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Recently a well-informed client of ours expressed surprise when a person she knew could not make a change in her individual health insurance plan when she wanted to. Our client works very hard to stay current with regulatory changes in her role as a Human Resources specialist for a number of client firms. Yet the changes effected by the Affordable Care Act are so numerous and varied that even the most vigilant have missed some of the new rules, so here are a few that apply to those with individual plans:

  1. Coverage is either Affordable Care Act compliant or it is not. Those individuals who do not have compliant plans will have penalties apply when they file their taxes. And yet, for 2014 certain plans were grandfathered and others were grand-mothered so penalties did not apply to them. Can we count on the same penalty waivers for the 2015 taxable year?
  2. Individuals who failed to enroll for coverage during the 2015 open enrollment period or whose coverage lapsed due to non-payment of premiums must wait until January 1, 2016 to re-enroll. When the coverage loss is the result of administrative error at either the Marketplace or the insurance carrier will we be successful getting coverage reinstated or will families be uninsured even when they made a good faith effort to meet the federal requirement of having coverage? (Of course, any individuals who lose coverage from an employer plan have a special enrollment opportunity if application is made within a prescribed window of time.)
  3. Affordable Care Act compliance applies to all plans, not just those provided to individuals who qualify for Marketplace subsidies. Some people seem to think that the plans that are not written through the Marketplace can have different benefits and enrollment rules than those that are offered through the Marketplace. Yet we see that not all carriers who offer health insurance provide plans on the Marketplace as well as off, and even if a carrier provides coverage both on and off the Marketplace the plan designs are not necessarily identical. Worse yet, we cannot determine which providers are available for plans on the Marketplace as the network lists include all providers who participate with a particular network even though many do not accept patients whose coverage is written through the Marketplace.

Are you confused yet? We certainly have our hands full explaining all these nuances to clients and prospective clients. I guess the Affordable Care Act is rather like the American language: more exceptions than rules. Ask any of us who had it learn it as a second language, it is more art than science and more idiom than hard and fast patterns. Maybe that is what makes the Affordable Care Act so special to us as Americans. We may be the only people who have the patience to try to navigate the hidden trail that is the new health insurance landscape.

For assistance in (literally) navigating the path of the Affordable Care Act, contact us at Czajkowski Dumpel & Associates, Inc. – we are here to help!