Health Plan FAQ’s

Individuals in health plans bought before March 23, 2010 are "grandfathered" and can keep those plans if they continue to be offered by their insurance carrier. Most carriers (UnitedHealth One and Florida Blue are the major exceptions in Florida) have terminated their grandfathered plans and no longer offer these plans.

Individuals who bought plans on or after March 23, 2010 and before January 1, 2014 (referred to as “grand mothered” plans) have been permitted to retain those plans on a year- to-year basis. Carriers make annual decisions on whether to retain these plans for the coming year. CIGNA notified Florida members in June 2020 they’d no longer be offering such plans as of January 1, 2021. CIGNA policyholders with one of these plans had to elect new plans for a January 1, 2021 effective date.

If you have any questions, you can call us at 877-734-3884 or 561-734-3884 for more information.

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 3).

In every state, open enrollment for ACA-compliant 2021 health coverage for individuals and families began November 1, 2020 and in most states ended on December 15, 2020. The December 15 deadline applied in all 36 states that use HealthCare.gov, and in the 15 states that run their own exchanges, except as follows:

California, Colorado, and DC have permanently extended their open enrollment periods:

• California: November 1 to January 31
• Colorado: November 1 to January 15
• District of Columbia: November 1 to January 31

Other state-run exchanges established these enrollment deadline extensions for 2021:

• Minnesota: November 1 to December 22, 2020.
• Pennsylvania: November 1, 2020, to January 15, 2021
• Nevada: November 1, 2020, to January 15, 2021.
• New Jersey: November 1, 2020 to January 31, 2021.

Carriers are permitted to establish different dates for off-exchange open enrollment (i.e. buying a plan directly from the carrier), 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.

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 May 15, 2021. 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 if they enroll through healthcare.gov during this period.

This blog from Health Sherpa is the most authoritative and up-to- date discussion of how the special enrollment period will work on the federal marketplace (i.e. Florida and the other 35 states that participate) as well as the other 15 states plus the District of Columbia that have their own state exchanges. Effective dates and requirements vary in some of the state exchanges, as explained in the blog.

Carriers will also be permitted to offer plans on a direct-enrollment basis (i.e. “off-marketplace”) during this period. Rules and eligibility can differ from the on-exchange plans. In Florida for example, not all carriers will be offering off-exchange plans, and at least one carrier will require proof of a qualifying life event for applicants to change plans (but not to buy plans if they didn’t have prior insurance).

Contact us at 877-734-3884 for information, plan availability, and help in in enrolling.

OTHERWISE, you won't be eligible to enroll outside the Open 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 are subject to the 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 May 15, 2021 (see FAQ 3, 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).

Pre-enrollment verification is required for these five SEP types:

• Loss of coverage
• Permanent move
• Marriage
• Gaining or becoming a dependent through adoption, placement for adoption, placement in foster care, child support or other court order
• Medicaid/CHIP denial

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 for On-Marketplace plans.

Qualified Health Plans (see FAQ 6) 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 your desired provider.

Please note that networks and network provisions can change each year and that particular providers can leave networks any time in the year when their contracts with the providers 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 14 and 15 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 20 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 the Exchange").

Carriers can not 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). 

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.

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.

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.

The Federal Poverty Level ("FPL") is used to determine your eligibility for a subsidy (see answer to FAQ 14). 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. You're not eligible for a subsidy if your income is more than 4 times the FPL.

Moreover, you're not eligible for a tax subsidy if your income is below your state's level for Medicaid eligibility. 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
• $35,160for a family of 6
• $39,640 for a family of 7
• $44,120 for a family of 8

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 whether they are eligible for a Cost Sharing Reduction if they purchase a Silver plan (see FAQ 17) 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).

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. 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 FAQ 13 for a definition and explanation of MAGI.

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

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 9.78% of his or her income, s/he CAN qualify for an ACA tax subsidy if his or her income is between 100% (non-Medicaid expansion state) or 138% (Medicaid expansion state) and 400% 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 (see FAQ 15) as well as any possible Cost Sharing Reduction (see this FAQ) for which you're eligible by going to www.healthcare.gov and making an application. (We can help you make an application by using one of our web brokerage systems (see FAQ 20).

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 and 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 number on each page and also include the page with the bar code, 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 www.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 (see chart in FAQ 13) as well as your Cost Sharing Reduction (see the chart at the end of this FAQ). 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. This chart shows the income levels required to qualify for cost sharing reductions in 2021:

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 17).

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 immediately 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 6, 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. It is 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 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 are in compliance. On-Exchange participants have to submit payment within 90 days and if they are 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 20)].

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 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.

Note that five jurisdictions--California, District of Columbia, Massachusetts, New Jersey, and Rhode Island—have penalties for not having ACA-qualified plans starting in 2020 (and also applying for 2021). 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 system as if we were the consumer.

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