middle aged couple discussing health insurance options at home table

4 Myths About the Individual Health Insurance Open Enrollment Period

We’ve heard a lot of Open Enrollment myths over the years and want to set the record straight.

Myth #1 “There are fewer insurers to choose from.”

Many carriers who initially fled the federal exchange have returned and now offer plans alongside others who have entered the marketplace. This increase in the number of plans being offered has allowed many individuals and families to re-examine their needs and adjust their coverage amounts accordingly.

Myth #2 “The premiums are too expensive.”

Now that the federal exchange marketplace has stabilized, there may be lower-cost options for ACA-compliant health plans than past Open Enrollment periods. For example, Blue Cross Blue Shield has filed for a 2.03% decrease in premiums in Texas.

Even if your coverage needs remain the same, you may be able to find a lower premium being offered by a different insurer. We recommend always reviewing the health insurance options available to you during the annual Open Enrollment period.

Myth #3 “You’ll be penalized at tax time for not having insurance.”

In previous years, if an individual did not have health insurance for more than 2 months of the year and did not qualify for an exemption they would face a tax penalty of $695 or 2.5% of their taxable income (whichever amount was greater). As of January 1, 2019, the tax penalty known as the individual mandate has been repealed, though some states may still enforce penalties on individuals who don’t have health insurance.

Myth #4 “Applications are processed instantly.”

On average, our team will process an enrollment application within 24 business hours and submit it to the carrier. Once the application is with the carrier, their team will take over and require an additional 10-15 business days to process the application.

The carriers often get overwhelmed with applications during the Open Enrollment period, so we recommend enrollees submit their health insurance applications as early as possible.

Securing ACA-Complaint Coverage for 2020

This year, Open Enrollment runs from November 1 through December 15 with a coverage effective date of January 1, 2020. This is the one time of year where individuals and families can enroll in ACA-compliant health insurance plans.

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Getting the Most out of Open Enrollment

With 2020 Open Enrollment period in full swing, families across the country are reviewing their current insurance coverages and seeing what other options may be available to them. Below are a few tips to help you navigate the process.

  1. Learn the Language

Insurance jargon may be enough to make some people’s heads spin but learning just a few key terms could help you pick the best health coverage for you and your family. To make it easy, here are a few words we feel you should know:

  • ACA-compliant” refers to plans that follow all the guidelines and regulations in the Affordable Care Act. These plans are only available during the annual Open Enrollment period or through a Special enrollment period, if you have a qualifying event.
  • Non-ACA plans” also known as short term health plans do not adhere to all of the Affordable Care Act’s guidelines and regulations.
  • Deductible” the amount of money you must pay out of pocket before your insurance kicks in
  • Premium” the amount you pay to your insurance company every month
  • In-network” refers to a provider that has a contract with your insurance provider
  • Out-of-network” refers to a provider that does not have a contract with your insurance provider
  1. Think of the Future

No one can predict the future, but you may be able to take an educated guess as to what the next 12 months could hold. Thinking about the coming year could help you determine how much coverage is right for you and your family. Have you had any health issues in the past year? Are you taking any medications? By examining your current health status and concerns you may be able to narrow down your health insurance plan options.

  1. Know Your Deadlines

Like last year, the annual individual health insurance Open Enrollment period began on November 1 and will run until December 15. For those who enroll in one of these ACA-compliant plans, you can expect an effective date of January 1.

Non-ACA plans typically do not follow the ACA open enrollment period dates and are available in most states year-round

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Knowing Your Options Outside of Open Enrollment

While the annual Open Enrollment period focuses on ACA-compliant individual major medical insurance, there are still other forms of insurance available for potential enrollees.

Knowing Your Options

According to healthinsurance.org, “ACA-compliant coverage refers to a major medical health insurance policy that conforms to the regulations set forth in the Affordable Care Act (Obamacare)…This means they must include coverage for the ten essential benefits with no lifetime or annual benefit maximums, and must adhere to the consumer protections built into the law.”

