Affordable Care Act Insurance Options

You have the right to health insurance regardless of pre-existing conditions, including pregnancy:

• A pre-existing condition is any medical condition that you have, or have had in the past, before your coverage begins.
• You can not be denied benefits or charged more for coverage because of a pre-existing condition. Your insurance provider cannot refuse essential health benefits for your pre-existing condition.
• After you are enrolled, your plan cannot raise rates or deny coverage based only on your health.
• Medicaid and Children’s Health Insurance Programs (CHIP) cannot charge you more because of a pre-existing condition.
• You cannot be rejected or charged more because you are pregnant when you apply for health insurance.
• Your pregnancy will be covered by your health insurance from the day your plan begins.
• If you have a 2020 health plan and give birth or adopt after you enrolled, the birth or adoption qualifies you for a special enrollment period, meaning you can change plans or enroll outside of the open enrollment period. Your coverage begins the day you gave birth or adopted, even if you enroll up to 60 days later.

Most health plans, including those in the Health Insurance Marketplace, cover preventative services like shots and screenings at no cost when administered by a doctor or health care provider.

To see a list of preventative services covered, visit HealthCare.gov’s preventative health services page: https://www.healthcare.gov/coverage/preventive-care-benefits/

All insurance providers give you access to a short, easy-to-understand breakdown of your healthcare plan.

This Summary of Benefits and Coverage (SBC) must include a glossary of all the terms used and provide coverage examples for two common situations — diabetes and childbirth.

Insurance plans must publicly explain any rate increase of 15% or more as part of the ACA’s Rate Review.

Insurance companies must spend  at least 80% (85% for larger companies) of the money they take in from customer premium payments on health care costs and quality improvement activities. This is known as the 80/20 Rule or Medical Loss Ratio.

Insurance companies cannot cancel your policy because you get sick.

Insurance companies cannot cancel your policy for minor mistakes in your application that have little bearing on your overall health.

You can choose any available doctor in your network as your provider.

No referral is required to see an obstetrical or gynecological (OB-GYN) specialist.

Your insurance plan may not require a referral to cover emergency treatment at an out-of-network hospital, nor can they ask for higher copayments or coinsurance.

Your insurance plan cannot put a limit on how much they spend on your healthcare in a given year.

Your insurance plan cannot put a limit on how much they spend on essential health benefits during the time you are enrolled on that plan.

Your employer cannot fire or retaliate against you in any way because you chose a Health Insurance Marketplace plan instead of your job-offered plan and received a premium tax credit.

Your employer cannot fire or retaliate against you in any way because you reported a violation of the ACA’s health care reforms to them or to the government.

For additional rights and protections not covered here, visit HealthCare.gov’s rights and protections page: https://www.healthcare.gov/health-care-law-protections/rights-and-protections/

The Affordable Care Act reduces the cost of health insurance for low-income consumers through something called a “premium tax credit.” It is essentially a tax credit that can be used to lower your monthly insurance payment (your monthly premium) or received as a refundable tax credit when you file your federal income tax return.

You can claim all, some, or none of your premium tax credit in advance to lower your monthly premium cost. This is called an “advance premium tax credit.”

Premium tax credits are only available through insurance plans available in the Health Insurance Marketplace.

Your premium tax credit is decided by the estimated income and household information that you put on your Marketplace Application.

• If you use more advance premium tax credits than you qualify for based on your final yearly income, you will have to pay back the difference when you file your federal tax return.
• If you less advance premium tax credits than you qualify for based on your final yearly income, you will get back the difference as a refundable credit when you file your federal tax return.

If you aren’t sure whether you would qualify for a premium tax credit, try out HealthCare.gov’s income level and savings estimator tool: https://www.healthcare.gov/lower-costs/

Created as part of the Affordable Care Act in 2010, the Health Insurance Marketplace (sometimes just called “the Marketplace” or “the exchange”) is where consumers go to compare, apply for, and purchase health insurance through the ACA.

While some states run their Marketplace through their own websites, most states — including Florida — use the federal government Marketplace which can be found at the official ACA website: HealthCare.gov.

The Marketplace application process will determine whether you are eligible for premium tax credits or cost-sharing reductions, and will let you know if you qualify for Medicaid or CHIP benefits.

There is a separate section of the Marketplace for small businesses (50 full-time employees or under) to offer health and dental insurance to their employees: the Small Business Health Operations Program (SHOP).

