HEALTH & MEDICAL INSURANCE AFTER ACA OPEN ENROLLMENT

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  and go back to allowing short-term plans to be issued for duration's up  to 364 days. And the Trump administration confirmed their commitment to  rolling back the limitations on short-term plans in an October 2017  executive order. The 

In the individual/family health insurance market (IE, coverage that people buy for themselves, as opposed to  getting from an employer), open enrollment for 2021 coverage ended on  December 15 in Arizona. 

Millions of Americans purchased ACA-compliant plans through the exchanges — and outside of the exchanges — during open enrollment. But there are still millions of Americans who don’t have coverage as of early 2021 (the total number of uninsured Americans has been steadily and in some cases dramatically increasing ever since Obamacare or the ACA went into effect.  The ACA is great if you get a subsidy, but the higher deductibles and premiums are out of control.  

If you didn’t sign up for health insurance during open enrollment,  you may have to wait until November 2021 to sign up for a plan that will  take effect in 2022. But you may find that you can still get coverage  for 2021, even if open enrollment has ended in your state. Let’s take a  look.

Good new for our indigenous neighbors is that Native Americans can enroll in exchange plans year-round.

And people who qualify for Medicaid or CHIP can also enroll at any time. Income limits are fairly high for CHIP eligibility,  so be sure you check your state’s eligibility limits before assuming  that your kids wouldn’t be eligible – benefits very much extend to  middle-class households.

And in states where Medicaid has been expanded, a single individual earning up to $17,608 can enroll in Medicaid.  Most states have expanded Medicaid, and both Oklahoma and Missouri will join them in mid-2021. But there are still 14 states (dropping to  12 once Medicaid expansion takes effect in Oklahoma and Missouri) where  there is a Medicaid coverage gap assistance is not available for most adults with income below the poverty level.

Similarly, if you’re on Medicaid and your income increases to a level  that makes you ineligible for Medicaid, you’ll have an opportunity to  switch to a private plan at that point, with the loss of your Medicaid  plan serving as a qualifying event that triggers a special enrollment period.

Applicants who experience a verified qualifying event can gain access to a Special Enrollment Period  (SEP) to shop for plans in the exchange (or off-exchange, in most cases) with premium subsidies  available in the exchange for eligible enrollees.

And in most cases, the current rules limit SEP plan changes to plans at the same metal level the person already has. The state-run exchanges (IE, the ones that don’t use www.healthcare.gov can use their own  discretion on this, but in general, if you’re enrolling mid-year, be  prepared to provide proof of the qualifying event that triggered your  special enrollment period, and know that you might not be able to switch  to a more robust or less robust plan (IE, from bronze to gold or vice  versa) during your SEP. And understand that in most — but not all —  cases, the current SEP rules allow you to change your coverage but not  necessarily go from being uninsured to insured. So you may be asked to  provide proof of your prior coverage in addition to proof of the  qualifying event.

For example, although a permanent move to an area where different  health plans are available used to trigger a SEP regardless of whether  you had coverage before the move, that’s no longer the case. Now, you must be able to prove that you had qualified health coverage in place before you moved or were transferred to your new address. The same is true of getting married.

And without a qualifying event, major medical health insurance is not available outside of general open enrollment, on or  off-exchange. This is very different from the pre-2014 individual health  insurance market, where people could apply for coverage at any time.  But of course, approval used to be contingent on health status, which is  no longer the case.

If you’re curious about your eligibility for a special enrollment  period, call (800) 436-1566 to discuss your situation with a licensed  insurance professional.
 

For people who didn’t enroll in coverage during open enrollment,  aren’t eligible for employer-sponsored coverage or Medicaid/CHIP, and  aren’t expecting a qualifying event later in the year, the options for  2021 coverage are limited to policies that are not regulated by the ACA  and are thus not considered minimum acceptable coverage.

And most of these plans are designed to be supplemental coverage,  rather than a person’s only health coverage. This includes things like limited-benefit plans , accident supplements, critical/specific-illness policies, dental/vision plans, and medical discount plans.

