Health Insurance

Each year there is a specified period when people can enroll in an individual market health plan. Consumers in most states use the federal marketplace through Healthcare.gov and, for them open enrollment runs Nov. 1 - Dec. 15. A few states either start open enrollment earlier or end it later. Consumers in California, Colorado, the District of Columbia, Massachusetts, Minnesota, New York and Rhode Island can use the links to check with their state marketplace and confirm dates.

There have been some updates regarding health insurance coverage—there will be no penalties for not having minimum coverage, short-term and limited duration options have been expanded, there are more direct enrollment options, and employer-based reimbursement arrangements are available to more employers. Read this Consumer Alert for more information.

In the past, consumers would pay a penalty with their federal taxes if they were not enrolled in a health plan. Starting Jan. 1, 2019, that federal tax penalty was reduced to nothing. However, some states have established their own penalties for going without insurance. If you don't have major medical health insurance, you'll be on your own for major health care costs and residents of some states may owe a penalty, but you won't be penalized with your federal taxes.

Most health plans are required to offer you a renewal each year. It's your option to renew such plans but plans often renew automatically each year unless you take action to cancel. If you buy coverage on your own, there's a time each year called the Open Enrollment Period when you can select a new plan or renew the one you have. If you get coverage through your employer, there is usually a similar period for changing plans.

Yes, you may opt out of an insurance plan. However, you should check with your health insurance provider to see if there is any penalty for cancelling your health insurance early.

You may not be able to enroll in another plan until the Open Enrollment Period, unless you qualify for a Special Enrollment Period. Check your policy first though, to see if there are any limitations on cancelling your plan. If you are not enrolled in any health plan, you’ll be on your own for major health expenses, but you won’t face a federal tax penalty. The federal tax penalty for not having coverage was reduced to nothing starting in 2019, but some states charge penalties when their residents go without coverage.

Yes, you may be enrolled in more than one plan. Some people are enrolled in employer-sponsored insurance as well as Medicare, or both Medicare and a Medicare supplemental plan. One plan will be considered primary and pay for your health claims. The other plan will be considered secondary and will process any remaining bills under its rules.

A Medigap policy is health insurance sold by private insurance companies to fill the "gaps" in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan does not cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will each pay their share of covered health care costs.

Medicare supplemental coverage is another way to refer to Medigap policies. The federal Medicare program pays most medical expenses for people 65 or older, or for individuals under 65 receiving Social Security disability benefits. However, Medicare does not pay all expenses. As a result, you may want to buy a Medigap policy, also known as Medicare supplemental coverage, that helps pay for certain expenses, including deductibles not covered by Medicare.

To buy a Medigap policy, you generally must have Medicare Part A and Part B. You are guaranteed the right to buy a Medigap policy if you are in your Medigap open enrollment period or covered under a Medigap protection. You might not be able to buy a Medigap policy if you are in a Medicare Advantage Plan, have Medicaid, already have a Medigap policy, or are under the age of 65 and you are disabled or have End-Stage Renal Disease.

When you elect coverage under Medicare Part B either due to age or disability, you have a 6-month open enrollment for a Medigap policy, which guarantees you coverage with a plan and company of your choice. You may choose from a list of standardized plans – listed as A through L (New enrollees cannot buy Plans C, F or F High Deductible after January 1, 2020. Find out more here.) If you do not purchase a plan within your 6-month open enrollment, any company you apply to can deny coverage based on your health conditions. There are some limited additional open enrollment periods available if you're unenrolling from a Medicare Advantage plan.

You may want to buy a Medigap policy because Medicare does not pay for all your health care. There are “gaps” or “out-of-pocket” costs that you must pay in the Original Medicare Plan. Some examples of costs not covered are hospital stays, skilled nursing facility stays, blood, Medicare Part B yearly deductible and Medicare Part B covered services. A Medigap policy will not cover long-term care, vision or dental care, hearing aids and private-duty nursing.

