Individual and Family (ACA) FAQ
ACA: Coverage
Yes. By law, all ACA plans cover preexisting conditions, with no annual or lifetime limits.
The annual Open Enrollment Period for individual and family plans varies by state.
- PA, DE, and WV: November 1 — January 15
- NY: November 16 — January 31
Anyone who qualifies for an ACA plan may enroll during this time period.
When you experience a major life event — like the birth of a child, the loss of a job, or a move to a new ZIP code — you may qualify for a Special Enrollment Period (SEP). An SEP typically gives you a 60-day window to enroll in a new individual or family plan and may occur at any time throughout the year.
All Highmark ACA plans cover the 10 Essential Health Benefits:
- Outpatient care
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including dental and vision care
Some Highmark ACA plans include optional adult dental and vision coverage. All ACA plans include pediatric dental and vision coverage.
- Short term health insurance plans don't cover preexisting conditions or the 10 Essential Health Benefits.
- Financial help is not available for short term plans.
- Short term plans are available year-round.
- Open Enrollment: For coverage that starts on January 1, enroll by December 15. For coverage that start on February 1, enroll by January 15.
- Special Enrollment Period: Coverage begins on the first of the month following the date you enroll.
Find in-network doctors, hospitals, labs, mental health professionals, diagnostic and imaging centers, medical supplies and service partners, urgent care and retail clinics, and other health care services here
This will depend on the plan you select. Every plan comes with a formulary: a list of prescriptions covered by your health plan.
Yes. Mental health services are covered as one of the 10 Essential Health Benefits.
Yes. Substance use disorder services are covered as one of the 10 Essential Health Benefits.
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ACA: Enroll
- Any U.S. citizen, U.S. national, or otherwise lawfully present in the U.S.*
- Individuals not currently incarcerated.
- Individuals not enrolled in a Medicare plan.
*Only a requirement for purchasing plans on the marketplace. There is no citizenship requirement for purchasing plans directly though Highmark or other health insurance companies.
Depending on the life event that qualifies you for an SEP, you may need documentation like:
- a letter from an employer
- a birth certificate
- a marriage certificate
You may need to provide documentation for each person in your household verifying:
- Yearly income estimate
- Immigration status
The annual Open Enrollment Period for individual and family plans varies by state.
- PA, DE, and WV: November 1 — January 15
- NY: November 16 — January 31
Anyone who qualifies for an ACA plan may enroll during this time period.
When you experience a major life event — like the birth of a child, the loss of a job, or a move to a new ZIP code — you may qualify for a Special Enrollment Period (SEP). An SEP typically gives you a 60-day window to enroll in a new individual or family plan and may occur at any time throughout the year.
You can purchase individual or family ACA plans via:
- online marketplaces also known as federal or state government exhanges
- direct from Highmark
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ACA: Finances
- Advanced Premium Tax Credits (APTC) can lower your monthly premium.
- Cost-Sharing Reductions (CSR) can help lower the out-of-pocket costs like deductibles or copays.
APTCs and CSRs will only apply to plans bought through the marketplace.
APTCs and CSRs are also known as subsidies. These are tax credits that get applied directly to your premium or out-of-pocket costs.
Visit highmark.healthsherpa.com to see if you qualify for financial assistance. Your household size and annual income will help determine eligibility.
- Pay by check
- Pay online
- Enroll in autopay
- Pay by phone
- 866-266-0654 for PA/DE
- 855-425-5663 for WV
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ACA: After you enroll
- You should report any changes to income or household size to the federal or state exchange you used to enroll.
- If you enrolled in an off-exchange plan directly through Highmark, call the member service number on the back of your ID card.
If you're happy with your plan and don't want to make changes, you don't have to do anything. Most plans auto-renew at the Open Enrollment deadline.
- Open Enrollment: For coverage that starts on January 1, enroll by December 15.
- Special Enrollment Period: Coverage begins on the first of the month following the date you enroll.
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