Individual and Family (ACA) FAQ

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.

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.

• online marketplaces also known as federal or state government exchanges
• direct from Highmark

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

  ACA: After you enroll

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

  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?
  • 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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  Highmark is a registered mark of Highmark Inc. © Highmark Inc., All Rights Reserved.

  All references to “Highmark" in this document are references to the Highmark company that is providing the member's health benefits or health benefit administration and/or to one or more of its affiliated Blue companies. This website is operated by Highmark, Inc. and is not the Health Insurance Marketplace website. It also does not display all Qualified Health Plans available through the Health Insurance Marketplace website. To see all available Qualified Health Plan options, go to the Health Insurance Marketplace website at HealthCare.gov.

  Highmark Blue Cross Blue Shield or Highmark Blue Shield are Medicare Advantage HMO, PPO, and/or Part D plans with a Medicare contract. Enrollment in these plans depends on contract renewal. ®Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Benefits and/or benefit administration may be provided by or through the following entities, which are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, Highmark Wholecare or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company, Highmark Wholecare or Highmark Senior Health Company. PA: Your plan may not cover all your health care expenses. Read your plan materials carefully to determine which health care services are covered. For more information, call the number on the back of your member ID card or, if not a member, call 866-459-4418. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield or Highmark BCBSD Health Options Inc. d/b/a Highmark Health Options. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company, or Highmark Senior Solutions Company or Highmark Health Options West Virginia Inc. d/b/a Highmark Health Options. Visit our website to view the Access Plan required by the Health Benefit Plan Network Access and Adequacy Act. You may also request a copy by contacting us at the number on the back of your ID card . Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
  

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