Question from Nora: I have an ACA (Affordable Care Act) plan that I purchased on Pennie last year. Is there anything I need to do during the Open Enrollment Period (OEP)?

Answer: The ACA Open Enrollment started November 1^st and runs through December 15^th. This is the only time someone who currently doesn’t have insurance can enroll in a plan. The good news is that ACA plans from the two companies that offer them in Western PA, Highmark and UPMC, have not made any significant changes for 2023. In fact, benefits on a couple popular plans have gotten better and rates remain relatively unchanged.

In the recommendation letter we sent out to our ACA clients this past week, we requested they contact us if any of the following applies: 1) Household adjusted gross income will be increasing or decreasing $5,000 or more in 2023. This can have a significant impact on premiums and even out of pocket costs. People or families who have an adjusted gross income under 250% of the poverty level get what is known as Cost Sharing Reduction (CSR), which can significantly lower deductibles, co-pays, and the MOOP, but only on certain plans. 2) Have a Bronze plan. With higher subsidies having been extended, moving to a Silver or Gold plan with much lower deductibles and co-pays may provide excellent value at a very reasonable cost. Bronze plans have very high deductibles and every single medical service that isn’t considered preventative, including primary care doctor visits and medications, are subject to the deductible. 3) Have a Silver plan and DO NOT get any subsidy. As crazy as it sounds, Silver plans with much higher deductibles are more expensive than Gold plans. I’m not even going to attempt to explain why but it’s indeed the case. The only people we recommend enroll in a Silver plan are those with adjusted gross incomes under 250% of the poverty level. 4) Moved to another county during 2022. Costs and plans differ by county and can have more or less restrictive networks. For example, the lowest cost Highmark and UPMC plans in some counties limit access to just Allegheny Health Network or UPMC providers and no others. 5) Those who have any questions or would like their plans reviewed. If none applies to you Nora, or anyone else who has an ACA plan, you will automatically be renewed in your current plan and don’t need to do anything.

There is one very significant and positive new ACA regulation that goes into effect for 2023. Up until now, if an employer offered health coverage to the spouse or children of that employee, regardless of the cost, those dependents were not eligible for a premium subsidy. We have continuously run into people who were offered plans through their husband’s or wife’s employer with extremely high deductibles and expensive monthly premiums of $600 or more. Now, these people qualify for ACA subsidies if the cost of the employer plan is more than 9% of the household income.

Another important item to remember is that only Highmark and UPMC offer true Major Medical individual health insurance in Western Pennsylvania that puts a cap on how much one can be billed for medical and prescription services in a calendar year. If you speak with someone who is offering any plan that isn’t provided by those two companies, it is not Major Medical and would put you in a terrible financial situation if you were to be diagnosed with Cancer, needed brand name medications, had a lengthy hospitalization or Skilled Nursing stay, complications from surgery, among other expensive care and treatment.

I want to mention that anyone who purchased an ACA plan through the marketplace or from another agent or agency can become a client of The Health Insurance Store with all the benefits that come with it. Our team is available to help clients to ensure they never pay an erroneous medical bill, advocate and file appeals and complaints if they are ever denied a claim or made to jump through hoops to get an MRI, CT scan, surgery, etc. We also have a dedicated Prescription Drug Caseworker, Tony Diroma, who is an expert at finding foundations, assistance programs, and other ways to help with the financial burden of costly prescription drugs. If you would like to have your ACA policy assigned to The Health Insurance Store, have questions about this column, or want to make an appointment for a no cost consultation, please give us a call or reach out to me personally at aaron@getyourbestplan.com.

My live radio show on WMBS Uniontown 590am and 101.1fm is this Monday, November 7^th from 1:15 to 3. I will be discussing the ACA as well as Medicare and taking calls on air. For those out of radio range, go to station’s website at wmbs590.com.

Lastly, with some employees of the Post-Gazette now on strike, it’s come to my attention that some people aren’t getting the paper on Sundays. I would like to remind my readers if for some reason the print edition is not delivered, is no longer offered, or if the digital edition goes down due to further implications of the strike, the columns can always be found on our website.