Frequently Asked Questions

• 60 days from the date of the qualifying event (in most cases).

• Loss of other health coverage (job-based, Medicaid, etc.)
• Marriage or divorce
• Birth or adoption of a child
• Moving to a new ZIP code or county
• Gaining U.S. citizenship or lawful presence
• Leaving incarceration
• Change in immigration status
• Changes in income affecting eligibility for subsidies

1. Covers 10 essential health benefits, including:

• Doctor visits
• Emergency services
• Hospitalization
• Prescription drugs
• Maternity and newborn care
• Mental health services
• Preventive services (like vaccines and screenings)

2. No denial for pre-existing conditions

3. No annual or lifetime limits on essential health benefits

4. Free preventive care (check-ups, screenings, immunizations)

5. Subsidies available:

• Based on your income, you may qualify for premium tax credits or cost-sharing reductions to make the plan more affordable.

• A tax credit for health insurance — usually called the Premium Tax Credit (PTC) — is financial help from the government that lowers the cost of health insurance premiums if you buy coverage through the Affordable Care Act (ACA) marketplace. It’s a subsidy based on your income and household size that helps you pay for a health insurance plan. Certain qualifications vary.

HMO (Health Maintenance Organization)

• Primary Care Physician (PCP) required: You must choose a PCP who coordinates your care and gives you referrals to see specialists.
• Network only: Coverage is usually limited to doctors, hospitals, and providers within the HMO network (except emergencies).
• Lower costs: Typically has lower premiums and lower out-of-pocket costs than a PPO.
• Less flexibility: You can’t usually see out-of-network providers unless it’s an emergency.

PPO (Preferred Provider Organization)

• No referrals needed: You don’t need a PCP to access specialists. You can go directly to a specialist.
• In- and out-of-network coverage: You can see doctors both inside and outside the PPO network (though in-network is cheaper).
• Higher costs: Premiums and out-of-pocket costs are usually higher than HMOs.
• More flexibility: Greater freedom to choose providers, even out-of-network.

Short-Term Health Insurance

• Designed for temporary coverage (e.g., between jobs, waiting for Medicare).
• Can last a few months up to 364 days, and in some states renewable for 3 years.
• Typically excludes pre-existing conditions and has coverage limits.
• Usually cheaper, but less comprehensive.
• Not available in all states

Fixed Benefit Indemnity Plans

• Pay a set cash benefit per service (e.g., $200 per day in hospital, $50 per doctor visit).
• You can use the money toward bills, but it may not cover full costs.
• Doesn’t replace major medical insurance — more of a supplement.

Medicare Advantage Basics:

• Covers everything Original Medicare covers (hospital care under Part A and medical care under Part B).
• Often includes extra benefits that Original Medicare doesn’t, such as:

- Prescription drug coverage (Part D)

- Dental, vision, and hearing care

- Wellness programs, gym memberships, transportation help, etc.

• Costs vary: You still pay your Part B premium, but the plan may have an additional monthly premium, copays, and deductibles depending on the design.
• Network restrictions: Most Medicare Advantage plans use an HMO or PPO structure, meaning you may need to see doctors in the plan’s network (except in emergencies).
• Out-of-pocket maximum: Unlike Original Medicare, Medicare Advantage has a yearly limit on what you pay out of pocket for covered services. Once you hit that cap, the plan pays 100% for the rest of the year.

A Medicare Supplement Plan (also called Medigap) is a type of insurance you can buy from a private company to help pay the “gaps” in Original Medicare (Parts A & B).

It doesn’t replace Medicare— you must stay enrolled in Original Medicare—but it helps cover out-of-pocket costs like:

• Copayments
• Coinsurance
• Deductibles

How Medigap Works

• You keep Original Medicare (Parts A & B).
• Medicare pays its share of your healthcare costs first.
• Then your Medigap policy helps pay what’s left (depending on the plan you choose).
• You can see any doctor or hospital nationwide that accepts Medicare—no networks or referrals required.
• Does not usually include prescription drug coverage—you’d need a separate Part D plan if you want that.