If you currently get Medicare benefits — Part A, Parts A and B, or Part C (Advantage plan) — you may not use the Marketplace. If you only have Part B you are still eligible for Marketplace insurance. The Marketplace does not offer Medicare part D plans (prescription drug coverage).

To be eligible to enroll in a Marketplace health insurance plan you must:

• Live in the United States;
• Be a U.S. citizen or national, or a lawful resident;
• Not be incarcerated.

Unless you qualify for a special enrollment period (see below) you must apply for Health Insurance Marketplace coverage during the open enrollment period. While open enrollment generally takes place toward the end of the year, the exact dates and length of the period tend to change. Go to HealthCare.gov or call 1-800-318-2596 to stay aware of all important enrollment dates.

You can apply online through HealthCare.gov: https://www.healthcare.gov/get-coverage/.

You can apply over the phone by calling 1-800-318-2596 (TTY: 1-855-889-4325) 24/7 (excluding holidays).

You can mail your signed and completed application to Health Insurance Marketplace Dept. of Health and Human Services, 465 Industrial Blvd., London, KY 40750-0001. Just print out and follow the instructions on this form: https://marketplace.cms.gov/applications-and-forms/marketplace-application-for-family.pdf.

You can find a Marketplace-registered agent, broker, or assister to help you with your application using HealthCare.gov’s “Find Local Help” search tool: https://localhelp.healthcare.gov/#/.

You can arrange to have a Marketplace-registered agent or broker contact you here: https://localhelp.healthcare.gov/#/get-contacted.

You can also enroll directly through one of the Marketplace’s certified enrollment partner websites (which include health insurance sellers and individual insurance companies.) You can only get premium tax credits through the Marketplace or one of their certified enrollment partners.

This application process will determine whether you are eligible for premium tax credits, cost-sharing reductions, or certain plans. 

During the application process you will have the chance to view health plans online and get personalized estimates to help you find what is right for you.

Your personalized health insurance plan estimates will be based on information about your household and your estimated income. For help figuring out your estimated income use HealthCare.gov’s estimator tool: https://www.healthcare.gov/income-and-household-information/.

Once you have chosen a plan, your insurer will give you instructions on how to pay your first premium. From this point forward, you will typically be dealing directly with your insurer or making payments and viewing your status online through your Marketplace account.

Your enrollment material will be mailed to you by your new insurance provider and you can check to make sure your coverage is active through your HealthCare.gov account.

To help those going through unexpected circumstances or significant life changes, the Affordable Care Act allows for Marketplace health insurance enrollment outside of the open enrollment period. This is called a “special enrollment period.”

Life changes that may qualify you for a special enrollment period include:

• Getting married within the past 60 days;
• Having a baby, adopting a child, or placing a child in foster care within the past 60 days;
• Losing health care coverage due to divorce or separation in the past 60 days; or
• Someone on your Marketplace plan has died within the past 60 days;
• Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder (See below);
• Becoming newly eligible for Marketplace coverage because you became a U.S. citizen;
• Leaving incarceration; or
• Starting or ending service as an AmeriCorps State and National, VISTA, or NCCC member.

A change in residence may qualify you for a special enrollment period if you are:

• Moving to a new ZIP code or county;
• Moving to the United States from a foreign country or U.S. territory;
• A student moving to or from the place you attend school;
• A seasonal worker moving to or from the place you live and work; or
• Moving to or from a shelter or other transitional housing.

If you or anyone in your household has lost health insurance coverage within the past 60 days or expects to lose coverage in the next 60 days you may qualify for a special enrollment period. Coverage losses that may qualify you include:

• Loss of job-based coverage;
• Loss of individual health coverage for a plan or policy you bought yourself;
• Loss of eligibility for Medicaid or CHIP;
• Loss of eligibility for Medicare; or
• Loss of coverage through a family member.

If you or anyone in your household gained access to an individual coverage Health Reimbursement Arrangement or a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) through an employer in the past 60 days or expects to in the next 60 days, you may be eligible for a special enrollment period. In this situation you must call the Marketplace call center (1-800-318-2596), you may not apply online.

To find out if you qualify, answer the questions on HealthCare.gov’s special enrollment period qualification screener page: https://www.healthcare.gov/screener/.

If you have had your eligibility for an insurance plan, health care coverage, or tax credits denied or terminated contact CLSMF for legal advice.

