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Individual & Family Health Insurance - Affordable Care Act

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1. What If I Bought My Present Plan Prior To January 1, 2014?

Individuals in health plans bought before March 23, 2010 are "grandfathered" and can keep those plans as long as they are offered by their insurance carrier. Some carriers (for example Aetna, Coventry and Humana) have terminated their grandfathered plans and are no longer offering these plans..

Individuals who bought plans on or after March 23, 2010 and before January 1, 2014 have been permitted to retain those plans (referred to as "grandmothered" plans) on a year- to- year basis.  With the most recent changes to the Affordable Care Act, these plans will probably be permitted to be offered as long as the carrier elects to provide them. Carriers will be making yearly decisions on whether to retain these plans for the coming year.

Your carrier will be providing you details regarding whether or not your grandmothered plan continues to be offered.  If you have any questions, you can call us at 877-734-3884 for more information.



9. Can I Buy An Affordable Care Act Plan If I Have A Pre-Existing Condition?

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 and geography (usually county of residence).

11. How Does The Affordable Care Act Define Smoking Status?

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.

7. What Are Essential Health Benefits And What Is A Qualified Health Plan (QHP)?

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").




    6. Are Providers Different Under Affordable Care Act 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. 

    Affordable Care Act plan networks must meet certain requirements, including the size of the network and how it is created. 

    Note that these networks are usually smaller or may be more restrictive (e.g. an HMO that requires referrals) than the networks utilized in plans purchased before January 1, 2014. Some carriers no longer offer PPO networks or have reduced the size of their PPO networks.  Other carriers have changed their PPO networks to what are called Exclusive Provider Organization (EPO) networks.  Some carriers who formerly offered PPO or POS networks now only offer HMO plans. 

    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.  

    With some exceptions, most plans offered on the Exchange are closed access HMO's that require you to choose a primary physician who must make referrals for you to be able to see other providers. 

    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. 

    The Market Stabilization Rule that created the Special Enrollment Period Pre-enrollment Verification Provess (see FAQ 5)  also contains provisions that makes it possible for carriers to further restrict their networks under certain circumstances.



    8. What Is An Exchange (Also Referred To As A Marketplace)?

    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 in a state that participates in Healthcare.gov,  you must enroll using the above link, 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 the Exchange").

    17. What Is Meant By Co-insurance, Co-pay, And Deductible?

    "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 or prescriptions before your plan pays for your benefits.



    10. How Are Deductibles And Out-of Pocket Limits Determined Under Affordable Care Act (ACA) Plans?

    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 copays against the deductible and all plans must count copays 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, copays, and coinsurance. Before January 1, 2014, copays and outpatient drug copays and deductibles usually did not count against out-of-pocket limits. 

    The maximum permitted out-of-pocket limit for ANY ACA plan 2019 is $7,900 for individuals and $15,800 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 co-insurance that applies after the deductible until the out-of-pocket maximum is met.



    18. What Types Of Plans Are Available?

    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:

    *  In accordance with the Market Stabilization Rule effective June 19, 2017, 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 in accordance with the Market Stabilization Rule.

    These metallic categories also apply to health plans sold to individuals outside of an Exchange/Marketplace (off-Exchange),

    13. What Is A Catastrophic Plan Under The Affordable Care Act?

    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, copayments, 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.




    12. How Is COBRA Affected By The Affordable Care Act?

    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 will either have to exhaust COBRA or apply during Open Enrollment. 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.



    14. What Is The Federal Poverty Level (FPL)?

    The Federal Poverty Level ("FPL") is used to determine your eligibility for a subsidy (see answer to 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. 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 2019 subsidies is:

    • $12,140 for a single individual
    • $16,460 for a family of 2
    • $20,780 for a family of 3
    • $25.100 for a family of 4
    • $29.430 for a family of 5
    • $33.740 for a family of 6
    • $38.060 for a family of 7
    • $42,380for a family of 8

    Federal Poverty Level For 2019 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 (either 100%, or 138% of the FPL for states that have enacted Medicaid expansion); whether they are eligible for a federal subsidy (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 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).

    Federal Poverty Level and Cost Sharing Reductions

    Cost Sharing Reductions are offered ONLY for silver level metallic plans.  The chart at the end of this FAQ 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 subsidy and Cost Sharing Reduction determinations for 2019 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 15 for a definition and explanation of MAGI.