But there are a few types of coverage that are available year-round  (generally only to fairly healthy individuals), and that can serve as  stand-alone coverage in a pinch:

There are also health sharing ministry plans available nearly everywhere, and although they are not compliant with  insurance laws, they are better than nothing and are available  year-round to people who meet their eligibility criteria.

Sort-term health insurance plans are available in 39 states,  and can serve as decent coverage if your other alternative is to remain  uninsured. In most states, it’s the closest thing you can get to “real”  health insurance if you find yourself needing to purchase a policy  outside of open-enrollment without a qualifying event.

For most of 2017 and 2018, short-term plans were capped at three months in duration, due to an Obama administration regulation. But the HHS (Department of Health and Human Services) finalized new rules that drastically expanded the allowable duration of short-term plans as of October 2018.

The Obama-Administration directed the HHS to cap short-term plans at three months in duration  in an  effort aimed at “curbing abuse” of short-term plans. At that point,  under HHS Secretary Sylvia Matthews-Burwell, HHS noted that short-term  plans are exempt from having to comply with ACA regulations specifically  because they’re supposed to only be used to fill gaps in coverage — but  instead, people had been using them for up to a year at a time,  effectively removing healthy people from the ACA-compliant risk pool and  destabilizing it over the long-run.

In 2017, several GOP Senators asked the Department of Health and Human Services (HHS) to reverse this regulation and go back to allowing short-term plans to be issued for duration's up  to 364 days. And the Trump administration confirmed their commitment to  rolling back the limitations on short-term plans in an October 2017  executive order. The new rules took effect in October 2018, implementing the following provisions:

• Short-term plans can now have initial terms of up to 364 days.
• Renewal of a short-term plan is allowed as long as the total duration of a single plan doesn’t exceed 36 months (people can string together multiple plans, from the same insurer or  different insurers, and thus have short-term coverage for longer than 36  months, as long as they’re in a state that permits this).
• Short-term plan information must include a disclosure to help consumers understand the potential pitfalls of short-term plans and how they differ from individual health insurance.

But states can still impose stricter rules, and the majority of states do.  Some are long-standing rules, while others are newly-adopted rules that  states have implemented in an effort to prevent the Trump  administration rules from destabilizing their individual insurance  markets and pushing healthy people into less comprehensive coverage.

Although premium subsidies such as tax credits, are not available for short term plans,  the retail prices on these policies are more affordable than the retail  price (IE, unsubsidized) on ACA-compliant plans, and they do still  serve as a good stop-gap if you just need the policy to cover you for a  few months when you’re in between other policies. However, if your  income makes you eligible for the ACA (Obamacare) premium subsidies, it’s essential that you enroll through your state’s exchange during  open enrollment (or a special enrollment period triggered by a  qualifying event like losing access to your employer-sponsored health  insurance); otherwise, you’re missing out on comprehensive health  insurance and a tax credit.

Some short-term plans have provider networks, but others allow you to  use any provider you choose (keep in mind, however, that you’ll likely  be subject to balance billing if your plan doesn’t have a provider network, since the providers will  not be bound by any contract with your insurer regarding the pricing for  their services).

And short-term policies are not required to be renewable; the new federal rule allows insurers to offer renewable short-term plans, but does not require them to do so. Depending on your state’s regulations and your insurer’s  business plan, you may be able to renew your short-term plans, or you  may be able to purchase a new short-term policy when your existing one  expires. But if you’re buying a new policy, the purchase will require  new underwriting, and in most cases, the new policy will not cover preexisting conditions, including any that began while you were covered under the first short-term policy.

