Newsletter

AFFORDABLE CARE ACT OPEN ENROLLMENT BEGINS TODAY

Open Enrollment on healthcare.gov to enroll for 2025 Affordable Care Act plans begins today.

Individuals enrolling between today and December 15 will have an effective date of coverage of January 1, 2025. Those enrolling between December 16 and January 15, 2025 will have an effective date of February 1, 2025.

If you’re presently enrolled for an ACA plan and don’t plan to enroll in a plan for 2025, please call healthcare.gov at 800-318-2596 to disenroll as of December 31. Otherwise, you’ll be automatically re-enrolled on December 15 for a January 1, 2025 effective date. If you need your present plan to continue in January but plan to terminate coverage effective February 1 you should call healthcare.gov to terminate coverage as of January 31.

Open enrollment in the 20 jurisdictions with state-based exchanges that do not participate on healthcare.gov must, as a minimum, follow the open enrollment calendar that applies to healthcare.gov. Georgia has established its own exchange effective January 1, 2025 and has left healthcare.gov. However, these jurisdictions (19 states plus the District of Columbia) are permitted to have earlier open enrollment starting periods and can end open enrollment after January 15. Contact your state exchange for further details if you live in one of these jurisdictions.

Individuals applying for Affordable Care Act plans during open enrollment must be legal U.S. residents (there is a special exemption for “Dreamers”) and are not required to have a qualifying life event to qualify for coverage. There are no pre-existing condition limitations.

Individuals/families must have household income that is between 100 (138% in Medicaid expansion states) and 400% of the Federal Poverty Level to qualify for an advanced premium tax credit (i.e., a tax subsidy).

In addition, those with incomes about 400% of the Federal Poverty Level can qualify for a tax subsidy if the gross premium for the second lowest-priced Silver plan in their geographic area is more than 8.5% of their family income. This provision will sunset as of December 31, 2025 unless new legislation is passed by Congress.

Married individuals must file joint tax returns to be qualified for a subsidy.

Legal residents over age 65 CAN apply for an Affordable Care Act plan with or without a subsidy IF they are either not eligible for premium-free Part A, or Part B of Medicare.

There are special rules for individuals and families with employer group coverage to qualify for a subsidy. These rules are complicated, so please call us at 786-970-0740 for details.  Separate determinations are made for the employed family member and the rest of the family. Cost of the employer group coverage must exceed 9.02% (up from 8.39% for 2024) to be eligible for a subsidy, and the benefits of the employer plan cannot meet what is called the “minimum value” test. There is an employer safe harbor of $133.20 for employee-only premiums. If the employee-only premium is under this amount the employee will not be able to qualify for a subsidy.



WHAT’S CHANGING FOR 2025?

According to the Petersen-KFF Health System Tracker, gross premiums are increasing 7% for 2025 (compared to 6% for 2024). Many individuals who receive high subsidies will not be affected by this increase, but those with low or no subsidies will probably see an increase in premiums for 2025.

The out-of-pocket maximum for 2025 plans has been lowered to $9,200 for individuals and $18,400 for families. This is the first time since the inception of the Affordable Care Act that this maximum has been decreased.

Generally, those who have reenrolled with the same carrier will not have to pay a “binder” payment (i.e., advance payment of the first month’s premium). However, Ambetter will require a binder payment if a member from a 2024 "Core" plan switches into a “Premier” plan.

There will be nine carriers in South Florida in 2025: Aetna CVS Health, Ambetter, AmeriHealth Caritas, AvMed, Cigna, Molina, Oscar, United Healthcare, and Wellpoint. Wellpoint is new for 2025, and Molina has changed from a plan that requires referrals to one that does not require referrals.

Premium competitiveness between carriers has changed. Competitiveness will vary depending upon the applicant’s income level, but, in general, AmeriHealth Caritas will be more competitive in Miami-Dade and Broward than last year, as will Oscar and Molina in Palm Beach County.

All carriers have established or improved their applications and/or websites. This will enable members to perform more activities online than heretofore. Depending on the carrier, this includes changing providers, looking up medications and/or providers, looking up claims histories, making appointments, etc.

All carriers have some kind of reward system for performing activities such as registering, completing an annual physical, etc. Reward systems vary between carriers, but all carriers have them, and these rewards can be substantial. We encourage all members to register for their carrier's reward program and to complete the requirements needed to obtain partial or full rewards. Most rewards are provided through Visa or Mastercards.

