FAQ of the Week: What to Expect When Expecting Health Insurance

Now that Open Enrollment is over in most states, many consumers have enrolled into a health insurance plan. We’ve compiled a number of frequently asked questions from our Navigator Resource Guide to help inform consumers on what to do next.

Step 1: Pay your first premium

I’ve picked the plan I want. Now do I send my premium to the marketplace?     

No, you will make your premium payments directly to the health insurance company. Once you’ve selected your plan, the marketplace will direct you to your insurance company’s website to make the initial premium payment. Insurance companies must accept different forms of payment and they cannot discriminate against consumers who do not have credit cards or bank accounts. The insurance company must receive and process your payment at least one day before coverage begins. Make sure you understand your insurance company’s payment requirements and deadlines and follow them so your coverage begins on time. Your enrollment in the health plan is not complete until the insurance company receives your first premium payment.

Note that since June 19, 2017, insurers can take into account any past due premiums you owe them for the previous 12 months of coverage. They can require you to pay those past due premiums before allowing you to re-enroll in their plan. This requirement does not apply if you are signing up for coverage offered by a new insurer and only affects the person responsible for paying premiums on the previous policy, not other family members enrolled in the plan. Further, the requirement only applies for the prior 12 months of coverage and applies to both open enrollment and special enrollment periods. If the insurer is requesting payment of past due premiums for prior 12-month coverage, and you think this is an error, contact your state marketplace or state insurance department, a list of states’ departments of insurance is available under our Resources, Where to Go for Help.

If you have qualified to receive a premium tax credit and have chosen to receive it in advance, the government will pay the credit directly to your insurer and you will pay the remainder of the premium directly to the insurer.

Step 2: Take care of any follow up verifications for your marketplace application

I received a notice saying there is a data matching issue on my application and the marketplace needs to verify my income. How should I verify my income?

A data matching issue means the marketplace is not able to verify the information on your application based on the data the marketplace already has for you. To resolve the data matching issue with your application, you can verify your income by uploading documents to the marketplace online or by sending photocopies in the mail. Verifying documents might include a federal or state tax return, wages, or pay stubs. To determine which documents you need to submit, please consult this guide here. See also: How do I resolve a data matching issue?

Step 3: When your coverage begins, make plans for your annual preventive services.

If I buy a plan during open enrollment, when does my coverage start?

Open enrollment is from November 1, 2019 to December 15, 2019, and make your first premium payment by the due date specified by your plan, your new coverage will start on January 1, 2020.

Are annual physicals for adults and children available without cost-sharing as part of the preventive service requirements?

Yes, routine annual physicals are covered as part of the preventive service requirements of the ACA. This means that insurers must provide coverage for preventive health services currently recommended by the United States Preventive Services Task Force (USPSTF) and federal guidance.

Some plans will also cover some limited services prior to meeting a deductible such as primary care visits, some urgent care, or a limited number of prescription drug refills. Check your Summary of Benefits and Coverage for information on what services are covered before the deductible is met.

Under federal rules, insurers must provide coverage for preventive health services that the USPSTF recommends at an A or B rating without any cost-sharing requirements such as a copayment, coinsurance, or deductible.

Step 4: Pay your monthly premium to keep your insurance throughout the year

What happens if I’m late with a monthly health insurance premium payment?

The answer depends on whether you are receiving advanced premium tax credits. For people receiving advanced premium tax credits, if a payment due date is missed, insurers must provide a 90-day grace period during which consumers can bring their premium payments up-to-date and avoid having their coverage terminated. However, the grace period only applies if an individual has paid at least one month’s premium.

If, by the end of the 90-day grace period, the amount owed for all outstanding premium payments is not paid in full, the insurer can terminate coverage dating back to the end of the first month of non-payment.

In addition, during the first 30 days of the grace period, the insurer must continue to pay claims. However, after the first 30 days of the grace period, the insurer can hold off paying any health care claims for care received during the grace period, which means the enrollee may be responsible to cover any health care services they receive during the second and third months if they fail to catch up on the amounts they owe before the end of the grace period. Insurers are supposed to inform health care providers when someone’s claims are being held. This could mean that providers may request that you pay out-of-pocket for care or may not provide care until the premiums are paid up so that they know they will be paid. Alternatively, providers may provide care and if your coverage is subsequently terminated, may bill you for the total cost of services. If you pay your premiums in full by the end of the 90 day grace period, your coverage will be reinstated and claims during that time will be paid.

People not receiving advanced premium tax credits are expected to get a much shorter grace period; currently, the general practice is 31 days but it may vary in each state.

Not paying your premiums may affect your ability to get future coverage. If you are seeking new coverage from an insurer to whom you owe premiums for prior 12-month coverage, the insurer can request that you pay your past due premiums as a condition of enrolling you into new coverage. This only applies to insurers to whom you owe premiums for prior 12-month coverage (i.e. if you switch to a new insurer, the company cannot condition enrollment on paying premiums you owe to your previous insurer). Insurers can impose this obligation during both open and special enrollment periods.

Leave a Reply

Your email address will not be published. Required fields are marked *

The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.