The Affordable Care Act (ACA) survived its latest Supreme Court challenge earlier this year and celebrated its 11th birthday. Whether that was a happy birthday depends on who you ask. Also known as Obamacare, the ACA makes health insurance more affordable for Americans who lack access to employer health plans and Medicare…but enrollees who don’t qualify for the system’s subsidies can end up paying steep premiums for coverage with massive out-of-pocket costs— as high as $8,700 for an individual or $17,400 for a family. Insurance can be confusing, whether purchased through this program or from an insurer. Traps to avoid with ACA health insurance…
Trap: Inconsistent enrollment windows. Healthcare.gov’s enrollment window for 2021 coverage was open from November 1 through December 15, 2020…and from February 15 through August 15, 2021. Some states extended those windows even further. But that second enrollment window was added to encourage people to sign up for insurance during the pandemic. In most years, you can sign up for ACA coverage only from November 1 through December 15, except under very specific circumstances.
The government’s attempt to get more people to enroll in 2021 could confuse some people about when they must act to obtain ACA coverage in future years. Reason: When people believe they can obtain insurance midyear, they sometimes reason that they’ll avoid paying premiums for now and sign up later if they experience a major health issue. People who put off signing up past December 15 this year might discover that they cannot get ACA coverage for 2022 at all. Exception: They might qualify to enroll midyear if they lose access to other insurance, relocate or experience certain other life events, such as the end of COBRA coverage.
What to do: Make ACA plan decisions for 2022 between the enrollment period November 1 and December 15, 2021. In fact, make these decisions as early as possible during that monthand- a-half stretch—if you don’t enroll until mid-December, you probably won’t have your insurance card in hand by January 1. You might not be able to schedule a medical appointment until you have your card in hand and can demonstrate that you’re covered.
Trap: Preventive care often is fully covered—but the line between preventive and diagnostic care can be unclear. Insurance sold through ACA marketplaces is required to completely cover the costs of a range of preventive care, such as colonoscopies and mammograms, as long as it is delivered by an in-network provider. Catch: The same procedure that’s covered as “preventive care” could result in treatment that is not preventive care…or the procedure itself might not be considered preventive if, for example, your doctor orders the procedure more frequently than is common because of a preexisting health issue. Example: A mammogram prescribed more than once a year might be considered diagnostic for a woman who has had a previous diagnosis.
Caution: Some procedures are coded diagnostic rather than preventive simply because someone in the doctor’s billing office entered the wrong billing code.
What to do: Before seeing your health-care provider for an exam or test, ask the doctor’s office, “Is this a diagnostic procedure or ‘well care’?” If the answer is diagnostic and you haven’t yet met your plan’s deductible, ask about costs. If the procedure is expensive, confirm with your doctor that it is medically necessary… and/or shop around to see if lower rates are available through a local lab or diagnostic center. Confirm that the facility is in-network for your insurance.
If you receive a bill for a procedure that you believed to be preventive, contact your provider’s billing department to ask why it wasn’t considered preventive and fully covered. If it turns out that the doctor’s office simply entered the wrong code, ask for the code to be corrected and the bill to be resubmitted.
Trap: Not just provider networks are shrinking—hospital networks can be narrow, too. You may know that many ACA plans have limited provider networks— many doctors are “out of network,” which means that ACA insurance provides limited or perhaps no coverage for out-of-network services. What many enrollees don’t realize is that many plans have narrow hospital networks—and often an area’s best hospitals are excluded.
What to do: Before enrolling in any ACA plan, determine if your preferred hospital is in its network. Recheck this during every open-enrollment period.
Reminder: If you have a medical emergency, consider heading to the closest hospital even if it is out-of-network. In emergencies, ACA plans are required to cover out-of-network hospitals as if they were in-network…and under new rules that take effect at the start of 2022, an out-of-network hospital typically cannot bill a patient for excess charges if his/her insurance’s in-network rates fail to cover the entire emergency care bill.
Trap: Your ACA coverage won’t follow you if you move to a different state. The ACA was federal legislation, but individual insurance plans are regulated by state insurance departments and are not portable across state lines— you will become ineligible for your current coverage if you relocate to a new state. That’s true even if you relocate only a few miles across a state line and continue seeing the same doctors.
What to do: Visit Healthcare.gov—or your state’s marketplace if you enrolled on its exchange—to report your move and sign up for new coverage in your new state. Moving to a new state will qualify you for a midyear special enrollment period. If you have multiple residences in different states, sign up for coverage in your state of residence for tax purposes. If you don’t qualify for tax subsidies to help pay the cost of your coverage, also consider obtaining coverage directly from an insurance company.
Trap: Your plan might kick you out at year-end. If you were satisfied with the ACA insurance that you had this year, you might opt to do nothing during the open-enrollment period and let your coverage automatically renew for 2022. Problem: While taking no action usually results in automatic renewal, insurers occasionally disenroll customers at year-end. This often happens when an insurer isn’t offering a similar plan in the coming year…but sometimes insurer’s disenrollment motivations are less clear. Insurers do send out notices warning people who will be disenrolled, often starting as early as late summer, but not everyone reads insurance company mailings carefully.
What to do: Visit Healthcare.gov or your state’s marketplace during open enrollment to confirm your coverage for 2022 even if you don’t plan to make changes. And always read correspondence from your insurance company.
Trap: ACA deductibles and out-ofpocket maximums are not prorated for partial years. ACA out-of-pocket costs can be significant—many plans provide little coverage until you meet a deductible of perhaps $4,000 to $8,000. But as staggeringly steep as those costs might seem, it can get worse—in certain situations,