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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.

young person sitting on floor with dog looking at piles of scattered bills

How to Cope With Medical Bills

If you are stressed out with medical bills, it’s time to develop a game plan for tackling your debt so you can eventually put it all behind you. No matter how much or how little medical debt you have, there are some steps you can follow to become proactive and get it paid off to avoid accumulating future debt.

Get Organized

Start by getting all your medical bills, invoices, insurance statements, and other paperwork organized. Avoid throwing any of these correspondences away and make sure all bills from the hospital are itemized. If they’re not, contact your hospital and request itemized versions so you can check them for errors. Believe it or not, about 99% of all medical bills contain incorrect charges. While reviewing your bills, check to ensure that your personal information is correct, that your insurance information is listed, and that you aren’t being charged for any services you didn’t receive.

Know Your Benefits

If you have medical insurance and use it to help pay for a medical service, you should receive an “explanation of benefits,” which will provide an overview of how much you were charged, how much your policy covered, and how much you have to pay out-of-pocket. Make sure to review this document carefully and ensure that it corresponds to the coverage you’re paying for. Don’t hesitate to call your insurance company if you have any questions or don’t understand your explanation of benefits.

Address Mistakes

Once you sit down and analyze your medical bills, it is not uncommon to find mistakes. If you think an error has been made, there are a few steps you need to follow to address it. For starters, contact the billing office at the hospital or medical office and explain the error to them; if it’s an obvious error, they should be able to fix it right away. In the meantime, understand that you’ll still be responsible for the bill, and they may have to refund you later on; you can’t refuse payment on a bill because of an error. Make sure to copy down names of people you speak to as well. By taking down contact names, you can potentially build a relationship and good faith with the bill collectors.

If You Can’t Pay. . .

The case may be that you simply cannot afford to pay your accumulated medical bills. Generally, the best thing you can do is to contact the billing department of each hospital or practitioner and try to work out a payment plan. By meeting with the billing office, there’s a good chance that you’ll be able to negotiate down some of your debt or get on a reasonable payment plan that works with your budget. Doing nothing is the worst thing you can do.

Avoiding Future Problems

Finally, you can avoid future debt from medical bills by making sure you fully understand your health insurance benefits. If you are not comfortable with the level of coverage your current plan offers, it may be time to re-evaluate your needs.

 

business group writing on white board

How To Find The Best Group Health Plan For Your Business

The Group Health Insurance industry continues to change with premiums continuing to rise. You have probably changed insurance carrier’s multiple times hoping to secure for the deal of the year.

So, the question is: Is that all there is? Change carriers and tweak my benefits?

What To Consider In Your Group Health Plan Decision

Not all Group Health Insurance plans are the same and one of the largest problems we come across in the industry is that so few companies are aware of all of their options. Most of the time, the reason behind this is because businesses are often dependent upon their insurance agent to present them with their group health options. In doing so, it is important for businesses to note and understand that like the differing group health plans on the market, not all agents are alike. Agents often differ greatly in regard to their level of experience and general knowledge pertaining to new and emerging trends in the industry.

Here at Member Benefits, we specialize in providing businesses with creative solutions that can greatly reduce their health insurance premiums, while still maintaining a comprehensive list of benefits that satisfy your employees and promote attraction and retention.

Perhaps one of the latest trends that many businesses have found themselves considering over the course of the past two years is something called level-funding.

Level-Funding is a partially self-insured option that functions just like a fully-insured plan and has little to no risk involved due to the built-in stop-loss insurance provisions. If your business qualifies, your premiums could end up being 10 to 15 percent less than what they would have been with a traditional fully-insured plan.

With a level-funded plan, there is no need for a separate bank account and the hospital and physician networks are nationwide and very large. As an added bonus, if your business has had a successful year and the claims are low, you may be entitled to receive a refund of up to 50 percent of the claims surplus. Some level -funded plans now offer no network limitations, giving you access to any doctor or hospital across the country!

Are you worried about the possibility of your deductibles resetting if you make the change now? One of the many great things about level-funding carriers is that they will give you credit for any deductible you may have met up until the point of transition.

So, when closing out your year, rest assured that there is no rule or law stating that you must settle for your same Group Health Insurance as opposed to weighing your options. Be confident in your decision. It is important to take the necessary time when you are not busy to explore your options and a level-funded option may prove to be a great place to start.

business man sitting at a cafe discussing his health options on his cell phone

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.

Young biracial woman in business attire smiling on a cell phone on an overcast day

Need Health Insurance and Miss out on Open Enrollment?

Your Guide to Understanding Qualifying Life Events and Special Enrollment

Life happens, and when it does, it is very likely that your health insurance coverage may need to change. When you encounter a qualifying life event that impacts your insurance needs, it is important to know that you can take advantage of a special enrollment period – since most people are unaware that they may enroll outside of open enrollment.
This guide is created to help you understand everything you need to know about qualifying life events and the special enrollment period. You will learn whether or not you qualify and what documents you will need prior to enrolling and shopping for coverage.

#1 Loss Of Coverage

Due To:

  • Termination of group coverage
  • Reduction of hours to part-time status
  • Loss of employer contribution
  • COBRA ending
  • REQUIRED PROOF: Letter from employer, Certificate of credible coverage

#2 Marital Status Change

Due To:

  • Marriage
  • Divorce
  • Legal separation
  • REQUIRED PROOF: Marriage Certificate or divorce/separation court documents, Certificate of credible coverage.

#3 Dependent Status Change

Due To:

  • Birth of a child
  • Adoption
  • Aged out of dependent status
  • REQUIRED PROOF: Child’s DOB, Legal adoption paperwork, Certificate of credible coverage.