    Federal poverty guidelines



    Family Size 100% 150% 200% 250% 400%
    1 $12,140 $18,210 $24,280 $30,350 $48,560
    2 $16,460 $24,690 $32,920 $41,150 $65,840
    3 $20,780 $31,170 $41,560 $51,950 $83,120
    4 $25,100 $37,650 $50,200 $62,750 $100,400
    5 $29,420 $44,130 $58,840 $73,550 $117,680
    6 $33,740 $50,610 $67,480 $84,350 $134,960
    7 $38,080 $57,090 $76,120 $95,150 $152,240
    8 $42,380 $63,570 $84,760 $105,950 $169,520

    15. What Are Tax Credits (Tax Subsidies) Under The Affordable Care Act?

    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 subsidy as well as any possible Cost Sharing Reduction (see FAQ 16) for which you're eligible by going to www.healthcare.gov and making an application. (We can help you make an application by using our web brokerage system; 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 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 eligibiility 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 as well as your Cost Sharing Reduction (see FAQ 16).  Actual subsidies and eligibility for a Cost Sharing Reduction eligibility 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 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.

    Current federal poverty guidelines





    16. What Is A Cost Sharing Reduction ("CSR")?

    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, the level will be indicated on the PDF referred to in FAQ 15: 

    • 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.



    3. When Can I Enroll In An Affordable Care Act Plan?

    Prior to January 1, 2014, individuals could enroll in health plans at any time.

    However, under the Affordable Care Act, individuals can enroll ONLY during Open Enrollment (the 2020 Open Enrollment Period for on-Exchange plans offered through the Federal marketplace begins November 1, 2019 and ends December 15, 2019) AND/OR if they have a "qualifying life event" (see answer to FAQ 4). 

    Note that some State Exchanges (e.g. Colorado) may extend open enrollment past December 15, as they did this for 2018 and 2019 enrollments; check your state Exchange for more details (or call us at 561-734-3884).

    Carriers are permitted to establish different dates for off-Exchange open enrollment; check your state and carrier to see if any carrier you're interested in permits a different open enrollment period for off-Marketplace plans.  For example, Florida Blue offered off-exchange plans beween October 1 and December 31.2018 for the 2019 plan year. 



    4. Under What Circumstances Can I Enroll In A Plan Outside Of Open Enrollment?

    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. Please see this pamphlet that contains more information about Special Enrollment Periods. 

    Following are many (but not all-inclusive) examples of events that will trigger a Special Enrollment Period: 

    • Renewal (usually the plan anniversary date) of a grandfathered or non-grandfathered individual major medical plan
    • Return from active military duty
    • Release from incarceration
    • Gain of immigration status or citizenship
    • Permanent move to a new state (or outside of your existing plan's service area within the same state)
    • Loss of minimum essential coverage (see answer to FAQ 21) due to:
      • Discontinuation of a current plan (including a "grandfathered" plan) that does not meet Affordable Care Act requirements
      • Legal separation
      • Divorce
      • Termination of domestic partnership or civil union
      • Change in full-time employment status
      • Loss of employer-sponsored insurance for reasons other than non-payment of premium
      • Death of a parent or spouse
      • Change in dependent status as a result of turning 26 (or higher age, depending on state law)
    • Gaining or becoming a dependent due to:
      • Marriage
      • Domestic partnership
      • Birth of child/children
      • Adoption of child/children
      • Placement for adoption of child/children
      • Guardian/court-ordered dependent
    • Loss of Medicaid
    • One spouse becoming eligible for Medicare [if both spouses are enrolled in an ACA plan and one spouse becomes eligible for Medicare, the Medicare-eligible spouse loses ACA coverage and the remaining dependent either remains in the same ACA plan or has a qualifying life event and can enroll in a different ACA plan if there is a substantial increase or decrease of income (see next bullet)]
    • If currently enrolled in a Marketplace plan, substantial increase or decrease of income (as determined by the Marketplace)

    The Special Enrollment Period Final Verification Rule (also called the Market Stabilization Rule; see FAQ 5) requires submission of proof that a qualifying life event has occurred, in addition to proof of having coverage within 60 days of the event in order to be eligible for many special enrollment periods. Acceptable proof must be submitted to the Exchange by the due date (generally within 30 days) indicated in the applicant's determination letter; failure to submit such proof by the due indicated will result in loss of coverage.  Under this rule, the enrollment is put on pending status and consumers have 30 days to provide documentation to verify eligibility.  

    Once documentation acceptable to the Marketplace is submitted and approved, the Exchange notifies the applicable carrier, the consumer is permitted to make payment, and coverage is made effective as of the Special Enrollment Period effective date as determined when the consumer applied and chose a plan through the Marketplace.

    Carriers offering plans off the Exchange generally also require proof of eligibility for a Special Enrollment Period.  Some carriers will issue off-Exchange plans based on the individual's attestation and then send letters requiring submission of proof of eligibility.  If an individual asked to submit proof of eligibility fails to do so within the time period stated in the letter, the plan will be cancelled.



