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Is short-term health insurance right for you?

Plans provide coverage for millions caught in the coverage gap, with incomes too high for subsidies, or those caught by the 'family glitch'

EDITOR’S NOTE: Short-term plans that were purchased by March 31, 2017, can remain in force as late as December 31, 2017, if allowed by the insurer. Policies purchased after that date are limited to 90-day terms, but some insurers allow consumers to purchase up to four consecutive short-term plans (each 90 days long) with only a single application. And President Trump signed an executive order in October 2017 instructing federal agencies to propose regulations that would once again allow short-term plans to be offered with durations of up to one year.

The premium increases for ACA-compliant health insurance were substantial for 2017, and they’re shaping up to be substantial again for 2018, due in large part to the uncertainty created by the Trump Administration and Republican lawmakers’ efforts to repeal the ACA. And although premium subsidies in the exchanges offset most or all of the increases for people willing to shop around for coverage, they don’t help everyone.

If you’re among those consumers, should you consider short-term health insurance plans?

Why consider short-term coverage?

There are currently about 2.9 million people who are caught in the coverage gap in 18 states that have refused to accept federal funding to expand Medicaid. Their household incomes are under the federal poverty level, so paying full price for health insurance is probably a non-starter.

Millions of Americans also have incomes above 400 percent of the poverty level, but not dramatically so. And thanks to the subsidy cliff, they can be facing premiums that are 25 percent – or more – of their income, depending on where they live.

Others are caught by the family glitch, and although their coverage is technically considered “affordable,” that may not actually be the case.

If you’re among these consumers – and you’ve looked at all the on- and off-exchange options for regular health insurance and simply cannot afford them – it’s worth at least weighing the pros and cons of short-term coverage. So here’s what you need to know:

Plans are now limited to less than three months in duration

Short-term plans are available in most states, but the type of temporary plan can vary considerably. And, in fact, there are five states (New York, New Jersey, Massachusetts, Rhode Island, and Vermont) where short-term plans aren’t available at all.

Availability of short-term plans has always varied from one state to another. But prior to 2017, short-term health insurance was defined by the federal government as a plan with a duration of less than one year (states were free to set shorter durations, and some states limited short-term plans to six months). The federal rules changed as of January 2017, though. In 2016, HHS finalized their proposal to limit short-term plans to “less than three months” in duration, for plans with effective dates of January 2017 or later. This rule applied in every state, although states were free to set more restrictive limits.

However, they noted in the final rule that they wouldn’t take enforcement action on this until April 1, 2017. So short-term plans with longer durations were still available for sale through the end of March, as long as they were scheduled to terminate on or before December 31, 2017. As of April 1, no short-term plans could be sold that have durations of three months or longer (90 days is ok).

Although all short-term plans sold on or after April 1 are limited to 90 days in duration, some insurers are allowing consumers to purchase up to four short-term plans at one time (each with a 90-day duration), with the plans running back-to-back. Enrollees only need to complete one application — and go through the medical underwriting process one time — but they can have coverage for up to 360 days.

Trump Administration is expected to roll back the limits on the duration of short-term plans

The new rule limiting short-term plans to 90 days started to be enforced after Trump took office, but it was an Obama Administration rule change, promulgated under then-Secretary of HHS, Sylvia Burwell. On June 8, 2017, a group of 14 Republican Senators sent a letter to HHS Secretary Tom Price (who has since resigned), asking the new administration to revert to the old rules for short-term plans.

President Trump signed an executive order in October 2017 that is expected to eventually result in a reversal of the Obama Administration rule and a return to the previous rule that limited the duration of short-term plans to anything less than a year. The executive order does not change anything in and of itself. Instead, it directs various federal agencies to “consider proposing” new regulations that would return to the previous rules for short-term plans.

Prior to 2017, eight states already limited short-term policies no more than six months — in addition to the five states that didn’t have short-term plans at all. And even in the states where the pre-2017 federal definition (ie, less than one year in duration) was being used in 2016, the majority of available plans tended to have a maximum length of six months. States will still be able to set tighter restrictions, just as they did prior to 2017, but it’s expected that longer-duration short-term plans will again become the norm starting sometime in 2018.