Initial Enrollment Period (IEP)

• For people first becoming eligible for Medicare (usually at age 65).
• A 7-month window:

            - 3 months before your 65th birthday month

            - Your birthday month

            - 3 months after your birthday month

• During this time, you can sign up for Part A (hospital) and Part B (medical), and also add Part D (prescription drugs) or a Medigap plan or a Medicare Advantage plan (Part C).

Annual Enrollment Period (AEP) — for changing coverage

• Every year: October 15 – December 7
• You can:

             - Switch between Original Medicare and Medicare Advantage

             - Change Medicare Advantage plans

             - Join, switch, or drop a Part D plan

• Coverage changes start January 1 of the next year.

Medicare OEP (Medicare Advantage Open Enrollment Period)

• When: Every year, January 1 – March 31
• Who: People already enrolled in a Medicare Advantage (Part C) plan
• What you can do:

             - Switch to a different Medicare Advantage plan (with or without drug coverage)

             - Drop Medicare Advantage and return to Original Medicare (and add a Part D drug plan if you want)

• What you cannot do:

             - Switch from Original Medicare into Medicare Advantage

             - Join a Part D plan if you don’t have Medicare Advantage

Health supplemental insurance (often called supplemental health insurance) is extra coverage you can buy in addition to your primary health insurance plan.

Its purpose is to help cover costs or services not fully paid for by regular health insurance, or to provide financial support when you experience specific health-related events.

What it Helps Cover:

• Out-of-pocket costs: Helps pay for copays, deductibles, and coinsurance.
• Cash benefits: Some plans pay you a lump sum or daily benefit if you’re hospitalized or diagnosed with certain conditions.

Specialized coverage can focus on specific risks like:

             • Critical illness insurance (for cancer, stroke, heart attack, etc.)

             • Hospital indemnity insurance (daily or lump-sum payments during hospital stays)

             • Accident insurance (coverage for injuries and emergency treatment)

             • Disability insurance (income replacement if you can’t work due to illness or injury)

             • Dental, vision, or hearing plans (not usually included in standard health insurance)

• To reduce the financial burden of unexpected health events.
• To get help covering services standard insurance excludes.
• For peace of mind if they have higher medical risks or limited savings.

Example:

If you’re hospitalized for surgery:

• Your primary health insurance pays most of the hospital bill.
• You still owe your deductible, coinsurance, and possibly lost wages while recovering.
• Supplemental hospital or critical illness insurance could pay you cash benefits to cover those extra costs.

It doesn’t replace your main health insurance, but rather fills in the gaps.

For employer group health plans (non-Medicare, just general insurance law in the U.S.):

• Small group plan: Usually 2 to 50 employees (some states define it as 1 to 50 if they allow “group of one”).
• Large group plan: 51 or more employees (in some states, 101+).

So, technically, it can take as few as one employee if the state allows a “group of one,” but in most places, you need at least 2 employees to form a group plan

An ICHRA stands for Individual Coverage Health Reimbursement Arrangement. It’s a type of employer-funded health benefit that started in 2020 as a way to give businesses more flexibility in offering health coverage.

How it Works:

• Instead of providing a traditional group health insurance plan, an employer gives employees a set monthly allowance of tax-free money.
• Employees then use that money to buy their own individual health insurance (on the Marketplace or directly from an insurer) or to get reimbursed for qualified medical expenses.
• Employers decide:

             - How much to contribute

             - Which employee classes are eligible (e.g., full-time, part-time, seasonal, salaried, hourly)

• Employees must be enrolled in individual health insurance (or Medicare) to participate.

Employer group health plans can include a wide range of benefits, depending on what the employer chooses to offer and what’s required by law.

Here’s a breakdown:

Core Health Benefits (usually included)

• Medical insurance (doctor visits, hospital care, preventive care, maternity, mental health, etc.)
• Prescription drug coverage
• Preventive services (like screenings and vaccines, often covered with no cost-sharing under ACA rules)

Common Supplemental Health Benefits

• Dental insurance 
• Vision insurance 
• Hearing coverage 

Financial Protection Benefits

• Life insurance 
• Disability insurance

            - Short-term disability (covers income for weeks to months)

            - Long-term disability (covers years, often to retirement age)

• Accident, critical illness, and hospital indemnity plans (supplemental cash benefits for specific events)
• Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA) (tax-advantaged accounts for medical expenses)