Unless you qualify for a special enrollment period, you cannot receive ACA-compliant individual health insurance coverage outside of the annual Open Enrollment Period, which typically runs from November 1st until December 15th of each year.

If you missed out on Open Enrollment but still need individual health insurance, you still have a few options available:

  1. COBRA

According to the U.S. Department of Labor, “The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan.”

  1. Qualifying Life Event (QLE)

There are certain life circumstances called Qualifying Life Events (QLEs) that can qualify you for a special enrollment period. Special enrollment periods allow you to obtain ACA-compliant health coverage outside of the annual Open Enrollment period for you and your eligible dependents. The most common QLEs pertain to:

  • Loss of health coverage
  • Changes in household
  • Changes in residence
  1. Non-ACA Compliant plans

Non-ACA compliant plans, also referred to as short-term medical plans, have recently become more appealing to a growing number of people due to their lower rates. According to the Henry J Kaiser Family Foundation, “Late last year (2017), President Trump issued an executive order directing the Secretary of Health and Human Services to take steps to expand the availability of short-term health insurance policies, and a proposed regulation to increase the maximum coverage term under such policies was published in February.”

So, what separates the ACA-compliant health plans from the ones that are not? One of the biggest factors being the ACA’s ten essential health benefits. Non-ACA compliant plans do not need to adhere to the numerous rules and regulations laid out in the Affordable Care Act.

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I Missed Open Enrollment and Need Health Coverage — What Are My Options?

The next official ACA Open Enrollment period isn’t slated to begin until November 1, 2019. But depending on your circumstances, you may not have to wait that long to obtain coverage.

Qualifying Life Events and Special Enrollment Periods

Sometimes our circumstances change, and if they change due to specific events, you and your dependents may be able to secure health insurance through a Special Enrollment Period. When this occurs, it is called a Qualifying Life Event, otherwise referred to as a QLE.

There are several types of Qualifying Life Events that may grant you a Special Enrollment Period. Some of the most common examples include:

  • Loss of health coverage
    • Losing existing health coverage – including job-based, individual, and student plans
    • Losing eligibility for Medicare, Medicaid, or CHIP
    • Turning 26 and losing coverage through a parent’s plan
  • Changes in household size
    • Getting married or divorced
    • Having a baby or adopting a child
    • Death in the family
  • Changes in residence
    • Moving to a different ZIP code or county
    • A student moving to or from the place they attend school
    • A seasonal worker moving to or from the place they both live and work
    • Moving to or from a shelter or other transitional housing
  • Other qualifying events
    • Changes in your income that affect the coverage you qualify for
    • Gaining membership in a federally recognized tribe, or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
    • Becoming a U.S. citizen
    • Leaving incarceration (jail or prison)
    • AmeriCorps members starting or ending their service

Non-ACA Health Plans

Haven’t experienced a QLE but still need health coverage? A non-ACA health plan could be the answer. Also referred to as Short Term Medical Plans, recent legislative changes have loosened the restrictions surrounding these plans and have increased their appeal.

Previously, a Short-Term Medical plan could only provide coverage for up to 90 days. But due to recent regulatory changes, these plans can now be continued for up to a year.  Additionally, in some cases applicants may now renew their plan for up to three years.

Because Short-Term Medical Plans are considered non-ACA health plans, it is worth noting that they may not cover all that an ACA health plan would. For example, applicants could be denied coverage due to a pre-existing medical condition, maternity care may not be covered, and there could be an annual dollar limit on coverage. However, these plans are also typically less expensive than ACA plans and could be a good alternative for individuals seeking more affordable options.

young african american man needing health coverage outside of open enrollment

What Are My Options if I Lose Healthcare Coverage?

Maintaining health insurance coverage is a vital step in your plan to remain financially secure. However, there are times in life when your health coverage may be interrupted. When this happens, it’s imperative that you find affordable health insurance coverage quickly in order to protect yourself and your family.

Why Would My Coverage Be Cancelled?

There are a few factors that could contribute to the loss or interruption of health insurance coverage. If an individual does not pay their premium, their policy may be canceled. This is not always a result of poor money management; if there has been a significant change in income or other pressing financial obligations, it is easy to redefine financial priorities and let those monthly insurance premiums slide. It is also possible that individuals can lose their coverage when a grandfathered plan is canceled. However, the loss of a job which provided insurance coverage is the more likely reason someone may lose their benefits.

These factors are very hard to foresee, and therefore can be very stressful when you learn that your health insurance coverage is going to be affected. However, as soon as you find out your coverage is being canceled, there are steps you can take quickly to make sure you maintain health insurance coverage for you and your family and protect your financial stability.

Option #1: Continue Existing Coverage through COBRA

COBRA is a Federal law that makes it possible for individuals who were covered under company health insurance plans to maintain those existing plans following a job loss. In order to take advantage of COBRA benefits, the individual must pay the full monthly health insurance premium amount. These amounts are usually substantially higher than what you were previously paying because in most cases the employer was paying a portion of your monthly premium. The COBRA plan, however, does ensure that your existing policy will stay intact for up to eighteen months following a job loss. This is crucial for many individuals who have severe health problems and would be in financial jeopardy if they lost their coverage for even a short amount of time.

Option #2: Purchase a New Plan on the Insurance Exchange

If an individual loses health insurance coverage due to the loss of a job, purchasing a new health insurance plan on the insurance exchange could be better, and more affordable, answer to your problem. The Insurance Exchange is a multi-carrier private exchange offering a wide range of health insurance choices for individuals and their families.

These types of benefits are time-sensitive, so it is best to begin the process before losing your insurance coverage. Although insurance exchanges usually have set open enrollment periods (running from November to February), those who suffer from a job loss are offered a Special Enrollment Period to allow them to obtain coverage within a specific time frame after the job loss occurs.

Which Do I Choose?

The most cost-effective solution for most people is to seek a new plan entirely. Insurance plans on the exchange offer generally lower monthly premiums than what you’d pay for your existing plan under COBRA. However, it is crucial that you do not waste time, as the special enrollment period for these plans is 60 days from the qualifying event or last date of coverage. It is important to act quickly to get the best selection of plans and ensure you are able to obtain coverage within the required time frame.

woman with curly hair in coffee shop holing her phone and smiling over good news

Short-Term Health Insurance Soon Available For Up To 36 Months

New Rule Loosens Current Restrictions

Effective October 2, 2018, a new rule will allow individuals to purchase short-term, limited-duration health insurance coverage for a period of less than 12 months, and renew such coverage for up to 36 months. Under current law, the maximum coverage period for short-term, limited-duration health insurance is less than 3 months, and these policies cannot be renewed.

Notably, short-term, limited-duration health insurance is:

  • Not required to comply with the Affordable Care Act’s ban on pre-existing condition exclusions and lifetime and annual dollar limits.
  • Not required to comply with the Affordable Care Act’s essential health benefits requirement, which requires individual health insurance policies to cover, among other things, hospitalizations, emergency services, and maternity care.
  • Not “minimum essential coverage,” meaning that policyholders may remain liable for an individual mandate penalty for any month in 2018.

Click here to read the new rule. A fact sheet is also available.

Check out our Health Care Reform section for more on the Affordable Care Act.

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Understanding IRS ‘Pay or Play’ Penalty Letters

Employers Have Opportunity to Respond Before ‘Pay or Play’ Penalty Assessment

The Internal Revenue Service (IRS) is currently issuing Letter 226-J to certain applicable large employers (ALE)—generally those with at least 50 full-time employees, including full-time equivalent employees, on average during the prior year—it believes owe a penalty for failing to comply with the Affordable Care Act’s employer shared responsibility provisions (“pay or play” provisions). In conjunction with Letter 226-J, employers will receive Form 14764, which they can use to respond to Letter 226-J. Employers who submit Form 14764 to the IRS will generally receive one of 4 letters back:

  • Letter 227-J, which acknowledges receipt of Form 14764 and the employer’s agreement to pay the penalty;
  • Letter 227-K, which acknowledges receipt of Form 14764 and shows that the penalty has been nullified;
  • Letter 227-L, which acknowledges receipt of Form 14764 and shows that the penalty has been revised; or
  • Letter 227-M, which acknowledges receipt of Form 14764 and shows that the penalty amount did not change.