The Senators who asked the Trump Administration to intervene claimed that the new rules hurt consumers by eliminating the option for short-term plans with durations longer than three months. This is a controversial stance, though, since it hurts the ACA-compliant major medical risk pool when healthy consumers opt for short-term plans instead of regular major medical coverage. Since short-term plans don’t cover pre-existing conditions, they are really only an option for healthy people. And when fewer healthy people sign up for regular health insurance, the risk pool for that coverage tilts more towards the sick end, driving up costs for everyone.

The Trump Administration is ostensibly rolling back the regulations on short-term plans in order to allow more consumer choice, but this action will have a destabilizing effect on the individual health insurance market — where about 17.6 million Americans get their coverage. Especially when combined with the Trump Administration’s efforts to minimize the impact of the ACA’s individual mandate penalty (the penalty is still in place, and will remain in place unless it’s eliminated via legislation. But Trump’s first executive order in January 2017 instructed federal agencies to be as lenient as possible in terms of ACA penalties).

If short-term plans can once-again be purchased for up to 12 months, it would help healthy people avoid the ACA-compliant market in favor of a cheaper option. The coverage is less robust in the short-term market, but some healthy people will see it as a valid trade-off for lower premiums. The problem is that those healthy people are the ones who are needed in the ACA-compliant market in order to keep the market stable.

The Obama Administration wanted to make sure that short-term plans would only be used for their original intent: as a stop-gap measure before another plan kicks in. Short-term plans were never intended to be used as a substitute for regular long-term health insurance, but that’s what some people had been using them for since the ACA regulations took effect in the individual market.

Potential savings – short-term plans are cheaper because they provide less coverage

A lower monthly premium is the primary draw for short-term plans. Consider a family of four, living in Colorado and earning $99,000/year (just over the upper limit for premium subsidy eligibility). The parents are around age 40, with two young children. For 2018, the cheapest plan they can get in the exchange would cost $1,190 per month in premiums. And it would have a maximum out-of-pocket exposure of $14,700 for the family.

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But there are numerous short-term plans available to them, with premiums that range from under $100/month to nearly $500/month. All of the plans are capped at 90 days, but they could purchase a second plan after the first expired (Colorado limited short-term plan duration at a maximum of six months prior to 2017, but currently available plans are limited to 90 days due to the federal regulations that took effect in 2017). There are several plan designs available, and although none of them are as comprehensive as ACA-compliant plans, the trade-off is that they have much lower premiums.

Short-term plans are not considered minimum essential coverage, which means that the ACA’s penalty applies to people who rely on short-term plans. However, there’s a penalty exemption if coverage is considered unaffordable. For 2018, if the cost of the cheapest bronze plan would be more than 8.05 percent of your household income, you’re exempt from the penalty. For the hypothetical family in Colorado, the penalty exemption would apply, since $1,190 per month would be more than 8.05 percent of their household income (the premiums would come to $14,280 for the year, and 8.05 percent of their income is only $7,970; the premiums would be well above the upper limit of what the IRS considers affordable for that family).

Other obvious advantages

If short-term coverage is available in your state, there are some features with obvious appeal for consumers who are in dire straits.

  • Immediacy. With short-term policies, healthy applicants can secure immediate individual and family coverage, with plans that can kick in as early as the next day. If you already know the number of days you will need to be covered, your insurer may allow you to make a single payment for the whole coverage period.
  • Costs. Short-term plans are typically offered with a selection of premiums, deductibles and benefit maximums. The policies are considerably less expensive than ACA-compliant major medical plans, so you may find that you can afford to purchase a plan with a low deductible and a high-benefit maximum.
  • Flexibility. The policies also cover a range of physician services, surgery, outpatient and inpatient care. In addition, policyholders can often choose their own doctor and hospital without restrictions, though there may be financial incentives for using in-network providers.
  • Enrollment / eligibility. The enrollment process is quick and easy, with just a handful of yes/no questions regarding major health concerns (even if your health conditions are not included, bear in mind that all short-term plans have blanket exclusions that apply to any pre-existing condition, regardless of whether it’s one of the conditions that determines eligibility for coverage).
  • You can extend coverage, but you’ll have to reapply and you’ll be starting over with a new plan. And any medical conditions that came up while you were covered under the first plan would no longer be covered under the second plan. If an insurer in your area offers the option to buy multiple back-to-back plans with one application, the additional plans will not require new applications. The deductible and other out-of-pocket costs will reset at the start of each new policy, however.