There are some issues that you may appeal directly through the Health Insurance Marketplace and others that must be appealed through your health insurance plan provider.

You cannot appeal a Marketplace decision unless you have received an Eligibility Determination Notice explaining that you are no longer eligible for coverage or that your savings have changed. You generally have 90 days from the date you received an Eligibility Notice to file a Marketplace appeal ( a “good cause” exception for late filing may be attempted through your appeals form or letter) . You can appeal the following Marketplace decisions:

• Not eligible for advance payments of the premium tax credit (APTC);
• Eligible for APTC, but the amount is wrong;
• Not eligible for a Special Enrollment Period;
• Not eligible to buy a Marketplace plan; and
• Not eligible to choose a Catastrophic plan.

The Marketplace will not accept appeals on the following decision (although some may be appealed directly to your health plan provider):

• You disagree with the date the Marketplace ended your coverage;
• Your health plan company did not apply your premium tax credits correctly;
• You want to change information on your Marketplace application;
• You believe your health plan owes you a refund;
• You want to end your health plan on an earlier date;
• You disagree with information on your Form 1095-A, or want a corrected form;
• Your health plan refuses to pay a claim you think should be covered; or
• When you filed your federal income tax return, you owed back some or all of the premium tax credits you used during the year to lower your monthly premiums.

File your appeal using the Marketplace Eligibility Appeal Request Form, which you can find at https://www.healthcare.gov/marketplace-appeals/appeal-forms/. Make sure to include signatures of all of the tax filers on your application and include copies of any documents you have to support your appeal.

You can also choose to mail your completed, signed paper form or a letter requesting an appeal. Make sure the letter includes:

• Your name and address;
• The appealer’s name, if the appeal is for someone else (such as a child);
• The reason for the appeal; and
• Copies of any supporting documents. 

Submit your paper form or letter to the Marketplace: Fax: 1-877-369-0130 Mail: Health Insurance Marketplace ATTN: Appeals 465 Industrial Boulevard, London, KY 40750-0061.

You will get a notice in the mail from the Marketplace letting you know that they have received your request and giving you further instructions on the appeals process. This should happen within 7-10 business days. If you believe the standard wait time would jeopardize your life, health, or permanent recovery you may request an expedited appeal on your form or letter to get a quicker response.

The full length of the appeals process depends on a number of factors but it usually proceeds with the following steps:

• The Marketplace Appeals Center reviews your appeal, your eligibility, and all related information.
• You will be contacted if the Marketplace Appeals Center needs additional documents from you.
• If the Marketplace can resolve your issue informally they will send you a “Notice of Informal Resolution,” generally within 30 days of the last form or document that you sent them.
• If you are not satisfied with the decision, the notice will explain how to schedule a hearing. Most hearings are conducted over the phone.
• Be sure to save all forms, documents, and notices related to your appeal. You have the right to request a copy of the appeal record, which you can do by following the instructions on this form: https://www.healthcare.gov/downloads/appeal-record-request-form.pdf

Once a final decision about your appeal has been made, the Marketplace Appeals Center will send you a notice informing you of the decision and including an explanation of the following:

• Any changes to your health coverage eligibility going forward;
• Any changes to your eligibility for financial assistance, such as premium tax credits or cost-sharing reductions; and
• How the Marketplace Appeals Center came to their decision.

If your insurance company has refused to pay your claim has terminated your coverage contact CLSMF for legal advice.

Your insurer is obligated to explain why they made a decision regarding your coverage or health care plan and they are obligated to instruct you on the proper steps to dispute that decision.

There are two types of appeals when dealing with your plan provider: internal and external. Internal is the first step, where the insurance company conducts a review. If the problem doesn’t get resolved to your satisfaction you can then request an external review, where a third party is brought in to make a decision on the issue.

If your health plan provider wants to deny your claim for coverage, they must notify you in writing and explain why within the time limits below:

• 15 days if you are seeking prior authorization for a treatment;
• 30 days for medical services already received; or
• 72 hours for urgent care cases.

You must file your internal appeal within 180 days of the notice that your claim was denied. If you have an urgent health situation you may request an external review and/or an expedited appeal at the same time as the internal review. To file an internal appeal, you need to:

• Complete all forms required by your health insurer, or you can write to your insurer with your name, claim number, and health insurance ID number;
• Submit any additional information that supports your position (such as a letter from the doctor);
• The Consumer Assistance Program in your state can file an appeal for you.

