Arizona health insurance marketplace
The Arizona Health Insurance Marketplace is a platform designed to help Arizona residents find health insurance coverage that meets their needs and fits their budget. It is part of the federal health insurance marketplace, where individuals, families, and small businesses can compare and purchase Affordable Care Act (ACA) health insurance plans. The marketplace offers “one-stop shopping” to find and compare private health insurance options, and it provides financial assistance based on household income and size to make coverage more affordable.
For 2023, there are eight insurers offering plans on Arizona’s exchange, including Aetna CVS Health/Banner Health, Arizona Complete Health, Blue Cross Blue Shield of Arizona, Cigna, Imperial Insurance, Medica Community Health Plan, Oscar Health Plan, and UnitedHealthcare of Arizona. The open enrollment period 2024 runs from November 1st through January 15th, with coverage starting on January 1st for enrollments completed by December 15th.
Health insurance plans.
Enrollment Process in the Arizona Health Insurance Marketplace
Enrolling in a health insurance plan through the Arizona Health Insurance Marketplace involves several steps, including the open enrollment period, special enrollment periods, and different enrollment methods.
Open Enrollment Period
The open enrollment period for 2024 runs from November 1, 2023, through January 15, 2024. If you enroll by December 15, 2023, your coverage will start on January 1, 2024.
Special Enrollment Periods
If you miss the open enrollment period, you may still be eligible for a Special Enrollment Period (SEP) if you experience certain life events, such as getting married, having a baby, losing other health coverage, or changes in income or family size.
Ways to Enroll
There are several ways to enroll in a Marketplace health plan in Arizona:
Online: Enroll directly through HealthCare.gov.
By phone: Call the Marketplace at (800) 318-2596 (TTY: 1-855-889-4325) to speak with an agent 24/7, except for holidays.
In-person assistance: Work with agents, navigators, certified application counselors, or an approved enhanced direct enrollment entity.
Certified enrollment partner: Apply for and enroll in Marketplace plans through an approved enrollment partner, such as an insurance company or online health insurance seller, like Blake Insurance Group.
Before starting enrollment, remember to gather all necessary documents and information, such as proof of income, Social Security numbers, and immigration status.
Plan Options
In Arizona, there are several types of health insurance plans available, including Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Exclusive Provider Organization (EPO), Point of Service (POS), and short-term health insurance plans.
Health Maintenance Organization (HMO)
HMO plans typically have lower monthly premiums and out-of-pocket costs. They provide coverage for care from doctors who work for or contract with the HMO and usually won’t cover out-of-network care except in emergencies. HMOs often require you to have a primary care physician (PCP) who coordinates your healthcare services, and you may need a referral from your PCP to see a specialist. HMOs might be a good choice if lower costs are most important and if you don’t mind using a PCP to manage your care.
Preferred Provider Organization (PPO)
PPO plans tend to have higher monthly premiums in exchange for the flexibility to use providers in and out of the network without a referral. Out-of-pocket medical costs can also run higher with a PPO plan. PPOs generally offer greater flexibility in seeing specialists and have more extensive networks than HMOs. A PPO may be better if you already have a doctor or medical team that you want to keep but doesn’t belong to your plan.
Exclusive Provider Organization (EPO)
EPO is a managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network, except in an emergency. EPOs typically have lower premiums than PPOs but offer less flexibility as they do not cover out-of-network care.
Point of Service (POS)
POS plans blend the features of an HMO with a PPO. A POS plan pays less if you use doctors, hospitals, and other healthcare providers in the plan’s network. POS plans require you to get a referral from your primary care doctor to see a specialist.
Short-Term Health Insurance
Short-term health insurance is a more budget-friendly option for individuals who only need emergency coverage or are between major medical plans. Seven insurers in Arizona offer short-term plans.
In addition to these, Arizona residents may also qualify for Medicaid or Medicare, depending on their income and age. The choice between these plans depends on your specific healthcare needs, budget, and preference for flexibility versus cost.
Health Insurance Costs in Arizona
In Arizona, the average monthly cost of health insurance for 2022 was $577, and the average yearly cost was $6,924. However, these costs can vary depending on location, income, and the chosen plan. For a 40-year-old buying a Silver plan, the average cost of health insurance in Arizona is $569 per month.