#4 Moving

Permanently move to another state and/or no longer live in the existing/prior plan’s service area.

REQUIRED PROOF: New Mortgage Bill/Renter’s Agreement and drivers license, utility, Postal Service change of address receipt.

#5 Death

Your primary policy holder passed away leaving you with no coverage.

REQUIRED PROOF: Death Certificate, Copy of termination letter from prior insurance company.

#6 Income Change

That makes you newly eligible or ineligible for a tax credit.

REQUIRED PROOF: Copy of certificate of creditable coverage OR a copy of the termination letter from prior Insurance Company and/or federal or state agency.

#7 Non-Calendar Year

Your current plan ends on a non-calendar year basis.

REQUIRED PROOF: Copy of termination letter from prior insurance company OR Certificate of Credible Coverage Anytime that you enroll in a plan you will be asked to provide the following information:

  1. What was your qualifying event?
  2. What was the date of this event?
  3. You’ll be asked to submit supporting documents.

So how long is this special enrollment period? Typically, you only have 60 days from the QLE to enroll in a new plan due to ACA law, carriers are very strict on enrollment timelines.

stressed young man at work

Crucial Health Insurance Terms You Need To Know

Navigating the tricky waters of health insurance terminology can be difficult. This is why we’ve put together this handy guide featuring some of the most popular insurance language terms and explaining just what they mean as it relates to you and your family.

Coinsurance:

Coinsurance is your share of the costs of a covered healthcare service calculated as a percent (for example, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductibles you still owe for a covered health service.

Premium:

A premium is the amount of money charged by an insurance company for coverage. The cost of premiums may be determined by several factors, including age, geographic area, tobacco use, and number of dependents.

Copayment:

A copayment, or co-pay, is a fixed amount you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.

Deductible:

A deductible is an amount you owe for health care services each year before the insurance company begins to pay. For example, if your annual deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services that are subject to the deductible. The deductible may not apply to all services, such as when a co-pay only applies or preventive care services. Deductibles are useful for keeping the cost of insurance low. The amount varies by plan, with lower deductibles generally associated with higher premiums. They are fairly standard on most types of health coverage.

Out-of-pocket Maximum (OOPM):

An out-of-pocket maximum is the most you should have to pay for your health care during a year, excluding the monthly premium. It protects you from very high medical expenses. After you reach the annual out-of-pocket maximum, your health insurance or plan begins to pay 100 percent of the allowed amount for covered health care services for the rest of the year. The deductible, coinsurance, co-pays and prescription drug co-pays are included in the out-of-pocket maximum.

Annual Limit and Lifetime Limit:

In the past, health insurance carriers imposed Annual and Lifetime limits on the benefits you receive. You are no longer subject to these limitations and there is no maximum to the benefits you may receive.

Preventive Care:

Rather than waiting for a patient to become sick, preventive care aims to keep people healthy, or at least catch illnesses at their earliest and most treatable stages. Preventive care includes preventive services performed by providers, such as annual physicals or mammograms. Under the provisions of the Affordable Care Act (ACA), policies must cover various preventive services for men, women, and children without sharing the cost for these services through coinsurance, deductibles or copayments. Certain Preventive care services are subject to frequency limitations.

PPO Plan:

This plan allows you to receive care from any doctor you choose, no referral for specialty care (except United HealthCare FL), may use out-of-network doctors – but may have to pay additional fees. PPO plans typically have higher monthly premiums.

POS Plan:

Very similar to a PPO. The biggest difference between the two is the contract between the insurance carrier and healthcare providers.

HMO Plan:

Must pre-select an approved Primary Care Physician, referrals are needed and for most plans, there are no out of network benefits except for qualifying emergencies. HMO plans typically have lower monthly premiums.

EPO Plan:

This is a hybrid network that has limitations that vary based on the carrier. In some instances, you would need to get referrals and may not have coverage for out-of-network. These plans typically have a lower monthly premium.

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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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Small Businesses May Be Able to Keep Existing Health Coverage Through 2019

Policies Renewed Under Extended Transitional Policy Must End by December 31, 2019

A previously extended transitional policy which allows health insurance issuers, at their option, to continue group coverage that would otherwise be terminated or canceled has been further extended to policy years beginning on or before October 1, 2019, provided that all policies end by December 31, 2019. Health insurance issuers that renew coverage under the extended policy are required to provide standard notices to affected small businesses for each policy year.

Policies subject to the transitional relief will not be considered to be out of compliance with key Affordable Care Act provisions, including:

  • The requirement to cover a core package of items and services known as essential health benefits;
  • The requirement that any variations in premiums be limited with regard to a particular plan or coverage to age, tobacco use, family size, and geography;
  • The requirements regarding guaranteed availability and renewability of coverage; and
  • The requirements relating to coverage for individuals participating in approved clinical trials.

Click here to review the extended transitional policy.

Visit our ACA by Year & Company Size section for an overview of other requirements related to Health Care Reform.

person inputting numbers into calculator for tax season

Reminder: Individual Mandate Remains in Effect for 2018

Requirement is Effectively Repealed Beginning in 2019

Individuals are reminded that the section of the Tax Cuts and Jobs Act which effectively repealed the individual shared responsibility provision (“individual mandate”) of the Affordable Care Act does not become effective until 2019. As a result, individuals are required to have minimum essential health coverage, qualify for an exemption from the requirement, or pay a penalty tax for 2018.

Our Individual Mandate (Individual Shared Responsibility) section provides additional information on the individual mandate.

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