By Sandy Ahn and Sabrina Corlette
In the wake of record shattering hurricanes in the East and wildfires in the West, consumers living in affected areas may have questions about their marketplace health insurance and their ability to use their coverage. With marketplace open enrollment for 2018 coverage scheduled to begin in less than one month, the lasting aftermath of these natural disasters may affect many consumers’ ability to sign up for or re-enroll into coverage. We’ve put together answers to questions that consumers may be asking about their marketplace health insurance.
1. I evacuated from my area because of the hurricane/wildfire, and none of my doctors are close by. What are my options?
Each marketplace health plan will have policies and procedures for reimbursing out-of-network providers (providers that are not under contract with your health plan). Since you may not have access to your health plan documents, calling the health insurance company and asking about your specific situation may be the best option. The contact information should be on your health insurance card. If you don’t have access to your health insurance card, contact the Marketplace Call Center (HealthCare.gov) at 1-800-318-2596 (TTY: 1-855-889-4325). In addition, some health insurance companies like Florida Blue and BlueCross BlueShield of Texas have information on their websites about how to access services and medication.
In Texas, the Insurance Department has issued a bulletin recommending that all health insurers waive any restrictions or penalties on members going out-of-network for necessary health and dental services on a non-emergency and emergency basis during the Governor’s disaster proclamation.
In emergency situations, the Affordable Care Act requires insurers to provide coverage for out-of-network care and prohibits insurers from charging higher coinsurance or copayment amounts for out-of-network care than for in-network care. The ACA, however, does not prohibit medical providers from billing consumers the “balance” of their charges after an insurer pays a portion of the charges. Some states have protections against this “balance billing,” in emergency situations including Florida, which prohibits medical providers from balance billing consumers when they receive emergency services by an out-of-network provider.
2. I take prescription medication and got evacuated from my home because of the hurricane/wildfires. I’m far from my local pharmacy and don’t know when I can get back. How can I get my medication?
You should contact your health insurance company and ask about your specific situation. Some health insurance companies like Florida Blue and BlueCross BlueShield of Texas have information on their websites about how to access services and medication. Many health plans also allow for mail-order prescription services, and this may be an option, but you will want to check with your health insurance company.
In Texas, the Insurance Department has issued a bulletin about accessing medication, recommending that all insurers allow their members up to a 90-day supply of prescriptions regardless of when they had their prescription filled.
Maintaining Marketplace Coverage
3. I have a lot of unexpected bills because of the hurricane/wildfire, and can’t afford to pay my marketplace premiums for the rest of the year. What are the consequences of not paying?
If you decide you can’t afford to maintain your coverage this year, you should contact the Marketplace Call Center (HealthCare.gov) at 1-800-318-2596 (TTY: 1-855-889-4325) as soon as possible to terminate your coverage and if applicable, stop receipt of any premium tax credits. You should also contact your health insurance company to ensure your health plan is terminated. Make sure to document the dates of your contacts with the marketplace and the insurer.
Recent federal guidance allows insurers to extend the grace period an additional sixty days to consumers who are receiving premium tax credits, if requested or directed to do so by state authorities. In Texas, the Insurance Department has issued a bulletin encouraging health insurance companies to suspend premium payments while continuing insurance coverage to provide relief to their residents in hurricane-affected counties. At least one insurer there indicates that it is working with its members to extend premium payment deadlines.
Note that not paying your health insurance premiums now and for the reminder of the year without terminating your plan could limit your ability to sign up for 2018 coverage on the marketplace. Under a new policy, insurers may condition your re-enrollment in their plan on payment of any outstanding premiums. However, insurers must provide notice of the new policy before they can apply it to you for failing to pay premiums. Also, the policy only applies to the insurer to whom you owe outstanding premiums. Other insurers offering plans in your area cannot deny you coverage for failing to pay premiums to another insurer.
4. I can’t afford to pay my health insurance premiums for the rest of the year because of hurricane-related expenses. Do I qualify for an exemption to the individual mandate (the requirement to maintain insurance coverage) or will I have to pay a penalty for being uninsured?
The marketplace offers a hardship exemption for floods or disasters causing substantial damage to your property and keeping you from getting health insurance. This exemption can apply to your entire tax household, and to disasters you experienced in the last three years. To qualify for the exemption, you must fill out the hardship exemption application, available here, and provide a copy of a “police record, insurance claim or other document including a news source” about the event, and mail the application and documents to the following address:
Health Insurance Marketplace – Exemption Processing
465 Industrial Blvd.
London, KY 40741
Note that this exemption is prospective, meaning you have to apply for the exemption now and be approved to be able to claim the exemption when you file your 2017 taxes. You can also request this exemption for 2018 coverage.
If you receive a hardship exemption, you become eligible to purchase catastrophic coverage, which may be less expensive than a marketplace plan. You may want to consider this coverage to protect yourself financially if you have an unexpected illness or injury. This type of coverage will provide for coverage of emergency or catastrophic health events, but note that catastrophic health plans have much higher out-of-pocket costs like deductibles when you want to use your coverage. You also cannot use any federal premium tax credits to purchase a catastrophic plan.
5. I’m not going to be able to sign up for 2018 coverage during this year’s open enrollment because my home was damaged in the hurricane/wildfire. But I’m hoping I’ll be able to return to my home by early the next year. Can I sign up for coverage then?
For people residing in or moving from areas affected by the hurricanes that the federal government has declared a major disaster or an emergency, an “exceptional circumstances” SEP is available from December 16 to December 31 to enroll into 2018 coverage. A list of federal disaster areas is available here and includes Florida, Texas, and Georgia. This SEP would also apply to those individuals moving from Puerto Rico to the U.S. mainland. Individuals can contact the Marketplace Call Center (HealthCare.gov) at 1-800-318-2596 (TTY: 1-855-889-4325) to request enrollment using this SEP.
After December 31, you may still be eligible for a special enrollment period (SEP) based on “exceptional circumstances” since the hurricane/wildfire kept you from enrolling during open enrollment. You should contact the Marketplace Call Center (HealthCare.gov) at 1-800-318-2596 (TTY: 1-855-889-4325) when you are ready to enroll into coverage. If you are denied a SEP, you can appeal the decision.
Tax Filing Questions
6. I got an extension to file my 2016 taxes and reconcile my premium tax credit, but because of the hurricane, I won’t be able to make my October 16 deadline to file. What will happen?
Currently the I.R.S. is postponing the deadlines for taxpayers in certain Texas and Florida counties affected by Hurricanes Harvey and Irma. Under the tax relief, taxpayers that have a valid extension to file their 2016 tax return in October have until January 31, 2018 to file. To date, no similar announcement has been made for taxpayers affected by wildfires in western states.
If you received premium tax credits in 2016 you must file your tax return and reconcile your premium tax credits by the January 31, 2017 deadline so you can remain eligible for premium tax credits in the future. During open enrollment, contact the marketplace and update your household and income information in order to receive a redetermination of financial assistance.
Note that the marketplace is providing an “exceptional circumstance” special enrollment period (SEP) for individuals residing in or moving from federally-declared incident areas impacted by the hurricanes from December 16, 2017 to December 31, 2017 to enroll into 2018 coverage. To use this SEP, individuals must contact the Marketplace Call Center at 1-800-318-2596 or TTY at 1-855-889-4325.
Special Enrollment-Related (SEP) Questions
7. Due to the hurricane/wildfires in my area I have moved and don’t know when or if I can return to my home. What should I do to maintain my health insurance?
According to federal guidance, if you temporarily relocated due to a hurricane and are now residing outside of your marketplace health plan service area, you may be eligible for a special enrollment period (SEP) due to the hurricane-related move for 2017 coverage. Contact the marketplace and Marketplace Call Center (HealthCare.gov) at 1-800-318-2596 (TTY: 1-855-889-4325) to apply for this SEP.
For 2018 coverage, the marketplace is providing an “exceptional circumstance” special enrollment period (SEP) for individuals residing in or moving from federally declared incident areas impacted by the hurricanes, and allowing them additional time, from December 16 to December 31, 2017 to enroll. A list of federally declared disaster areas is available here and includes Florida, Texas, and Georgia. This SEP would also apply to those individuals moving from Puerto Rico to the U.S. mainland. To apply, contact the Marketplace Call Center at 1-800-318-2596 or TTY at 1-855-889-4325.
The federal guidance does not specifically discuss dislocation from your home due to a wildfire, but you may also be eligible for 2017 coverage under a move SEP. Contact the Marketplace Call Center at 1-800-318-2596 or TTY at 1-855-889-4325. If you are denied a SEP, you can appeal the decision.
If the dislocation from the wildfire prevents you from enrolling into 2018 coverage during open enrollment, you may also be eligible for an “exceptional circumstances” special enrollment. The wildfire may likely fall under a natural disaster preventing someone from enrolling into marketplace coverage during open enrollment.
8. Due to a hurricane/wildfire or other natural disaster, I no longer have access to documents I need to verify my eligibility for a special enrollment period, and won’t make the marketplace’s 30-day deadline to submit them. What should I do?
The federal marketplace is waiving the verification requirement for those individuals impacted by the hurricanes who started the special enrollment application and whose application was pended for verification. In addition, the marketplace is providing an additional sixty days for people who experienced a qualifying event between 60-days prior to the hurricane and December 31, 2017 to enroll into 2017 coverage or make changes to your existing coverage. You will be able to request retroactive coverage based on the date that you would have selected a health plan under the original SEP. Contact the Marketplace Call Center (HealthCare.gov) at 1-800-318-2596 (TTY: 1-855-889-4325) to apply.
The guidance also allows states to direct or allow insurers to provide more generous deadlines for first month’s premium payment (i.e., binder payments) to effectuate coverage. If no state guidance exists, insurers can provide up to a 60-day extension from the original binder payment deadline.
As responses to these natural disasters continue to unfold we’ll be sure to update this post.