    19. When Must I Make The First Payment For My New Affordable Care Act Plan?

    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 differ between on- and off-Exchange plans.

    (Note: the requirements for Off-Exchange plans are stricter than for On-Exchange plans: generally, participants in Off-Exchange plans have to make payment within 30 days of the first of the day of the coverage month or they will lose coverage;  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.)

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

    In accordance with the Market Stabilization Rule effective June 19, 2017, 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.



    20. What Is The Penalty For Not Enrolling In An Affordable Care Act Plan?


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

    Note that three jurisdictions--District of Columbia, Massachusetts, and New Jersey--have established  LOCAL or STATE penalties for not having insurance.  Vermont has established a penalty beginning in 2020, and at least seven other ("blue") states are considering establlishing state penalties.  These penalties are all calculated differently; check with your tax preparer for information about these penalties.



    21. What Is A Web Brokerage?

    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 ACA Express web brokerage system with most of our clients who want to enroll in a Marketplace plan.  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.



    2. Will There Be (And Have There Been) Changes To Obamacare?

    Efforts to rescind thr Affordable Care Act have not been successful, but efforts to make changes continue and three major changes have occured so far:

    1. The law has been amended to eliminate the penalty (see FAQ 20) for not having a plan that meets Obamacare's minimum essential benefit requirements (see FAQ 21) effective January 1, 2019. (The penalty was effective for 2018 and will be applicable for 2018 tax returns.)

    2.  The Administration originally eliminated funding for "cost sharing reduction" plans (see FAQ 16) for 2018 and many state insurance commissions (e.g. Florida) increased premums to provide funding for these plans. In general, most individuals who are (or will be) eligible for these types of plans for 2018 were not affected  by the Administration's decision, as the law still requires these types of plans to be offered.  The Administration has now resumed funding cost sharing reductions.

    3 .The Administration finalized regulations on June 21, 2018 to expand opportunities for establishing Association plans across state lines and to make it easier for Associations to establish such plans.  Association plans established in accordance with these new guidelines are not expected to be available until some time in 2019.

    Other changes have and will occur through rule making authority granted to the President or the Secretary of Health and Human Services. For example, a Special Enrollment Pre-enrollment Verification (SEPV) process has been implemented.  This process (see FAQ 5) establishes requirements for eligible individuals to prove entitlement to many Special Enrollment Periods and in most cases requires the consumer to have minimum essential coverage sometime within the past 60 days.

    Some members of Congress continue to work on "ACA stabilization" efforts.  We''ll notify you in these FAQ’s and our newsletter if and when any other significant changes are made.



    5. What Is The Special Enrollment Period Pre-enrollment Verification (SEPV) Process?

    Applicants who attest to certain types of SEP qualifying events are subject to the Special Enrollment Period Pre-enrollment Verification (SEPV) process.

    Eligible consumers must submit documents that confirm their SEP eligibility before they can enroll and start using their Marketplace coverage. Consumers participating in the Federal Marketplace have 30 days after confirming their plan selection to upload their documents at HealthCare.gov or send them by mail to:

    Health Insurance Marketplace
    Attn: Supporting Documentation
    465 Industrial Blvd.
    London, KY 40750-0001

    Requlations (called the Market Stabilization Rule) 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) and in most instances NOT for those who previously did NOT have coverage.

    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, or a child support or other court order
    • Medicaid/CHIP denial

    Once the Marketplace has confirmed their eligibility based on the documents they send, consumers will receive a notice that they can pay their premium and start using their coverage.

    Consumers’ coverage will be effective based on their SEP type and date of plan selection, so in some cases the effective date will be retroactive. A consumer may choose to start coverage later than the effective date would have been if the following apply:

    • The enrollment is delayed until after the Marketplace's verification of the consumer’s eligibility for an SEP, and
    • The original coverage effective date would result in the consumer being required to pay two or more months of retroactive premiums to effectuate coverage or avoid cancellation.

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

    For more information, check out the following resources:

    "Overview" Special Enrollment Period Pre-Enrollment Verification (SEPV) Process" webinar slides

    Special Enrollment Periods Available to Consumers

    How to Submit Documents

    Carriers are not required to follow healthcare.gov rules for Off-Marketplace special enrollment periods, although in the past most carriers have made requirements for such plans equally or more restrictive than those of healthcare.gov for On-Marketplace plans.



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    See other FAQs:

    Medicare Beneficiaries--Overview

    Medicare Beneficiaries--Medicare Supplement Plans

    Medicare Beneficiaries--Medicare Advantage Plans

    Medicare Beneficiaries--Part D Prescription Drug Plans

    All Individuals Regardless of Age--Dental Plans

    All Individuals Regardless of Age--Vision Plans