A few important caveats to keep in mind

  • No coverage for pre-existing conditions. Even if you’re eligible for coverage based on the short list of questions asked on the application, you will not have coverage for any pre-existing medical conditions while you’re enrolled in the plan. Short-term plans exist solely to provide coverage for medical conditions that have not yet arisen. They will not be any help at all in terms of medical conditions you already have. Be sure to check the list of exclusions on any policy.
  • It’s not comprehensive coverage. These plans weren’t designed to cover everything, and they do not provide coverage for all of the ACA’s essential benefits. They typically won’t cover your routine office visits, maternity, mental health or preventative care, and many plans don’t cover prescription drugs unless you’re hospitalized. Again, be sure to check the list of exclusions on any policy.
  • You could still pay a penalty. This is a biggie. Unless you qualify for an exemption from the ACA’s individual mandate penalty, you will owe a penalty if you rely on short-term health insurance. (Everyone in the coverage gap is exempt from the penalty, as is anyone for whom the least-expensive plan in the exchange — after accounting for any available subsidies — is more than 8.05 percent of household income in 2018.)
  • You could still end up facing a gap in coverage. When your short-term plan ends, you will not be eligible to purchase a regular plan in the individual market if it’s outside of open enrollment. Loss of minimum essential coverage is a qualifying event that triggers a special enrollment period, but a short-term plan is not considered minimum essential coverage. But if you know that you’re going to have a qualifying event during the year that will allow you to enroll in an ACA-compliant plan, a short-term policy might be the perfect bridge to get you there and save money on premiums. (So for example, if you’re getting married in March 2018, you’ll have access to an ACA-compliant plan at that point. And short-term plan for the first few months of the year might end up being a good solution.)

How the new federal rules impact availability, and what’s likely to change under the Trump Administration

The Obama Administration’s changes to the definition of short-term health insurance were aimed at “curbing abuse” of short-term plans, as these policies were never intended to serve as a long-term solution to coverage needs.

The policies are supposed to fill in the gaps between other plans, and HHS was trying to ensure that they can’t continue to be used as a replacement for regular health insurance.

So as of 2017, all new short-term policies were limited to a duration of no more than three months. But that wasn’t being enforced until April 1, 2017, so short-term plans were still being sold for the first three months of 2017 with durations that extend — in many states — to as late as December 31, 2017. For people who purchased coverage in early 2017, a short-term plan could still be considered a “bridge to 2018.” That ceased as of April 1, however, when the new rule enforcement took effect.

But as noted above, insurers in some areas are allowing people to purchase up to four short-term plans with one application. Each plan has a 90-day duration, and they run consecutively, effectively providing up to 360 days of coverage without having to reapply.

The executive order that President Trump signed in October 2017 calls on federal agencies to reverse the Obama Administration regulations and return to defining short-term plans as durations of less than a year. 364-day plans were available in some areas prior to 2017, and that will likely be the case again after the new regulations are implemented, which is likely to be towards the very end of 2017 or the beginning of 2018 (the executive order was signed on October 12, and gives federal agencies 60 days to draft the regulations; there would then be a public comment period — likely 30 days — before the regulations would take effect).

However, states will still have the authority to limit short-term plans — either prohibiting them altogether or capping their duration at something less than a year.

Keep your ACA-compliant coverage if you can

One other factor to keep in mind: If you’re healthy enough to enroll in a short-term plan and you drop your ACA-compliant coverage to do so, you’re inadvertently harming the ACA-compliant risk pool, and leaving it with sicker enrollees. If a significant number of people do this, the problems with rates that we’ve seen for 2017 and 2018 could be exacerbated in future years. If there’s any way you can remain in the ACA-compliant risk pool, we’ll all be better off in the long-run.

Obamacare has made it much easier for a lot of the previously uninsured population – including those who are temporarily uninsured – to obtain high-quality individual health insurance. The law has done a great job of providing considerable financial assistance in the form of cost-sharing subsidies and premium subsidies.

But there are still situations when a short-term policy makes a lot of sense. If you’re choosing between a short-term plan versus being uninsured, that’s a situation where short-term coverage is a good idea.

Here are short term policies that can cover you for a year: