November 1 marked the first day of the 2023 marketplace Open Enrollment Period (OEP) which goes until January 15, 2023. Here are the most important things you need to know about the 2023 Affordable Care Act (ACA) health plan and the resolved Family Glitch to best serve your clients.
Gathering Client’s Information:
To suggest the optimal plan for your clients, you need to gather their demographic information. This includes their household income, the number of members applying for coverage, and the gender and age of all applicants.
Your client’s household income will determine their eligibility for premium tax credits, or subsidies. The ACA family glitch fix and the Inflation Reduction Act (IRA) affect who qualifies for these subsidies and for how long.
If you have more than one client signing up for coverage within the same household, make sure to make note of that. You must provide information for the number of children in their household, anyone claimed as a dependent on their tax return, and anyone under 21 in their home.
Knowing your client’s area will also help you know what plans are available to them and guide them to the right coverage. Make sure to research if their state has its own exchange or if they take part in the federal exchange; this will allow you to help your client accurately register for coverage.
Compiling and understanding these demographics for your clients can make all the difference in locating affordable and accessible coverage for them.
What is the Family Glitch? What’s the Fix for 2023?
The ACA family glitch is referring to a rule that bases eligibility for a family’s insurance premium subsidies on whether available employer-sponsored insurance is affordable for the employee only, even if it’s not actually affordable for the whole family.
This means affordability is determined based on the one person directly receiving the employer-sponsored plan, and the glitch does not consider the cost to add family members (dependents).
However, a recent IRS rule change finalized a family glitch fix in time for the 2023 ACA open enrollment period. The new rule change means that the cost of employer-sponsored health insurance will now be based on the employee and their family members if applicable, rather than just the individual employee.
Locating Available Providers:
Once you’ve compiled the necessary components to determine the correct exchange for your client, understanding the major hospital system(s) close to your client will help you in the process of solidifying their plan. A beneficial first step to locating these major hospital systems is to search through carriers’ websites to locate specific providers. Consider prioritizing their primary care provider’s (PCP) carrier for their marketplace coverage.
If your client’s state participates in the federal exchange, you can use an enrollment tool such as HealthSherpa to search for providers. There are also state-based marketplace enrollment tools that allow you to search for providers.
What Kind of Coverage is Available:
The good news for you and your client is that there are many different ACA plans available from insurance carriers. However, they aren’t the same across the board. There are three different plan types regarding provider networks: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Exclusive Provider Organization (EPO). The main differences between each are:
- HMO:
- Coverage is limited to local providers with rare out-of-network coverage, excluding emergency services.
- Limited flexibility: requires a referral from a PCP to see a specialist.
- Lowest premium cost.
- EPO:
- Coverage is limited to local providers with rare out-of-network coverage, excluding emergency services.
- Moderate flexibility: does not require a referral from PCP to see a specialist.
- Moderate premium cost.
- PPO:
- Large provider networks with out-of-network coverage at higher premiums.
- High flexibility: does not require a referral from PCP to see a specialist.
- Highest premium cost.
There are also four different tiers to consider: bronze, silver, gold, and platinum. These tiers explain the cost breakdown between the policy and the beneficiary. You can see the cost breakdown in the chart below:
| Tiers | Bronze | Silver | Gold | Platinum |
|---|---|---|---|---|
| % Covered Medical Costs Paid by the Policy | 60% | 70% | 80% | 90% |
| % of Covered Medical Costs Paid by the Policyholder | 40% | 30% | 20% | 10% |
| Monthly Premium Comparative Cost | Lowest | Moderate | High | Highest |
| Unsubsidized Annual Deductible Comparative Cost | Highest | Moderate | Low | Lowest |
| Eligible to Apply a Cost-Sharing Reduction? | No | Yes | No | No |
| Eligible to Apply a Premium Tax Credit? | Yes | Yes | Yes | Yes |
Source: RitterIM.com
Manage Enrollment and Coverage Timelines:
Your clients’ coverage will begin once they complete their enrollment application and pay their first monthly premium.
To submit an enrollment application, confirm enrollment, or make a payment, have your client follow these steps:
- Log in to their marketplace account.
- Select the application under Your Existing Applications.
- Click the blue button that says Pay Your First Health Insurance Monthly Premium.
- If online payment is available, select the green button Pay for Health Plan Now to go to the insurance company’s website to pay.
You can also verify your clients’ enrollment status by visiting HealthCare.gov and viewing the My Plans and Programs page.
For health plans sold during the ACA OEP 2023, their health coverage will begin on January 1, 2023. If you sold your client a health plan between December 16, 2022 and January 15, 2023, their coverage will begin February 1. However, effective dates may be different for those enrolling through a federal exchange versus a state exchange. It’s important to keep track of your clients’ effective dates for their coverage and make them aware of this.
What if My Client Misses the OEP?
If your client misses the OEP, they have a few options for health coverage. If their case includes a significant life change, they may qualify for a Special Enrollment Period (SEP) through HealthCare.gov. These significant events may include changes in the household such as having a baby, losing health insurance, or changes in residence. It’s important to note that a SEP is the only way to get a marketplace health plan outside of the ACA OEP. If your client is denied a SEP but still needs coverage, you can always consider a short-term health plan.
The ACA OEP is a critical time to finding an affordable and accessible marketplace plan for your client and we know there is no one-size-fits-all guide to the process. If you have any questions pertaining to marketplace enrollment, if you’re an agent with Carolina Senior Marketing, please feel free to reach out to us. Our Health Insurance Specialist focuses on the Under-65 market and can assist you. Just call us at (919) 460-6073 and follow the prompts.
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As your North Carolina Medicare FMO, Carolina Senior Marketing is committed to serving you, the Independent Insurance Agent. If you’re not an agent with us, we’re still glad to meet a new face and answer any of your questions you may have. Please email us at [email protected] to reach out.
