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Individual and Family (ACA) FAQ

ACA: Coverage

Is there coverage for preexisting conditions with Highmark ACA plans?

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Yes. By law, all ACA plans cover preexisting conditions, with no annual or lifetime limits.

When can I get Highmark ACA coverage?

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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.

What do Highmark ACA plans cover?

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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

Do Highmark ACA plans include dental and vision coverage?

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Some Highmark ACA plans include optional adult dental and vision coverage. All ACA plans include pediatric dental and vision coverage.

What's the difference between ACA and short term insurance?

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  • 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.

When does ACA plan coverage start?

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  • 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.

How do I know if my doctors are covered in an ACA plan?

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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

What prescriptions are covered with Highmark ACA plans?

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This will depend on the plan you select. Every plan comes with a formulary: a list of prescriptions covered by your health plan.

Is mental health covered by a Highmark ACA plan?

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Yes. Mental health services are covered as one of the 10 Essential Health Benefits.

Is substance abuse coverage included in a Highmark ACA plan?

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Yes. Substance use disorder services are covered as one of the 10 Essential Health Benefits.

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ACA: Enroll

Who is eligible for Highmark ACA plans?

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  • 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.

What documents do I need for Special Enrollment?

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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

What documents do I need to enroll in a marketplace plan?

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You may need to provide documentation for each person in your household verifying:

  • Yearly income estimate
  • Immigration status

What are the dates and deadlines to enroll for an ACA plan?

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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.

How do I enroll for an ACA plan?

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You can purchase individual or family ACA plans via:

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ACA: Finances

What financial assistance is available for ACA plans?

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  • 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.

What are ACA subsidies?

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APTCs and CSRs are also known as subsidies. These are tax credits that get applied directly to your premium or out-of-pocket costs.

How do I know if I qualify for financial assistance for an ACA plan?

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Visit highmark.healthsherpa.com to see if you qualify for financial assistance. Your household size and annual income will help determine eligibility.

How do I pay my Highmark ACA plan premium?

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ACA: After you enroll

How do I report income/family changes after I enroll in an ACA plan?

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  • 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.

How do I renew my ACA plan?

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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.

When does my ACA plan coverage start?

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  • 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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