Frequently Asked Questions

Understanding your health plan is just as important as having one. We're here with the answers to your questions.
Individual and Family (ACA)

ACA: Coverage

Is there coverage for preexisting conditions?
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Yes. By law, all ACA plans cover preexisting conditions, with no annual or lifetime limits.

When can I get 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 ACA plans cover?
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All 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 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 or Health Care Sharing Ministries (HCSM) insurance?
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  • Short term or HCSM health insurance plans don’t cover preexisting conditions or the 10 Essential Health Benefits.
  • Financial help to lower monthly premiums is not available for short term or HCSM plans.
  • There is no limit on out-of-pocket costs for short-term plans or HCSMs.
When does my 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 in-network?
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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?
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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?
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Yes. Mental health services are covered as one of the 10 Essential Health Benefits.

Is substance abuse coverage included?
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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 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 (if applicable)
What are the dates and deadlines to enroll?
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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?
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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

What financial assistance is available?
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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 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?
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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 premium?
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ACA: After you enroll

How do I report income/family changes after I enroll?
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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 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 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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