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Health Insurance

Health Insurance gives you coverage if you need medical care or are in the hospital. Your insurance policy explains in writing what is and what is not covered. An Individual/Family Policy is insurance you buy outside of an employer or association. The policy is issued to the individual who applies for it and their family. Once you have an individual/family policy, you can add other family members and dependents in some cases.

Should I get a marketplace or off-market plan?

Marketplace insurance refers to insurance plans available on the federal (Healthcare.gov) or state health insurance marketplace. As part of the Affordable Care Act, California created a health insurance marketplace called Covered California. Individuals, families, and small businesses purchase insurance products sold by private insurers in the Marketplace. The Marketplaces help determine qualificaton for the government programs and APTC subsidies.

Off Market insurance plans are purchased directly from an insurance company without going through a state or federal marketplace. Depending on your state, private insurance plans may differ from marketplace insurance plans in various ways. Many who don't qualify or want to apply for APTC credits choose to go Off-Market.

Most of these plans provide you the same ACA protections as marketplace plans, but not assistance in the premiums. Most of the plans are similar in coverage and pricing as a Marketplace plan without the APTC pricing, but that's not guaranteed. Carriers tend to offer a few different options that aren't in the marketplace.

An Advanced Premium Tax Credit (APTC) is a federal subsidy designed to lower your monthly health insurance premiums when you buy a plan through the federal or state Health Insurance Marketplaces (i.e. Healthcare.gov & Covered California) Instead of waiting until you file your taxes to get a credit, the government sends this subsidy directly to your insurance company each month, immediately reducing the amount you pay out-of-pocket for your coverage.

To qualify for an Advanced Premium Tax Credit, you must meet the following federal criteria:

Income Limits: Your household income must fall within a specific range, typically between 100% and 400% of the Federal Poverty Level (FPL).
No Affordable Employer Coverage: You cannot have access to affordable, comprehensive health coverage through an employer.
No Government Coverage: You must not be eligible for or enrolled in Medicare, Medicaid, CHIP, or TRICARE.
Filing Status: If you are married, you must file a joint federal tax return to claim the credit.
Legal Residency: You must be a U.S. citizen or be lawfully present in the United States and not be incarcerated.

When do I enroll?

Open Enrollment

The Open Enrollment Period (OEP) for the Affordable Care Act (ACA) is the specific window of time each year when individuals and families can sign up for, change, or cancel a private health insurance plan through the government health insurance marketplaces.

Outside of this designated window, you cannot purchase an individual ACA health plan unless you experience a major life shift that triggers a Special Enrollment Period (SEP).

Key Features of ACA Open Enrollment:

Guaranteed Coverage: Insurance companies cannot deny you coverage or charge you higher premiums for having pre-existing conditions like diabetes, cancer, or pregnancy.
Plan Modification: You can change your existing plan, upgrade or downgrade your coverage tier (Bronze, Silver, Gold, Platinum), or switch to a completely different insurance company.
Financial Aid Assessment: This is when you update your household income and size details to see if you qualify for an Advanced Premium Tax Credit (APTC) to lower your monthly payments.

Open Enrollment Dates:

The Federal ACA Marketplace (Healthcare.gov)

Enrollment Period: November 1 - December 15

Effective Date: January 1

Note: The federal timeline for 2027 coverage is shorter than prior years

Covered California provides an extended enrollment window:

Enrollment Period: November 1 - January 31

Effective Dates A: January 1 for November & December Enrollments;

Effective Dates B: February 1 for January enrollments

What Happens If I miss open enrollment?

If you miss the Open Enrollment deadline, your next opportunity to get coverage will be the following year's open enrollment, unless you experience a Qualifying Life Event (QLE). A QLE unlocks a 60-day window to sign up mid-year and includes milestones like:

Losing job-based health insurance
Getting married or divorced
Having a baby or adopting a child
Permanently moving to a new zip code or state
Aging off a parent's plan at age 26
State of Emergency granted by the State (issued for cities and counties)

Shopping for Individual/Family Coverage

You probably have questions about all this still. Most people do. Schedule a consult or call now we will do the hardwork and explain your options for Marketplace and Off-Market plans.

Schedule an ACA Consult

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