For more information on IRS “pay or play” penalty letters, click here.

Visit our “Pay or Play” (Employer Shared Responsibility) section for more on pay or play compliance.

 

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Form 5500 Filing Deadline for Many Health Plans is July 31

Certain Group Health Plans Required to File

Group health plan administrators are reminded that Form 5500 must be filed with the U.S. Department of Labor (DOL) by the last day of the seventh month after the plan year ends. For calendar-year plans, that due date falls on July 31.

Who Must File Form 5500

In general, all group health plans covered by the Employee Retirement Income Security Act (ERISA) are required to file Form 5500. However, group health plans (whether fully insured, unfunded [meaning its benefits are paid as needed directly from the general assets of the plan sponsor], or a combination of the two) that covered fewer than 100 participants as of the beginning of the plan year are exempt from the Form 5500 filing requirement. For more on the Form 5500 requirement, click here.

How to File Form 5500

Forms 5500 must be filed electronically with the DOL using either the IFILE web-based filing system or an approved vendor’s software.

Visit our ERISA section for more ERISA compliance information.

 

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Individual Mandate Exemptions Available for 2017 Tax Returns

Affordability, Tax Filing Threshold, and Other Exemptions Available

Under the Affordable Care Act’s (ACA) ”individual mandate” (also called individual shared responsibility) provision, every individual must have minimum essential health coverage for each month, qualify for an exemption, or make a payment when filing his or her federal income tax return for tax year 2017.

Among other exemptions, individuals may claim the following exemptions from the individual mandate by filing Form 8965Health Coverage Exemptions, along with his or her 2017 tax return:

  • Affordability Exemption: The lowest-priced coverage available to the individual, through either a Health Insurance Marketplace or employer-based group health plan, would have cost the individual more than 8.16% of his or her household income for plan years beginning in 2017, as computed on the tax return.
  • Tax Filing Threshold Exemption: The individual’s gross income or household income was less than the applicable minimum threshold for filing a tax return (see ”2017 Federal Tax Filing Requirement Thresholds”).
  • Short Coverage Gap Exemption: The individual went without coverage for less than three consecutive months during the year.
  • Medicaid Expansion Exemption: The individual’s household income is below 138% of the federal poverty line for his or her family size, and at any time during the year, the individual resided in a state that did not participate in the Medicaid expansion under the ACA. States that did not expand Medicaid for all of 2017 include: Alabama, Florida, Georgia, Idaho, Kansas, Maine, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.

Click here to learn more about individual mandate exemptions.

Be sure to visit our Individual Mandate (Individual Shared Responsibility) section for additional details.

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Deadline to File Paper Returns With IRS was February 28

Employers subject to the Affordable Care Act’s (ACA) information reporting requirements are reminded that the deadline to electronically file ACA information returns with the IRS is April 2.

The reporting deadlines in 2018 are for the 2017 calendar year, and are as follows:

  • Applicable large employers (ALEs)—generally those with 50 or more full-time employees, including full-time equivalents—must electronically file Forms 1094-C and 1095-C with the IRS no later than April 2. The deadline to file paper returns was February 28.
  • Self-insuring employers that are not considered ALEs, and other parties that provide minimum essential health coverage, must electronically file Forms 1094-B and 1095-B with the IRS no later than April 2. The deadline to file paper returns was February 28.

Note: Employers filing 250 or more Forms 1095-B or 1095-C are required to electronically file them with the IRS.

Additional information on electronic filing can be found on the IRS’s ACA Information Returns (AIR) Program webpage.

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