The timeline of your internal appeals process depends on if you have already received the medical service on your original claim yet: If your appeal is for a service you haven’t gotten yet, your insurer must give you their final decision in 30 days. If you have already received the service, your internal appeals must be completed within 60 days. 

Your insurance company must give you their decision in writing. If your insurance company still denies you the service or payment for a service, you can ask for an external review. The insurance company’s final determination must tell you how to ask for an external review.

You must file a written request for an external review within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied. You can request an external review if you are appealing one of the following:

• Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan;
• Any denial that involves a determination that a treatment is experimental or investigational; or
• Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage.

While some states have their own external review process that meets federal standards, Florida does not. External reviews in Florida are overseen by the Department of Health and Human Services (HHS) or an independent review organization, depending on which option your insurer chooses.

External reviews do not take more than 45 days after the request was received to complete. If your review was expedited for urgent health reasons, you should receive a decision within 72 hours or less (depending on the medical issue).

The external reviewers decision is the final step in your appeal — whether it is in your favor or not — and your insurer must comply with it.

A grandfathered health insurance plan is a plan that was created before March 23 of 2010 (when the ACA was signed into law) and is able to offer the same coverage as it did before the Affordable Care Act.

Grandfathered plans may not offer some of the rights and protections that all Health Insurance Marketplace plans have, such as those for pre-existing conditions. To see a comparison of the rights and protections Marketplace and grandfathered plans must cover, read HealthCare.gov’s page on grandfathered plans here: https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/.

Grandfathered plans that are offered through your employer can only enroll new members and keep their grandfathered status if:

• They do not substantially raise costs or cut benefits for plan holders;
• They notify plan holders of their grandfathered status; and
• They have continuously covered at least 1 person since March 23, 2010.

Health insurance plans that are not job-based can keep offering the same policy to members who enrolled before March 23, 2010 and maintain the grandfathered status, but they cannot enroll new members and still have that coverage considered a grandfathered plan.

You can switch from a grandfathered plan to a Marketplace plan in these two instances:

• During the yearly open enrollment period. Coverage may begin on January 1st. Check with your  insurance provider to find out their policy and procedure for cancelling your current plan.
• During a special enrollment period. If your grandfathered plan’s year ends or the plan is cancelled by your insurance provider you can enroll in a Marketplace plan outside of the open enrollment period. Your special enrollment period lasts from 60 days before your plan ends to 60 days after.

Up until recently, people who could afford health insurance but chose not to purchase it were charged a fee called the “Shared Responsibility Payment.” This fee (also referred to as the “penalty,” “fine,” or “individual mandate”) stopped applying at the beginning of the 2019 plan year, the same year you would file taxes for in April of 2020.

Some states have passed their own individual mandates, but Florida is not currently one of them.

In addition to premium tax credits, you may also qualify for certain cost-sharing reductions which could decrease the amount you pay for your deductible, copayments, and any other out-of-pocket expenses you will need to pay for health care services.

Just like with premium tax credits, cost-sharing reduction eligibility is determined by the income estimate and household information you put in your Marketplace application.

To see if your income might be low enough for you to be eligible, visit HealthCare.gov’s income level and savings estimator tool: https://www.healthcare.gov/lower-costs/.

Certain benefits are available to members of federally recognized tribes or Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders, while other are available to people of Indian descent or who are otherwise eligible for services from the Indian Health Service (also known as an Indian hospital or Public Health Service (PHS)), a tribal program, or an urban Indian health program.

Health Insurance Marketplace benefits to American Indians or Native Alaskans may include:

• A “zero-cost-sharing” plan — meaning you would not pay deductibles, copayments, or coinsurance — if your income is between 100% and 300% of the federal poverty level;
• Zero-cost-sharing plans regardless of income if you get services from an Indian Health Care Provider;
• Enrollment in Marketplace insurance plans whenever you want and changing plans as often as once per month, instead of having to wait for the open enrollment period;
• Enrolling in a Marketplace insurance plan while still getting services from the Indian Health Service, tribal health programs (also known as tribal 638 programs or tribal health clinics), or urban Indian health programs.

For more information on benefits to American Indians and Alaskan Natives through the Affordable Care Act visit HealthCare.gov’s page on the topic: https://www.healthcare.gov/american-indians-alaska-natives/