. a "standard" population) will likely spend ("actuarial value") for Essential Health Benefits (described in the answer to FAQ 7, above) during the year. Plans in each metallic level differ in premium and plan design.

While each plan in a metallic level has the same actuarial value determined on a standard population, you should determine what features and benefits are most important to YOUR situation (for example, a lower deductible may be more important to YOU than lower co-pays OR the reverse may be true), but the percentages the plans will spend, on average, are:

• * 60 percent (bronze),
• **70 percent (silver),
• **80 percent (gold), and
• **90 percent (platinum)

Notes:

* This percentage can be up to 4 percentage points lower or 5 percentage points higher (except for bronze plans meeting certain conditions)

** This percentage can be up to 4 percentage points lower or 2 percentage points higher

These metallic categories also apply to health plans sold to individuals outside of an exchange/marketplace (off-exchange).

You must make payment BEFORE the effective date of coverage for coverage to be effective. (Note: you generally must make payment for a plan selected during the COVID-19 Special Election Period within 30 days; you can make payment through our Web brokerage system with almost every carrier.) It’s VERY important that premiums are paid on a timely basis, and, unlike for pre-Affordable Care Act plans, reinstatement is not permitted for plans that have lapsed due to non-payment of premium. Payment requirements can differ between on- and off-Exchange plans.

(Note: the requirements for making continuing payments for off-exchange plans can be stricter than for on-exchange plans: with some carriers, participants in off-exchange plans have to make payment within 30 days of the first day of the coverage month or they will lose coverage, whereas other carriers permit up to 90 days. Check with your carrier to determine their payment rules and make sure you’re in compliance. On-exchange participants must submit payment within 90 days and if they’re late in paying also need to pay intervening missed payments, as well, in order to retain coverage. Off-exchange participants who have longer than 30-day grace periods will also have to make up intervening missed payments. In order to minimize chances of losing coverage due to non-payment, we recommend paying through electronic funds transfer (EFT), if at all possible.

Please note that you generally must make payment directly to the carrier [payments for Federal marketplace plans for most carriers can be made either through the marketplace or on a web brokerage system; (see FAQ 21)].

An individual applying for an on-exchange plan with the same carrier can be required to pay up to a maximum of three months' additional premium if s/he was in arrears (or failed to pay premiums and coverage was cancelled) within the previous twelve months BEFORE the new coverage can become effective.

In addition if you apply for a Special Enrollment Period (with the exception of the COVID-19 Special Election Period described in FAQ 1) and the exchange requires you to submit proof substantiating the qualifying life event, you will need to submit proof to the exchange within 30 days or you will lose your coverage. The effective date of coverage will be pended until you send in the proof and the exchange accepts that proof. Upon acceptance of proof, the exchange will notify you and will also notify the carrier. You can make payment to the carrier when the carrier posts the notification they receive from the exchange to their system. It's important to make timely payment; effective date of coverage will be the date the exchange determined your effective date of coverage to be when it asked you to submit the proof.

The Federal tax penalty for not having a plan that complies with the Affordable Care Act was eliminated effective January 1, 2019.

Five jurisdictions--California, District of Columbia, Massachusetts, New Jersey, and Rhode Island—have penalties for not having ACA-qualified plans.. These penalties are all calculated differently; check with your tax preparer for information about these penalties. Vermont has a mandate that non-Medicare eligible state residents must buy an ACA-qualified plan but there is no penalty for non-compliance.

This is a system that permits you to work with an insurance agent and enroll in a federal marketplace plan. You provide your personal and income information to an agent and authorize that agent to process your application with the marketplace using the web brokerage system. Working with an agent who uses a web brokerage system helps you speed up the enrollment process significantly.

Web brokerage systems must comply with HIPAA privacy and security requirements. CMS is required to certify these systems and only permits those systems that meet this requirement to have what is called a direct link to healthcare.gov.

We utilize the Health Sherpa web brokerage system [which uses what is called enhanced direct enrollment (“EDE”) technology] with most of our clients who want to enroll in a marketplace plan. This significantly shortens the time it takes to complete an enrollment if we enrolled through healthcare.gov instead of using this technology. Otherwise, we make three-way calls (with us, the consumer and the marketplace on the line) to effectuate enrollments or we assist consumers who want help in utilizing their own healthcare.gov account. We are prohibited from asking a consumer for their healthcare.gov user name and password and can NOT go on the healthcare.gov as if we were the consumer.

We follow all privacy and informed consent requirements irrespective of the method of enrollment we use.