The deductible, the amount you pay for covered health care services before your insurance plan starts to pay, can vary. For example, one plan in Arizona has an in-network deductible of $1,500 for an individual and $3,000 for a family.
The out-of-pocket maximum, the most you must pay for covered services in a plan year, also varies. For the 2023 plan year, the out-of-pocket limit for a Marketplace plan can’t be more than $9,100 for an individual and $18,200 for a family.
Financial Assistance in Arizona
Several forms of financial assistance are available to help cover Arizona’s health insurance costs.
The Health Insurance Premium Tax Credit is a tax credit for a participating health insurance company that enrolls qualified small businesses not previously covered by health insurance. The credit amount is passed on to the small business through reduced premiums. The credit is based on $1,000 per year for single coverage and $3,000 per year for family coverage or 50% of the annual premium, whichever is less.
Many uninsured individuals could be eligible for AHCCCS (Arizona Health Care Cost Containment System) or qualify for free or reduced-cost health insurance through the Marketplace via advanced premium tax credits. AHCCCS provides medical insurance coverage to thousands of Arizonans each year, helping to cover the cost of doctor’s office visits, physical exams, immunizations, prenatal care, hospital care, and prescriptions.
For small businesses, Arizona’s lowest monthly SHOP health insurance premiums vary based on the enrollee’s age. For example, for an enrollee aged 50, the lowest monthly premium for a Bronze plan is $403.20, for a Silver plan is $533.89, and for a Gold plan is $596.41. If the business has fewer than 25 employees making an average of $50,000 annually, it may qualify for a tax credit worth up to 50% of the employer’s contribution to employees’ premiums.
Marketplace health plans are required to cover treatment for pre-existing medical conditions. This means that no insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started. Once enrolled, the plan can’t deny you coverage or raise your rates based only on your health. Medicaid and the Children’s Health Insurance Program (CHIP) also can’t refuse to cover or charge you more because of your pre-existing condition.
In terms of specific conditions, pregnancy is covered from the day your plan starts. If you’re pregnant when you apply, an insurance plan can’t reject you or charge you more because of your pregnancy. Once you’re enrolled, your pregnancy and childbirth are covered from the day your plan starts. If you give birth or adopt after enrolling in your Marketplace plan for the year, your child’s birth or adoption qualifies you for a Special Enrollment Period. You can enroll in or change plans outside the annual Open Enrollment Period. Your coverage can start from the date of birth or adoption, even if you enroll up to 60 days afterward.
However, it’s important to note that grandfathered plans don’t have to cover pre-existing conditions or preventive care. You may need to change your insurance if you have a grandfathered plan and want pre-existing condition coverage.
The Affordable Care Act (ACA) protects against discrimination based on pre-existing conditions. Before the ACA, insurers could deny coverage, charge higher premiums, or limit benefits based on pre-existing conditions. The ACA prohibits these practices, ensuring people with pre-existing conditions have access to affordable health insurance.
In Arizona, the Pre-Existing Condition Insurance Plan (PCIP) provides health insurance to those who have been denied coverage by private insurance companies because of a pre-existing condition. To qualify for the PCIP, individuals must have been uninsured for at least six months, have a pre-existing condition or have been denied health coverage because of a health condition, and be a U.S. citizens or residing in the U.S. legally.
All Marketplace and Medicaid plans cover these conditions for pregnancy and childbirth. This is true even if your pregnancy begins before your coverage starts. Maternity care and newborn care — services provided before and after your child is born — are considered essential health benefits, which means all plans inside and outside the Marketplace must cover them.
Medicaid and Other Public Programs
Medicaid and other public programs play a crucial role in Arizona’s health insurance landscape, providing coverage for individuals who meet certain income and other requirements.
The Arizona Health Care Cost Containment System (AHCCCS) is Arizona’s Medicaid agency, offering health care programs to serve Arizona residents. AHCCCS provides medical insurance to thousands of Arizonans annually, covering costs such as doctor’s office visits, physical exams, immunizations, prenatal care, hospital care, and prescriptions.
