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  • Writer's pictureRoger Masterson

Health Insurance 101

How much do you know about health insurance? Most of us have become comfortable with how health insurance works on a group plan through our employer but do you really know the details behind your plan? If you leave an employer the details can get very confusing very fast.



I answer questions about health insurance all the time so this will be the first blog in a series where I'll be explaining the many pieces and parts to finding the best plan for you. Let's start super high-level with three types of health insurance plans (there are a few more but we'll look at the most common today).

Health insurance plans through an employer are a type of major medical plan. They not only cover the cost of your healthcare but other care as well such as mental health counseling and pregnancy. These plans can be fairly affordable since the expense of that plan is shared amongst everyone within the company. For example in a health insurance plan through an employer, someone who has preexisting conditions who visits the doctor and/or hospital frequently would pay the same premium as someone who doesn't. These plans typically are renewed each year without health qualifications on the part of the applicant.

If you are not on a health insurance plan through an employer you will need a private health care plan. People without a major health condition (e.g. diabetes) or a pre-existing condition where you're going to need care (e.g. back pain/surgery) can choose a short term medical plan (aka STM plan) where the coverage can be specified to your needs (eg if you don't need mental health counseling you don't need to include it). The STM plans are, as it sounds, for a specific term where health qualifications for the applicant are evaluated each application. The most common duration for an STM plan is for 364 days but you can get shorter plans if needed to bridge gaps in coverage.

When you apply for an STM or renewal of an STM you will be asked to divulge any conditions or illnesses you may have developed during that year. This means that if your doctor is treating you for back pain and believes you may need surgery or more care in the next year, this back pain becomes a 'preexisting condition' that your STM plan may not cover the following year.

Take a moment and think about what that means.

If this happens to you and you have an STM plan, your insurance broker will likely begin speaking with you about whether you believe you'll need treatment for your back in the following year. If you believe you may, then the insurance broker will advise you to sign up for an Affordable Care Act plan (aka ACA or Obamacare).

ACA plans are offered by some of the same insurance companies that offer STM plans however they are considered major medical plans (just as the employer plans mentioned above) because they cover many types of care (e.g. mental health counseling, pregnancy, etc.) and cover pre-existing conditions (like your back pain). So some of the coverage you are paying for you may not use – but it may be worth it to you to have treatment for your condition covered. Each year, if you need an ACA plan, you are restricted to the enrollment period of November 1st – December 15th. So if you needed to 1) change your ACA plan, 2) get an ACA plan or 3) qualify for a subsidy for your ACA plan it has to be done during that time for a January 1st coverage date only.

Except for this year

On January 28th President Biden signed an executive order removing the annual date restriction for ACA enrollment for 2021. The executive order allows you to sign up for an ACA plan, change your ACA plan or apply for a subsidy for your ACA plan beginning today through May 15th for coverage beginning the 1st day of the month immediately following your application. This is great news for those of you with pre-existing conditions looking for coverage.

If this pertains to you please reach out to me via my website or cell and I'll walk you through your options.

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