Many carriers have established special plans for diabetics and, in some cases, those with cardiac disorders. These plans have more generous medication costs and other benefits not included in regular plans, and individuals can qualify for these programs without having the condition the plans are designed for.

Available plans and plan designs change every year, carrier competitiveness changes annually, new carriers come to the market, and 2025 will be no exception. Please contact us at 786-970-0740 so we can help you choose a plan that best meets your requirements.

Anti-fraud procedures have been established for the application process. This is due to the problems encountered in 2024 where individuals or families were enrolled in plans they did not apply for and where dishonest agents changed the Agent of Record from the client’s agent to themselves. As a result, there is now a special consent form individuals must agree to before they can receive help from an agent. There are also special procedures that must be utilized when an individual with an existing application on healthcare.gov uses a different agent than in the past. Finally, applicants must provide Social Security numbers for all enrolled family members, or they will have to follow special procedures to get enrolled.

ACTIVE VS. PASSIVE ENROLLMENTS

Although present enrollees can follow what are called passive (automatic) re-enrollment procedures where they are automatically re-enrolled as of December 15 into their present (or “crossover”) plans if they don’t take active steps to re-enroll, we highly discourage doing this. One major reason is their income projections won’t be updated to reflect their 2025 income and, as a result, their subsidies may be lower than what they would be if they updated their projections. Those with Bronze plans who would be better served by switching to Silver level Cost Sharing Reduction Plans if they qualify will miss that opportunity. Another reason is that available plans change every year, and they will be unable to enroll in a different plan with the same or another carrier. Finally, unless their income projections are accurate, they could face unpleasant surprises when they file their 2025 income taxes and must reconcile their actual income against the income used to calculate their advanced premium tax credits. Accordingly, we highly recommend that all our clients contact us at 786-970-0740 and let us help them update their personal and income data, learn about available options, and enroll in a plan that best meets their income and medical needs for 2025.

Individual Group Insurance Plans

Short-term health insurance has been an alternative to marketplace plans in recent years and has been especially popular with those who are not eligible for high tax subsidies or are not otherwise qualified to enroll for an Affordable Care Act plan. However, the rules affecting the duration of available short term health plans have been changed, and those plans cannot be offered beyond a maximum period of three months plus a one-month extension. Accordingly, short-term health plans are NOT an alternative for those needing health coverage in 2025 beyond a four-month period.

Note that loss of short-term coverage DOES NOT qualify as a “qualifying life event,” so those losing short-term health insurance outside of the open enrollment period (i.e., November 1 to January 15 in most states) will NOT qualify to enroll in an Affordable Care Act plan.

Individual group health insurance plans that offer PPO networks either through Blue Cross/Blue Shield or Cigna are an attractive option to Affordable Care Act plans for those who are looking for lower-priced alternatives. (Note, however, that some individuals have “grandfathered” short-term health insurance plans for periods of up to three years; they retain their health insurance coverage and don’t need to look for alternatives until their short-term coverage ends or unless they develop a significant health condition that makes it prudent to look for a plan that provides more comprehensive coverage.)

Individuals must answer health questions to qualify for one of these plans and must be self-employed, otherwise have 1099 income, or be a member of a qualifying Association to be eligible for one of these plans.

Please contact us at 786-970-0740 to learn if you can qualify for one of these plans or if such a plan is a good fit for your situation.

Note: medical cost sharing programs can also be an attractive alternative for healthy individuals who are willing to take an active role in managing their healthcare. Cost sharing contributions can be 50% or more lower than premiums for Affordable Care Act plans. Members of medical cost sharing programs share health expenses with other program members, and these programs are NOT insured. Nevertheless, we offer such programs from reputable and financially stable medical cost sharing organizations. And in most cases these programs qualify for exemptions from tax liabilities in those jurisdictions (CA, DC, MA, NJ, and RI) for not having coverage that does not meet Affordable Care Act requirements.

About Paul Cholak

Paul has over forty years of benefits experience and has been Director of Employee Benefits for large companies, as well as a benefits consultant with major consulting firms. He understands the health and life insurance needs of individuals and families of all ages. He also has considerable experience in selling health and life insurance to employer groups.

He guides you through the steps of getting health and/or life insurance and is available to help you both BEFORE and AFTER you've made your purchase decision.