Eligibility for Medicaid in Arizona is linked to a person’s eligibility for Aid to Families with Dependent Children (AFDC) and the Supplemental Security Income (SSI) program. These programs provide aid to children whose families have low or no income and to the aged, blind, and disabled, respectively. Other categories of individuals who may be eligible for AHCCCS include adults, caretaker relatives, children, individuals who are 65 or older, individuals who are blind or have a disability, individuals who require nursing home or in-home care, individuals with developmental disabilities who need long-term care, individuals who need help paying Medicare costs only, pregnant women, women who want screening for breast or cervical cancer, and working individuals with a disability (Freedom to Work).
To apply for benefits, individuals can use the online platform Health-e-Arizona Plus or call 1-855-432-7587. The application process involves providing necessary documentation and meeting the eligibility requirements.
Choosing the Right Plan
Choosing the right health insurance plan that fits your needs and budget involves several considerations. Here are some key factors to consider:
Type of Plan and Provider Network
Different types of health insurance plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), and Point of Service (POS) plans. Each type has its own rules about whether you can see providers outside the plan’s network and whether you need a referral to see specialists. It’s important to check if your preferred healthcare providers, hospitals, and pharmacies fall within the plan’s network.
Premiums
Premiums are the monthly bills you pay your insurance company, even if you don’t use medical services that month. Plans with higher premiums usually have lower out-of-pocket costs when you need care and vice versa. If you frequently need medical care or have a planned surgery coming up, a plan with a higher premium and lower out-of-pocket costs might be a better fit. Conversely, if you’re young, healthy, and don’t anticipate needing much care, a plan with a lower premium and higher out-of-pocket costs might be more suitable.
Deductibles
A deductible is the amount you pay for healthcare services before your insurance starts to pay. Plans with higher deductibles usually have lower monthly premiums, and vice versa. Check if your plan has a combined deductible for medical and pharmacy services or a separate prescription deductible.
Co-pay or Coinsurance
You may be required to pay these costs to access care, even after you reach your deductible. A co-pay is a fixed amount for a covered healthcare service after you’ve paid your deductible. Coinsurance is your share of the costs of a covered healthcare service, calculated as a percent of the allowed amount for the service.
Coverage Benefits
Review the healthcare items or services covered by the plan. These may include emergency services, hospitalization, prescription drugs, laboratory services, and wellness visits.
Quality Ratings
Remember that plans may also differ in quality. Using various tools, you can search, compare, and assess providers, hospitals, and other care facilities.
Financial Considerations
Consider your budget and how healthcare costs fit into it. Some people prefer to keep their monthly premium payments low, while others may pay higher monthly premiums so they may pay less for co-pays when they need care. Depending on your income, you might also want to consider the potential for savings through a premium tax credit and cost-sharing reductions.
Personal and Family Health Needs
Consider your current and anticipated health needs. If you or a family member has specific ongoing health needs, such as a chronic condition or plans for a major medical procedure, this information can help you choose the most suitable plan.
Lastly, don’t hesitate to seek professional help if you find the process overwhelming. Free, impartial professional services are available to help you choose and enroll in a health insurance plan.
Legal Protections - Arizona affordable care act
In Arizona, consumers in the health insurance marketplace are protected by several laws and regulations prohibiting discrimination based on pre-existing conditions and ensuring fair treatment.
The Affordable Care Act (ACA) is a federal law providing significant consumer protections. It requires insurance plans to cover people with pre-existing health conditions, including pregnancy, without charging more. It also provides free preventive care, ends lifetime and yearly dollar limits on coverage of essential health benefits, and holds insurance companies accountable for rate increases.
In Arizona, the state law also prohibits discrimination based on health status-related factors or a lack of evidence of insurability. A health benefits plan may not deny, limit, or condition the coverage or benefits based on a person’s health status-related factors. The law also states that a health benefits plan shall not exclude coverage for pre-existing conditions.
The Arizona Department of Insurance is responsible for enforcing these protections. Consumers with questions or health insurance issues can contact the Department for assistance.
The state also has a Pre-Existing Condition Insurance Plan designed to help people with pre-existing conditions find health insurance. The monthly premiums for the Arizona PCIP range from $323/month for people 0-34 years old to $688/month for people over 55.
Furthermore, the Federal No Surprises Act applies to individuals insured under individual and group health insurance plans, student health insurance plans, and others in Arizona.
However, it’s important to note that there have been debates about the adequacy of these protections. For example, there has been criticism of a bill banning insurance companies from denying coverage to someone in the individual market due to a pre-existing condition, with some arguing that it doesn’t include any cost controls.