Unlike ACA-compliant plans, short-term policies have benefit  maximums. But the limits on some short-term plans tend to be more  reasonable than the infamous pre-ACA "mini-medical" plans that barely covered a few nights in the hospital. Lifetime maximums of $750,000 to $2 million are common on short-term plans. While this is not as good as regular individual insurance plans that no longer have annual or lifetime caps on their benefits, it’s roughly similar to a lot of the plans that were available several  years ago in the individual market. And the concept of a “lifetime”  limit doesn’t really matter when you’re talking about a plan that lasts  for at most 36 months (the maximum amount of time a single plan can  remain in effect under the new federal rules), since you won’t be able  to purchase another short-term plan if you develop a serious health  condition.

But you’ll see plenty of short-term policies with much lower benefit  limits. As a general rule, you’ll want to focus on plans that offer at  least $1 million in benefits — yes, health care is shockingly expensive.

The application process is very simple for short-term policies. Once  you select a plan, the online application is much shorter than it is for  standard individual health insurance, and coverage can be effective as  early as the next day.

There are no income-related questions (since short-term policies are  not eligible for any of the ACA premium subsidies), and the medical  history section is generally quite short – nowhere near as onerous as  the pre-2014 individual health insurance applications were.

Keep in mind that although the medical history section generally only  addresses the most serious conditions in order to determine whether or  not the applicant is eligible for coverage, short-term plans generally  have blanket disclaimers stating that no pre-existing conditions are  covered.

And post-claims underwriting is common on short-term plans. So although the insurer may accept your  application based simply on what you disclose when you apply, they can —  and likely will — go back through your medical history with a  fine-toothed comb if and when you have a significant claim. If they find  anything indicating that the current claim might be related to a  pre-existing condition, they

can rescind your coverage or deny the  claim. So although a short-term plan might work well to cover a broken  leg, it’s going to be less useful if you end up with a health condition  that tends to take a while to develop, as the insurer may determine that  the condition, or something related to it, began before your coverage  was in force. 

Clearly, short-term plans are not as good as the ACA-regulated  policies that you can purchase during open enrollment or during a  special enrollment period. Short-term insurance is not regulated by the  ACA, so it doesn’t have to follow the ACA rules: The plans still have  benefit maximums, and they are not required to cover the ten essential benefits. (Most often, short-term plans don’t cover maternity, prescription  drugs, preventive care, or mental health/addiction treatment), they do  not have to limit out-of-pocket maximums, and they do not cover pre-existing conditions. They also still use medical underwriting, so coverage is not guaranteed issue.

The majority of short-term medical plans do not cover prescription drugs. Using a pharmacy discount card may lower medication costs without  health insurance, and some discount prices may be lower than an  insurance copay.

Although loss of existing minimal essential coverage is a qualifying event that triggers a special open enrollment period  for ACA-compliant individual market plans, short-term policies are not  considered minimum essential coverage, so the loss of short-term  coverage is not a qualifying event (loss of a short-term plan is a qualifying event for employer-sponsored coverage, however, so you’d  be able to enroll in your employer’s plan when you short-term plan  ends).

Let’s say you lose your job and your employer-sponsored health plan.  You then have a 60-day window during which you can enroll in an  ACA-compliant plan.  You also have the option to buy a short-term plan at that point, and  it may be available with a term of up to a year, depending on where you  live. But when the short-term plan ends, you would no longer have access  to an ACA-compliant plan (you’d have to wait until the next open  enrollment, and a plan selected during open enrollment would become  effective on January 1) and although you could purchase another  short-term plan, your eligibility would depend on your current medical  history. [Some short-term plan insurers offer guaranteed renewability  under the new federal rules, meaning that people can renew the plan,  without going through medical underwriting, and keep it for up to 36  months. But not all insurers offer this option.]

Although short-term plans do not provide the level of coverage or  consumer protections that the new ACA-compliant plans offer, obtaining a  short-term policy is better than remaining uninsured. But your best bet  is to maintain coverage under an ACA-compliant policy; if you’re not  enrolled, you’ll want to do so if you experience a qualifying event  (most people don’t take advantage of their qualifying events, perhaps  unaware that their opportunity to enroll is limited) to where they are.