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Can I buy health insurance outside of the Marketplace that meets all ACA standards?

Written by HummingbirdinsAdmin on . Posted in Frequently Asked Questions.

Yes.  Many insurers that offer policies through the Marketplace also offer identical policies outside of the Marketplace, in the individual health insurance market.  These ACA-compliant policies also will meet all ACA standards.  They will cover essential health benefits; and they won’t turn you down, charge you more, or limit coverage based on your pre-existing condition.  In addition, ACA-compliant policies will only be offered during Open Enrollment, or at other times during the year, only to people who are eligible for a special enrollment period (SEP).

Sometimes people prefer to buy outside of the Marketplace, for example, when they are sure they won’t qualify for financial assistance. However, many other policies that are not ACA-compliant are also for sale outside of the Marketplace, and this can make comparison-shopping more complicated.

Some signs that a health policy is not ACA-compliant include:

  • The application asks questions about your health status or health history
  • The policy doesn’t cover essential benefits, such as maternity care or prescription drugs
  • The policy has annual or lifetime dollar caps on covered benefits
  • The policy is offered for sale outside of Open Enrollment to people regardless of whether they’re eligible for an SEP, for example, because they recently lost other coverage

Plans that are not ACA-compliant, including short-term health insurance, may have lower premiums because they can exclude people with pre-existing conditions and offer more limited benefits.

If you are shopping outside of the Marketplace and you want an ACA-compliant policy, be sure to specify that to the insurer or broker you’re working with.

Finally, even if you think you won’t qualify for financial assistance, it still might be worthwhile to shop for coverage on the Marketplace.  All policies offered through the Marketplace will meet ACA standards; no other non-compliant products are sold there.   In addition, if you are not eligible for financial assistance now, but your circumstances change later during the year (for example, your income declines), you can begin receiving financial assistance right away if you are already covered under a Marketplace plan.  Or, when you file your tax return at year-end you can claim a premium tax credit to have some of the premium you paid for the Marketplace plan refunded to you.  However, if you bought an ACA-compliant policy outside of the Marketplace, and then you become eligible for financial assistance mid-year, you may have to wait until the next Open Enrollment to switch to a Marketplace plan and get financial assistance.

I’m pretty healthy now. Does it make sense to buy a cheaper, short-term policy now, and then go back to a Marketplace policy if I do get sick?

Written by HummingbirdinsAdmin on . Posted in Frequently Asked Questions.

That strategy involves some risks.  First, if you do get sick while covered under a short-term policy, it might not cover benefits for the care you need.  For example, many short-term policies don’t cover, or only provide limited coverage for prescription drugs.

Second, if you do get sick while covered under a short-term policy, the insurer can look back to see if your condition could be considered “pre-existing.”  For example, if you are diagnosed with cancer, the insurer might decide the cancer was growing in you before you bought the policy, even though you didn’t know it, and so exclude coverage for the pre-existing condition.

Third, if you become seriously ill or injured while covered under a short-term policy, the insurer will most likely refuse to sell you new coverage once your policy term ends.  At that point, you might be able to buy a comprehensive policy through the Marketplace that won’t turn you down, but these are only offered during annual Open Enrollment periods and new coverage won’t start until January 1.  That means you could be  uninsured for many weeks or months before new Marketplace coverage begins.  Loss of coverage under a short-term policy will not make you eligible for a special enrollment period to buy Marketplace coverage mid-year.

I notice short-term policies are for sale outside of the Marketplace and they are cheaper than many other policies. What is a short-term policy?

Written by HummingbirdinsAdmin on . Posted in Frequently Asked Questions.

As the name implies, a short-term health insurance policy offers coverage for a period of less than 12 months.  Many offer coverage for just 3 to 6 months.  Beyond that term, coverage generally can only be continued if the insurance company agrees.  This is sometimes called a non-guaranteed-renewable policy.  If you’ve made claims since you bought the short-term policy, the insurer can, and likely will refuse to continue coverage once the policy term ends.

In addition, short-term policies do not offer other protections found in Marketplace plans.  For example, short-term policies can exclude coverage of pre-existing conditions.  Short-term policies also typically do not cover essential health benefits such as prescription drugs, mental health care, substance abuse treatment, or maternity care.

I didn’t apply for a hardship exemption from the Marketplace during Open Enrollment. Is it too late to apply for a hardship exemption for this year?

Written by HummingbirdinsAdmin on . Posted in Frequently Asked Questions.

No, you can apply to the Marketplace for a hardship exemption at any time during the year.  Most hardship exemptions will be granted for the month before the hardship, the months of the hardship, and the month after the hardship. You will need to document the timing of the hardship in your application.

In addition, for the 2018 tax year, you can claim a hardship exemption directly on your tax return, by checking the box on Form 1040, without having to apply to the Marketplace.  You won’t be required to submit documentation of the hardship with your tax return, though you should retain any documents for your own records.

We buy health coverage in our state Marketplace and our son attends college in a different state. We want to cover him on our policy. Can we do that?

Written by HummingbirdinsAdmin on . Posted in Frequently Asked Questions.

Yes, you can. One key consideration, though, will be whether he can access in-network services while he is away at school. Some insurers sell coverage in many states and offer a regional or national provider network. In addition, some health plans may have agreements with insurers in other states to cover their providers as though they were in-network. If you can’t find a plan that offers network providers in both states, you could consider buying a separate plan for your son.  You could also evaluate what out-of-network coverage, if any, your plan offers.

I’ve picked the plan I want. Now do I send my premium to the Marketplace?

Written by HummingbirdinsAdmin on . Posted in Frequently Asked Questions.

No, in most states you will make your premium payments directly to the health insurance company. Once you’ve selected your plan, the Marketplace will direct you to your insurance company’s website to make the initial premium payment. Insurance companies must accept different forms of payment and they cannot discriminate against consumers who do not have credit cards or bank accounts. The insurance company must receive and process your payment at least one day before coverage begins. Make sure you understand your insurance company’s payment requirements and deadlines and follow them so your coverage begins on time. Your enrollment in the health plan is not complete until the insurance company receives your first premium payment.

Note that if you have qualified to receive an advanced premium tax credit, the government will pay the credit directly to your insurer and you will pay the remainder of the premium directly to the insurer.

I’m buying coverage on the Marketplace for my family. I notice many health plans don’t cover pediatric dental care, but there are also stand-alone dental plans for sale. Is that allowed?

Written by HummingbirdinsAdmin on . Posted in Frequently Asked Questions.

Each health insurance Marketplace can decide whether to require all insurers to cover pediatric dental benefits or whether to allow the sale of stand-alone dental policies. When stand-alone dental policies are allowed, health insurers in the Marketplace might not be required to cover pediatric dental benefits. If your health plan covers dental benefits, you will pay one premium for everything. If you get dental benefits through a stand-alone plan, you will have to pay a separate premium for the dental benefits.

What health benefits are covered under Marketplace plans?

Written by HummingbirdinsAdmin on . Posted in Frequently Asked Questions.

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.