Not necessarily. All Marketplace health plans are required to cover the ten categories of essential health benefits. However, insurers in many states will have flexibility to modify coverage for some of the specific services within each category. Any modifications must be approved by the Marketplace before plans can be offered. All health plans must provide consumers with a Summary of Benefits and Coverage (SBC). This is a brief, understandable description of what a plan covers and how it works. The SBC will also be posted for each plan on the Marketplace web site. The SBC will make it easier for you to compare differences in health plan benefits and cost sharing.
Plans might differ in other ways, too. For example, the network of health providers might be different from plan to plan.
All qualified health plans offered in the Marketplace will cover essential health benefits. Categories of essential health benefits include:
Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Emergency services
Hospitalization
Maternity and newborn care (care before and after your baby is born)
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including dental and vision care
The precise details of what is covered within these categories may vary somewhat from plan to plan.
All health plans offered through the Marketplace must meet the requirements of “qualified health plans.” This means they will cover essential health benefits, limit the amount of cost sharing (such as deductibles and co-pays) for covered benefits, and satisfy all other consumer protections required under the Affordable Care Act.
Health plans may vary somewhat in the benefits they cover. Health plans also will vary based on the level of cost sharing required. Plans will be labeled Bronze, Silver, Gold, and Platinum to indicate the overall amount of cost sharing they require. Bronze plans will have the highest deductibles and other cost sharing, while Platinum plans will have the lowest. Health plans will also vary based on the networks of hospitals and other health care providers they offer. Some plans will require you to get all non-emergency care in-network, while others will provide some coverage when you receive out-of-network care.
It is important that you contact both the Marketplace and the health plan and let them know you no longer need coverage. In HealthCare.gov states, you can log into your Marketplace account, select the “terminate coverage” option, and enter the required information.
If you have a family policy and want to remove one person from the policy but keep coverage in effect for others, in HealthCare.gov states, log in to your Marketplace account, select the “reporting a life change” option, and enter the required information.
If you have questions about these changes, contact one of the agents here at Hummingbird. We will be happy to assist you in updating your information through Healthcare.gov.
Making these changes through your Marketplace account will create a written record that you tried to end coverage.
Do not simply stop paying the premium for your Marketplace health plan as a way to terminate coverage. Nonpayment will eventually cause your coverage to end, but in the future, if you try to enroll in coverage again with that insurer, you might be prevented from doing so until you repay the missed premium.
In most states if you enroll in a private health insurance plan any time between November 1 and December 15 and make your first premium payment by the due date specified by your plan, your new health coverage starts January 1.
Yes, leaving your job and losing eligibility for job-based health coverage will trigger a special enrollment opportunity that lasts for 60 days. You can apply for Marketplace health plans and (depending on your income) for premium tax credits and cost sharing reductions during that period. If you enroll in COBRA coverage through your former employer, however, you will need to wait to the next Marketplace Open Enrollment period if you want to switch to a Marketplace plan.
No, voluntarily dropping your COBRA coverage or ceasing to pay your COBRA premiums will not trigger a special enrollment opportunity. You will have to wait until you exhaust your COBRA coverage or until the next Open Enrollment (whichever comes first) to sign up for other non-group coverage.
During Open Enrollment, you can sign up for a Marketplace plan even if you already have COBRA. You will have to drop your COBRA coverage effective on the date your new Marketplace plan coverage begins. After Open Enrollment ends, however, if you voluntarily drop your COBRA coverage or stop paying premiums, you will not be eligible for a special enrollment opportunity and will have to wait until the next Open Enrollment period. Only exhaustion of your COBRA coverage triggers a special enrollment opportunity.
No, in general, once you sign up for a plan, you are locked into that coverage for 12 months, or until the next Open Enrollment period. A change in health status doesn’t make you eligible for a special enrollment opportunity.
Yes, in most states. The federal Marketplace (HealthCare.gov) requires people to provide documentation of eligibility for special enrollment before you can enroll in coverage. Pre-enrollment verification is required for the following qualifying events:
Loss of minimum essential coverage
Permanent move
Marriage
Adoption, placement for adoption, placement for foster care, or child support or other court order, and
If you experience one of these qualifying events and apply for coverage in a federal Marketplace state, HealthCare.gov will let you select a health plan, but will delay the effective date of coverage while it verifies your eligibility for the SEP.
HealthCare.gov will tell you what documents are acceptable to verify your eligibility for the SEP and how to submit them. Once you apply for the SEP and select a health plan, you will have 30 days to provide documentation to the Marketplace. Once the Marketplace verifies your eligibility, you will be able to complete enrollment in the plan you selected.
It is very important to act quickly to complete this verification process. If you do not submit the required documentation within 30 days, your plan selection will be cancelled and you will no longer be eligible for the SEP.
If you submit documentation on time but the Marketplace determines it to be insufficient, you can apply for an extension of the 30-day review period to submit additional documentation. However, you cannot apply for an extension of your special enrollment period. If your eligibility is not verified by the end of your 60-day SEP, your plan selection will be cancelled and you will not be able to enroll until the next open enrollment period.