Under Federal law, you have rights and protections regarding your Medigap coverage. These include your right to buy Medigap coverage, protections if you lose or drop your health care plan, and protections for people with Medicare under the age of 65. It is illegal for anyone to pressure you into buying a Medigap policy, lie or mislead you to switch to another company, or sell you a second Medigap policy when they know that you already have one. It is also illegal to sell you a policy that cannot be sold in your state. Call your State Health Insurance Assistance Program to better understand these rights and protections.

Medicare Advantage plans are private managed care plans that provide the standard Medicare benefits plus additional supplemental benefits for a monthly fee. These plans may include prescription drug coverage. Medicare Advantage participants may receive a subsidy for their prescription drug benefits in most cases.

Medicare Select plans are Medicare supplemental coverage plans that provide benefits through a network of providers similar to a Preferred Provider Organization (PPO). If the participant receives care from a provider under contract with the insurer, the cost will be lower.

Under COBRA, if you leave your current job you have the option to continue your health care coverage for up to 18 months. You are required to pay the full premium yourself, even if your employer paid part of your premium while you were employed, and the employer may charge an additional, limited administrative fee.

You can find out more about COBRA continuation of group health benefits from the Federal Department of Labor Office of Employee Benefits Security Administration website.

• Why do you need health insurance?
• Is the plan with the lowest premium really the most affordable?
• Who are you buying health insurance for?
• How long do you need health insurance – a full year or for a few months?
• Do you have a known health condition (a pre-existing condition)?
• What prescription drugs do you need?
• Do you have any chronic health conditions, like high blood pressure, diabetes or an autoimmune disorder? Even if you haven’t been to a doctor, are you in pain or having problems you believe will result in any health care services or treatment?
• Do you have a family doctor or hospital?
• Are you ready to pay the full cost for services until a deductible is reached?
• Are you able to pay the full cost for services if the plan limits how much it will pay?

• How did you get my information?
• May I have your full name and contact information, please?
• What is the exact name of your company and where are you located?
• Is your company licensed? Are you a licensed insurance agent? If so, what’s your license number for (state)?
• What’s the exact name of the insurance company on the policy and the name/type of policy I would be buying?
• What’s your company’s phone number?
• Will I need to pay a fee to join a group?
• Please send a copy of the information to me through the mail.
• Can I call you back after I’ve read your plan information?

• Is this a marketplace plan?
• Does this plan cover the same benefits as a marketplace plan?
• Does the plan cover pre-existing conditions?
• What benefits doesn’t this plan cover, and what benefits have limits?
• Where can I find out whether this plan covers my prescription drugs?
• Where can I find the list of health care providers in this plan’s network?
• What is the monthly premium I would pay for this plan?
• What out-of-pocket costs will I have to pay when I need services?
• What is the deductible?
• Is there a maximum I would have to pay out- of-pocket?
• Is there a limit on what the plan pays, per day, per year, or over my lifetime?
• How long does this plan last?
• Am I guaranteed the right to renew this plan?

Assess if you have any pre-existing conditions or will need specific doctors, services, or prescription drugs.

Don’t automatically renew the option you had before. If you buy a plan on your own, shopping on the marketplace each year gives you a chance to find a better deal. And many employers make changes from year to year, so it’s best to review your options.

Find out if your employer offers a wellness program that includes money-saving incentives for healthy behaviors such as exercising regularly or not smoking.

In addition to your health insurance coverage, you may be eligible to open a Flexible Spending Account (FSA) or a health savings account (HSA). And don’t forget about dependent care savings accounts.

Don’t make a decision or purchase a health plan after a single phone call or website visit. Compare policies and the financial help you may qualify for.

Check with your state insurance department to make sure your agent and insurance company of interest are licensed within your state.

The premium is the amount you will pay each month to have coverage. Your out-of-pocket costs are what you’ll pay when you need health care services. A plan with a lower premium may come with higher out-of-pocket costs. Make sure to consider your total costs—both the monthly premium and what you’ll owe if you need services.