Use Caution When Enrolling in Health Exchange Plans

Under the Affordable Care Act you will generally have 3 ways to in which to enroll in an Exchange Health Plan.

1) Through a Navigator,  or

2) Directly with the exchange, or

3) A licensed insurance agent who has certified with the exchanges to offer enrollment into the new ACA plans. and who may also help you compare to plans outside the Exchange for a complete side by side comparison.

Navigators have been enlisted namely by community organizations that have received funding grants through Affordable Care Act to help facilitate the enrollment into the Exchange’s Health Plans.  Navigators were required to take a minimum number of training hours to help them navigate the enrollment process.  Most are either volunteers or minimally paid to do so, few if any have an formal training with Insurance, are not licensed and have little oversight by regulatory authorities.   Some members of Congress recently expressed concern to Human Health Services, the agency overseeing the implementation of the ACA, that personal and confidential information provided to these Navigators may be extremely vulnerable to identity theft.  When enrolling in a health plan, applicants will need to provided extremely confidential data to enroll, and those assisting with the enrollment process will have access to this information.

By applying directly with the Exchanges, applicant will be able to apply themselves.   However, applying for all of the applicable benefits and credits may require several hours of study and many may find it confusing and inadvertently apply for the inappropriate coverage and subsidies.  Telephone assistance will be available through call centers which are neither licensed or experienced with health insurance in their respective states.

While many insurance agents and brokers have chosen not to participate with enrolling individuals in the ACA plans, some have.  Generally, most insurance brokers will have hundreds of hours of  training, and years of experience dealing with health insurance.  Many Insurance Professional will also be able to help consumers shop and compare plans both inside and outside of the exchanges.  There will be a number of competitive insurance plans offered outside of the Exchanges.  By contacting the Exchange directly or a Navigator, consumers will only be shown those plans inside the Exchange.  Further, a knowledgeable and experienced broker will be able to illustrate plans which may supplement coverage under a lower cost health plan while reducing your overall out of pocket exposure.  Insurance Agents and Brokers and licensed and strictly regulated by the State  Insurance Commissioners’ of their respective states.  Many may also carry Professional Errors and Omissions Insurance coverage to help protect you against their mistakes.

If you prefer to review a comprehensive comparison of plans both inside and outside the Exchanges, insure your confidential information is strictly safeguarded against identity theft, and receive help to make sure you apply for all the benefits you may be entitled to, not only from the ACA but from the other various federal and state assistance programs we suggest you submit a request for more information to be sure you receive all the benefits you are entitled to.






Enrollment Periods

After their eligibility has been determined, individuals may enroll in a QHP during various timeframes throughout the year. The three timeframes are the initial open enrollment period, the annual open enrollment period, and special enrollment periods (SEP).

The initial open enrollment period begins October 1, 2013 (before the Marketplaces first make coverage available on January 1, 2014), and continues through March 31, 2014.
The annual open enrollment period is between October 15 and December 7 each year, beginning in 2014.
SEPs occur throughout the year, based on individuals’ special circumstances.

Beginning in 2014, the Marketplaces will send an annual open enrollment notice to each enrollee, between September 1 and September 30, to ensure enrollees are aware of the upcoming annual open enrollment period.

When Enrollment Selection is Received on October 15, 2014 to December 7, 2014 (or later year), Health Insurance Coverage Begins on January 1, 2015 (or later year).

When Enrollment Selection is Received on the 1st-15th calendar day of a given month, Health Insurance Coverage Begins on the 1st day of the following month.

When Enrollment Selection is Received on the 16th-31st calendar day of a given month, Health Insurance Coverage Begins on the 1st day of the second following month.
Note that Medicaid and CHIP do not limit the time periods during which an individual can enroll.

Special Enrollment Periods

Under certain circumstances, individuals may change QHPs outside of the annual open enrollment period. These SEPs are based on certain triggering events or exceptional circumstances.

Events that permit a SEP include, but are not limited to:

Gaining or becoming a dependent
Gaining status as a citizen, national, or lawfully present individual
Loss of minimum essential coverage (e.g., loss of Medicaid eligibility, termination of a QHP), except if enrollment is terminated based on failure to pay premiums
Loss of affordable employer-sponsored coverage
Determination that an individual is newly eligible or ineligible for premium tax credits or a change in eligibility for cost-sharing reductions
Permanent move to an area where different QHPs are available
Other exceptional circumstances identified by the Marketplace

In most cases, SEPs will extend for 60 days from the date of the triggering event. Under certain circumstances, such as the pending loss of minimum essential coverage due to the termination of a QHP, a SEP may begin before the triggering event takes place.

The Employee Retirement Income Security Act (ERISA)

ERISA was enacted to protect the interests of participants in employee benefit plans as well as the interests of the participants’ beneficiaries. Much of the law deals with qualified pension plans, but some sections also apply to group insurance plans.

Fiduciary Responsibility

ERISA mandates very detailed standards for fiduciaries and other parties-in-interest of employee welfare benefit plans, including group insurance plans. This means that anyone having control over plan management or plan assets of any kind must discharge that fiduciary duty solely in the interests of the plan participants and their beneficiaries. Strict penalties are imposed on those who do not fulfill this responsibility.

Reporting and Disclosure

ERISA requires that certain information concerning any employee welfare benefit plan, including group insurance plans, be made available to plan participants, their beneficiaries, the department of Labor, and the IRS.

ERISA imposes severe monetary penalties for failure to comply with its reporting and disclosure requirements within prescribed time periods. In addition, civil and criminal action may be taken against any plan administrator who willfully violates any of these requirements or who knowingly falsifies or conceals ERISA disclosure information.

The Americans with Disabilities Act (ADA)

This act has a widespread impact on almost all facets of American life. With respect to group insurance, it makes it unlawful for employers with 15 or more employees to discriminate on the basis of disability against a qualified individual with respect to any term, condition or privilege of employment. Employees with disabilities must be accorded equal access to whatever health insurance coverage the employer provides to other employees, although certain coverage limitations may be acceptable for mental and nervous conditions as opposed to physical conditions as long as such limitations apply to employees without disabilities as well as those with disabilities.

Among other things, the law forbids exclusion or limitation of benefits for:

  • specific disabilities such as deafness or AIDS;
  • individually distinct groups of afflictions, such as cancer, muscular;
  • dystrophy or kidney disease; and
  • disability in general.

If the equal employment Opportunity commission determines that a health plan violates the ADA, the burden of proving otherwise is on the employer.

Age Discrimination in Employment Act

This Act applies to employers with 20 or more employees and is directed toward employees who are age 40 or older. Generally speaking, this act prohibits compulsory retirement, except for those in executive or high policy making positions. Employee benefits, which in the past usually ceased or were severely limited when an employee turned 65, must be continued for older workers, although some reductions in benefits may be allowed. Some states have laws that are even stricter with regard to retirement and benefits