Media Contact:
Division of Insurance - Vincent Plymell
vincent.plymell@state.co.us
As Open Enrollment for 2025 continues until Jan. 15, the Division shares tips on avoiding plans that may not cover what you need.
DENVER - The Colorado Division of Insurance (DOI), part of the Department of Regulatory Agencies (DORA), offers a reminder that open enrollment for individual market health insurance (for people that don’t get their insurance from an employer) continues until January 15. The DOI encourages people who haven’t chosen coverage for 2025 to take advantage of this time to enroll in plans that meet the robust benefit requirements of the Affordable Care Act (ACA), because quality health insurance is a key component in maintaining one’s health and the health of one’s family.
At least 80% of people currently enrolled in health insurance through the state’s marketplace, Connect for Health Colorado, will be eligible for financial assistance in 2025 that will help to make their insurance more affordable. And that financial assistance can be significant, as 77% of those customers getting assistance will be able to find a plan with a premium less than $100 a month, and 62% will be able to find a premium under $25.
However, the DOI cautions Coloradans that some plans marketed to consumers offer only limited coverage, and DO NOT meet the requirements of the ACA. These might be short-term plans, limited benefit plans, trade association plans, discount plans, or even plans that claim to be employer plans without being connected to an employer. And these types of plans and products ARE NOT sold through Connect for Health Colorado.
The low monthly costs of such products can make them look attractive, but these plans can stick consumers with huge medical bills from doctors and hospitals as the plans deny and limit health care coverage in ways such as the following.
- Limiting coverage regarding the treatment for pre-existing conditions
- Limiting prescription coverage
- Limiting coverage for hospitalizations and emergency rooms
- Limited or no coverage for mental health / behavioral health treatment
- Limited or no coverage for pregnancy-related care and delivery
- Limiting coverage for outpatient / same-day surgery
“Open enrollment is a valuable time for people buying health insurance - a time to shop and compare the options that meet their needs,” said Colorado Insurance Commissioner Michael Conway. “We’re sharing these tips so people don’t get stuck with thousands of dollars in medical bills when it turns out the plan they purchased wasn’t what they thought it was.”
Look for these red flags to show the product may limit coverage and would not meet ACA requirements.
- Aggressive and high-pressure sales tactics from an insurance broker or the company
- Being told that the coverage is “just as good as the ACA” or that the plan “offers the same types of coverage as the ACA.”
- Use of words such as “limited benefit plan” or “supplement plan.” Limited benefit plans and supplemental plans are intended to be used in conjunction with a major medical plan, but are not intended to be a type of stand-alone health insurance coverage.
- The plan pays you a set amount for your care, rather than paying a doctor, hospital or other health care provider.
How can you avoid these products? Before buying or signing up, ask for plan details in writing, such as how coverage works when visiting a doctor for tests and follow-up care, how the plan covers pre-existing conditions, how it would cover emergency care or how the plan might cover a hospital stay that would include labs, surgery and specialists. Know that you have the right to ask questions and get details in writing, and you shouldn’t be pressured into a decision. Don’t provide banking information or a Social Security number before you’ve had a chance to review the materials and get your questions answered.
Here are other questions to ask before buying.
- Is this a short-term, limited duration plan, or other limited-coverage plan? Is it sold through an association you are required to join or pay a membership fee to? Do you have to sign a partnership agreement in order to enroll? Typically, such products offer limited coverage and are not ACA-compliant.
- What is the name of the insurance company underwriting the coverage and is it licensed in Colorado? This can also be confirmed with the Division of Insurance.
- Does it cover your prescriptions?
- Does it cover pre-existing conditions? What benefits and services doesn’t the plan cover?
- Does the plan have deductibles? What are they?
- Is there a maximum out-of-pocket amount for the year - meaning the most you’ll have to pay for the year?
- For services that are covered, how much will the plan actually pay?
- Is there a limit on the total amount the plan will pay per person, per service, or per year? Know that ACA plans do not have a yearly or lifetime cap that the insurer will pay!
- Will the plan pay you directly, or send payment to the health care provider?
- Does the plan have a provider network of doctors, hospitals and other health care workers? If yes, ask for information about the network. Is your doctor or hospital in the network?
Asking these types of questions helps you know that you are getting a health plan that protects you and your family, and not being sold a plan that doesn’t provide appropriate coverage for your health care needs.
The DOI encourages Coloradans to shop for individual plans through Connect for Health Colorado, where you can be connected to insurance brokers, assisters and online resources to get help selecting a plan that can best meet your needs.
If you or a family member need help determining what kind of questions to ask when considering health insurance, or you just want some assistance decoding the language of a health plan, contact the Division of Insurance Consumer Services Team: 303-894-7490 / DORA_Insurance@state.co.us / doi.colorado.gov (click on “File a Complaint”).
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About the Division of Insurance:
The Colorado Division of Insurance (DOI), part of the Department of Regulatory Agencies (DORA), regulates the insurance industry and assists consumers and other stakeholders with insurance issues. Visit doi.colorado.gov for more information or call 303-894-7499 / toll free 800-930-3745.
About DORA:
DORA is dedicated to preserving the integrity of the marketplace and is committed to promoting a fair and competitive business environment in Colorado. Consumer protection is our mission. Visit dora.colorado.gov for more information or call 303-894-7855 / toll free 800-886-7675.